A Tea-Steeping or i-Doc Model for Medical Education?

There was a great article written by Dr. Brian Hodges (@BDHodges1) and published in Academic Medicine¹ in 2010. Dr. Cunningham (@amcunningham) provided the link via Twitter in a discussion about different models of competence in medical education.

This article starts out with a historical description of the current system, which was established in 1910 after most recommendations from Flexner’s report were implemented (prior blog posts on Flexner Report – Next 10 Years, Flexner redux 2010). The author describes the characteristics and implications of the current two models to assess competence — time-based and outcome-based competence. He concludes by suggesting that a more accurate model will result from integration of what works best in both systems.

Time-Based Competence: Tea-Steeping

• This traditional model focuses on admission (finding the right candidate) and time-fixed curriculum (content) design.
• It defines competence in terms of knowledge and reflection. “Tea (student)-steeping(medical school) for a set time and then voilà.”
• It’s the model in place despite no evidence connecting it to patient outcome or trainee’s competence.
• Puts emphasis on summative assessments and subjective evaluations by supervisors.
• Has proven quite resilient mostly due to political issues, and has a lot of emphasis on old established basic sciences.
• Medical school officials are pressured to add more content to this already overwhelmed curriculum.

Outcome-Based Competence: i-Doc

•  Focuses on functional capabilities of the end-product via standardization and efficiency. Production of “i-Docs” via the use of standardized examinations resembles assembly lines in factories.
• Originated in psychometric discourse now incorporated into production discourse.
• Has led to loss of the mentor-apprentice model and lacks flexibility for the student.
• Already being used to effectively train nurse practitioners which may take the role as sole providers in areas with physician shortages.
• Performance under real settings is the ultimate display of competence.
• Psychometricians provide methods which assess/measure the learner’s performance via reliability, standardization, and multiple sampling.
• Looks at training from a perspective of what’s needed in a community.
• The training of technical skills is undertaken in a modular process until the trainee demonstrates proficiency.
• There is an emphasis on more frequent testing, integration of simulation, objective structured assessment of technical skills, and more.

Recent reports have addressed weaknesses and gaps in medical education in both Canada and the United States. A list of recommendations from the reports is provided in the article along with the author’s description of the changes in the curriculum.

The author states there is a drive towards guided self-assessment with “continuous formative assessment and feedback in practice.” There’s going to be a new outlook on the lifelong learner and exploration on the specifics of external and internal assessments. The argument towards an outcome based model, as the time based model weakens, is about “increasing efficiency, shortening training time, and reducing the overall cost of medical education.” Interesting enough this past summer New York University announced that it will  offer a 3 year curriculum to a small number of medical students. It reassures no loss of quality, lower cost, and efficiency in production. The YouTube talk below by Dr. Thomas Talbot on “Designing Medical Education for Today’s Brains” also calls for more effective ways of teaching the medical student with the help of simulation, technology, frequent testing, and emphasis on relevant material.

The solution?

Outcome-Based Adapted to Individuals: Swimming the Length of the Pool

The author offers his recommendation in which the outcome-based training is adapted to the needs of the learner until the outcome is achieved in which time might be more of a variable. “This form of competence, what ten Cate has called entrustable professional acts, requires evidence of performance in real settings.” The emphasis is not placed on what the learner has the potential to do, but rather on actually doing.

Another important characteristic noted by the author is that currently medical education places too much emphasis on what each individual does but the actual practice of medicine takes place in a team setting. See “Collective Competence” TEDTalk below by Dr. Lorelei Lingard (H/T Dr. Cunningham for the link) in which she talks about having competent individuals creating incompetent teams when they come together.

Ultimately, the author envisions a model that will reduce training time and cost while at the same time being flexible and individualized. It will tolerate ambiguity; handle complexity; and foster curiosity, innovation, and lifelong learning. The appropriate setting will be one in which there will be coaching, a closer teacher-student relationship, a curriculum rich in practice and feedback, continuous formative assessment, and a stepwise, developmental approach. The new hybrid model would be very time and resource intensive for the educator, because the system will go from a “see one, do one, teach one” model to a “watch until you are ready to try, then practice in simulation until you are ready to perform with real patients, then perform repeatedly under supervision until you are ready to practice independently.” The author states implementing these new recommendations will be quite complex for the students, the educators, and the educational system. Fundamentally, he suggests keeping characteristics that work in the time-based model while adopting the best practices from the outcome based model.

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Javier Benitez, MD

ALiEM Featured Contributor

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