1
INTRODUCTION
In February 2020 when I was asked to submit some thoughts on trends in the future
of health professions education, I had no idea that we were about to experience a
once in a century pandemic that would profoundly change health care and the lives
and education of health professionals in this country. As I write these personal reflections,
we are still in the midst of the COVID‐19 pandemic and cannot yet define what the
“new normal” will be for health care, health professional education or society as
a whole on the other side of the pandemic. Acknowledging this uncertainty, I believe
that the trends I have identified will be more relevant than ever in the post‐COVID
world with some specific caveats.
The six trends that I have identified for the future of health professions education
are:
Interprofessional education in order to better prepare health professionals for future
collaborative practice.
Longitudinal integrated clinical education that is more patient, community, and chronic
disease oriented.
Education in the social determinants of health and the social and humanistic missions
of the health professions.
More emphasis on the continuum of health professions education for the life‐long learning
and long‐term well‐being of health professionals.
A shift to competency‐based, time variable health professions education to better
fulfill our social contract and to produce the most competent practitioners most efficiently.
The integration of artificial intelligence and new educational and information technologies
into the continuum of health professions education and practice.
It is impossible, of course, to touch on all of the educational issues relevant to
every health profession, but I believe I have identified high level trends that will
impact all health professions education.
The observations that follow are based on my personal experiences of four decades
as a faculty member at Harvard Medical School and several of its affiliated hospitals
(Massachusetts General, Brigham and Women's, and West Roxbury Veterans Administration),
two decades as a board member and chair of a graduate school of health professions
education (the MGH Institute of Health Professions) and a decade leading the only
national foundation devoted to improving the nation's health through innovations in
health professions education (the Josiah Macy Jr. Foundation).
As I reflect on my five decades in health professions education my observation is
that for the first four decades the pace of health‐care delivery reform far exceeded
the pace of health professions education reform. The passage of Medicare and Medicaid
in the 1960s, advances in science and technology to improve both diagnosis and treatment
stimulated by rising NIH budgets in the 1960s and 1970s, increases in the costs of
care leading to managed care and mergers and acquisitions in the 1980s and 1990s,
the quality improvement and patient safety movements of the 1990s and beyond, and
the rise in consumerism with more open access to medical information have all contributed
to dramatic changes in the organization and delivery of health care in this country
without a parallel transformation in the education of health professionals. Happily,
I have witnessed in the past decade a significant openness and willingness to change
in health professions education with notable experimentation in both prelicensure
(undergraduate) and postlicensure (graduate) education. These changes are heartening,
but much more needs to be done to keep pace with this rapidly changing health‐care
world and changing societal demographics and expectations.
When I assumed the Presidency of the Macy Foundation in January 2008, I outlined a
vision for educational reform that would better align health professional education
with societal needs and with an evolving health‐care delivery system. I felt that
the health professions education enterprise must not view itself as a closed system
in the ivory tower, but as one closely interconnected with the delivery system in
which its graduates would work and with the society that they would serve. Health
professions education needed to derive its curricular goals from outside rather than
inside, and it in turn must be accountable to society in measuring and fulfilling
those goals. This framework was very similar to that developed by the Lancet Commission
1
2 years later in their work assessing health professions education worldwide. It is
a framework that has been adopted by Canada and some western European countries.
The themes to create this alignment became the funding priorities for the Foundation
for a decade. The trends that I have identified grew out of this work to align health
professions education with societal needs. The trends have been refined and modified
based on experience and continuous monitoring of the external environment. In elucidating
these trends, I am drawing on very personal experiences as a medical educator and
Foundation President.
For each of these six trends I will explain why it is important, provide some examples
(drawn heavily from my Macy Foundation experience), identify some challenges, and
speculate about the future. I will then conclude with some additional comments about
the potential lasting impact of COVID‐19 on health professions education and how the
lessons derived from COVID‐19 relate to these trends.
1.1
Trend number one: Interprofessional education in order to better prepare health professions
for true collaborative practice
The practice of medicine is more and more dependent on teams of professionals caring
for complex patients and patients with multiple chronic conditions. Access to reliable,
high‐quality primary care is also enhanced by a team approach.
2
,
3
There is an increasing body of evidence that care delivered by highly functioning,
collaborative teams leads to better patient outcomes. Yet, until recently, health
professional education has been designed to keep the professions apart until the completion
of the training process. This is in spite of the fact that interprofessional education
(IPE) has been written about in the United States since the 1960s, and a 1972 Institute
of Medicine Report (“Education for the Health Team”)
4
strongly recommended IPE.
There are many reasons why IPE did not gain traction in the United States; among these
are the logistical obstacles, the strong cultures of each of the professions, the
political dominance of physicians who as a group did not embrace IPE, and the lack
of a sense of urgency about changing the design of the health‐care delivery system.
The tide began to turn in the last decade as several institutions demonstrated that
logistical barriers could be overcome, educational leaders in many professions (including
MDs) saw the advantages of IPE, and there developed greater urgency about the need
for health‐care reform that met the “triple aim” of better health outcomes, better
patient experiences, and lower costs. The time was right to assert that the ability
to work in a team is a core competency that should be possessed by all health professionals.
5
I am proud that the Macy Foundation was a leader in this change. In the decade 2008
to 2018 the Macy Foundation supported 44 large grants and 41 small grants with IPE
as the primary or secondary theme. In addition, 24 educational innovation projects
of Macy Faculty Scholars were interprofessional. IPE was the largest investment that
the Macy Foundation made in any of its priority areas. The reasons for the decision
to make the investment were that this seemed to be a propitious time to take advantage
of the alignment of forces favoring IPE, the belief that IPE could have a large positive
impact on improving the health of the public, and the hope that by creating a critical
mass of affirmative work we could make this the norm in health professions education.
By design, all of the large IPE grants included medical schools and nursing schools.
Many included other health professional schools, such as pharmacy, dentistry, public
health, and social work. We reasoned that since nurses and doctors were the most numerous
and visible of the health professionals caring for patients, changing the culture
in those two professions would be models for others.
In reviewing this body of work,
6
we derived five important lessons that informed our subsequent grant giving. 1) Leadership
from the top is essential. Deans, Provosts, Chancellors, and Presidents must embrace
IPE and make it a high priority as expressed by budget and organizational structure
(such as an office of IPE). Only in this way can the inevitable logistical and political
barriers be overcome. 2) Intensive planning with clear educational goals and metrics
must lay the groundwork for all IPE initiatives. IPE experiences must be as rigorous
as all other parts of the formal curriculum. 3) Interprofessional learners must be
engaged through real, meaningful work that advances patient care and their own professional
development. These experiences must be reinforced in a developmentally appropriate
way throughout the entire educational trajectory. 4) Innovative use of educational
technology such as simulation and on‐line, asynchronous learning can help overcome
logistical barriers and complement face to face encounters and real patient experiences.
5) Much attention must be paid to faculty development since most faculty have had
little or no experience working with faculty or learners from other health professions.
One of the other lessons learned is that IPE is at its best when each profession has
the strongest possible educational program—strong uni‐professional education leads
to strong inter‐professional education. This is consistent with the experiences of
those who have studied successful teams—it is the diversity of points of view and
experiences that are brought to bear on the problem that leads to the most successful
outcomes. Health science campuses or universities with multiple health science schools
that have made IPE a high priority have found that it has helped bring about a cultural
change towards greater openness and inclusion that has benefited all faculty and students.
The Health Professions Accreditation Collaborative, which started with Medicine, Nursing,
and Pharmacy and now includes 25 entry level health professions education accrediting
boards, reports that 22 of its 25 members have or are developing an IPE standard.
So now that IPE is being required by nearly all the health professional prelicensure
accrediting bodies (who are also working on a common set of definitions of IPE), can
we declare victory and move on? Hardly. There is still great unevenness in the quality,
robustness, and penetrance of IPE across all our health professional schools nationally.
Free‐standing health professional schools without nursing or medical partners are
particularly challenged. We still have more to learn about which are the most meaningful
IPE experiences and what are the ideal timing and duration. We also need to solve
the challenge of incorporating more IPE in the core clinical experiences of both prelicensure
and postlicensure of health professionals.
Almost all of the formal IPE programs to date involve prelicensure health professionals.
Though there have been many logistical barriers to overcome to reach our current level
of success in prelicensure education, the challenges are even greater in the heterogenous
and complex postlicensure world where education takes place virtually entirely in
the health‐care delivery system and not in health professional schools. But if IPE
is to truly demonstrate a positive impact on the practice of health professionals
and the health outcomes of patients, it must become more a part of these later stages
of professional development (including what we have called “continuing medical education”).
There are some encouraging movements in this direction including a VA primary care
program that has medical residents and nurse practitioners sharing practices, a Macy
funded pilot study of Ob/Gyn residents and midwifery students training together, and
work by the Accreditation Council for Continuing Medical Education (ACCME) to jointly
certify interprofessional continuing education programs in nursing, pharmacy and medicine.
But much more needs to be done in this arena if our patients are to get the maximum
benefit of IPE. This should be an important source of pilot projects and innovations
in the future.
Finally, we need to consider the potential contributions of non‐health professionals
in a broader definition of IPE. Biomedical Sciences, Engineering, Architecture, Law,
Public Policy—to name just a few professions—have important intersections with health
and health‐care delivery. There are only a handful of instances that I am aware of
in which learners from these professions interact with learners from the health professions,
and in each case, it has proven to be beneficial. One can imagine a future real or
virtual university where such IPE experiences are more routine.
IPE is here to stay. I regard the last decade as proof of concept. Now that concept
needs to be refined, broadened, and linked more closely to improved patient outcomes,
1.2
Trend number two: Longitudinal integrated clinical education that is more patient,
community and chronic disease oriented.
Since the Flexner Report in 1910 medical school education in the United States has
been predominately hospital based and scheduled as a series of rotations on hospital
services. As formal graduate medical education (GME) programs for physicians evolved
in the decades following the Flexner Report these followed the hospital‐based models.
Subsequently, Medicare became the predominant funder of GME in the United States with
the payment through the hospital, which reinforced the hospital‐based rotational model.
To varying degrees, other health professions have followed this model of hospital‐based
rotational clinical education and training.
There are many good reasons why the hospital became the principal site of education
in the health professions. The hospital contains the highest concentration of sick
patients and this afforded ready access to “teaching material.” It also brought together
faculty and learners in one place for increased efficiency of combining teaching and
care delivery. As technology and specialization increased, the hospital became even
more important as the sole place to have access to all technologies and all specialties.
While many of these positive attributes of hospitals continue today, it has been increasingly
apparent over the last two decades that there are significant limitations of the hospital
and the rotational system as the sole or even principal pedagogical site and method
for clinical education in the health professions.
First, the patient population in the hospital of academic medical centers today is
less and less representative of the patients that our graduates will care for. Because
of both economic and technologic factors hospitals care for only the sickest and most
complex patients and for a shorter and shorter period of time. Second, the intensity
of care and changes in the schedules of both learners and staff have made it more
difficult to accomplish optimal learning environments and achieve educational goals.
Third, the rotational model of clinical education lessens the opportunity for learners
to appreciate the full impact of illness on patients or to form meaningful relations
with patients, faculty, and staff. This is particularly true as logistical and regulatory
issues have led to shorter and shorter rotations with more frequent turnover of staff.
There is less opportunity for meaningful supervision, assessment, and feedback.
For these reasons, a number of medical schools have piloted and then established a
new model for clinical education based on the principles of continuity: continuity
of care, continuity of curriculum, and continuity of supervision.
7
In the full expression of this model, the specialty‐specific rotational clerkships
are entirely replaced by a year‐long longitudinal experience that integrates the specialties
and emphasizes the care of patients over time with mentoring and supervision by a
constant group of faculty. Many of these experiences employ small group problem‐based
learning which has been more common in the preclinical than clinical curriculum. A
high percentage of the teaching is in the ambulatory setting, but learners also spend
time in the hospital when their patients are hospitalized and for certain planned
specialty experiences. Some schools have developed hybrid models that retain the traditional
specialty clerkships at least in part, and overlay more longitudinal ambulatory and
didactic experiences to achieve some of the continuity goals.
The continuity principles are consistent with what we know about successful experiential
learning.
8
The longitudinal integrated clerkship (LIC) permit both horizontal (across disciplines)
and vertical (basic science to clinical science) integration and allow for a more
planned developmentally appropriate curriculum. Studies comparing LIC students with
traditional clerkship students show comparable knowledge and clinical skills in the
two groups, but LIC students show greater satisfaction, higher confidence, and a strong
sense of patient centeredness.
9
Perhaps because of markers of more successful professional development, they are more
likely to retain the idealism expressed on entry to medical school, which many studies
have shown to erode in the clerkship year.
This model has not been as fully tested for other health professions, but one can
readily see applicability in other frontline clinical health professions such as nursing,
pharmacy, or physician assistant.
In addition to the evidence of improved learner performance and attitudes, there are
a number of other potential benefits to a more widespread adoption of this model for
at least a portion of health professions clinical education. Many of these relate
to the other educational trends discussed in this paper. First, this model creates
opportunities for interprofessional learning and the development of team‐based skills,
which are much harder to accomplish in short rotations in the intense hospital environment.
Second, the appreciation of the impact of an illness on patients over time and the
location of the education in ambulatory settings afford more opportunities to understand
the social determinants of health and to develop true partnerships with patients and
their families. Third, the continuity of the relationship between learner and faculty
affords the opportunity to do much more meaningful assessment and give feedback more
continuously in the developmental process. This is a prerequisite to achieving competency‐based
education. Fourth, the evidence of higher learner satisfaction with the meaningful
work they are able to engage in may be at least a partial antidote to the alarming
rates of burnout reported among learners in the health professions.
10
It is also likely that these experiences better prepare them to be life‐long learners.
Fifth, there is much concern about the added burden learners place on stressed health‐care
delivery sites. Learners in longitudinal experiences can be much more successfully
integrated into the workflow of care organizations. Trust can only be developed with
time, and with trust comes greater opportunity to make meaningful contributions to
the work of the organization in which the learner is embedded.
There are many obstacles to the widespread implementation of the longitudinal integrated
clerkship and these include less infrastructure to support teaching in many ambulatory
settings, economic pressures for productivity, departmentally based culture and deficiencies
in faculty development and incentives for teaching. Pilot programs in a number of
institutions have shown that these obstacles can be overcome on a site‐specific basis.
In fact, when successful, the LIC model is more popular with both faculty and the
host sites. Several new medical schools have been able to institute the LIC model
for the entire class, as they have had the advantage of small class size and no prior
history of traditional clerkships.
The principles of continuity also should be applied to graduate education, but they
will look different than the LIC on the undergraduate or prelicensure level. They
may take the form of differentiation into tracks that are tailored to the career goals
of the graduate learner. The graduate learner would spend larger blocks of time in
specific settings (hospital or ambulatory) that are designed to prepare her for independent
practice. This means she would spend less time repeating rotations for which she has
already demonstrated competence. In this model the final stages of training look more
and more like the beginning of practice, emphasizing the concept of the continuum.
The well‐established primary care tracks in many US Internal Medicine programs are
an example of this model, but I believe these can be made even more robust and differentiated.
In these longer experiences the trainee (about to become practitioner) has the advantage
of continuity with patients, site, staff, and mentors.
There will always be a role for shorter, intensive experiences in the hospital or
some other technology‐rich site for early learners, graduate learners, and life‐long
learners. The ideal educational model will be a blend of experiences designed specifically
for the needs of the learners in a developmentally appropriate way. I believe there
is growing evidence that some part of the core clinical educational experiences of
all prelicensure health professional students should be in a longitudinal experience
that is based on the principles of educational continuity.
1.3
Trend number three: Education in the social determinants of health and the social
and humanistic missions of the health professions
Much of health professions education appropriately focuses on understanding normal
human anatomy and physiology, the pathogenesis of disease, diagnostic and therapeutic
decision making, and communication skills. It is absolutely essential that every health
professional has a keen understanding of the basic and clinical sciences as they pertain
to their practice and keep current in them. All of these together contribute to what
we call health care. But we realize that health is more than health care. In fact,
it has been estimated that all we do in health care contributes about 20% to the health
of the public. Larger contributions to health are what have been called the “social
determinants of health.” The WHO defines social determinants of health as “the conditions
in which people are born, grow, work, live and age, including the health system. These
circumstances are shaped by the distribution of money, power and resources….”
11
Social determinants of health are important not only because they are major contributors
to health, but because they also are the principle cause of health disparities (or
inequities) that we find in our society. WHO defines health inequities as “the unfair
and avoidable differences in health status.” These health inequities have been documented
to be prevalent in the US health‐care system.
If the ultimate goal of health professions education is to improve the health of the
public (which I believe it is), then one would be incomplete as a health professional
without an understanding of the social determinants of health. Therefore, teaching
about the social determinants of health should be a part of the education of all health
professions.
A recent consensus study of the National Academy of Medicine has provided “A Framework
for Education Health Professionals to Address the Social Determinants of Health.”
12
There are several aspects of this framework which are synchronous with the trends
we are discussing in this paper. First, this requires an interprofessional approach
to education in order to gain insights from both the direct care health professions
(nursing, social work, medicine, etc.) as well as public health and many other professions
whose work affects health (architecture, urban planning, law, public policy, clergy
to name but a few). Understanding and influencing the social determinants of health
requires a collaborative approach. Second, a true understanding of the social determinants
of health requires longitudinal and community‐based educational experiences. This
reinforces the need for the kind of experiential learning exemplified by the longitudinal
integrated clerkships. Third, addressing the social determinants of health requires
a commitment to life‐long learning across the whole continuum of the career from the
prelicensure learner to fully independent practice.
There are several consequences that will follow from making this commitment to teaching
and addressing the social determinants of health. It reminds us that the health professions
are at their core humanistic professions, which mean that they place human interests,
values, and dignity at the center of their focus.
13
The health professions are unique among the professions in combining a humanistic
heritage and a scientific heritage. In recent decades the scientific heritage has
received much more attention, and the challenges of today call for a restoration of
the balance. Humanism is elevated not at the expense of science, but to be allied
with science so that they together can improve the health of the public.
Addressing the social determinants of health also forces us to confront the issue
of diversity and inclusion within our professions and institutions. We cannot dismantle
racism, which is one of the most powerful social determinants of health in our society,
if we do not exemplify inclusiveness and equity in our own work and organizations.
Addressing the social determinants of health also reminds us that as health professionals
we have a social contract. Society has given us special privileges, and in return
we are expected to put their interests above our own and use our special knowledge
and standing to improve society. We, therefore, have a responsibility not only to
understand the social determinants of health, but to help address health inequities.
Sometimes we will do this working individually, sometimes through professional organizations,
and sometimes through our institutional policies and practices.
14
Health professionals should learn to be advocates for constructive social change;
it is part of our professional responsibility to fulfill our social contract.
15
Addressing the social determinants of health will better position us to truly partner
with patients, families, and communities in linking better interprofessional education
and collaborative practice with better health for the public. We cannot achieve better
health for the public without these partnerships.
16
Addressing these goals will not be easy and will require some fundamental changes
in our educational processes and the cultures of our institutions. It will require
breaking down the silos between the professions and breaking down the walls that have
separated the professions from the public we serve. It also will mean introducing
new content (social science, humanities, economics) across the continuum of health
professions education, and it will require new models for clinical education and community
engagement. There have been encouraging movements in these directions in the changes
of the last decade. But the pace must accelerate if we are to prepare health professionals
who can understand and address the social determinants of health in order to lessen
the widening health disparities and improve health for all.
1.4
Trend number four: More emphasis on the continuum of health professions education
for the life‐long learning and long‐term well‐being of health professionals
Historically each phase of health professional education has been treated separately
with different administrative structures, different regulatory structures, and even
sometimes different nomenclature. There has been a sense that each phase has the equivalent
of a “final exam” and produces a “finished product.” The education of physicians in
the United States is an example. There is a clear separation between medical school
(undergraduate education) and residency and fellowship (graduate medical education).
Undergraduate education occurs within one of 150+ (the number is growing) medical
schools in the United States, each with its own administrative structure for education,
and nationally it is regulated by the Liaison Committee on Medical Education (LCME)
a partnership of the American Medical Association and the Association of American
Medical Colleges. The medical school graduate (the “finished product”) then enters
into the world of graduate medical education, overseen by over 1,500 hospitals and
academic systems as program sponsors, each with their own unique educational administrative
structures. Regulation is by the independent Accreditation Council of Graduate Medical
Education (ACGME). The “finished products” of this GME system enter practice where
they must comply with state licensure laws and hospital/health systems standards.
All are required to have some degree of continuing medical education which is administered
by a large array of academic institutions, professional associations, delivery systems,
and private entities. This enterprise is regulated by the Accreditation Council of
Continuing Education (ACCME). Other health professions have similar, if not as complicated,
fragmentation of the educational continuum.
The reality is that there is no “final exam,” and there are no “finished” products.
Ideally, the health professional is always learning, always in the state of becoming
(perhaps that is why we call it “practice”). It is necessary and appropriate that
there be milestones and checkpoints along the way to assure the progress of the learner/practitioner
and to fulfill our social contract to assure competency. External regulations notwithstanding,
it is essential that the attitudes and skills required for life‐long, self‐motivated
learning be instilled in all of our learners from the beginning of the educational
trajectory. That is what will ultimately assure competency across the continuum.
An important aspect of this is a much greater attention to the quality of the learning
environments in which learning and work take place across the life span of the health
professional.
17
,
18
Without improved environments for learning (and working) other initiatives for educational
enhancement and improvement will be for naught. There are many elements to these environments:
the personal perspective of the learner, the community in which teaching and learning
occur, the organizational culture and practices that surround that learning, and the
physical and virtual spaces in which it occurs.
19
That environment is often shared by learners and practitioners across the whole spectrum
of health professions education, which is why the continuum should be the conceptual
model.
Another important aspect of the continuum conceptual model and the emphasis on life‐long
learning is that it also facilitates the focus on learner and clinician well‐being.
There has been an alarming rise in the reported rate of burnout among health professional
learners and clinicians, and a recent report of the National Academy of Medicine (“Taking
Actions Against Clinician Burnout”) (reference 10) made many concrete recommendations
on how system changes can help lessen burnout and promote well‐being. Many of those
recommendations deal directly with the learning and working environment. Suboptimal
learning environments (across the continuum) contribute to burnout.
Another consequence of this renewed and enhanced emphasis on the continuum, life‐long
learning and the learning environment is that this conceptual model is more likely
to lead to empowered learners who feel they are doing meaningful work.
20
Understanding that the ultimate goal of all health professions education is improved
health of the patient, the progressive increase in responsibility across the educational
continuum enables learners to find purpose in their work and feel like they are making
contributions. This is likely another antidote to burnout.
While there are some encouraging movements toward this conceptual model of the continuum
of education, this will not be any easy change. Administrative and regulatory structures
are well embedded in our system, and there is a lot of territoriality. Academic institutions
and health‐care delivery systems need to work more closely together to improve both
education and care across the continuum.
21
And regulatory bodies must work to eliminate the barriers to common language and standards
for assessment across the continuum and facilitate smoother and more flexible transitions.
1.5
Trend number five: A shift to competency‐based time‐variable health professions education
to better fulfill our social contract and produce the most competent practitioners
most efficiently
Health professions education has the responsibility to society to produce practitioners
who are competent across broad domains of knowledge, attitudes, and skills. Each profession
is responsible for establishing its competencies and the educational program to achieve
them. All agree that assessment of these competencies is critical in fulfilling our
social contract, but historically that assessment has not been rigorous. “Time in
place” has often been accepted as a proxy for competency assessment. The required
number of months in a given site or discipline and the required number of years in
a given program are taken as assurance of competency. This has led to a fragmented
and rigid time‐based system of education that does not meet the needs of learners
or of the public.
While elements of a competency‐based, time‐variable approach exist within our current
educational system, few programs or institutions have fully embraced this model. Two
major concepts drive this model: (1) There is a comprehensive curricular, instructional,
and assessment strategy based on a framework of observable and assessable competencies
derived from patient and societal needs (2) Time is used as an educational resource
rather than a limitation or a rule with the consequence that learners and teachers
will use time as necessary to achieve the desired competencies.
The connection between the competencies and the needs of society is absolutely central
to the success of this model; “competency‐based education begins with an uncompromising
focus on translating the needs of contemporary society for improved health care into
competencies that must be mastered by health professionals across all disciplines.”
22
This is an ongoing process across the education/practice continuum and it must be
accompanied by robust assessment.
The concept of time as a resource has a liberating effect on both learner and teacher.
Learners are allowed adequate time to achieve educational goals but are not required
to spend time that is not needed to achieve these goals. Teachers are afforded adequate
time for observation, assessment, and coaching to feel comfortable with their judgments.
This could result in some learners achieving competencies and moving on in the continuum
in less time (and some may take more time). In many instances the total time may be
the same, but how that time is used will be different from one learner to another.
Thus, the instructional program becomes more individualized, even more so as the learner
is farther along the educational trajectory.
This model creates an entirely different dynamic between learners and teachers, and
the role of feedback is entirely different than in the traditional model. The learner
becomes much more self‐motivated to achieve the competency in order to move to the
next level and actively seeks feedback. The teacher becomes the helper and enabler.
There are many challenges in making this paradigm shift, and it will require changes
across many domains.
23
Some of those changes are directly within the control of each educational enterprise,
such as curriculum and faculty development reforms. Other changes will involve external
bodies for regulatory changes to permit greater flexibility in accrediting programs
and certifying individuals. There will need to be more research done to develop more
rigorous assessment systems and to evaluate outcomes. Some of the other trends we
are discussing in this paper should facilitate this transformation. This work must
be interprofessional, emphasize continuity and the continuum of education, and will
be facilitated by educational technologies.
Though these changes will be difficult, several programs have demonstrated their feasibility.
(reference 23). The Education in Pediatrics Across the Continuum (EPAC) program has
successfully integrated undergraduate and graduate medical education for pediatrics
in a competency‐based, time‐variable fashion in a pilot program at four US institutions
(University of California, San Francisco; University of Colorado; University of Minnesota;
and University of Utah). Oregon Health and Science University School of Medicine has
implemented a competency‐based, time‐variable curriculum for its entire medical school
class. The University of Wisconsin, Milwaukee has a Flex‐Option Program for RN to
BSN completion that is competency based and time variable. Queens University in Canada
has instituted a competency‐based, time‐variable system for all of its graduate medical
education programs. Canada has now made a commitment that all of the GME programs
nationally will be competency based and time variable. There are many examples of
such programs in Europe and many more pilots underway in the United States.
All of these examples represent “proof of concept” and gives encouragement that both
the internal and external changes that are necessary are possible. As in other areas
of innovation, the early adopters will pave the way for those that follow.
1.6
Trend number six: The integration of artificial intelligence and new educational and
information technologies into the continuum of health professions education and practice
Technology is changing in every aspect of our lives, and the pace of that change is
accelerating. Health professions education has been slow in adopting new technology,
but that pace, too, has now accelerated.
24
There are now many technologies embedded in our educational system that have improved
efficiency and pedagogy and have helped to accomplish other educational goals. Simulation
has provided safe and controllable settings for skill development, learning clinical
reasoning and developing communication and teamwork skills. It also has been a powerful
tool for promoting interprofessional education. Online learning has provided efficient
means for knowledge acquisition so that student/faculty time can be more productively
spent in higher level functions of interpretation, reasoning, and team skills (the
“flipped classroom”). Computerized models have largely replaced cadavers for learning
anatomy, and computerized images have largely replaced microscopes in the classroom.
Asynchronous, interactive learning has helped to resolve some of the logistic problems
with IPE and with distributed models of education and training at multiple sites.
Large databases (sometimes obtained from computerized medical records) are being successfully
used to direct curricular content and to evaluate educational and clinical performance.
All of these changes have helped to improve the education process and also to create
closer links between education and our health‐care deliver system, but these changes
are small compared with those that are likely to follow.
I will consider three separate aspects of this trend: (1) the increased use of technology
as an alternative to traditional education, (2) increased education about technology
and artificial intelligence to produce practitioners who are able to successfully
use and integrate these tools, and (3) an increased focus on how to capture and utilize
time freed by technology to devote to other important functions that cannot be accomplished
by technology.
In the realm of technology as an alternate to traditional education, there are now
a multitude of online degree and certificate programs in the health professions. This
trend will only accelerate as pressures increase to produce more health professionals
at a lower cost. There will be an ongoing challenge for quality control and a continued
need for faculty development and technological support to adjust to this new educational
model. For the clinical disciplines there will always be a need for some real, nonvirtual
experiences. More research will be needed to understand the optimal dose and timing
of face to face encounters in these “hybrid” models.
Much more time needs to be spent in the future educating and preparing health professionals
for a career in which they will be constantly using information technologies and artificial
intelligence. By artificial intelligence I mean all of the ways that machines use
large data sets to replicate or approximate human cognition. This concept has been
around since the 1950s, and for a long time the focus was on the projections that
this would someday replace the doctor or other professionals. A more likely scenario
is that successful clinicians will harness artificial intelligence to assist them
in clinical practice—the two together will be better than either alone. To do that
the health professional of tomorrow must have a better understanding of probabilities,
confidence intervals, and the use and limitations of large data bases. There is much
concern that the algorithms used in AI could actually exacerbate health disparities
because of built‐in biases. The health professional of the future must understand
the strengths and limitations of these algorithms.
The health professional of tomorrow also will need to be trained in the uses and limitations
of telemedicine for both patient and student encounters. All health professional will
need training in using the computerized medical record and other technological aids
in ways that enhance the patient experience and the patient–clinician relationship
rather than detract from them. Our current disappointing experiences with electronic
medical records that were developed for business rather than clinical transactions
should be a warning to us. Health professionals must be actively involved in developing
the systems of the future.
And that brings us to the last aspect of this trend—educators, learners, and clinicians
must work together to see that technology enables them at each step along the continuum
to devote more time to the higher level functions of reasoning, communication, compassion,
and empathy. It will be easy to continue to lament the intrusion of technology or
to be nostalgic about the past, but it will take effort and creativity to seize this
opportunity to actually elevate the status and role of health professions education
and clinical practice. The greatest dividend of the technological revolution will
come when all health professionals are freed up to truly “work up to license.” Machine
learning can never provide the human touch that all patients want and need in a healing
relationship with their clinicians. We must harness technology to enable us to make
clinical practice more humanistic.
This sixth trend may in many ways be the most exciting, but it also can be the scariest
and most threatening. That is why engagement with the issues should not be delayed,
and these concepts must be built into the earliest phases of health professions education
and reinforced across the continuum.
1.7
Significance of COVID‐19 on these trends
It is, of course, impossible to predict today the long‐term effects of the disruption
we are now experiencing from the COVID‐19 pandemic. That disruption has profoundly
affected the health of the public with corollary challenges to the health‐care delivery
system and health professions education. Beyond that, the economic, social, and psychological
effects on society are likely to be felt for years, if not decades. But with those
caveats, I will posit that it is likely that the COVID‐19 experience will actually
reinforce and accelerate these trends I have identified. I will also note some other
issues it has raised about the preparation of health professionals for the future.
First, as to COVID‐19 and the trends. It is quite clear that the enormous stress placed
on our health‐care delivery and public health systems could not have been dealt with
without a collaborative and interprofessional approach. The daily heroic stories of
frontline health workers have stressed the interdependence of the team. If we ever
had any doubt that we are preparing health‐care workers of the future to work in teams,
the COVID‐19 story has put that doubt to rest.
Regarding the second trend, the disruption in hospital‐based education during the
pandemic has been profound. For all practical purposes clinical education in the hospital
stopped. This was done to protect the learners and to conserve scarce personal protective
equipment, but also because of the realization that the COVID‐19 hospital was not
an environment conducive to education. On the other hand, ambulatory education did
continue in many settings, and students who have acquired both the trust and skills
that are part of a successful longitudinal integrated experience were actually able
to be helpful to their patients and the care sites in these stressful times. I received
a personal communication from one of the leaders of these experiences with the following
observation.
25
“LICs are proving particularly resilient and beneficial in the time of Covid. Indeed,
I keep learning of stories in the United States, and in other countries, of how LIC
students are able to continue to benefit their patients, preceptors, offices/institutions,
and communities precisely because of the model—with the LIC model, students are known
and trusted and the students know their patients and clinical microsystem so well.
All this is to say that on top of all the proven educational benefits over these many
years, we now see that the power of time affords the trust, connectivity, systems
training, patient–preceptor–system relationships need to address current COVID needs
and the likely care delivery that is coming. LICs create time and relationships AND
flexibility and these offer enormous benefits for education and service.”
The pandemic has also highlighted the importance of the social determinants of health
because of the striking differences in outcome based on race, ethnicity, economic
status, and zip code. The relationship between social factors (racism, housing, job,
transportation, air quality, access to care) and health outcomes has never been clearer
or starker. COVID‐19 has called for us to not only better understand these relationships
but to do something about them. And health‐care professionals must be central to that
discussion and action.
The importance of the environments in which we work and learn and the importance of
focusing on the long‐term well‐being and resilience of our health professionals have
also been drawn in sharp relief by the pandemic. The other side of the coin of the
heroism of health‐care workers has been the effect of this continually stressful environment
on increasing the likelihood of burnout, depression, and suicide. We will not know
for some time the long‐term psychological and morale consequences of the pandemic
on health‐care workers, but we will need to pay more even more attention to these
environmental factors at each point in the education and clinical continuum going
forward. The extraordinary humanism shown by our health professionals must be returned
in kind by developing and maintaining humanistic systems of care and learning.
The stress on the whole health‐care system showed the importance of assuring competence
at all levels of the health professions and also of assuring that we have enough health
professionals with the right skills in the right places. That is, after all, our social
contract.
Finally, the pandemic has shown very clearly the increasing role that technology will
play in education and care. Most health professional schools went to entirely online
learning, and that is likely to continue in some fashion into the next academic year.
In the clinics, a high percentage of visits become telemedicine visits. This enforced
rapid transition in both these domains is likely to lead to rapid improvement in and
acceptance of these technologies, and I expect some of these changes will be permanent.
So, each of the trends has been reinforced and I suspect accelerated by the pandemic.
As traumatic as has been this disruption, we may look back at it as an accelerant
of change albeit at a very high price.
There are some other changes that also are likely to stay that were not part of the
trends I have identified. There must be a greater emphasis going forward in health
professional education on emergency preparedness, with the likelihood that other epidemics
and pandemics will occur in the professional lives of all of our trainees. Also, the
pandemic has reminded us of the enormous importance of public health and epidemiology
in our health‐care system. This has profound implications at a policy level because
we have so woefully underinvested in public health and public health planning. But
it also has implications at the education and practice level in that we must much
more actively integrate these disciplines with the other health professions—consistent
with the interprofessional education trend.
2
CONCLUSION
This is an exciting time in health professions education. Building on a decade of
innovations that provided proofs of concept and some guiding principles, we are poised
for a decade of explosive innovation along the six trends outlined. It is good that
we are ready for this, because the public we serve desperately needs these changes
to enable it to achieve the health that is our goal.
It should also be apparent that these trends are not totally independent from one
another; they are, indeed, interconnected. Interprofessional education helps to create
the culture for addressing the social determinants of health and life‐long sustaining
learning environments. Longitudinal integrated clinical experiences facilitate insights
into the social determinants of health and create the continuity environment for competency‐based
assessment and professional development. Educational technologies and big data, properly
harnessed, can help promote all of these changes. These are but a few examples of
the interconnectedness of the trends, and illustrate why these changes need to be
done together.
All of these changes together will in fact be needed if we want to produce the health
professionals we need for an optimal health‐care system and a healthy public. This
will require leadership and culture change. We must break down the barriers that separate
the professions and the barriers that separate education from health‐care delivery
and that separate both from the patients, families, and communities we serve. We must
remember that health professions education and health‐care delivery both have the
same goal—the improved health of the public. That will only happen if we produce health‐care
professionals who are truly collaborative, community oriented, cognizant of the social
determinants of health, resilient, competent life‐long learners who are adept at harnessing
technology to serve their patients, and who possess empathy and compassion. In other
words, they model the ideal blend of humanism and science. It is a tall order, but
we can do it.