It's Transforming the Nature and Delivery of Medical Education
Cover Story -- January 2002
By Laurie Stoneham
Computerized manikins that look and behave like human bodies. Interactive multimedia magic that brings alive everything from cell biology to patient case studies with a level of three-dimensional insight the printed world simply can't match. Whole new disciplines regarding the interdisciplinary flow of information. Online curricula, complete with syllabi, lecture notes, slides, self-assessment tools, and discussion forums. Fingertip access to knowledge around the world. Videoconferencing that creates classrooms of students located around the state and nation.
This is the stuff of today's medical education. Hands-on, interactive, multidimensional, and interdisciplinary study has replaced furious note taking and the so-called "sage on the stage" approach you probably knew in medical school.
One of the more intriguing examples of how medical schools are using new technology to train physicians of the future can be found at Baylor College of Medicine in Houston. Baylor is piloting the use of a robotic manikin that has the anatomy and physiology of a human body. The computerized "patient" breathes, his eyes blink and his pupils dilate, and he has a heartbeat and blood pressure. The robot is fully programmable to mimic various disease states. If it's in anaphylaxis, for example, wheezing is heard. The vocal chords swell when it is intubated. Peripheral lines enter the body to practice injections.
"It's an amazing advance, very much like a flight simulator that offers students the finest level of actual hands-on learning and skills practice," said Michael Fordis, MD, director of the school's Center for Collaborative and Interactive Technologies and associate dean and director of the Office of Continuing Medical Education.
Technology is spawning new cultures in medical education, as it is in health care as a science and business.
"Most wise men and women are telling us that the next decade in medicine will bring more new knowledge than we've seen in the last century," said David Smith, MD, president of Texas Tech University Health Sciences Center and interim chancellor of Texas Tech University. "There are only certain ways that we'll be able to make sure that it's in the hands of future physicians for the benefit of the patient. It's an exciting time but it's going to require dedication. This is truly a light-speed era, and we're going to have to be able to demand high performance from our systems, and our patients are going to demand it from us."
And like almost everything else in medicine these days, it comes with a large price tag.
Most of the schools in Texas have some level of Internet-based courseware. It typically consists of course management information -- calendars, schedules, assignments and other announcements, and course syllabi -- available through commercial programs such as Blackboard, WebCT, and Prometheus.
At Texas A&M, the medical physiology faculty have developed simulations and online quizzes. They also have an interactive discussion site where students can post questions that are promptly answered by faculty members. In their fourth-year Computers & Medical Information elective, A&M students use interactive patient case simulations and interactive diagnostic-assist software (not all of which is Internet-based).
Last year, as part of a major revision of the second-year curriculum, the Medical Sciences Library and Learning Resources Unit collaborated with A&M faculty to develop EdNet -- a password-protected electronic resource of curriculum materials. From their home computers or on campus, students can get to lecture notes, slides, and information resources.
Texas Tech uses the National Library of Medicine's Visible Human Project, anatomically detailed, three-dimensional representations of the normal male and female human bodies, created from transverse computerized tomography, magnetic resonance imaging, and cryosection images of cadavers. High-quality cameras are also used to produce video-based dissections, which are available on the Internet.
Interactive Web-Based Learning
The University of Texas Southwestern Medical Center at Dallas has the state's most sophisticated and comprehensive online curriculum. About 90 percent of the first two years' courses are available and offer students interactive access to thousands of color slides (2,000 in cell biology alone), detailed charts, original medical illustrations, and downloadable files of syllabi and lecture notes.
Sequential graphs show such things as the tricarboxylic acid cycle and provide pop-up self-assessment questions and answers. The move of a computer mouse over various parts of a slide will highlight more detailed views.
These Web-based materials are also available on a searchable CD-ROM, and a complete printed syllabus also is available for students who need paper copies. A search function for the Web site was scheduled to be fully operational by the end of 2001.
The Web Curriculum Group staff, which includes two medical illustrators, two programmers, and one graphic artist, maintain this site. Hepatologist Jennifer Cuthbert, MD, heads the group, in addition to her duties as professor of internal medicine and associate dean for undergraduate medical education. Dr. Cuthbert says the Web-based curriculum creates "24/7 education, delivering information where you want it, when you want it."
At the University of North Texas Health Science Center in Fort Worth, the bioskills lab offers students an interactive means of studying anatomy. Each dissection station is equipped with a computer that allows students to zero-in on detailed illustrations of the particular cross-sections they're examining.
Texas Tech is developing a virtual three-dimensional surgery suite, equipped with haptics -- instruments that simulate the use of various scopes, scalpels, and other surgical devices.
Several of the labs at Tech use bar code and laser disc technology. Students can run a laser pen across bar codes in their lab manuals and detailed slides appear on a television screen for viewing by small groups.
The Department of Family Medicine at The University of Texas Medical Branch at Galveston (UTMB) has finalized a Web-enabled, multimedia patient case study that allows students to follow the care of a patient with spina bifida. With this open-ended resource, students use the Internet to research various treatment alternatives.
"It's a library at everybody's keyboard, and a rich story unfolds to let them study and discern the value of various Web sources from around the world," said Rodger Marion, PhD, professor and assistant dean for research and educational technology at the UTMB School of Allied Health. The case is the first in a series that will highlight the use of complementary and alternative medicine in the health sciences.
William Weems, PhD, director of academic computing at The University of Texas-Houston Health Science Center, describes other multimedia applications. "You have an anatomical figure, for example. A particular part of the diagram or figure will have links that students click on that take them to what could be text description, a video, or even a model that they can interact with by putting in various parameters to see what certain treatment regimes might do."
Dr. Weems says today's medical education is not so much the model of Socrates walking students through the pillars of knowledge as it is working with Merlin the magician, who can "conjure up something in three dimensions or almost put you in the spot in a much more viable learning environment that brings the subject matter alive. In some cases, the visualizations are even better than being there because you can immediately pull up the lab results, you can pull up what something would look like on the histology slide, you can view how a particular cell might go through various stages of the disease process, and so forth."
Many of the UT health science centers provide some level of distance learning. The University of Texas Health Science Center at San Antonio has its own television studio and produces some 250 hours of programming a week, which it sends to 140 rural and remote sites primarily in South Texas. These programs include grand rounds, courses, discussions, and referrals.
Texas Tech has an elaborate network that links its six campuses and makes "our campus work as one," said Mike Phillips, chief information officer and vice president for information technology. For years, technology has been used so "that students at a distance are not at a disadvantage," Mr. Phillips said. Satellite technology and streaming video are used to distribute educational programs and undergraduate, graduate, and continuing medical education (CME) courses to 250 sites throughout the state, nation, and world. "We try to leverage technology to provide services where services don't exist," Mr. Phillips said.
Increasingly, videoconferencing is being used to gather students together to learn and interact as teams and with instructors. One of the students in the recently formed UT-Houston School of Health Information Sciences lives in Alabama. Another student, who works with astronauts at NASA's Johnson Space Center in Clear Lake, participates in the course while in Antarctica on a training mission.
"This is not videoconferencing as big, expensive displays. We're talking about people sitting at home with their PCs with a $50 camera doing videoconferencing," said Jim Turley, PhD, RN, associate dean for academic affairs at UT-Houston School of Health Information Sciences.
Technology Expands CME
While Web-based CME courses are not new, Baylor College of Medicine has taken novel approaches both to program development and use of technology. It has developed rich multimedia interfaces to deliver CME to physicians. According to Dr. Fordis, one of its objectives is to provide online instruction that will accommodate a variety of learning styles and can also serve as a reference resource. Physicians all over the world access Baylor's library of more than 95 presentations with more than 45 hours of CME credit.
Dr. Fordis explains that Baylor has produced a variety of online instructional resources (including comprehensive databases of PowerPoint slides with talking points and references) that are used by faculty throughout the world to train physicians. Two of the most popular Baylor sites include lipidsonline.org and hypertensiononline.org. In yet a third approach, other sites blend physician education with patient education materials that can be downloaded for use in the clinic.
Three sites addressing issues in childhood cancer provide online guidance and definitions to patients. They simply move the computer mouse to a term that's seen in blue, and an online definition appears in a window below the text or diagram.
Baylor has also developed patient education kiosks that provide answers to common health questions and concerns. Cheryl Hardin, MD, a pediatrician at the Fort Bend Family Health Center, says her patients frequently use the touch screen models to get information in English or Spanish. "We're able to bring cutting edge technology to Fort Bend County. It's like having the health science center right next door," she said.
Scott and White Hospital in Temple is one of only a handful of institutions with software in place that allows bedside access to the electronic version of patients' medical records in a PDA (personal digital assistant) handheld computer format. This includes clinic dictations, radiology reports, pathology reports, labs, and even the ability to graph labs. Physicians are able to access this information either through a wireless network or by automatic download at a docking station.
"For some of us, this is almost a complete replacement of the paper chart," said Raymond Harrison, MD, associate director of medical informatics at The Texas A&M University System Health Science Center, who wrote most of the software for the program. "We are about to begin a project in which we will issue these devices to our residents, since they are the ones tasked with keeping up with daily patient data on the hospital wards."
Health Informatics: A Whole New Discipline
UT-Houston has the nation's only School of Health Information Sciences, offering both master's and doctoral degrees in health informatics, what US News & World Report recently categorized as one of the fastest growing careers in health care. This burgeoning field looks at the way information flows among professionals in the clinical setting.
"It's not just what happens in medicine or just what happens in nursing that's important in the communication of information; it's what happens across the discipline lines and care settings," explained Dr. Turley. "So as we start modeling health care in the future as being an interdisciplinary, team-based undertaking, we're trying to look at how information flows among the various disciplines."
The informatics curriculum is a hands-on curriculum. "We're moving from an educational model that was driven by the instructor in front of the classroom, the sage-on-the-stage approach, to a much more collaborative learning environment in which students and faculty work together to learn the knowledge that's needed to solve problems in the real world," said Dr. Turley.
"The rule of thumb we use is if you can't do it, you don't know it. It's getting the performance and the didactic knowledge together in the educational program. We're creating an Internet-based work environment so that students have course material that's on the Web. They interact with each other using e-mail, videoconference, and chat, and use the technology to work on the problems and projects they're addressing for the course," said Dr. Turley.
Students develop and test multimedia projects. Jack Smith, MD, PhD, associate dean for research with the School for Health Information Sciences at UT-Houston, describes one such project in which a game is used to inform children with diabetes about how diet affects insulin levels. They then enter their personal data onto a computer program to understand and track this information and to provide individualized decision support. This same program is linked back to the clinician who is alerted if problems occur.
One of the greatest advantages of technology-enhanced education is its ability to be individualized and to suit the various student learning styles. Visual learners, for example, are bolstered by seeing and interacting with full-color images. Online access to individual syllabi and reference materials enables students to learn at their own pace and offers a variety of media for reviewing and absorbing information.
"At Southwestern, every medical school class has 200 students. They're all very bright, they're all very hard working, and they're all very dedicated. But they have different learning styles. Technology helps us provide each one of them with an opportunity to learn as well as they can," said UT-Southwestern's Dr. Cuthbert.
"Technology is the vehicle to level the playing field where resources aren't as rich and to allow for individualized paths of learning," said Tech's Mr. Phillips. "It offers more flexibility, a broader scope of content, and a variety of approaches that directly affect students in shaping their future."
Evaluations and Feedback
Knowing that students understand what's being presented is a paramount challenge in medical education. UNT-Fort Worth is using what's described as an "audience response system" to give faculty real-time feedback. Students have a wireless touch-pad device that allows them to demonstrate their understanding of the material that's being covered. It offers faculty members a means of tracking and revising instruction on an ongoing basis to ensure effectiveness.
UNT-Fort Worth also has an electronic database that offers detailed logistical and content information. This information is linked to a second database that analyzes course content items with actual test questions to evaluate student understanding of key concepts. Joel Lanphear, PhD, director of the Department of Biomedical Communication and chair of the Department of Education at UNT-Fort Worth, says these evaluation methods are designed to continually track, monitor, and revise teaching materials and methodologies.
What the Students Are Using
Today's medical students have grown up with computers. In addition to desktop and laptop computers, an increasing number of students rely on PDAs to keep their calendars and schedules. The continually updated eProcates Rx, an electronic drug reference guide that's available only in handheld computer format, is extremely popular with students, as are fingertip versions of the Merck Manual, the Physicians' Desk Reference, and Harrison's Principles of Internal Medicine.
For Anh Trinh, a fourth-year medical student at Texas A&M, online reference materials have been invaluable. She says she relies heavily on the Cochrane Library, which provides detailed evidence-based analysis of research articles. Other tools that offer easy-to-locate answers include PubMed and MD Consult, which provide full-text electronic access to medical textbooks and journals, as well as patient information and news. Ms. Trinh says a recent search into the potential organ damage that hypertension could cause an adolescent took her only minutes instead of hours to complete.
Creating a New Student Culture
As technology is changing the entire culture of how information is exchanged and how people relate within the health care environment, it's having an impact on how students learn and work together. Gone are the days of cutthroat competition in medical school. Cortney Youens, a second-year medical student at Texas Tech, calls it more of a team approach. She says of her class, "It's a big family."
Marc Elieson, a first-year student at Tech, has been working with classmates to distill and compile notes, guides, and useful study tools on a CD-ROM that's being made available to fellow students for $1. Mr. Elieson has also taken it upon himself to create digital image keys of anatomy cross-sections and putting them online.
Information on Demand
"Access to information has changed phenomenally. The emphasis is on teaching students the skills to find information when they need it," said Gale Hannigan, PhD, MLS, MPH, director of informatics for medical education at Texas A&M College of Medicine and Medical Sciences Library. "They don't have to acquire and hang on to physical pieces the way students had to before, when that was all they could go back to. Now they can dip into the world of information through the Internet."
Marc B. Hahn, DO, dean of the Texas College of Osteopathic Medicine at UNT-Fort Worth, calls it "just-in-time learning," borrowing the term from industry to describe how manufacturers eliminate inventory by delivery parts just as they're needed in the manufacturing process. Just-in-time learning, he says, is the strategy of relying upon technology to deliver information as you need it and as you can use it. These techniques will include the use of wireless palm-based devices, Internet resources, and evidence-based treatment protocols.
A Whole New Way of Conducting Business
"The Internet has just completely revolutionized the way our faculty live," said Robert Alpern, MD, UT Southwestern dean. "I now spend at least one-and-a-half hours everyday on the Internet communicating with people -- those used to be all phone calls. We've invested heavily into this type of infrastructure, and it's paid off. As an institution, we're convinced that one should keep searching for new technologies. If you invest in them, they'll keep paying you large rewards," he concluded.
High-Tech, High-Touch Learning
"I think med ed, like all education, really has an opportunity now to take the next quantum leap from the classroom and observational sort of training into not only distance learning and getting information in a new way but also hands-on training before seeing a patient," said Ronald Blanck, DO, UNT-Fort Worth president. "So in the very near future, before someone performs an appendectomy on a patient, he or she may well have done 40 appendectomies in a simulated setting. It's just mind boggling how much we can do with these tools, but they will never replace the person-to-person interaction that's part of a physician's training. So I use the term 'high-tech, high-touch' to describe what I think is really the hallmark of medical education of the future," he concluded.
"The goal is to get students familiar and comfortable with technology to become part of the lifelong learning process," said Dr. Fordis.
The Price Tag for All This
While Web-based courses can be standardized and packaged for repeated use, they are a costly undertaking. Mr. York says it requires three professionals -- the content expert, the technologist, and a specialist in curriculum design. "There's a financial responsibility we need to keep in our crosshairs because developing and delivering these courses is expensive. We need to make sure that we have the audience who can and will use them," he said.
"We initially started with a very small budget and just tried to get everything on the Web," said Dr. Alpern. "Now the budget is large, because we realized that doing it on a shoestring created more frustration than it added value. Now we have a large staff, and we're committed to making the product really good and improving it every year."
"There's a pipeline of technology that we're going to have to deal with," said Dr. David Smith. "How big is that pipeline and how connected is it are key questions. I think we're all going to have to make major, multimillion-dollar investments annually just to keep it up, on top of the initial investments, which will amount to tens of millions of dollars per institution."
All the schools are being deliberate in adapting technology to education. It's too expensive and too easily outdated to invest in without care.
"Technology mustn't drive the curriculum," said Rebecca Kirkland, MD, senior associate dean for medical education at Baylor. "The curriculum needs to determine where technology can add value and complement the curriculum to assist in what you want students to learn and what you want them to do and how you want to teach."
"Technology is certainly center stage in a lot of ways, but it's really about information," said Dr. Hannigan. "We get all caught up in PDAs and that sort of thing, but the technology is only as useful as the information it delivers for better medical decision making."
Re-engineering Health Care Delivery
Advances in technology are going to be the driver behind a whole new culture in health care delivery. Every area will be impacted, from communication systems to reimbursement policies.
"It's not just technology, it's about how we will re-engineer the process of clinical care to take advantage of the technology," Dr. Jack Smith offers.
"We'll begin to understand health care in completely new ways, because as you look at having information available in new ways, you've got a completely different critter," said Dr. Turley.
"With advances in technology, medical errors due to unavailability of patient information, which had been tolerated to a certain degree in the past, will become absolutely unacceptable in the modern clinical environment," said Texas A&M's Dr. Harrison. "The physician of the future needs to realize this and to embrace and be savvy in the use of information systems. Our patients of the future, and indeed many already, will not accept anything less."
Tom Ferguson, MD, senior research fellow with the Pew Internet & American Life Project in Washington, D.C., is an expert in how the Internet is changing the face of health care. "Initially, we assumed that technology would improve the efficiency of what we were doing. The surprise is that it's actually transforming our work, and we're going to practice medicine in very fundamental ways," he said.
So, too, is technology transforming the nature and delivery of medical education.
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