|Year : 2020 | Volume
| Issue : 1 | Page : 120-124
Reimagining medical education: Part three – Necessity, change, and innovation in uncertain times
Elizabeth M Wooster1, Jerry M Maniate2
1 Leadership, Higher and Adult Education, OISE, University of Toronto, Toronto, Canada
2 Department of Medicine, The Ottawa Hospital; Department of Medicine; Department of Medical Education in Innovation, University of Ottawa, Ottawa, Ontario, Canada
|Date of Submission||04-Jun-2020|
|Date of Decision||12-Jun-2020|
|Date of Acceptance||12-Jun-2020|
|Date of Web Publication||20-Jun-2020|
Dr. Elizabeth M Wooster
OISE, University of Toronto, Toronto, Ontario
Source of Support: None, Conflict of Interest: None
Change has been the keyword to describe the dramatic and rapid impact that the COVID-19 pandemic of 2020 has had on the medical education system worldwide. As a result, there has been a clear necessity for learners, faculty/teachers, leaders, health-care organizations, and academic institutions to “react,” “pivot,” and “reimagine” the system to address the numerous challenges that we have had not only to face in the short term but also to ensure that functions and processes are ready to be reinitiated to move ahead. The rapidly evolving circumstances of the pandemic have caused considerable uncertainty about almost everything, and as such, it has been difficult to anticipate what the future will be like, let alone the intermediate term. The environment of change and uncertainty has created the opportunity for many to be creative and innovative as they strive to support learners, faculty/teachers, health-care organizations, and academic institutions within the ever-changing reality we have found ourselves within.
Keywords: Change management, COVID-19, medical education, uncertainty
|How to cite this article:|
Wooster EM, Maniate JM. Reimagining medical education: Part three – Necessity, change, and innovation in uncertain times. Arch Med Health Sci 2020;8:120-4
|How to cite this URL:|
Wooster EM, Maniate JM. Reimagining medical education: Part three – Necessity, change, and innovation in uncertain times. Arch Med Health Sci [serial online] 2020 [cited 2020 Oct 29];8:120-4. Available from: https://www.amhsjournal.org/text.asp?2020/8/1/120/287346
| Introduction|| |
The COVID-19 pandemic of 2020 has underscored the importance of the medical education system to able to rapidly assess and respond to the numerous challenges that are being faced. The dizzying pace of change in an environment of uncertainty and unpredictability has reinforced the need for leadership structures and governance models that must be nimble yet collaborative, decisive yet flexible, and hopeful yet realistic.
Change has occurred at a number of levels. At the organizational or programmatic level, there has been an urgent need to rapidly assess traditional silos both within health education organizations and between them and determine whether they need to be either shelved or morphed into new structures that are broad, function focused, thinking about the spectrum of care, and more regional in orientation. In fact, those organizations and programs that were thinking this way prior to the pandemic were often able to rapidly shift into a higher gear based on the trusting relationships that had already been established between partners. The collaborative approach to pre-pandemic established networks and groups facilitated this shift. Similar re-examination and determination have also been occurring within the health-care system, with dramatic shifts being experienced as well.
At the individual level, the pandemic has reinforced the importance of system thinking, efficient teamwork, critical analysis, and thinking laterally (or “outside the box”), the importance of clear, regular, and effective communications, but also collaborative leadership and followership skills. Those individuals who are focused on the task at hand, rather than personal achievement or gain, can effectively engage their teams to transition their functions. These types of individuals are often at the leading edge of innovative thinking and creation of solutions in an environment of scarcity. The pandemic has underscored the importance that these educational leadership competencies need to be established, developed, and supported at the individual, team, organization, and system level well ahead of a crisis.
| Impact of COVID-19 on Medical Education|| |
On March 11, 2020, the World Health Organization (WHO) declared COVID 19 to be a worldwide pandemic. This declaration has resulted in massive changes to all aspects of life, including within the medical education system. In medical education, these changes were dramatic and included the following examples, with local variation depending on geographic location and incidence rate of COVID-19:
Undergraduate medical education
In many jurisdictions, with the mandated closure of colleges and universities, there was a cessation of in-person educational experiences such as classroom/tutorial and laboratory sessions in pre-clerkship. Clinical learning experiences that traditionally occurred in health-care settings such as hospitals and clinics were also impacted by many medical schools suspending these activities out of concern for learner safety. In addition, opportunities for medical students to observe different specialties, travel for visiting electives, and be involved in research projects and other activities normally associated with the medical school experience were curtailed.
Graduate medical education or postgraduate medical education
During the COVID-19 pandemic, dramatic changes in the health-care system led to the dramatic decrease or even cessation of certain clinical activities such as ambulatory care appointments, community-based care, as well as elective surgeries and procedures such as endoscopy and diagnostic imaging. In the meantime, based on the incidence rate of COVID-19 in certain jurisdictions, acute and critical inpatient care became the necessary focus of entire health-care systems, which may have resulted in the redeployment of resident physicians and fellows in addition to prolonged work hours and impact on educational opportunities. These redeployments may have arisen from two causes, first, to augment staff needed to treat critically ill inpatients or second, to other wards as trainees were felt not to have the necessary training to treat these critically ill patients. These changes have dramatically impacted the ability of residents and fellows to demonstrate vital competencies required by their programs. Additionally, the traditional educational programs and activities available to them have been curtailed. In essence, there has been a radical shift to focus on the necessity of clinical care and a near cessation of dedicated educational activities.
Continuing professional development
Conventionally, health professionals have sought out educational opportunities through in-person activities such as weekly rounds and conferences. The COVID-19 pandemic and the associated restrictions on travel and the need for physical distancing have forced many of these activities to shift to virtual formats. As a result, webinars and interactive discussion rooms have become the preferred format for many practicing clinicians to learn about the latest information about the diagnosis and management of COVID-19 and its impact on patient populations. This rise in the use of web-based technology has led to a change in the skills necessary to participate in and develop CPD opportunities. This is a trend that may continue post-COVID-19.
| Virtual Education in the Health Professions|| |
Prior to the COVID 19 pandemic, there was a paucity of the use of high-quality virtual education throughout the medical education continuum. What was occurring tended to rely on placing traditional education methods into an online platform. This can be seen across the continuum with recorded lectures for undergraduate medical education, webinars for postgraduate medical education, and online modules for continuing professional development consisting of a recorded voice reading as a slide show display. While there were pockets of innovation that were occurring in medical education, these were often short lived, localized, and tied to a limited funding source. It was rare to see those innovations broadly invested in and expanded upon.
As the medical education continuum proceeds into the area of the “new normal,” it is anticipated that virtual education will be playing a larger role. Virtual education is a term that has had many interpretations. Beginning its life as online learning or education, virtual education often consisted of notes or documents posted to a site for review prior to or after an in-person course, as an archive of content. It then moved toward a more interactive format with the addition of discussion boards or the lecture happening in “real time.” Virtual education is now poised to enter a new realm, and with it, there reside a number of opportunities and challenges to be explored.
Virtual learning environment
With the move toward using virtual education, there are a number of factors to be considered. According to Dillenbourg, virtual learning environment consists of the following characteristics if they wish to provide high-quality educational experience:
- The information space has been designed. They are not simply documents or information that is posted to a website
- Educational interactions occur in the environment, turning spaces into places
- The information/social space is explicitly represented. The representation varies from text to three-dimensional immersive worlds
- Students are not only active but also actors. They co-construct the virtual space
- Virtual learning environments are not restricted to distance education. They also enrich classroom activities
- Virtual learning environments integrate heterogeneous technologies and multiple pedagogical approaches
- Most virtual environments overlap with physical environments.
These elements should be kept in mind as health professional education expands its use of virtual education.
In addition, other factors that influence virtual learning environments must be considered. These include needs of the participants (both in terms of content and physical environment), technological support, and need of the facilitators. The needs of the participants fall into two major categories: (1) clinical content and (2) physical environment.
Impact of COVID-19 on clinical practice
With a move toward virtual learning, there is the opportunity to increase the speed at which information is delivered, and this impacts the amount of information that is available on daily basis. In their article, Reimagining Medical Education: Part Two – Practicing in an Age of Uncertainty and Change, Wooster and Maniate discuss the impact of the increase of knowledge on uncertainty and change and the fact that change must be accepted and then managed. This management of the change that occurs impacts the clinical content. In a pandemic such as COVID-19, there is considerable uncertainty, and so clinical content and knowledge tend to change rapidly. As a result, those creating and facilitating virtual education must be prepared to flexibly respond to the changing clinical knowledge and environmental landscape.
Impact of COVID-19 on physical environment
In terms of the physical environment for learners, it must be acknowledged that many learners were not prepared to be thrust into an almost entirely virtual learning environment. With this change comes many challenges. These challenges include having the appropriate technological supports to participate in virtual learning (internet access, bandwidth capacity, software to access the webinars, etc.) and having the appropriate physical environment (quiet, no interruptions, and conducive to participating in interactive virtual learning). While these may not have been apparent as challenges when the exposure to virtual learning was low as it increases, they may begin to play a larger role. As mentioned by Dillenbourg, learners participate in constructing the virtual environment. If they are unable to play an active role in a relatively easy way, they may become frustrated and no longer wish to be an active participant.
Similarly, teachers and faculty members may have been equally unprepared for this rapid shift into the virtual learning environment. It is one thing to engage with technology to participate in personal videoconferencing using platforms such as FaceTime or Skype, and it can be another thing entirely to teach in an interactive manner, a class that is geographically dispersed using Zoom or Microsoft Teams. Some of these challenges pertain to comfort with using the platforms, while others relate to the hardware or absence of relevant hardware, such as webcams, microphones, and headsets. Many teachers and faculty members simply have not participated in applicable faculty development to provide these interactive experiences in a virtual learning environment.
| Responding to a Crisis|| |
When confronting a crisis, such as the impact of the COVID-19 pandemic on our daily lives, we are often faced with options on how to move ahead. Whether as individuals or as departments/programs or as organizations, we can choose to try to weather the situation and maintain the status quo, its structures and forms, its traditions, and nostalgic feelings or we can thoughtfully react to the circumstances (short to intermediate term), pivot to respond to needs (intermediate term), and reimagine the future (intermediate to long term) to create an opportunity for growth, innovation, and development.
In the setting of the COVID-19 pandemic, the medical education system was faced with a number of immediate challenges. First, the unknown of the virus and the illness itself meant considerable uncertainty both clinically and in terms of education., Second, as new information and experiences were being gathered and communicated from around the world, it resulted in a rapidly shifting situation in which, many times, decisions needed to be made with incomplete or inaccurate data. Third, the rapidly progressing scenario led to the realization of the inadequacy of resources and even the collapse of some local/regional/national health-care systems,, and fourth, the speed and seeming ease in which the virus causing COVID-19 was spreading worldwide led to the rapid development and implementation of new policies (such as physical distancing), legislation (such as mandated lockdowns that were put in place in certain jurisdictions), and new structures (such as regional collaboration networks) to react to the considerable pressures on the health-care system. All of these challenges had significant implications on intertwined health professions education systems worldwide, some of which were described earlier in how it impacted the medical education continuum.
The COVID-19 pandemic forced many leaders in medical education to rapidly address needs that could no longer be met in traditional or historical ways. This meant seeking alternative means and resources to provide these functions for learners. While the solutions may not have been elegant or extensive, they were functional and meant to pragmatically address the needs within the constraints placed on the system as seen through the following four examples:
- Example 1: There was a dramatic shift due to the cancellation of in-person meetings and learning opportunities for using videoconferencing platforms to facilitate these activities
- Example 2: Providing asynchronous virtual support for learner experience through virtual office hours and digital resources such as websites and apps
- Example 3: Creation of accessible digital education resources such as videos, including virtual reality, to share knowledge and teach skills for learners
- Example 4: The teaching of how to use virtual care technology to provide clinical care for patients in the inpatient and ambulatory care settings.
Many of these examples were designed and implemented with such rapidity on the wide scale that it was impossible to do what most academics strive to do with their educational initiatives due to the lack of time, money, and resources. Instead, what tended to happen was a more pragmatic approach to rapidly implement, rapidly gather data on experience, and rapidly integrate that feedback into adjustments and changes into the initial design – otherwise known even in the education literature as “building the plane as you fly.”
There will likely be some underpinning assumptions that will guide the future of health professions education, especially in the absence of preventive measures (such as vaccines) or effective treatment measures for the virus causing COVID-19.
The need for ongoing physical distancing measures to continue to protect health-care professionals, patients, and the public at large will impact how medical education is delivered. Rounding on patients may be forever changed in terms of the numbers of learners and how rounds are conducted. Additionally, concerns about access to health care facilities, their capacity and the need for personal protective equipment will further impact the delivery of medical education. Physical distancing also changes the interaction between health care professionals and patients. These changes will continue to manifest as time progresses until the development of preventive measures or simply persist as the new “normal” of health-care systems.
As the medical education system has begun to shift its focus from time based to competency based, the COVID-19 pandemic has underscored the need for additional relevant competencies to be incorporated within our programs. Some of these competencies may be related to the following examples below.
The use of personal protective equipment
The use of personal protective equipment adds an additional layer to the complexity of the pandemic. Not only must learners have up to date knowledge of how to use PPE but they most also demonstrate consistent and appropriate doffing and donning techniques. This is critical for patient safety as well as the safety of the healthcare providers themselves. Morbidity and mortality rates of health care providers have been linked to inadequate PPE or improper use.
The use of virtual care
During the early days of the COVID-19 pandemic, there was a rapid and dramatic upswing in the usage of VC in the provision of health care. This was seen in the North American setting with the shift of ambulatory care, which had been predominantly in-person based prior to the pandemic, to one that was almost entirely, in certain jurisdictions, delivered virtually. This shift to virtual care impacts multiple facets of the health care continuum. Whether this shift will become the new standard of care remains to be seen.
The importance of teamwork in a virtual setting
Teamwork and the ability to work in teams is essential for modern-day health-care professionals. As larger amounts of virtual care and virtual settings are being integrated into daily health-care provision, the skills and competencies needed to succeed in these environments are also shifting. Some of these competencies may not be apparent for some time to come. This adds additional change and uncertainty into an already taxed system.
Consensus building and conflict negotiations
Time is of the essence in a crisis. There is no time or appetite for traditional committee meetings and prolonged project timelines. Speed and quality design are needed to rapidly address the urgent identified needs. Decision-making through the building of consensus and addressing tensions through conflict negotiations will be critical to ensure that all voices, especially those of marginalized populations, are heard and integrated into what is designed. For example, prior to the COVID-19 pandemic, there had been growing engagement and involvement of patient voices into the decision-making in many North American health-care organizations. These voices appear to be sidelined in many of these organizations in the midst of the current challenge casting doubt on how integral they are perceived to be.
| The Future IS Uncertain|| |
The rapid shifts in clinical care brought on by the COVID-19 pandemic have caused medical educators to reimagine health professional education across the continuum. While some of the changes will be temporary, a number will likely remain in force. Regardless of the time frame of the change, the impact of these changes will have on education across the health-care profession continuum that will reverberate for significant time to come. As a result, it is unlikely that we will be able to evaluate the impact and outcome of many of these changes for some time to come due to the dynamic reality we find ourselves in.
Managing these types of changes, and the events that bring them on, calls for different knowledge and skill set than we have become accustomed to. Health-care professionals will need to have the skills to manage these situations on multiple levels, personally, for their patients, as part of a specialty and for society as a whole. The ability to “react,” “pivot,” and “reimagine” will be necessary for leaders in medical education to inform successful decision-making in a crisis context. It will be important for us to begin to explore, identify, and describe the required competencies that underscore these abilities to influence and lead the medical education system into the dynamic future that lies ahead.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. We have Therefore Made the Assessment that #COVID19 can be Characterized as a Pandemic”-@DrTedros #Coronavirus; 11 March, 2020. Available from: https://twitter.com/WHO/status/1237777021742338049
. [Last accessed on 2020 May 25].
Schwartz AM, Wilson JM, Boden SD, Moore TJ, Bradbury TL, Fletcher ND. Managing resident workforce and education during the COVID-19 pandemic. JBJS Open Access 2020;5. doi:10.2106/JBJS.OA.20.00045.
Wooster EM, Maniate JM. Reimagining medical education: Part two – Practicing in an age of uncertainty and change. Arch Med Health Sci 2019;7:92-5. [Full text]
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al
. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-36.
Coulthard P. Dentistry and coronavirus (COVID-19) Moral decision-making. Br Dent J 2020;228:503-5.
Armocida B, Formenti B, Ussai S, Palestra F, Missoni E. The Italian health system and the COVID-19 challenge. Lancet Public Health 2020;5:e253.
Chaplin T, McColl T, Petrosoniak A, Hall A. Building the plane as you fly: Simulation during the COVID-19 pandemic. CJEM 2020; p. 1-5. doi:10.1017/cem.2020.398.