University Times

“What does current practice in medical education reveal about our underlying beliefs?” asked former School of Medicine vice dean Steven L. Kanter during his keynote address to the inaugural Med Ed Day in Scaife Hall. “Do these beliefs still make sense? What threats can limit our effectiveness?”

The Sept. 30 daylong event, billed as a first annual celebration of educational innovations in the Schools of the Health Sciences, also included six presentations on fresh approaches to medical education, two poster sessions highlighting current scholarship in the Health Sciences schools and an educational resource fair.

Kanter, who left Pitt in 2014, now is dean of the University of Missouri-Kansas City (UMKC) School of Medicine. His talk, “Charting a Rational Course for the Future of Medical Education,” noted that UMKC’s approach to medical education is common throughout the world — except in the U.S. and Canada.

UMKC recruits students right out of high school for a six-year BA/MD program. It teams small groups of students with faculty mentors, and pairs older and younger students for internal medicine training.

“The students end up being very skilled clinicians” when they graduate from UMKC, Kanter said. “Because they stand out, they are often given some other opportunity,” usually a leadership role as they continue their education and begin the practice of medicine.

For a med school whose six-year program was designed to train primary care physicians, Kanter said, UMKC has turned out a disproportionate number of graduates in leadership positions in the profession.

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Why haven’t these successful practices been emulated in the majority of American medical schools?

It appears, Kanter said, that U.S. med schools believe their students need more undergraduate education than students in the rest of the world — despite complaining about a doctor shortage and the length and expense of a medical education.

Since American medical schools also accede to state legislators’ demands to accept in-state students with lower qualifications than those accepted from the admissions pool as a whole, they also must believe the needs of the state are more important than individual student qualifications, he added.

Based on their behavior, American medical schools seem to believe that students are blank slates who still learn by receiving raw information from teachers; that it is not very important to assess clinical reasoning in students; that critical thinking is valued less than the retention of information; that it isn’t important to assess a medical student’s moral or emotional development over time; and that medical schools aren’t responsible for the health of surrounding neighborhoods.

But education at all levels has been changing since the middle of the 20th century, Kanter pointed out, when society became dissatisfied with established educational models. New educational theories view the learner as more active “in the construction of meaning rather than the acquisition of knowledge,” he said.

In medical schools and other educational institutions, “students are beginning to say to faculty, ‘We don’t need you any more as a source of information.’” And, given online resources, faculty aren’t necessarily authorities on the latest information anyway. Instead, students are saying, “We need to know what to do when we are uncertain, when we are struggling with information and we can’t see our way forward.’” Students need better ways to assess the quality of information, Kanter said.

To chart a better, more sensible course for medical education’s future, he said, U.S. medical schools need to:

• Create a student-centered, not state-centered, admissions process — perhaps a national admissions program along the lines of the national match day for medical residents;

• Institute more six-year BA/MD programs;

• Allow students to use modern technology to gather more information, freeing instructors to engage in better forms of teaching;

• Create ways to assess clinical reasoning;

• Track students’ emotional and moral development; and

• Assess and aid health outcomes among people who live nearby.

Standing in the way of such improvements, Kanter said, are a variety of issues, including “a failure to correctly define the problem.”

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Among the faculty members from Pitt Health Sciences schools who highlighted the latest in medical education techniques during Med Ed Day’s afternoon session were:

• Lorin Grieve, a School of Pharmacy instructor, presented RxPedition, a drug development game he designed for the school’s Drug Development 1 class.

The semester-long game placed students into executive roles at biotechnology companies, each with a promising new compound to develop. Teams performed all the roles of a drug company, from designing phase-1 drug efficacy trials to managing the company’s finances and public image.

Panels of faculty members judged student presentations and then divided an investment pool among the teams. The students then developed their drugs and presented the results to a simulated Food and Drug Administration panel, followed by market simulations for the teams’ creations.

Not only did students learn in better ways than a purely didactic class, Grieve said, “what’s more, they even enjoyed themselves. They enjoyed the class,” finding the autonomy of group learning fulfilling.

• Deepika Mohan, faculty member in medicine’s critical care medicine and surgery departments, soon will be testing her classroom video game Night Shift, which is aimed at revising how physicians make clinical judgments. Such decisions under pressure are called “heuristics.”

“Heuristics can be very powerful,” Mohan said, “but they can lead you astray.”

Simply eradicating the use of heuristics, she added, would remove physicians’ abilities to use experience to find patterns that allow them to recognize proper treatments.

But, she said, “what if you don’t have four decades of experience?”

The solution is to prompt physicians to pause during the decision-making process to consider what new data might help.

In Night Shift, medical students play the role of a young doctor. Dialogue trees simulate a variety of doctor-patient interactions and the treatment choices physicians could make.

“You’ve started at a new hospital,” Mohan said in summing up the game. “Try not to kill anybody.”

Such games will not just be useful in teaching clinical actions, she concluded. “It’s not just about trauma — it’s about how we teach every day.

“We need to make heuristics a source of power.”

• Melissa Hogg, faculty member in the GI surgical oncology division, spoke about new methods of teaching her own specialty: minimally invasive foregut surgery using robot technology.

“We have a lot to learn from the airline industry,” Hogg said, where pilots train extensively on simulators, with many milestones and metrics to measure their progress.

“We’re way behind,” she said. “Pilots prepare not only for the unusual, they prepare for the unknown. Simulation can make the improbable possible.

“The dictums of surgical education have been crude,” she added, citing “See one, do one, teach one,” which can work for very basic procedures but not for six-hour specialty operations.
“There has to be a better way,” Hogg said.

Improvement especially is needed when teaching robotic surgery, she explained. Here, the surgeon may be sitting across the room from the patient, controlling four robotic arms. Such procedures have even been done remotely, across the world.

Breaking this surgery down into smaller parts and practicing them via simulations is the key, Hogg said. “It’s about a deliberate practice,” she concluded, “getting some of those 10,000 hours in before you see a patient.”

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Also presenting were Nicole Donnellan on the implementation of a web-based tool to evaluate medical students’ progress; Paul E. Phrampus on innovative simulation curricula around the world; and Robert M. Arnold on creating case stories that allow for realistic practice for dealing with patients.

—Marty Levine