Medicine, We Have a Problem
Working and learning, as individuals and in teams, in analog and digital spaces. Three intersecting tensions form the backdrop of medical education currently in the wake of public health, geopolitical, and environmental crises.1, 2 However, medical educators have been walking and chewing gum—behind the mask—at the same time now for almost three years. It isn’t our first rodeo, dropped video call, or full-on dumpster fire. Experience has taught us that survival in the heavy crosswinds won’t cut it for the patients and learners who depend upon our care and teaching. Learners and patients don’t just call upon us, they count on us to thrive, go the distance with them, and not “go it alone.” They and we can’t accomplish it all ourselves. The mission before us will require a creative blend of co-constructed learning, teamwork, and technology.
Ground Control to Co-construction
Contemporary clinical learning is characterized by an exponential explosion of knowledge against a relatively stable denominator of cognitive load. The doubling time of medical knowledge has diminished significantly over the past seven decades: from 50 years in 1950, in 2010, 3.5 years, and in 2020 only 73 days.3 Not only has the depth of knowledge increased but also its breadth, as well as others’ ability to access this information, through both formal and informal streams. This ongoing growth of the information superstructure results in our rapidly diminishing ability to meet the demands of knowledge and practice of medicine as it evolves exponentially.
The composition of teams and the people that make up teaching teams represent another extraordinary shift. This change is in favor of greater diversity, inclusion, and the democratization of teaching and learning. This human-level shift calls out for collaborative approaches that fuel greater integration across domains of knowledge and experience. In our overlapping systems of clinical care, learner independence is not so much the end objective as learner interdependence.4 Learners can vitally contribute as part of integrated teams that extend beyond the traditional roles of physician and patient.
Finally, technology has outpaced the methods we use to teach in medicine, still largely dependent on in-person or analog modes, with some e-learning on the margins. As medical teams shift towards embracing social, constructive, and collaborative aspects of new technologies, the importance of learning network creation in the blended, digital learning space is evident. The resulting shift from personal knowledge management to team knowledge management deserves additional attention in medical education.
Based on these intersecting trends, the only way forward that we can see for clinical teachers is with collaborative teams, that engage in continuous practice-based learning, drawing from distributed knowledge bases, and engaging new technologies to support connectedness of people and ideas in ways previously only imagined.
Pushing (and Pulling) the Envelope
In his best-selling The Right Stuff from 1979, Tom Wolfe wrote the captivating story of seven astronauts in training in the Mercury program. In addition to coining the phrase “push the envelope”—to practice at the boundary limits of performance—Wolfe defines having the right stuff as taking risks “in a cause that means something to thousands.”
Clinical teachers, take note. We can’t mail in (or email in) the teaching. No longer is it enough for the clinical teacher to just “show up” or simply don one of the many hats that they wear at any time. Model clinical teachers today are team-focused, responsive to feedback, and iteratively developing, rehearsing, and improving what they teach. They take risks, teach across platforms, try out new methods to push (deliver) as well as pull (retrieve) ideas that engage the boundary limits of individual learners and learning teams.
One of the most important ways to address these system shifts while encouraging peak performance is to give patients and learner teams what they deserve most: intentionality. Intentionality requires forethought and can’t be achieved impromptu or via superficial routine. Teams of educators, physicians, athletes, and even master chefs have called attention to the role of (deep) performance: maximizing capabilities through activities that improve behaviors, skills, and attitudes. Only through targeted interventions that properly match learning activities to different learner levels can this level of performance be reached.
This can’t all happen simultaneously, particularly while patients need to be examined and evaluated, learners take time to present their assessments and plans, and learning points are being created and distributed. The workplace environment isn’t always conducive nor helpful to these endeavors. Clinical teachers too need the right stuff to harness the inherent intersecting tensions in the current teaching environment and empower their learners and patients to reach their full individual and collective potential.
Clinical Teaching with “the Right Stuff”
How can clinical teachers best navigate this new landscape? First, recognize the clinical teaching environment for what it is: a unique and shared space that brings together real-world patient care while pushing the envelope of learner knowledge and educator skill. Remember that the digital environment serves at best to supplement or augment traditional in-person teaching, not replace it. Apply proactive frameworks in your teaching such as the Master Adaptive Learner model5 and self-regulated learning. Approach teaching rounds, or any teaching interaction, with a developmental perspective. A pre-/intra-/post-approach can be helpful to follow:
- Before rounds (Pre-): Digitize and distribute your attending expectations for your team.
Have these ready to be sent out to team members even before you meet them. A short document describing your specific objectives for learners of all levels on your team will contribute to shared decision making and a collaborative learning environment. Create a shared notebook for your team to use during the rotation in a secure, cloud-based learning system readily available at your institution.
- During rounds (Intra-): Ask members of your team to share their learning goals with you and each other. Generate and crowdsource hypotheses and questions organically as you see patients together. Write these down as action items to investigate further as learning activities. In this way, teaching points are valued as equally important as checking Ins and Outs or daily weights, you can make the workflow a teaching process, and each captured item becomes an opportunity to collaborate.
- After rounds (Post-): Follow through on the teaching by creating, sharing, and posting learning points asynchronously based on the topics referenced previously on rounds. Invite all learners to participate equally. Interleave and use recall, reflection, and bring in diverse sources with links: .pdf files, multimedia, diagnostic schemas, infographics. Carry forward newly discovered answers, insights, and questions (calling out team wins) into the rounds on subsequent days.
The Future Is Bright beyond the Clouds
Each generation has its unique challenges, but every storm must pass. How prepared clinical teachers will be for future challenges will depend upon how well they’ve responded to the lessons of the present. We have a duty to strengthen our teams as people, improve our processes, and adapt technologies at our disposal as teachers to leave the teaching environment in a better state than we found it. Only then will we look back on our current problems as beginnings, rather than ends. What will matter most is whether we (and our teams) have acquired the right stuff to do things better the next time. The future of medical education is bright beyond the clouds.
- Minter DJ, Geha R, Manesh R, et al. The future comes early for medical educators. J Gen Intern Med. 2021 May;36(5):1400-1403. doi: 10.1007/s11606-020-06128-y. Epub 2020 Sep 1.
- Hilburg R, Patel N, Ambruso S, et al. Medical education during the Coronavirus Disease-2019 Pandemic: Learning from a distance. Adv Chronic Kidney Dis. 2020;27(5):412-417. doi:10.1053/j.ackd.2020.05.017. Epub 2020 Jun 23.
- Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.
- Bowen J; Parsons A, Rencic J, Bowen J, annotators; Abdulnour R-E, ed. Educational strategies to promote clinical diagnostic reasoning: Annotated and updated. NEJM. http://nej.md/3pV5heM. Published November 23, 2006. Accessed September 15, 2022.
- Cutrer WB, Miller B, Pusic MV, et al. Fostering the development of master adaptive learners: A conceptual model to guide skill acquisition in medical education. Acad Med. 2017;92(1):70-75. doi:10.1097/ACM.0000000000001323.
Clinical Practice, Leadership, Administration, & Career Planning, Medical Education, Research, SGIM, Wellness
Dr. Webber (email@example.com) is assistant professor of clinical medicine in the Department of Medicine at Vanderbilt University Medical Center and master clinical teacher at the Vanderbilt University School of Medicine. Dr. Russell (firstname.lastname@example.org) is assistant professor of medical education & administration and director, learning system outcomes at the Vanderbilt University School of Medicine. Dr. Cutrer (email@example.com) is associate professor of pediatrics, critical care medicine, and associate dean for undergraduate medical education at the Vanderbilt University School of Medicine.
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