EDUCATE TO TRANSFORM: THE ART OF DEVELOPING CURIOUS MINDS

Abstract

With rapid changes in health care and academic medicine, deans and medical educators need to carefully optimize medical education in order to best prepare our students for the future. Fundamentally, it is critical that future medical practitioners develop curious minds that look beyond the obvious to ask questions not yet asked and glean reality. This paper summarizes optimal adult learning, including (for example) concepts such as deliberate practice, active and interactive learning, and the flipped classroom.

INTRODUCTION

Today is a time of change and challenge in medicine. We live in an era of rapidly changing health care dynamics and new challenges in education. Within this context, we need to prepare our medical students and residents for the future. However, we must do this in deeply thoughtful ways. It is up to us, as academic medical center leaders and faculty members, to find those better ways and investigate the art of developing curious minds. Such a process is the only way to truly optimize lifelong, conscious, and reflective learning.

THE LEARNING PROCESS

Expert performance requires thousands of hours of thoughtful training and practice. Whether perfecting a pirouette, improving writing skills, or understanding how to administer a physical examination, practicing the right way can mean the difference between being good and being great. When it comes to understanding expertise and expert performance, psychologist K. Anders Ericsson is perhaps the world’s leading expert. His research is the basis for the 10,000-hour rule that suggests at least 10,000 hours of deliberate practice is required to achieve an expert level of performance in any given domain—and in the case of musicians, this number often translates into 15 to 25 years to attain an elite international level (1).

Deliberate or mindful practice is a systematic and highly structured activity that is, for lack of a better word, more scientific. Instead of mindless repetitions, it is an active and thoughtful process of hypothesis testing where we relentlessly seek solutions to clearly defined problems. It might involve monitoring one’s performance, e.g., with a practice notebook, where one keeps track of practice goals and what one discovers in practice sessions, and perhaps even jots down insights and discoveries (2). It might also involve the teacher as a significant influence. In addition, specific pedagogical methods have been shown to result in specific outcomes that influence the quality of education, performance of students, and success in instilling a desire for lifelong learning. A literature review identifies a few opportunities where teaching method is a strong influence: engaged versus didactic learning, interactive learning, active problem solving, and the flipped classroom or flipped learning (a pedagogical approach that calls for a dynamic learning environment where the educator guides students as they apply concepts and engage creatively in the subject matter).

The results of such thoughtful and effective adult learning strategies can be dramatic and visible. For example, ballerinas are extreme athletes who, for artistic and aesthetic reasons, are expected to remain lean with strength in order to be graceful athletes. Here, practice method makes the critical difference. If ballerinas use their quadriceps femoris to lift from the top, they promote muscle hypertrophy, or bulk, leading to muscular, athletic shapes, more often seen in modern dance. If they instead use their biceps femoris to support their leg from below, strength can be achieved while promoting willowy limbs (3).

ENGAGED VERSUS DIDACTIC LEARNING

Returning to medical education, the literature on engaged versus didactic learning suggests that incorporating more engaging learning sessions improves both qualitative experiences and performance levels of professional students. Miller et al found that the use of engaging lectures (also referred to as broken or interactive lectures, whereby, typically, students are given short periods of lecture followed by breaks that can consist of 1-minute papers, problem-solving exercises, brainstorming sessions, or open discussion) led to a statistically significant higher average on unit exams compared with traditional didactic lectures (8.6% higher, P <0.05) (4). Furthermore, students demonstrated improved long-term retention of information via higher scores on the comprehensive final examination (22.9% higher in engaging lecture sections, P <0.05). Many qualitative improvements were also indicated via student surveys and evaluations, including an increased perceived effectiveness of lectures, decrease in distractions during lecture, and increased confidence with the material.

ACTIVE AND INTERACTIVE LEARNING

Positive outcomes likewise are reported for active and interactive learning. For example, a study of student satisfaction with a near-peer interprofessional education classroom session for physical therapy and medical students reported a high degree of satisfaction with the sessions and an expressed desire by the students for further interaction (5). Further, active problem-solving in realistic scenarios also has been shown to confer deeper understanding of science than a standard lecture (6). In this case, a scenario (e.g., bioterrorism with a vial of ebola in the Washington, D.C., subway) initiates active, practical learning in epidemiology, infection control, emergency care, and public management of crises. This type of exercise, designed to engage students over weeks to months, embeds concepts in practical ways that are more easily retrieved than when each of the exact same concepts are taught independently, out of context, in a lecture course (7).

More and more, short epochs of active learning are being found to work most effectively for adult learning (8,9). Active learning can be integrated with the flipped classroom model—in this model, as defined by McLauglin et al (10) and other education researchers, course content often is offloaded (i.e., made available online or via video, for students to learn on their own time before class) so class time can be dedicated to engaging student-centered activities such as problem-based learning and inquiry-oriented strategies; this gives students more opportunities for critical thinking, independent learning, and learning from peers (10−12). Additionally, the instructor has more flexibility in covering a range and depth of material, providing in-class applied learning opportunities based on problem-solving activities, and offering timely feedback and guidance to students (13). Compared to their peers in more traditional coursework built on textbook assignments and classroom lectures, students involved in flipped classroom and active learning have higher class attendance, are more engaged in coursework, appear more prepared for class, prefer the flipped classroom environment, and achieve better final examination grades (14).

PREPARATION FOR MEDICAL SCHOOL

A review of the literature also suggests the importance of a deep liberal arts background as preparation for a medical career. The aim of a liberal arts education typically is seen as fostering insight, understanding, imagination, and discovery—an aim achieved through study in communication, the humanities, social sciences, and natural sciences. These areas all are fundamental for physicians who must have the capacity to express themselves well and listen to others, appreciate cultural differences, understand the historic and dynamic forces behind our societal institutions, and of course, comprehend the scientific basis on which medicine operates. This broad background builds critical thinking, analysis skills, and cross-disciplinary fertilization of ideas (15).

A deep liberal arts background, whether at a small college or large university, might therefore enhance curiosity in medical students. However, this is hard to measure. Currently, lifelong curiosity is embedded, yet not a formalized outcome in Accreditation Council for Graduate Medical Education (ACGME) competencies. Having said this, and as discussed in numbers of reports and studies on teaching and assessing the ACGME competencies, nimble problem-solving skills and creative thinking are critical to excellence in all the competency domains—patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (16−22).

Medical schools recognize the importance of the well-rounded background. To this point, in recent years, some medical schools have begun revamping their admissions process to include a “holistic review,” which the Association of American Medical Colleges describes as “a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes, and academic metrics and, when considered in combination, how the individual might contribute value as a medical student and physician.” (23,24) One report from Boston University School of Medicine describes when this medical school began incorporating a holistic approach in its admission process 6 years ago; faculty members have noted that students appear to be more collegial, supportive of one another, open to new ideas and perspectives, and engaged in community activities (25). They also have turned out to be as prepared as previous students, with no significant differences in average Medical College Admission Test scores and college grades (26,27).

MEDICAL EDUCATION AND THE INFLUENCE OF OVERALL STRUCTURE

Researchers (e.g., Bell et al, among others) suggest changes in medical education might include shortening the time to a medical degree or residency (28−38). As a result, there are many emerging 3-year programs in the United States for a selected subset of students. Emanuel and Fuchs, among others, suggest that medical education can be shortened by 30% without eroding clinical skills, if the goal is producing only competent clinical physicians (39−45). However, as we have stated, physicians of the future need to be continual learners and have skills beyond mastering today’s clinical algorithms.

Indeed, the shortened-curriculum approach has been tried before. Since the 1970s, universities have tried to shorten medical school, challenging the 4-year model in response to perceived physician shortage (46). By 1973, nearly 25% of US medical schools offered 3-year programs, with enrollment peaking at approximately 2,600 students between 1973 and 1974 (47,48). Not all of these schools persisted in the 3-year model, although shorter medical schools now have enjoyed a 4-decade-long run in Canada. In any case, many programs demonstrated that traditional core components of medical school can be mastered in 3 years (49−57).

Success of any medical school program, of course, depends on what outcome we are interested in measuring. If success means equipping doctors to lead teams of clinicians rather than following protocols, who are curious rather than merely satisfied with knowledge, then lifelong learning will be crucial, especially as new sciences emerge, e.g., informatics, quality and safety science, healthcare delivery science, and as yet unknown areas of research. For example, a rural-track medical student with a master’s of science degree in clinical informatics could exert a transformative influence. Instilling the desire and the capacity for lifelong learning—and thus fostering a lineage of innovative leaders in fields like quality and safety science, medical education, and biomedical research—will depend greatly on foundational learning experiences. As one example, Duke University School of Medicine places such a premium on the contextual, experiential, and creative aspects of critical thinking and problem solving that the entire third year contains a required research experience (58).

CONCLUSION

Creative, curious doctors are needed to lead the future of medicine. Such leaders are going to emerge necessarily from innovative approaches to medical education. What is needed is an ability to think carefully and critically through material, a skill that might be grounded in a deep liberal arts background, and that might evolve in an alternative to the traditional medical curriculum timeline and structure. What is needed, among our medical school leaders and educators, is a willingness to create fresh approaches to medical education that take into account all the new learning tools and resources that have evolved over the last 20 years for adult learners, such as interactive learning and engaged classrooms.

We can stay the course of traditional medical school curricula and perpetuate the status quo of competent and well-qualified physicians. But if we want our medical leaders of the future to be creative and curious, then so must we be creative and curious. As medical school educators, we must become deeply engaged in creating new possibilities for our students, in cultivating the art of developing curious minds, in learning how to educate in order to transform. As medical leaders, we have a clear choice, and how we choose will mean all the difference to the world of medicine and the quality of health care for generations to come.

DISCUSSION

Zeidel, Boston: Absolutely wonderful talk. A couple of questions. As each of our medical schools grapple with new approaches to curriculum, focused or based on learning theory and some of the empirical evidence you brought forward, I just have a few comments. There is much empirical data behind the learning theory of active learning; however, effective implementation often means utilizing educators who may have done any discovery—and what does that do to the medical school and its curriculum when the students are now exposed to people who are professional educators and never see anyone who has actually done discovery? Is there a role for transference in the interaction between the students and the teachers as to how discoveries occur (today and historically)? I suspect most of us in this room would not be allowed to teach medical students in the so-called “flipped classroom” unless we went through extensive training in how to become new-style educators.

Schwinn, Iowa City: I think that is a great question. First, I would argue that our educators should ideally be involved in educational outcomes research themselves and therefore academically and intellectually curious and transferring that excitement to our students. Second, I believe our faculty are “getting” flipped classrooms. Like you, we have gone through a recent rollout of a new curriculum that has gone well, and our faculty were initially very concerned about the idea of a flipped classroom. However, now faculty can be heard saying, “Oh, I can have students read this information the night before and then we can discuss the concepts in more detail in class…” Therefore, I think it is a matter of educating our own faculty to use flipped classroom approaches rather than a PowerPoint presentation in order to enhance the learning environment. And, as usual, 20% of faculty love it and are early adopters while 20% cannot conceive of changing their methods and will only be dragged forward into the new method; it is really those in between we can transform and move forward.

Zeidel, Boston: And just a quick add: are you going to measure the impact of your new curriculum and/or compare it to the curriculum that you are currently doing? Very often, we adopt wholesale new things, and it’s kind of like the new math curriculum and the public school systems… Every 5 years, there is a new math curriculum and no one evaluates whether it’s any better.

Schwinn, Iowa City: That’s another great point. Kristi Ferguson, PhD, a national leader in curriculum evaluation, leads our curriculum evaluation effort, and she has been very thoughtful on how we evaluate the impact. It’s very difficult to take the whole class and continually test them, as well as being very expensive, so we are using cohorts of 12 and 24 students to try to answer that question. We collected data from the last class on the old curriculum, and now are collecting data with classes on the new curriculum. In this way we will be able to definitively assess the impact of our New Horizons curriculum.

LeBlond, Billings: Harry Truman said that “The only thing new in the world is the history you don’t know (or haven’t read).” I am struck by the data presented on 10-minute epochs of engaged learners — pretty much defines attending rounds the way I did them with Paul Beeson and Bob Petersdorf and David Dale and other great mentors in the past. It’s still a very effective way of teaching case-based studies and is very active. But then I ask myself, what do people do in practice when they leave attending rounds and enter their clinics? They practice getting fast with an electronic medical record (EMR), and are not going and researching the literature, studying physiology. They are so bogged down in getting the work done that that little epoch of learning just gets sloughed off more often than not, I think, because the work overwhelms them. So limiting the patients to four patients or figuring out a way to do that to get the service obligation down so people can take that 10-minute epoch of teaching/learning and use it as a spring board and build off, is important. Right now residents, and I suspect students, are really so crunched for time that they need space to explore and learn.

Schwinn, Iowa City: I am not sure if that was a question, Dick. I actually believe 10-minute epochs of time are more doable in our days if we plan for it, than trying to get our residents out for a 45-minute traditional lecture. After residents have read material the night before, it is a little easier to slot one-on-one discussions into the day. If we think of it this way, we can enhance teaching rather than just the work of the service.

Michael Gershon, New York City: One of the problems I think we face is that a lot of the medical schools, when instituting new curricula and new ways of doing things, do a lot of magical thinking, particularly on the part of the administrators. Because there is a great deal of financial pressure, both on the faculty and the schools, everybody wants to do all the new things but there aren’t people to do it. Nobody is adding the faculty, nobody is mobilizing the scientific faculty or giving them an opportunity to compensate for extra time, and so we wind up doing things like a flipped classroom with 250 students in the room, some of the students in the balcony, and then state we are having a discussion. You can’t do that. The reason it doesn’t work is that you [institutions] don’t provide the resources, the training, or don’t use actual faculty to do it, but rather have a dedicated cadre of a few educators who do these things and then they are not adequately in the end ever really evaluated… So we wind up instituting a new program, we hear how well it works, everyone is all excited about the new program, and then 5 years later, we are doing another new program. So what happened to the previous success? How many times has Harvard changed its curriculum since its New Pathway? You know what happens is you keep doing these things and we all think things are probably a little bit worse now, because of all the changes, than it used to be before we made the changes.

Schwinn, Iowa City: I think the answer to your question may not rest with me alone, rather with all of us putting our heads together. You make great points. The amount of teaching required for all medical learners often exceeds most medical school revenue streams. However, we are all dedicated to teaching none-the-less. It is difficult to find release time for busy clinicians and that problem is not going to go away. We must be creative together.

Michael Gershon, New York City: Tuition has limits, the NIH has pulled the rug out from under science, and insurance companies have pulled the rug out from clinical revenue streams, so where is the money to support the kind of things that you are now saying could work beautifully. The resources are just not there and they are not going to come. In the end, nothing is going to stop the corporatization of medical schools and provide the resources that are necessary to do the kinds of things you are talking about. Magical thinking of introducing them, I would say, might be counterproductive unless the resources can be found. So, perhaps if every medical school would put an oil well in their backyard, it would work — but that would be damaging to the environment, so I take it back.

Schwinn, Iowa City: This group of individuals is a unique group to be asking this question, because as physician scientists, we have an opportunity to think smarter about how we are doing education as well as science. Some of these concepts actually don’t cost extra money, because they can be blended in. We don’t have that “extra cream” that allows us to do this easily, but that doesn’t mean we should stop and do nothing. I am simply saying, if we are going to be asked by the LCME to initiate reforms, we need to think about them deeply and thoughtfully.

Southwick, Gainesville: I have been using the flipped classroom for the last year, and I have a studio in my house to study with a green background screen where I create 10-minute vignettes. My fellows actually watch all those vignettes. Then I spend an hour twice a week with them teaching them concepts of quality and safety, and I can tell you it is an absolute joy. All the communication is now from the students toward me instead of me toward the students. I learn a tremendous amount, they learn by actively discussing the issues with their personal experiences, and guess what? The studio cost me $2,500, which I was happy to donate to the education of our students.

Schwinn, Iowa City: That is terrific! You should be aware there are many physiologic concepts now encapsulated in 10-minute or 15-minute YouTube videos, available for free, or at minimal cost, through many medical schools. So our faculty do not need to reinvent the wheel continuously. You can assign two or three of these short videos to cover concepts needed as background for class discussion with the expectation that the student will have viewed them before class. It is that easy!

Southwick, Gainesville: One of the things we are trying to do in the infectious diseases field is actually create a set of infectious disease videos that virtually everyone can use for education in all medical schools in the US or across the world. I think that, if we all got together as subspecialist societies, and created these videos with very interesting, different people, you would actually build interest in each subspecialty and teacher/students in a much more efficient and effective way.

Schwinn, Iowa City: Great idea and the Khan Academy may be competing with us to do that as well!

Thibault, New York City: Thanks for this stimulating discussion. Thanks for this vision of the future. I do believe you are right; this is the way we are going, and we have enough examples around that it can be done. It need not be more expensive, and it can help revitalize our faculty. Moving faculty from a role as sole transmitter of knowledge to the role of coach, and from a role of analyzer to the role of interpreter, is an exciting transformation. But it is going to take a concentrated effort on the part of leadership to move the faculty along. It can be done, it can be exciting, it can be rewarding, and thank you for this vision of the future. I believe it is where we are going.

Schwinn, Iowa City: Thank you. I love the point you are making about this energizing our faculty as well. That is crucial.

Ludmerer, St. Louis: Thank you also for this very fine discussion; a thought or two: There are lots of ways to teach and lots of ways to learn, and given that, it is often helpful to step back a step and remember basic principles. My suggestion would be that the challenge to all of this is to remember that, whatever the format we are providing medical education, we are meeting our responsibilities only if we provide a true education and not vocational training. That means not giving little snippets but providing the opportunities and, in fact, requiring learners to probe issues in depth and not only what there is to do but also why do we do them and what is the underlying biology and how might we make things better in the future. That needs to be the goal regardless of the specific format of teaching. On the financial aspects, in my view, this is a matter of values. If a medical school were to do one time [for education] what it does each year for its physical plant, it would have enough money to endow the teaching mission. Not necessarily to provide the salary of every faculty member, but we don’t need a lot of faculty for education—we need a core group of maybe a few dozen to several dozen throughout the medical school, if we are looking at medical students. That means perhaps a $100-million endowment to generate perhaps $5 million to pay for a salary here, a third of the salary there, and so forth. This is a lot of money, and it would have to be raised privately. On the other hand, the opportunity is there. We do this all the time for physical plants. I believe that the medical school that is willing to invest in people rather than physical plants is going to be the educational leader of the 21st century as Johns Hopkins was for the 20th.

Goodenberger, St. Louis: I want to echo what Ken said. We used to be across the hall from each other for 15 years and talked about this sort of thing for a lot. I looked at this about 10 to 12 years ago at Washington University, which had an endowment at the time of $1.5 billion, probably approaching $2 billion now. I figured out—by looking at all the course masters at Washington University, all the people who led all the courses from the first day of medical school to the last—that an endowment of about $20 million would have funded the salary, the self-reported efforts for their salaries for education… I would say, echoing what people have talked about in regard to Paul Beeson, I think this is also a moral leadership issue. I think this is a matter of setting priorities, and I think there is no secret that we have not spent any money on clinical education in medical schools for 30, maybe 40 years. You know the evolution was that, in the 1970s, when practice plans came about, you could be dumb as a rock and make a lot of money, and so, deans were only too happy to have the clinical departments fund the education in their departments. That’s the model that really persists today, so my dean is sitting on the third- and fourth-year tuition and paying nothing toward the medical education of the medical students in the third and fourth years. That is moral issue number one. Moral issue number two is, how do you set priorities? We are talking about amounts of money that are relatively trivial in comparison to the whole, and so I think it is a matter of setting priorities.

Schwinn, Iowa City: I believe medical education needs to be a crucial priority going forward. We should balance education across different realms of students and teaching topics, and ensure curiosity is enhanced during the process. In addition, I want to ensure we are not only getting our students through a good process, we are also thoughtful about teaching them in a way that is replenishing to our academic faculty as well. It is important that we remember that educators are scientists too, as exemplified by educational outcomes research across our various learning environments such as basic research, translational research, and high-quality clinical care environments. Thank you for your wonderful comments!