Innovation, Advances & Regulations in Medical Education

Prof KR Sethuraman. MD, PGDHE.VC – Sri Balaji Vidyapeeth.

Puducherry

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“The Physicians of Tomorrow are taught by the Teachers of Today using Curricula of yesterday.”

- Sethuraman KR (2000)

The Current Problem

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Dedication

Innovate for the New Generation

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Objectives for this talk…• Compare creativity and innovation• Discuss the stages in creative and innovative

processes• Consider barriers to & assessment of

innovation • Survey the ongoing innovations in USA • Invite comments on our reasons, rights and

responsibilities to foster innovation in Med Edu

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Innovation – What, How & Why

REASON

RIGHTS RESPONSIBILITY

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Creativity in StagesGraham Wallas (1858 – 1932) In The Art of Thought (1926), he proposed this model of the creative process:

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Steps in Innovative Processes• Permit a Creative Environment • Generate Ideas• Present & Discuss the Ideas• Filter & Choose the best• Do Pre-Validation• Implement the Prototype• Do Evaluation & Post-validation• Plan for Dissemination

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Avoid these 8 Idea Killers! • “We tried that already –• “We don't do it that way here -• “Not in our budget -• “Not an interesting problem - • “We don't have time -• “People won't like it -• “How stupid are you? “• “You are smarter with your mouth shut!”

from Scott Berkun's book, The Myths of Innovation, Sebastopol: O'Reilly Media, Inc., 2010.

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Can We Teach Innovation?... • Rigid training does not help innovation and can even

harm the processes.• Knowledge is important but formal qualification is not

essential• Requires new approaches and different ways of

looking at problems.– Some are naturally more creative - ‘creative gene’

• Education can help in identifying barriers to innovation• Innovation can be cultivated by teaching skills such as

lateral thinking.

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Developing Creativity - i

• Brainstorming – invented by an American businessman Alex

Osborn– it encourages the generation of possible solutions

to a well defined problem • Synectics– to explore relationships between apparently

unconnected elements of a problem using analogy and metaphors

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Developing Creativity - ii

• Lateral Thinking– reject standard methods for solutions– take a fresh perspective, involving spatial or visual

support for ideas• Problem Solving– Break down the problem into smaller solvable

components – Generate possible solutions, consider pro’s and

con’s of each and choose the most appropriate

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Evaluation of Educational Innovations

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Story: OSCE as a formative tool to impart error-free ‘must do’ skills

• Reason was through Epiphany (1987 exams)– A final MBBS student did not know-how to use a

sphygmomanometer (kept mercury column flat!)• Responsibility (all should do ‘Must Do’ Skills)• Rights (as a Unit Head) • Resistance to overcome – educators / HOD• Spin offs (The first manual on OSCE – 1988)• Sustainability (Formative OSCE still going on)

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Story: Motivating the students to learn the local language

• Reason (importance of talking with patients)• Responsibility - to create LRM (1988)• Resistance to overcome – student apathy• Epiphany – Alumnus feedback from NEFA • Lesson: Tools + Motivation = Success• Outcome – (1995 to 2005) all learnt Tamil• Dissemination – JIPMER / AIMST / MGMCRI

http://jipmer.edu.in/wp-content/uploads/2013/01/tamil-bk.pdf

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Story: Emergency Care Posting• Reason & Responsibility (experiential T-L in ER)• Creative problem solving: – Once a week posting from 4 pm to 10 pm in the

emergency dept (“casualty”) in groups of 2 or 3– Shadow the Medical team on duty and clerk cases– 50% of Viva voce in internal exam based on this

posting of around 10 sessions (60 + hours)– Other depts (Surgery, Paeds) also replicated this

• Outcome assessment by external examiners was supportive of gains

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Objectivising Clinical/Practical Exams

• MCI – ’97 has recommended ‘Objectivising Clinical/Practical Exams’

• Only a lip-service by most institutions• At SBVU: a year-long capacity building effort• OSCE/OSPE was ‘do-able’ in the summative

assessment (field-tested blue-print; years 1-5)• National expert group meeting to endorse the

report and submit to the regulatory body• Still waiting for the “Nod” from MCI

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Barriers to Innovations - i

• Internal Barriers – Culture of Blame (discomfort with new ideas)– Staff Motivation (non-risk taking and inept)– Unapproachable Management (lack of foresight)– Management Systems (Not tuned to innovate)– Inexperience – Investment Capital (Human resource, time, fund)

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Barriers to Innovations - ii

• External Barriers– National Regulations– Local Regulations– Opposition from Interest groups

Source: http://akri.org/thinking/innovation-process.html

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“Attitude-Spectrum” to Innovations

• A – LEADER. • B – COLLABORATOR• C – SUPPORTER. • D – ACCOMMODATOR

OPPONENTS:

• G – PARTICIPATING ~

• H – PASSIVE~

• I – RESISTING ~

• J – HOSTILE ~E – INDIFFERENT. F - UNINFORMED

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MEDICAL EDUCATION IN 21ST C

Current Advances & Focus Following Lancet Commission Report, 2010

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AMSA - Students' Voices• Current curricular lacunae:– a narrow technical focus without contextual

understanding in a holistic manner – poor teamwork– predominant hospital orientation at the expense

of primary health care– quantitative and qualitative imbalances in the

health professions (market forces)

http://media.amsa.org.au/policy/2012/201206_medical_curricula_for_the_21st_century_professional_policy.pdf

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AMSA – Curricular Needs for 21st C• Instill respect for the rights and dignity of the

individual and community, • inculcate leadership & advocacy skills to respond to

the health needs & priorities of the community,• promote an understanding that actions within

healthcare settings have broader social and economic implications

• provide graduates with the skills necessary to apply global research and resources to local practice and health priorities

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AMSA – Curricular Needs - ii• provide the skills and attitudes necessary to

engage in interdisciplinary and trans-disciplinary collaborations with key stakeholders– from health and non-health professions

• Recognize the expertise of other health disciplines with the aim of improving patient care in multidisciplinary teams

• Embody transformative learning methods that foster leadership skills to be enlightened change agentshttp://media.amsa.org.au/policy/2012/201206_medical_curricula_for_the_21st_century_professional_policy.pdf

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Obstacles to Curriculum Change• Status quo: a culture of conservatism• Opposition: teachers not convinced about the benefits of

change• Cost of the proposed changed: the increased workload of

implementing the change• Process of change: teachers’ work not being rewarded • Conflict of interest: teachers’ conflicting interests of

research and clinical care

• AMEE 2013 Conference, Prague: http://medine2.com/Public/docs/MEDINE2-WP5.pdf

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Faculty & Students* speak out 1. Exclude redundant information from curriculum. 2. Make medical training more patient-centered.3. Future physicians to usher change in Health care delivery 4. Increase diversity in medical education. 5. Include massive open online courses (MOOC) and Create

curricula for a “Medical school without walls.”6. Entrance Exams (Step-1 USMLE etc) be modified as they

promote a "parallel curriculum“ diverting students’ focus? 7. Effective ways to shorten student training by "outcomes

based" approach.

*Faculty & students from 110 institutions at CHANGEMEDED conf Oct-2015http://www.ama-assn.org/ama/ama-wire/post/9-challenges-medical-educators-want-solve-right-now

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AMA – A PROACTIVE REFORMIST

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AMA - Accelerating Change in Medical Education

Six key themes for the 11-member consortium:1. Developing flexible, competency-based pathways2. Teaching & assessing new content in health care

delivery sciences3. Working with health care delivery systems in novel ways4. Making technology solutions to support learning and

assessment5. Envisioning the master adaptive learner6. Shaping tomorrow’s leaders

(In Nov,2015, consortium added 21 more to make 32 members)

https://www.ama-assn.org/resources/doc/about-ama/x-pub/ace-monograph-interactive.pdf

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AMA’s Innovation Push – 11. Mayo: to prepare students for patient-centered,

community-oriented, science-driven care and lead collaborative care teams that deliver high-value care.

2. Warren Alpert: to educate a new type of physician leader equipped to promote the health of the population

3. University of Michigan: to transform its curriculum to graduate physician change agents who will improve health care at a systems and patient level.

4. Vanderbilt University: to create master adaptive learners who are embedded in the health care workplace throughout their undergraduate medical education

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AMA’s Innovation Push – 25. Oregon Health & Science University: to implement a

learner-centered, competency-based curriculum that enables students to follow individualized learning plans

6. San Francisco School of Medicine: to learn to work expertly in inter-professional teams to advance science and improve health care.

7. NYU School of Medicine: to implement a three-year, flexible, individualized, technology-enabled blended curriculum to improve care coordination and quality improvement.

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AMA’s Innovation Push – 38. Davis School of Medicine: to create a 3-year medical school

pathway, the Accelerated Competency-based Education in Primary Care (3+3) program.

9. The Brody School of Medicine: to implement a new comprehensive Longitudinal Core Curriculum in patient safety for all medical students.

10. Penn State College of Medicine: to design educational experiences that align medical education with health system needs.

11. Indiana University: to teach electronic medical record (tEMR) to ensure competencies in clinical decision-making as well as system-, team- and population-based health care.

http://www.ama-assn.org/sub/accelerating-change/grant-projects.shtml

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REGULATION OF HEALTH PROFESSIONS EDUCATION IN INDIA

REASON

RIGHTS RESPONSIBILITY

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Regulation in India is the proverbial “elephant in the room”

• Plan 4+• Organize 2+• Lead effectively 1+• Implement +/-• Co-ordinate &

Collaborate 2 (– )• Evaluate outcomes &

impact 4(– ) – Ex PM Rajiv Gandhi

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Declarative vs. Procedural Tussle

Declarative sentences, well articulated by the regulatory bodies, since it is a conscious, considered and explicit act

Innovative, tacit and exploits any loop-hole in the declared regulations to “Some-How” fulfill the stated requirements

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Summing Up: Regulations can delay the inevitable But,

• “Enlightened educators need to push the agenda to innovate and usher in reforms

• As Tagore put it, “The Next Generation deserves it.” – Let us not limit them