• The Future of Medical and Neurosurgical Education: Three Drivers, One Revolution

    • Jun 26, 2019

    Author: Gustaf Axelsson, MD, MPhil, MMSc'

    "The brain is the organ of destiny. It holds within its humming mechanism secrets that will determine the future of the human race." - Wilder Penfield, MD

    This line, uttered by American-Canadian neurosurgeon, Wilder Penfield, describes how something seemingly personal and context- specific, an individual's brain, acts to achieve a greater impact than on the mere personal level of the individual.1 Similarly, medical and neurosurgical education may be considered isolated entities of the institution, where individual fate can be determined in a specific context, yet little achieved on a wider scale. However, the trajectory and purpose of medical education are changing along with the healthcare landscape at large, driven by societal, economic and ethical challenges, and leveraged by technological innovation.2 Technology is playing a large part in bringing education closer to clinical care; through simulation, the 'flipped classroom', video-based education, clinical outcome measures of education, or through collaboration with clinical colleagues at the educational level. Curricula are increasingly driven by need rather than tradition, and competence in the clinical environment rather than textbook knowledge is becoming a marker of educational outcome.

    Neuroscience is changing the way we teach, and pedagogy is migrating into the biological neurocognitive world, away from the world of anecdote and tradition. The Sponsoring Institution 2025 project was commissioned by the ACGME's Board of Directors and identified three major drivers that unite healthcare and medical education. These drivers include democratization, commoditization, and corporatization. These concepts reinforce some of the structural changes occurring where technological innovation is driving education away from the classroom setting and into virtual learning environments. Simpson and colleagues described the competent clinicians of the future as 'superb communicators, fluent with digital data and technology, agile and innovation-driven, and capable as leaders and members of inter-professional teams'.3 The role of educators goes beyond teaching learners the content knowledge of our specialty, to also preparing them in a multidimensional manner to deliver effective clinical outcomes. So, what is the future?

    The growing involvement of neuroscience

    The neuroscience of learning informs the way we can utilize what we know regarding how the brain reacts to information, how humans learn, and how this learning is best retained and applied in a clinical setting to develop the most effective educational methods. This view has been popularized by books, such as 'Make It Stick'4, and the scientifically based educational context found therein-such as interleaving, retrieval practice, spacing, and the testing effect-are the foundation of many of the new curricula within medical schools and postgraduate clinical training. The actual evidence for how we learn will thus inform the education we provide, just as evidence-based and value-based care are changing the clinical realm.

    Increasing role of educational technologies in curricula and assessment

    Technology is having a significant impact on all aspects of life within and beyond healthcare. It is no surprise that technology will also help shape the future of medical education, both in the delivery and assessment of education. Some of these new delivery methods have already gained considerable traction, including the 'flipped classroom' approach enabled by video-based education, augmented reality (AR) or virtual reality (VR) that enable immersion into a complex clinical environment from an early stage, and adaptive learning and AI-enabled testing software powered by the principles of the neuroscience of learning. The flipped classroom is based on the idea that asynchronous learning through video-based content and self-assessment, complemented by focused classroom problem-solving settings, will improve learning outcomes and better prepare learners for the environment at the clinical frontline.

    Similarly, AR/VR will also influence medical education with particular promise in the surgical and neurosurgical space.5 Several innovative companies have developed approaches to simulate the operating room, surgical planning, and surgical decision-making. These simulations allow learners to learn with a level of contextual fidelity never seen before and practice rare clinical events with infinite variations. In addition, online learning platforms use adaptive learning algorithms that harness the principles of neuroscience that allow us to learn more effectively.6

    Data analytics and Learning Outcomes closer to the real-life clinical realm

    With the advent on new learning technologies, and the drive towards competency and evidence-based education, the future of medical education will benefit from and be challenged by vast amounts of qualitative and quantitative performance data with regards to educational outcomes. This wealth of data will impact both the individual's learning process, as well as the institutional delivery and assessment of curricula. On an institutional level, medical schools and residency programs will have access to a vast amount of longitudinal data on their trainees' performance, radically changing the processes for assessing trainees in the workplace, and for carrying out remediation.3 The rise of the field of 'learning analytics' will help faculty, program directors, and competency committees to interpret all this data, enabling continuous modification of curricula and teaching to fit the needs of the learners.3

    The Future: Better Medical Education for Everyone, Everywhere?

    The future of medical education is promising and challenging. The onus on educators is not only to provide education, but to do so in an effective, engaging way, driven by neuroscience, evidence, and clinical outcomes. The democratization and commoditization of education has meant that learners can 'shop around' for the best education, and increased competition means that institutions have to differentiate themselves vis-a-vis other institutions and private corporations that have successfully entered medical education, or collaborate more effectively. The technological development has enabled more effective educational methods and assessment mechanisms, and also made high-quality, peer- review, and scientifically sound medical education available anytime, anywhere. Whereas many topics could once be taught only within the walls of the institutional bastions of academia and healthcare, learners can now engage in education through online learning, video platforms and learning communities, all independent of geography.

    Medical education research has not traditionally been considered a priority topic in neurosurgery; however, the field holds unique promise to demonstrate how a challenging clinical environment can benefit and act in synergy with the most effective education, rather than hinder it. Worryingly, the literature is clear that the basics of neurosurgery are currently under-delivered in virtually all medicals schools in the United States, with 59% of medical school deans not considering neurosurgical knowledge as 'essential'.7 This is one of many areas of medical education, where neurosurgery can truly lead the way into the future of medical education, by embracing some of the changes discussed in this article-neuroscience-grounded, needs-based medical education, driven and shaped by real-life data and evidence.7 Neurosurgery has a role in leading the charge into the future by embracing these changes and challenges, and just like in Wilder Penfield's notion of the human brain, be part of the future destiny.

    References

    1. Penfield, Wilder (1963). The Second Career
    2. Maniate, JM (2017). Trends and Opportunities in Medical Education. Aligning to Societal Needs and Expectations. 5(2)
    3. Simpson, D., Marcdante, K., Souza, KH., Anderson, A., Holmboe, E (2018). Job Roles of the 2025 Medical Educator. Journal of Graduate Medical Education, June 2018.
    4. Brown, P. C., Roediger, H. L., III., & McDaniel, M. A. (2014). Make it stick: The science of successful learning. Cambridge, Massachusetts: The Belknap Press of Harvard University Press.
    5. Seymour, NE., Gallagher, AG., Roman, SA., O’Brien, MK., Bansal, VK., Andersen, DK., Satava., RM (2002). Virtual Reality Training Improves Operating Room Performance: Results of a Randomized, Double-Blinded Study. Annals of Surgery. 236(4)
    6. NEJM Knowledge+ ® (2018). https://knowledgeplus.nejm.org
    7. Fox B et al (2011). Neurosurgical rotations or clerkships in US medical schools. Journal of Neurosurgery: 114(1): 27-33. Retrieved online from http://thejns.org/doi/abs/10.3171/2010.5.JNS10245

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