Transformations in medical education: A prudential perspective

Abstract

A decade ago we asked the question, “Is there something in medicine that is eternal or enduring?” Our aim was to write a manuscript entitled, “That which does not change in medicine.” The publication begins as follows: “The practice of medicine involves continual change, driven by a constant stream of developments in the understanding of biological structure and function relevant to human diseases, and the parallel improvements in pharmacologic and other technological interventions. This change is also driven by evolving social philosophies, ethical trends, and lifestyles.” [1] That preamble reverberates as strongly now as then, perhaps even more so, given the velocity of technological change. When we deliberated on which aspects of medical practice should remain stable, we had few premonitions that implantable chips, robotic surgery, virtual reality, and artificial intelligence (AI) would soon become ubiquitous. The needle has clearly moved, propelled by extraordinary advances in bioengineering, computer and data sciences; major shifts in the governance and organization of clinical practice; and powerful sociocultural trends. As we explore current transformative developments we are reminded of our earlier conclusions: that certain dimensions of medical practice are, indeed, immutable. Most importantly, the relationship between physician and patient depends on moral obligations, characterized by a compassionate response best described as clinical engagement [2]. The requisite virtues are affective as much as cognitive. The challenge for educators, physicians, and policymakers is to accommodate the benefits of transformational change, both technological and conceptual, whilst remaining true to the fundamental, dyadic clinical relationship. Thus, pedagogic change should welcome innovations but do so with restraint that is, with an attitudinal disposition that is neither cynical nor inhibitory but rather alert and mindful, especially when faced with announcements that a given innovation will solve the problems of an overburdened hospital system. By insisting on a cautious approach we may avoid the pendulum that swings too far, resulting in unintended consequences and costly backtracking to undo the damage of untrammeled enthusiasms. We consider two illustrative innovations germane to healthcare delivery: one in medical education and one in technology. We try to anticipate and understand impacts and conclude by posing a set of questions that may be useful to those who manage systemic changes. An innovation, unfolding in medical schools world-wide and often regarded as “transformative,” is competency-based medical education (CBME). We analyze this trend, relying on a hierarchy of knowledge as a frame of reference. The historian Jill Lepore, using the metaphor of a filing cabinet with four drawers, proposed a categorization of knowledge [3]. Each drawer contains knowledge of a different kind. The top one is for “mysteries”; the second one is for “facts”; the third is for “numbers”; and the lowest is for “data”. With respect to their epistemologies, she suggests that mysteries are accessible by revelation (thus, discernable by “God”); facts are derived by way of experimental scientific methods or observations (i.e., the product of the natural sciences and the humanities); numbers are entities that can be counted (e.g., measured by statisticians and epidemiologists); and, data are generated by computers (i.e., the product of data science). Each of these categories is potentially valuable to medical practice. CBME lives, metaphorically speaking, in Lepore's third drawer. Its ontology is reductionist; it views professional development as the accumulation of small quanta of knowledge, accompanied by the accretion of discrete psychomotor skills, which are then presented as stepwise progress in personal abilities. Its epistemology, given the tenacity with which it defines educational outcomes in behaviorally measurable ways, is aligned wit