Digitizing and Democratizing Undergraduate Medical Education

Introduction to Modernizing Medical Education

Medical students are professionals. If you consider their path from high school to white coat ceremony, one certainty emerges: they know how they learn best. Large or small classrooms, seminars, theses or navigating technical curricula, our medical students have shown resilience and pluck to get accepted in an academically competitive arena. In this post, I hope to explore a few ways—some small, and some large—that medical schools should return the favor to our students for their hard work and do some of our own adapting in turn.

Challenges in Traditional Preclinical Medical Education

Undergraduate medical education (UME) must promote the deepest understanding of the subject matter by the largest number of students. Any other equation implies that we have lost our way and their tuition squandered. But teaching for preclinical years, classically the first two years of medical school, has remained largely unchanged for decades. Hour long lectures (especially serially) has been answered with a grass-roots decision to skip class altogether.

Students protest with their feet, testimony that many motivated learners just don’t learn best in this setting.

The lecturer, in turn, resents their wasted time and lack of interaction with a sparse audience. (Frankly, this practice has not changed much since I was a preclinical student at AECOM in 1984-1986, when many students used a “note-service” to side-step lectures.) 

Why then do well-intentioned educators continue to ignore the quiet screams of our savvy, motivated and high-paying sophisticated audience? Regardless of the reason, recent trends in the delivery and consumption of preclinical material present some paths forward. 

Study Insights: Shifting Paradigms in Medical Education

Most preclinical material has been captured and is available digitally. Many medical schools record the lectures and still others offer live-stream. Supplementary resources—including Sketchy, among several others—are easily available to reinforce or teach the same lessons, complete with questions and explanations to solidify the learning. The term “parallel curriculum” refers to this growing resource of instruction.

Let’s take a hard look at preclinical teaching in our medical schools, or rather, look at a recent study published in The American Journal of Medicine by a group at Johns Hopkins this past February (v.137, (2), p.178).

This group conducted a survey of all curricular Deans in our 155 allopathic US medical schools and received a 42% return rate. As the study was done between November of 2021 and January of 2022, the COVID pandemic had an obvious powerful effect and promoted fresh thinking about digital delivery of material.

81% (53/65) of respondents indicated that pre-pandemic lectures were both in-person and recorded and subsequently uploaded with optional attendance. Post pandemic, 81% of these (43/53) plan to continue this practice. A few were planning on adding live-stream and 3 schools, (6%) were going to a fully online curriculum. A handful still insist on mandatory attendance to lecture with no digital recordings for (re)viewing subsequently. This latter group, it seems to me, is clinging to an outdated method of teaching protested by our medical students.

Mandatory attendance without recording for the opportunity for self-learning serves few and represents bygone models of instruction that disrespect students’ autonomy and self-determination.

The Case for a Universal Preclinical Curriculum

With so much material now on the digital record, more interesting still is the option for a universal preclinical lecture curriculum. The authors inquired about this possibility, and 54% of the medical school Deans indicated definitely or possibly a future option. Verbatim comments include, “Standardized lectures could allow for faculty to focus on active learning”, and “frees up faculty from lecturing to a handful of people and gives time to develop more interactive sessions.” And, perhaps more reflective of faculty resentment, “These online resources provide the opportunity to stop wasting faculty time preparing lectures and focus more time on experiential learning,” and “Our students already pretty much do this, and we need to get on board.” Thought provoking ideas of changing the duration of preclinical instruction in the “classroom” naturally emerge, and indeed there has been an increasing trend towards rethinking the 2+2 years for pre/clinical training, with many schools considering truncating preclinical studies to 1.5 years or even shorter.

The decision by The USMLE to adopt a pass-fail system for Step 1 exam underscores the notion of “competency” rather than mastery of this body of knowledge.

7 Key Changes to Make to Todays Preclinical Curriculum

With “better late than never” hopes, I would advocate UME educators to deliberate the merit of the following seven changes:

1. A universally agreed upon minimal curriculum for the preclinical years. There will always be room for local contribution, as patients from northern Maine may have needs that are very different from those living in South Dakota or Texas. However, a group re-think of subject matter is in order.
   
   
2. Establishment of a bank of continually updated all-star lectures. This could be orchestrated by all 155 medical schools submitting student-voted best lectures with input from the curricular Dean. A Herculean amount of work initially, the upkeep would be a small fraction on an annual basis as material evolves. I foresee this as best-served by a group of teaching faculty with input from residents and medical students. These lectures would be available online to all students, nationally or even internationally. I am aware this may change medical school as we know it. But the need for world-wide education would open the field of medicine to all corners of the globe. 
   
   
3. It is heretical, but perhaps formal medical school starts after passing Step 1 and is reduced to 2+ years. This would be a major cost reduction, diminish post-graduate debt, and make medical school an option to a greater number of deserving students. Faculty would save hours not repeating the same lectures.  Matriculation would have a different meaning for the first two years.
   
   
4. Use of vetted “parallel curriculum” resources woven into preclinical education. Naturally there is some bias here, as I am an advisor for Sketchy and this article is being published on Sketchy’s website, but there is a reason that students and schools pay for this additional resource, as it boosts learning and focuses on how our students learn best. Students enjoy and benefit in equal measure, and along with other proven and vetted supplementary resources, warrant more formal integration into medical education.
   
   
5. Implement the flipped classroom: if there are 2 years of preclinical matriculation, students should learn the material on their time from the resources above, and come to class for problem sets, clarification, and group learning exercises.
   
   
6. Revise curricula to the needs of modern and future physicians: Obesity is an epidemic with little instructional time devoted to this chronic disease. Nutrition is incompletely taught, and the lay person is often more informed than is their physician. Artificial intelligence is already shaping the practice of medicine without formal teaching or practice in UME or GME. Where are these (and other topics) in medical school curricula? Is there room for an advocacy curriculum or teaching research methodology? Can we teach medical Spanish?
   
   
7. Abandon policies of mandatory attendance to present-day lectures, especially without recorded support. Who or what is served by this antiquated practice? It is unreasonable to teach required material in a method that hinders students’ best chances of learning, especially at such a high cost.
   
   

Conclusion: Advocating for Change in Medical Education

Physicians are conservative professionals, reluctant to change. Students have been turning away from our typical format of instruction and medical schools are slowly reacting. Let’s trust that medical students know how they learn best and keep UME nimble and flexible to best serve our audience and their purpose.

• Paul Bernstein, M.D. Associate Professor, Department of Internal Medicine, Yale School of Medicine

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References:

• Neha Verma, MD, Jennifer C. Yui, MD, MS, Janet D. Record, MD, Nancy A. Hueppchen, MD, MS, Rahki P. Naik, MD, MHS. The Changing Landscape of the Preclinical Medical School Curriculum: Results from a Nationwide Survey of United States Medical School Curriculum Deans. Am J Med. 2023; 137(2): 178