Paradigm shift in medical education: The future beckons

“Education is not the learning of facts, but training the mind to think”- Albert Einstein

Medical education is presently at the crossroads of a paradigm shift. To hold on to the tried and tested traditional methods or to break out into a totally new avatar is the inevitable question on the minds of policymakers, educators, and students alike. The at-times rigid standard classroom teaching has presently given way to an unprecedented, at times uneasy fully online classroom teaching, a fallout of the present COVID pandemic. This new normal has given an opportunity for all stakeholders to pause, rethink, recalibrate, and move forward to rejuvenate medical education. It is important to identify challenges that are inevitable as we prepare to transform the medical education system in the country.

The need of the hour is to focus on the development of core skills. Whether it is an undergraduate learning the ropes of trying to elicit a cardiac murmur, palpating for hepatomegaly, or a resident learning various procedures, these learned skills would bear fruit only if they can be extended by all learners to real-life situations and thus benefit mankind. For this to happen, standard algorithms and protocols for the diagnosis and management of emergency and common clinical conditions need to be identified. These structured training modules also require trained faculty and therefore faculty development to conduct these training sessions and assess the training is another cornerstone for implementation of these modules.

Another challenge is the training of medical officers, registered medical practitioners, or basic specialists located at remote or isolated places, where probably they are the only medical consult available. To solve this emergent issue, a holistic view of all specialties has to find a place in the medical curriculum. For instance, if a medical practitioner or physician is posted in a remote area where a dermatologist is not available, he should have adequate knowledge of common skin lesions so that he can make as accurate a diagnosis as possible and even have the skills to treat such patients and mitigate complications so that they can be transferred to centres where the requisite specialist facilities are available. The clinical decision support systems should be made available to all medical echelons through technology in the form of artificial intelligence and mobile apps which would help take care of this deficiency to a large extent.

In this age of focus on super-specialty, the basic specialties and the medical officers/registered medical practitioners need to be equipped with skills so that the peripheral hospitals can handle most of the emergencies. This would also provide the much-needed boost up in bed occupancies in such hospitals compared to the overwhelming rush faced in tertiary care centres. Training in ultrasound, mechanical ventilation, and such other investigational and procedural skills which would help in diagnosing and treating many emergent conditions should be administered to not only the concerned superspecialists or specialties but also extended to basic specialties like medicine, surgery, and gynaecology who also need to have adequate skills in these fields. This skill learning will also motivate the basic specialty workers to produce better work results for maximum clientele satisfaction and also further their academic aspirations.

A holistic medical education approach is the call for the day. Competency-based medical curriculum (CBME) for undergraduates as introduced by the National Medical Commission in 2019 is a major positive step in this direction.¹ Our institute has chalked up a competency-based medical education curriculum for the postgraduates as well, across all specialties, and is ready for implementation. This curriculum has taken into account all core competency requirements of the postgraduates not only in their respective fields but also in such spheres where they are required to perform beyond their routine expertise. The present skill sets of various specialties were reviewed and the requirement for additional skills reassessed. Repurposing and reinventing were the two main principles involved in developing this curriculum. The age of memorising facts is a thing of the past. The stress of this curriculum is on understanding the clinical situation, responding based on learned skills, applying the skills to produce practical successful results, and reproducibility of these skills in everyday practise.

Skills that need to be developed include communication, empathy, history taking with reasoning, accurate examination, good procedural expertise, management based on evidence-based medicine, emergency care, data keeping, documentation, teamwork, multidisciplinary approach, professionalism, and above all ethics. The idea is to get them to be to be experts in all fields-preventive, curative, palliative, and promotive. Inculcating empathy in a doctor for a patient would bring a positive change to the physical and mental health of the patient and this is another important focus area in medical training.

Teaching mostly through pedagogy-based lectures alone should be put on the backburner. Skill-based training at the bedside and by simulation are the cornerstones of a good medical curriculum. The curriculum should not appear as a burden to the students but must look interesting, capable of doing and producing results. Bedside teaching is the key to instill clinical skills in students. When bedside teaching is not possible in situations as in this pandemic era, simulation of the clinical background requires tremendous innovative skills from the teachers. We need to extend this reach to even first-year and second-year undergraduate subjects like anatomy, biochemistry, physiology, pharmacology, and microbiology which can be made more interesting by showing their clinical implications on bedside or simulations. This increases the assimilation capacity of students and enhances learning by the interest and curiosity generated.

Simulations have the added advantage whereby students can acquire skills without causing harm to patients. Simulations also train students to get confidence and produce similar results in real-life situations. Skill studios simulating all atmospheres like Intensive care units (ICU), Neonatal Intensive care units (NICU), operation theatres, labour rooms, imaging facilities, high altitude, and underwater care are the need of the hour wherein real-life situations can be simulated and the students trained in such life-threatening situations. Short duration capsules and reinforcement-based training would yield the best results. Mannequins, simulators, role plays are all part of this skill-based learning. We need to borrow knowledge from modules that enhance simulations on a teamwork principle like STEPPS (Strategies and Tools to Enhance Performance and patient safety) which can further add to inter-professional skill development.² To make these high technology-based curricula cost-effective is another major challenge in the road to success, for this skill-based learning.

Massive open online courses (MOOCS), though introduced a few years ago, are yet to realise their full potential. The blending of MOOCs with traditional teaching needs to be smooth and this “own time learning” needs better evaluation techniques to gauge the actual benefit accrued from it.

Motivating medical students to undertake research early in their careers is another area that needs impetus. Helping them develop robust research protocols, undertaking path-breaking studies, data banking and finally, the publication of highly cited manuscripts should also be inculcated seamlessly into the curriculum.

The teachers need to themselves first get accustomed to these methods so that they can deliver a tested modality of skills to the motivated students. Feedback and evaluation are key aspects to the success of this curriculum and need to be given their due importance. Creating a clinical setting and assessing the students on these taught skills is the major role for which the educators should be trained. It is not the memorised facts but the demonstrable clinical skills which should be the focus of assessment. Assessments should be competency-based, have construct and content validity, reliability, and based on higher-order thinking skills and problem-solving. The outcomes have to be declared using Entrustable Professional Activities (EPA) and Workplace Based Assessment (WBA).³

The curriculum planner, developer, and implementer all need to wake up to this challenge and need to innovate with their creativity and sincerity in making this new face of education successful and futuristic. The smooth transition to this new methodology would require a great effort and we hope that the teachers are all geared up for this.

The transition from teacher-centric to student-centric methods puts a lot of stress on educators and the administrators need to be aware of this stress and give adequate freedom to the teachers. With the increasing use of technology in medical education, there is a possibility of students becoming less empathic, and losing their communication and demonstration skills. Mobile phone and laptop addictions should be factored in while designing the CBME curriculum especially in this era of the pandemic so that the touch with reality is not lost in translation. The ever-increasing usage of social media is another monster that can tilt the balance. It needs to be directed at facilitating new ideas, collaborations, and multidisciplinary research and not veer into addiction, depression, poor academic outcomes, and the like.

Medical technology has far outgrown its potential and medical education needs catching up. Artificial intelligence and Machine learning are two technologies that should be utilised to their maximum as clinical accessor support systems for tackling emergencies. Todays' world demands quality medical services to be provided within the economic, social, and ethical frameworks to the best satisfaction of the patients and their relatives.

Standardisation of medical education is of utmost importance if any gains are to be made from this change. Standardisation can be achieved by adopting great and innovative methods, enacting them through nationwide common training programmes and disseminating this information across the country through appropriate technology. Uniform accreditation policies for institutions, collaborative research and training protocols, single universal exit exam and acceptance of standard competency-based curricula across the board are cornerstones for achieving great standards in medical education and now is the time to adopt these strategies on a war footing.

The above needs were the impetus for us to think of a Medical Supplement issue for the journal and hope that the CBME curriculum and new paradigms in Medical Education take us to a better and healthy future.