Medical Education and Technology: Intertwined like the Rod of Asclepius

Some of the earliest known roots of medical education stem from ancient Egypt, presaging the Greek and subsequent European medical traditions. Ancient texts mainly provided documentation of a finding, treatment, and/or a theory, without actual scientific proof, as the methodologies we now take for granted did not yet exist. This led to the establishment of a belief system, more so than one based on fact. However, these written texts did allow for the transfer of information, some of which is still useful today, such as the four cardinal signs of local inflammation: rubor, calor, tumor, and dolor, thought to have first been written by Celsus (c. 25 BCE – 50 CE). These texts were clearly limited in the degree to which they could transfer information, as not many people could access them, and the scope was often very narrow.

Medical Education Revolution

The modern approach to medical education started gaining popularity in 1910 following the publication of The Flexner Report. The ideals defined in this report reflected the German model of medical education which had been implemented many years earlier at Hopkins by founding dean William Welch. Prior to The Flexner Report, medical schools were unregulated, with poor quality control. Following publication, the report ultimately led to one-third of US medical schools closing and a medical education revolution. A relevant example is the “New Pathway” of Harvard Medical School (HMS) that was adopted in 1985. This followed “Flexner’s model,” which included two years of basic science followed by two years of clinical apprenticeship. More recently, an evolution has started to occur, as there is debate on the degree to focus on basic science versus clinical experience. Programs have looked for ways to improve their educational curriculum, including HMS, and have continued to adapt to meet changing expectations. HMS continues to innovate, recently with the Pathways Curriculum, where they moved the core clinical experience to the second year and incorporated clinical and science experience throughout the third and fourth year.

The extensive biomedical science foundation nurtured in undergraduate medical education better allows physicians to understand the pathobiology of disease and mechanisms of homeostasis. By developing a full understanding of disease and developing scientific analysis skills, we engender the ability to innovate medical technology. We run the risk of eroding this position if new curricula focus too much on expediting graduation or simply gaining clinical skills for entrance into the workforce, while neglecting the natural process of learning.

Medical school clinical experience traditionally has limited dermatology education and exposure. In one survey study of 65 dermatology residency programs and 10 medical schools without dermatology residency programs, half of the responding institutions required 10 or fewer hours of dermatology instruction, eight percent require no dermatology instruction; only 10 percent of schools required a clinical dermatology rotation at all. A survey of medical students performed in 2014 showed that many students (87.6 percent) felt that they received inadequate training in dermatology with an average score on a dermatology knowledge quiz well below what is considered proficient. For the dermatologist, an additional four years of training, one year internship and three years specialty, must be accomplished prior to board certification, but primary care physicians and other healthcare providers caring for patients with dermatologic diseases do not always receive adequate dermatology training.

Using Tech to Teach

Direct patient care is currently the backbone of medical education, however many pitfalls exist when dealing with real patients. Trainees may be less willing to ask questions for fear of losing the respect of their peers and may be uncomfortable doing a procedure initially for fear of causing harm or failing. Interaction with a teacher/trainer helps to engage and challenge the learner, typically through cooperative argumentative dialogue, often referred to as the Socratic method, where medical decision making can be encouraged. During these interactions, students are introduced to and can learn to deal with medical uncertainty. Given the complexity of the health care system, patient variability, disease heterogeneity, and inconsistent practice patterns, the inability to predict patient outcomes with certainty is an unfortunate reality of medicine.

Technology has been proven a valid learning tool and must be considered an important ally in supplementing traditional training techniques. By reviewing studies that measure IQ, personality traits, attitudes, reading preferences, and expectations, Twenge has developed some potential ways to better engage modern learners. Students of today seem to prefer instruction delivered in shorter segments, perhaps with more material presented through media such as videos, and they may need a more structured, interactive learning format. Importantly, teachers who provide specific instructions, frequent feedback, and connect the information to what is relevant may see improved student engagement. Goals should also be considered, since the methods used to introduce new therapies, practice emerging techniques, try the latest medical devices, or gain exposure to realistic and challenging cases will likely vary widely. By using electronic technology it may be possible to move beyond the Socratic and into a new era. Notably, McCleskey et al. found that only about 50 percent of responding programs indicated they used computer resources at all, which included websites and/or computer programs, suggesting that we are still in the early days of what could be the next medical education revolution.

Digital Health Education

Digital health education (DHE) or eLearning is an educational approach that incorporates digital technology to deliver or improve learning outcomes. Many different modalities exist, offering flexibility, portability, and cost-effectiveness. Videos and the internet have certainly pushed things forward with education, yet limitations are still present. Xu et al. recently performed a systematic review of studies measuring the effectiveness of health professions’ digital education in dermatology to improve knowledge, skills, attitudes, and satisfaction. They included a total of 12 studies, all of which were randomized controlled trials. The DHE included offline computer-based tutorials, online computer-based tutorials, and computer-based learning-software. The effectiveness of DHE in dermatology is mixed, but overall they determined the findings to be inconclusive, mainly due to predominantly very low quality evidence.

Simulation Technology

Video technology has allowed education to become more visual and thus caters to visual learners. Simulation allows one to experience an event, making it potentially more powerful than simple video-based learning. Simulation is defined as a method or technique to produce an experience without going through the real event. So et al. reviewed simulation programs, discussing how simulation extends beyond technology and should also incorporate engagement of learners in the experience, effective feedback, and debriefing. Simulation is a great way to supplement training as it enables control over the sequence of tasks offered, provides opportunities for support and guidance, prevents unsafe and dangerous situations, and even makes it possible to create training scenarios of uncommonly encountered clinical cases.

Choi et al. discuss the importance of engagement in simulation and how our evolutionary-based responses that allow for survival are as important in the creation of simulations as the actual medical information the learner is to understand. Many trainers have been created that are designed to engage the learner. Some trainers are designed to force the occurrence of errors, so that recovery techniques can be trained and error management processes evaluated. Simulation programs can be housed in many different settings and can be announced or unannounced in situ simulations. However, simulation programs are limited by expense and availability and still have many obstacles to overcome for future development.

The New Way: Games in Medical Education

Provocatively, it has been shown that video game skills correlate with laparoscopic surgical skills. Therefore, playing video games and developing skill may help diminish the technical barriers between surgeons and screen-mediated applications. Additionally, video games may be a practical teaching tool to help train health care providers. Currently, there are many gaming resources available for use in medical education that provide gamified training platforms incorporating electronic education games, mobile applications, and virtual patient simulations.

Gamification has been shown to support potential educational advantages including increased engagement, enhanced collaboration, clinical decision making, and learning analytics with swift feedback. A serious game is an interactive electronic application designed to help the user develop skills, knowledge, or attitudes that are transferable to the real world. Serious games have gained popularity as an educational tool providing a challenging simulated environment for training both technical and non-technical skills, however these games need additional validation before being integrated into teaching curriculum. While a serious game should be fun to play and entertaining, these are not the primary objectives. Key elements that should be built into serious games include a challenging goal, engaging environment, and a scoring system.

Akl et al. performed a Cochrane Systematic Review investigating educational games for teaching health professionals’ performance, knowledge, skills, attitude, and satisfaction as well as on patient outcomes; they could neither confirm nor refute the utility of games as a teaching strategy for health professionals. More recent reviews continue to find studies that show encouraging results for training purposes, yet are unable to fully recommend serious games for educational curricula due to the relatively low quality of evidence.

Medical video games have the capacity to allow physicians to practice difficult cases multiple times, providing repetition of common and uncommon cases on-demand and can train clinicians to perform as elite athletes train, with repetition. This could facilitate experimentation through use of virtual time, allow the user to see the impact of different actions on outcomes, and observe the future without the wait and risk. If mistakes are made, the student has the option of simply pressing the reset button. Surgical video games could be used to increase awareness of techniques and complications prior to working on an actual patient by practicing and perfecting a technique through full immersion, working on challenging and collaborative cases, and through trying out different methods. These students could learn from mistakes without harming patients in an environment where mistakes are allowed and their ability to recover from errors tested—something generally not allowed in a direct patient care environment. Such games have the potential to increase personal satisfaction and confidence during live procedures.

From a less procedural aspect, complex medical issues can also be explored in this way. Moving beyond a simple lecture format, question and answer session, or video, a game environment can allow for many combinations of issues to be addressed from multiple angles. Scenarios that are rare but important can be presented in proper context, something impossible in a standard textbook or passive educational material.

Serious Games, Gamification, and Deliberate Practice

Throughout medical school and post-graduate training, many physicians are not educated on how to train or coach less experienced providers, yet if employed at an academic institution, they are expected to have this skill set developed. Unfortunately, this leaves many trainees to learn by merely observing and absorbing all they can in an effort to master the material. However, it is well-established that the acquisition of expert performance relies on deliberate practice, as well as having processes in place for monitoring and guiding further improvement. K. Anders Ericsson summarized the research on expert performance as it pertains to medical expertise and building superior performers, stating that the goal should be excellence rather than simply competence. This can be achieved through repetition and refinement of goal-directed, individualized training regimens that provide immediate feedback, i.e. deliberate practice. While innate talent is one factor commonly thought to lead to top performers, it has been shown in many domains that the willingness to engage in sustained training is often what separates elite performers from the rest.

In medicine, progression toward expertise often comes slowly, as practice sessions and the objectives needing to be achieved are not uniformly provided. While longitudinal coaching relationships could help maximize progress towards our goal, it is often difficult due to people routinely changing institutions for medical school, residency, fellowship, and eventual employment. If we are genuinely committed to maximizing the next generation of expert clinicians’ potential, we may need to look elsewhere for this coaching.

Gamification harnesses the addictive power of games toward this end. When well-designed, they can actually encourage such practice by harnessing the same techniques used by addictive games in general. The same impulses that draw millions to sink hours into video games could be applied to improving medical skills and knowledge. Deployment of well-designed serious games in medicine could lead to more people becoming addicted to learning, developing new skills, and nurturing of elite performers.

In a randomized trial investigating educational video game use on behavioral outcomes in adolescents and young adults with cancer, improved treatment adherence and knowledge was achieved. Additionally, gamification has been incorporated in platforms that help educate people on skin cancer awareness. One such platform has been shown to be an effective method for improving melanoma recognition. Importantly, patients preferred this educational technique over written materials. When people enjoy the experience, they are more likely to recommend it to others and engage in additional play.

When employing gamification techniques, being able to measure outcomes allows for optimization of each game to build a better learning experience that has lasting impact. Duolingo is a learning platform that employs gamification to help teach language. Language learning is a serious environment, and game elements are used to increase motivation and engagement of learners, and not simply used to make a course entertaining. Huynh et al. analyzed the attractiveness of game elements by calculating game refinement values and the effects when combined with a language course’s structure. They compared Duolingo to other sophisticated games like sports and boardgames and found that the game components of this language course only increased the motivation for advanced users or those learning with a purpose as novice users or nonnative-language learners, give up their study easily. The study emphasized the importance of having methods in place to assess gamification techniques, so that the platform can be adapted to best promote engagement, motivation and ultimately learning.

Vesselinov and Grego performed an eight-week effectiveness study of Duolingo, where they took a random representative sample from Duolingo users (N = 88) who studied Spanish. The effectiveness measure factored in the effect or improvement in language skills in relation to the effort put forth or study time. They found that students’ standardized test results improved at a mean rate of 8.1 points for each hour of study. Ultimately, having the ability to track study habits or game engagement and calculate efficiency can lead to better game design and learning.

Non-virtual Needs

Most people find games fun, that is until one starts to lose the game or does not compare well to others playing. Gamification of labor and human resource management has created serious moral debates. This is concerning, since games should be used to motivate and improve productivity, not quash the spirit of those that play.

The training environment and the individuals who need to be trained are constantly changing. According to an analysis of the 2014 Medicare Physician and Other Supplier Public Use File, nonphysician clinicians (NPCs)—physician assistants and nurse practitioners—perform a variety of dermatologic procedures to Medicare beneficiaries and bill for them independently. According to an analysis of the American Academy of Dermatology’s 2007 practice profile survey, the use of NPCs has increased 43 percent since 2002.Additionally, with the rapid pace of medical technology advancement there is increasing demand for Continuing Medical Education (CME) and Maintenance of Certification (MOC). Maintaining knowledge and competency should be viewed as a professional responsibility, as well as staying current with new technology, however the methods to achieve this is furiously debated. When looking at novel educational approaches for medical students, residents, NPCs, and/or CME/MOC, it is important to clearly define the metrics that will be used for evaluation and demonstration of proficiency. Therefore, measuring outcomes when implementing new technology remains very important and gives us the ability to adapt the training to the students’ learning style and goals while reducing the risk of missing an educational opportunity.

A Continued Evolution

Medical education continues to evolve, and technology often drives the transformation, however, environmental factors can expedite this change. Some medical schools have suggested that all preclinical classes should be available exclusively online by 2025, and as we rapidly adapt to the COVID-19 pandemic, the post-COVID era may continue to encourage physical distancing. It may be time to toll the death knell for in-person lectures and fully embrace the advantages a virtual learning environment offers. While recorded lectures may be more convenient—and at times safer—for students, we should ask ourselves if we can do better than simply recording a professor lecturing. Novel educational pathways that include video game technology in the training curriculum could allow for deliberate practice, providing experiential learning in a risk-free environment. If serious games are to be included, they should incorporate the strengths of simulation programs, the enjoyment of playing games and the ability to measure outcomes and adapt training style in real time. Serious games and gamification could prove to provide a more enjoyable and effective way to learn through deliberate practice. Through high quality research studies that follow reporting guidelines, we will be able to better assess how to implement serious games and other technology into our medical education curricula.

FOR FURTHER READING:

Adamson, Adewole S., Elizabeth A. Suarez, Philip McDaniel, Paul A. Leiphart, Alana Zeitany, and Joslyn S. Kirby. 2018. “Geographic Distribution of Nonphysician Clinicians Who Independently Billed Medicare for Common Dermatologic Services in 2014.”

Akl, Elie A., Victor F. Kairouz, Kay M. Sackett, William S. Erdley, Reem A. Mustafa, Michelle Fiander, Carolynne Gabriel, and Holger Schünemann. 2013. “Educational Games for Health Professionals.”

Buja, L. Maximilian. 2019. “Medical Education Today: All That Glitters Is Not Gold.”

Cheng, Adam, David Kessler, Ralph Mackinnon, Todd P. Chang, Vinay M. Nadkarni, Elizabeth A. Hunt, Jordan Duval-Arnould, et al. 2016. “Reporting Guidelines for Health Care Simulation Research: Extensions to the CONSORT and STROBE Statements.”

Choi, Wayne, Ollivier Dyens, Teresa Chan, Mariles Schijven, Susanne Lajoie, Mary E. Mancini, Parvati Dev, et al. 2017. “Engagement and Learning in Simulation: Recommendations of the Simnovate Engaged Learning Domain Group.”

Dienstag, Jules L. 2011. “Evolution of the New Pathway Curriculum at Harvard Medical School: The New Integrated Curriculum.”

Duffy, Thomas P. 2011. “The Flexner Report--100 Years Later.”

Ericsson, K. A., and A. C. Lehmann. 1996. “Expert and Exceptional Performance: Evidence of Maximal Adaptation to Task Constraints.”

Ericsson, K. Anders. 2015. “Acquisition and Maintenance of Medical Expertise: A Perspective from the Expert-Performance Approach with Deliberate Practice.”

Ericsson, K. Anders, K. Anders Ericsson, Ralf T. Krampe, and Clemens Tesch-Römer. 1993. “The Role of Deliberate Practice in the Acquisition of Expert Performance.”

Finnerty, Edward P., Sheila Chauvin, Giulia Bonaminio, Mark Andrews, Robert G. Carroll, and Louis N. Pangaro. 2010. “Flexner Revisited: The Role and Value of the Basic Sciences in Medical Education.”

Gentry, Sarah Victoria, Andrea Gauthier, Beatrice L’Estrade Ehrstrom, David Wortley, Anneliese Lilienthal, Lorainne Tudor Car, Shoko Dauwels-Okutsu, et al. 2019. “Serious Gaming and Gamification Education in Health Professions: Systematic Review.”

Gorbanev, Iouri, Sandra Agudelo-Londoño, Rafael A. González, Ariel Cortes, Alexandra Pomares, Vivian Delgadillo, Francisco J. Yepes, and Óscar Muñoz. 2018. “A Systematic Review of Serious Games in Medical Education: Quality of Evidence and Pedagogical Strategy.”

Graafland, M., J. M. Schraagen, and M. P. Schijven. 2012. “Systematic Review of Serious Games for Medical Education and Surgical Skills Training.”

Hartmann, Anke. 2016. “Back to the Roots - Dermatology in Ancient Egyptian Medicine.”

Huynh, Duy, Long Zuo, and Hiroyuki Iida. 2016. “Analyzing Gamification of ‘Duolingo’ with Focus on Its Course Structure.” In

Kato, Pamela M., Steve W. Cole, Andrew S. Bradlyn, and Brad H. Pollock. 2008. “A Video Game Improves Behavioral Outcomes in Adolescents and Young Adults with Cancer: A Randomized Trial.”

Kim, Tae Wan. 2018. “Gamification of Labor and the Charge of Exploitation.”

Law, Katherine E., Eran C. Gwillim, Rebecca D. Ray, Anne-Lise D. D’Angelo, Elaine R. Cohen, Rebekah M. Fiers, Drew N. Rutherford, and Carla M. Pugh. 2016. “Error Tolerance: An Evaluation of Residents’ Repeated Motor Coordination Errors.”

McCleskey, Patrick E., Robert T. Gilson, and Richard L. DeVillez. 2009. “Medical Student Core Curriculum in Dermatology Survey.”

McCoy, Lise, Joy H. Lewis, and David Dalton. 2016. “Gamification and Multimedia for Medical Education: A Landscape Review.”

Resneck, Jack S., Jr, and Alexa B. Kimball. 2008. “Who Else Is Providing Care in Dermatology Practices? Trends in the Use of Nonphysician Clinicians.”

Rosser, James C., Jr, Paul J. Lynch, Laurie Cuddihy, Douglas A. Gentile, Jonathan Klonsky, and Ronald Merrell. 2007. “The Impact of Video Games on Training Surgeons in the 21st Century.”

Sakakushev, Boris E., Blagoi I. Marinov, Penka P. Stefanova, Stefan St Kostianev, and Evangelos K. Georgiou. 2017. “Striving for Better Medical Education: The Simulation Approach.”

Santen, Sally A., Robin R. Hemphill, and Martin Pusic. 2019. “The Responsibility of Physicians to Maintain Competency.”

Sharma, Amit, Muneeb Ilyas, Nishita Maganty, Nan Zhang, and Mark R. Pittelkow. 2018. “An Effective Game-Based Learning Intervention for Improving Melanoma Recognition.”

So, Hing Yu, Phoon Ping Chen, George Kwok Chu Wong, and Tony Tung Ning Chan. 2019. “Simulation in Medical Education.”

Sørensen, Jette Led, Doris Østergaard, Vicki LeBlanc, Bent Ottesen, Lars Konge, Peter Dieckmann, and Cees Van der Vleuten. 2017. “Design of Simulation-Based Medical Education and Advantages and Disadvantages of in Situ Simulation versus off-Site Simulation.”

Twenge, Jean M. 2009. “Generational Changes and Their Impact in the Classroom: Teaching Generation Me.”

Ulman, Catherine A., Stephen Bruce Binder, and Nicole J. Borges. 2015. “Assessment of Medical Students’ Proficiency in Dermatology: Are Medical Students Adequately Prepared to Diagnose and Treat Common Dermatologic Conditions in the United States?”

Vesselinov R, Grego J. 2012. “Duolingo Effectiveness Study.”

Walker, Jessica L., Jay N. Nathwani, Hossein Mohamadipanah, Shlomi Laufer, Frank F. Jocewicz, Eran Gwillim, and Carla M. Pugh. 2017. “Residents’ Response to Bleeding during a Simulated Robotic Surgery Task.”

Wray, Charlie M., and Lawrence K. Loo. 2015. “The Diagnosis, Prognosis, and Treatment of Medical Uncertainty.”

Xu, Xiaomeng, Pawel Przemyslaw Posadzki, Grace E. Lee, Josip Car, and Helen Elizabeth Smith. 2019. “Digital Education for Health Professions in the Field of Dermatology: A Systematic Review by Digital Health Education Collaboration.”