Creative Education
2013. Vol.4, No.6A, 20-22
Published Online June 2013 in SciRes (
Copyright © 2013 SciRes.
Pedagogical Shifts in Medical Health Education
Alberto J . de A rmendi 1, Edmund A. Marek2
1Department of Anesthesiology, Oklahoma University Health Sciences Center, Oklahoma City, USA
2Jeannine Rainbolt College of Education, University of Oklahoma, Norman, USA
Email: alberto-dearme n d i,
Received April 24th, 2013; revise d M a y 25th, 2013; accepted June 2nd, 2013
Copyright © 2013 Alberto J. de Armendi, Edmund A. Marek. This is an open access article distributed under the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original wor k is properly cited.
The medical education system has evolved over time and undergone a radical transformation in the past
few decades. With advancements in disease treatments, emergence of new specialties and highly competi-
tive practicing environment, the focus has shifted from gaining knowledge to acquiring degrees. This pa-
per presents 1) where we have been, 2) problems that we have faced, 3) our present status and 4) where
we need to be in the future.
Keywords: Medical Health Education
When Abraham Flexner was a research scholar at the Carne-
gie Foundation for the Advancement of Teaching, he described
medical education at the turn of last century as, “students pay-
ing a fee for a diploma for their mediocre medical education”.
The Flexner Report (Flexner, 1910) transformed medical school
education to strictly adhere to protocols of mainstream science
teaching (basic sciences, research, and clinical care) (Cooke et
al., 2006). Since then, multiple reports have criticized the rote
lecture memorization and the regurgitation of scientific knowl-
edge in medical schools. Does passing organic chemistry with
good grades guarantee development of good doctors? Cooke
and others (Cooke et al., 2006) disagree and instead emphasize
the need for focusing on practical and professional skills that
allow for the maturation of reasoning and the development of
professional values and compassion. As Cooke points out, it is
much easier to teach basic sciences than to teach inter-personal
professional teamwork, self-evaluation, and self-improvement.
The single mission of academic medicine is to improve the
health of the population (Ramsey & Miller, 2009). Instead,
healthcare costs have escalated, and waste persists with major
medical errors and patient safety concerns. In 2011, Orszag, as
Director of the USA Congressional Budget Office, reported to
the US Senate Budget Committee that more than $2 trillion is
spent on medical care with $700 billion failing to improve
health care when compared to other countries that spend less.
Medical and health education focuses need to change if we are
going to control the continuous rising cost of health care.
McGlynn and colleagues, researchers at the Rand Corpora-
tion, noted that “In America, there is no guarantee that any
individual will receive high-quality care for any particular
health problem. The healthcare industry is plagued with over-
utilization of services, underutilization of services, and errors in
healthcare practice” (McFlynn et al., 2003). The research also
showed that Americans receive evidence-based healthcare only
50% of the time. Deyo and others (Deyo, 1991) (at the Univer-
sity of Washington showed in their interdisciplinary study,
Back Pain Patient Assessment Team, that what physicians
thought worked well for treating back pain, in reality did not.
Given the status of our healthcare system, what is the present
condition of medical and health education (MHE)? Do MHE
instructors continue to deliver large residential, conference
lectures to health care students in conventional settings? Inno-
vations began in the early 1990s at Harvard University Medical
School. Harvard’s medical education connected the classroom-
learned knowledge to immediate clinical applicability of the
same subject (connecting the basic sciences and the clinical
rotations). A new era had begun. The relationship of classroom
learning and immediate applicability was the buzzword of the
In the early 2000s, problems paying medical schools’ aca-
demic faculty resulted in faculty seeing as many patients in as
short a period of time as possible. This practice was to the det-
riment of the faculty becoming advisors, role models, and
mentors for the new generation of medical students. The loss
included quality teaching. In addition, physicians’ egocentric-
ities did not allow for team building and collaboration with
other health care workers. Intimidation, nested in hidden cur-
riculum, led to abuse and unprofessional behavior toward sub-
ordinates creating an atmosphere of fear and not learning.
Aware of deficiencies in MHE, the Graduate Medical Educa-
tion recognized the importance of self-improvement and system
awareness (ACGME, 2006). In 2006, the Accreditation Council
for Graduate Medical Education set requirements for integrat-
ing six general competencies into the medical school curricula:
1) medical knowledge, 2) patient care, 3) professionalism, 4)
interpersonal and communication skills, 5) system-based prac-
tice, and 6) practice-based learning and improvement. MHE
continues to struggle with how to teach and evaluate these com-
Medical and health educators are also compelled to teach
Comparative Effectiveness Research (CER), which offers qual-
ity, safety at lower cost. In other words, what teaching practices
and learning theories work best at the greatest cost-to-benefit
ratio. The Institute of Medicine (IOM) reported the need to
have a federal CER organizational infrastructure roadmap to set
future CER priorities and to teach CER to every student in
clinical practice. At this time, over 100 priority study topics are
on the website out of over 1250 nominated research proposals
(IOM, 2009). In addition, Crew Resource Management (CRM)
has been shown to reduce medical errors. The future is to teach
interactive dynamics, patient safety, care delivery improve-
ments, communication, and teamwork skills in these settings. In
order for this to occur, we need the convergence of curriculum
reform interests from among all major national stakeholders
(the Association of American Medical Colleges, The Institute
of Healthcare Improvement, the American Medical Student
Association, the Agency for Healthcare Research and Quality
and the Lucian Leape Institute), as well as, the international
academic community.
Present Educational Issues
At present, efforts are underway nationally and internation-
ally at health sciences’ medical centers and at conferences to
incorporate simulation technology to educate our health care
force. Among others, examples include: computer-based virtual
reality simulators, high fidelity and static mannequins, plastic
models, live animals, professional patient-actors, inert animal
products, and human cadavers. Gurusamy et al. (Gurusamy et
al., 2008) evaluated randomized controlled trials and concluded
that virtual reality training can supplement and/or replace con-
ventional laparoscopic training in surgical trainees with limited
or no laparoscopic experience. Ma et al. (Ma et al., 2011) in a
systematic review and meta-analysis of 20 studies on central
venous line catheterization, concluded that simulation-based
education was associated with significant improvement and
benefits in a) learner outcomes (performance on simulators,
knowledge, and confidence) and b) selected patient clinical
outcomes (fewer needle attempts and pneumothorax). Cook et
al. (Cook et al., 2011) in a systematic review and meta-analysis
of almost 11,000 articles prior to 2012, concluded that when
compared to no intervention, technology-enhanced simulation
training of health care professionals was consistent with large
effects for knowledge, skills, and behavior and moderate effects
for patient related outcomes. The authors also question the need
for any further studies showing the benefit of simulation tech-
nology considering that only 4% of the studies failed to show
an association when comparing no intervention to simulation
intervention. They suggest that we focus on clarifying when
and how to apply simulation most effectively and cost-effi-
The culture of MHE is gradually changing to a new one of
accountability in quality improvement. In 2001, the IOM pro-
posed six fundamental patient care aims to be learned by health
care students: 1) safety, 2) effectiveness, 3) patient-centered-
ness, 4) timeliness, 5) efficiency, and 6) equitability. A pre-
mium needs to be placed on efficient team-oriented promoters
of quality, safety, patient’s preferences, prevention and well-
ness (IOM, 2001). In 2002, the American Board of Internal
Medicine, the American College of Physicians, the American
Society of Internal Medicine and the European Federation of
Internal Medicine chartered a professionalism creed that states,
“… improvement of quality of care, maintaining clinical com-
petence, reduce medical errors, work with other professionals,
increase patient safety, and optimize outcomes …” (ABIM,
2002). Additionally, in 2004, the IOM reported the need to
teach behavioral and social sciences to equip health care stu-
dents to respond to patients as individuals and not just symp-
toms. The expected outcome was to build better therapeutic
relationships and to be more patient-centered. At the University
of South Florida, a project addressing these issues to surgical
residents exposed to lectures, role model playing, and mentor-
ing reduced medical errors (Brannick et al., 2009). The Univer-
sity of North Carolina uses the Team Strategies and Tools to
Enhance Performance and Patient Safety (TeamSTEPPS) to
prepare medical health care providers. TeamSTEPPS has re-
sulted in physicians reporting 1) prevention in medical errors, 2)
removal of the hierarchical inhibition to speak, 3) time-outs, 4)
sign placement to protect patients, and e) utilization of team
huddles before procedures (AHRQ, 2013). [Other centers are
applying similar educational tools to address all of these areas.]
In the US, we have one of the highest ratios in the world of
physicians/population (25/10,000) trailing Europe and Russia,
30s and lower 40s per 10,000-population, respectively. Other
parts of the world, like most of the sub-Sahara Africa countries,
average about 0.5-1 physicians per 10,000-population (Chart-
Bin, 2013). With such deficiencies in underdeveloped countries,
medical and health educators must resort to preparing the health
care force in th e least expensi ve and most efficient ma nner. For
example, can we teach an adult with an eighth-grade education
to deliver anesthesia in an African country over the internet? Is
that better than having no anesthesiologists, as is the case pres-
ently, in some of those countries? For circumstances like these,
perhaps the future of health care education is global Massive
Open Online Courses (MOOC) or a high-quality online educa-
tional content course available for the international health care
community. These are not online lecture courses, but rather, an
understanding, connecting, and exchanging of ideas through
interaction with others via discussions that form the basis of the
future of education in general (Faust, 2013). Skype is such an
example today. Medical health education continues to advance
through technology by the use of evolving digital computer
innovations, which allow us to share in global knowledge. Both
MOOCs and simulations will lead medical health education in
the years ahead.
The Future
In concluding, health care delivery will change in the future.
Continuously rising costs will be curtailed as the public de-
mands make the profession accountable in quality improvement
and safety. In order to do so, medical school educators need to
change the curricula to emphasize the: 1) integration of patient
care aims to become sensitive patient-centric and customer-
focused rather than provider-centric; 2) introduction of compe-
tencies to self-evaluate, improve and develop lifelong learning
and quality-improvement skills, be system aware, be evidence-
based standardized medical practice, develop interdisciplinary
professional teamwork and evaluate efficiency, quality and
safety; 3) teaching of Comparative Effectiveness Research to
deliver the best effective, efficient, safe benefit-to-cost health
care; 4) decision-making attitudes; 5) formation of data bases to
compare efficacy of disease/treatment results; 6) acknowl-
edgement of accountability; 7) practice of human dynamics,
such as, basic communications and teamwork skills, which
coordinate care efficiently and proactively promoting wellness
Copyright © 2013 SciRes. 21
Copyright © 2013 SciRes.
(Kumar, 2011); and 8) incorporation of simulation technology
for quality and collaborative patient-centered care and global
Massive Open Online Courses to facilitate Medical and Health
Education world-wide.
ABIM Foundation, American Board of Internal Medicine, ACP-ASIM
Foundation, American College of Physicians-American Society of
Internal Medicine, European Federation of Internal Medicine (2002).
Medical professionalism in the new millennium: A physician charter.
Annals of Internal Medicine, 136, 243-246.
Agency for Healthcare Research and Quality. Back Pain Patient Out-
comes Assessment Team (BOAT). URL.
Agency for Health Care Research Quality. TeamSTEPPS: National
Implementation. URL.
Brannick, M. T., Fabri, P. J., et al. (2009). Evaluation of an error-re-
duction training program for surgical residents. Academic Medicine,
84, 1809-1814. doi:10.1097/ACM.0b013e3181bf36b0
Cook, D. A., Hatala, R., Brydges, R., Zendejas, B., Szostek, J. H.,
Wang, A. T., Erwin, P. J., & Hamstra, S. J. (2011). Technology-en-
hanced simulation for health professions education: A systematic re-
view and meta-analysis. Journal of the American Medical Associa-
tion, 306, 978-988. doi:10.1001/jama.2011.1234
Cooke, M., Irby, D. M., Sullivan, W., & Ludmerer, K. M. (2006).
American medical education 100 years after the Flexner report. New
England Journal of Medicine, 355, 1339-1344.
Faust, D. (2013) The future of education. The view from mast hall.
Harvard Magazine, 63.
Flexner, A. (1910). Medical education in the United States and Canada:
A report to the Carnegie Foundation for the Advancement of Teach-
ing. New York: Bulletin Number Four.
Gurusamy, K., Aggarwal, R., Palanivelu, L., & Davidson, B. R. (2008).
Systematic review of randomized controlled trials on the effective-
ness of virtual reality training for laparoscopic surgery. British Jour-
nal of Surgery, 95, 1088-1097.
Institute of Medicine (IOM) (2009). Initial national priorities for com-
parative effectiveness research. Washington, DC: The National Aca-
demies Press. URL.
Institute of Medicine (IOM) (2001). Crossing the quality chasm: A
New health system for the 21st Century. Washington, DC: The Na-
tional Academies Press.
Kumar, S., & Nash, D. B. (2011) Demand better: Revive our BROKEN
healthcare system (p. 187). Bozeman, MT: Second River Healthcare
Ma, I. W., Brindle, M. E., Ronksley, P. E., Lorenzetti, D. L., Sauve, R.
S., & Ghali, W. A. (2011). Use of simulation-based education to im-
prove outcomes of central venous catheterization: A systematic re-
view and meta-analysis. Academic Medicine, 86, 1137-1147.
McFlynn, E. A., Asch, S. M., et al. (2003). The quality of healthcare
delivered to adults in the United States. The New England Journal of
Medicine, 348, 2635-2645. doi:10.1056/NEJMsa022615
Ramsey, P. G., & Miller, E. D. (2009). A single mission for academic
medicine: Improving health. Journal of the American Medical Asso-
ciation, 301, 1475-1576.