Just Imagine: New Paradigms for Medical Education

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Another great article from the same issue of Academic Medicine as “Medical Education Reimagined.” This article focuses on the shortcomings of our current system of medical education and offers a review of the current “disruptive innovations.”

The “second Flexner report”

The authors cite the 2010 publication “Educating Physicians: A Call for Reform of Medical School and Residency” as identifying 4 goals to improve medical education:

  1. Standardization of learning outcomes and individualization of the learning process
  2. Integration of formal knowledge and clinical experience
  3. Development of habits of inquiry and innovation
  4. Focus on professional identity formation

Shortcomings and problems

“For all of it’s traditional successes, the current model of medical education in the United States and Canada is being challenged on issues of quality, throughput, and cost, a process that has exposed numerous shortcoming… A radical change in direction is required because the current path will not lead to a solution.”

This article doesn’t hold back any punches and list several key shortcomings in the current system including:

  • “Arcane assessment methods
  • Learning focused on test performance
  • Lack of direct observation
  • Lack of knowledge assessment or problem-solving ability
  • Productivity pressures faced by faculty
  • Inattention to improving residents’ teaching skills
  • Gaps in trainees’ clinical exposure
  • Unmet need to train more physicians
  • Medical student debt

Disruptive innovations

“In an ideal future state, all students would experience every essential inpatient and ambulatory clinical experience, would be observed during these encounters, and would receive formative feedback on such interactions to guide them in improving their knowledge, skills, and socialization to the profession.”

Several of the disruptive innovations now available to use are:

  • Flipped classrooms – eLearning content frees up class time for active learning
  • Massive open online courses (MOOCs) – 24/7 access to low cost, collaborative courses forstering “knowledge duplication”
  • Digital badges – electronic images and tracking that can follow learners through their lifetime

The authors’ vision is to achieve the goals set forth by the “second Flexner report” by transforming medical education with disruptive technologies. 

We are living in exciting, “disruptive” times and I look forward to see how the re-imagining of medical education will change us.


Cooke, et al. “Educating Physicians: A Call for Reform of Medical School and Residency.” San Francisco, CA: Jossey-Bass; 2010

Mehta, et. al. “Just Imagine: New Paradigms for Medical Education.” Academic Medicine. 2013; 88(10)

Medical Education Reimagined: A Call to Action

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This is one of those articles that may (hopefully) help define a new era of medical education!

Charles Prober (senior associate dean at Stanford SOM and author of the article “Lecture Halls Without Lectures”) and Salman Khan (creator of the Khan Academy) have co-authored an editorial calling for “a collaborative, multi-institutional effort to reimagine medical education.” This “reimagining” recognizes that the current medical system is generally inflexible to individual learners and embraces the flipped classroom model at it’s core.  

They argue that the convergence of 3 key factors compels a need for change:

  1. The modern “digital native” learner
  2. Exponentially growing biomedical knowledge
  3. A dated medical education delivery system

To do this, they propose the following:

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Building a framework of core knowledge

This is the central element of the proposal and calls for a curricular change to focus on medical knowledge that is “evergreen,” or foundational and known to be true. They then call for the creation of a medical school collaborative to identify the core content, and based on this, to create short (~10 minute) videos of this core content.

Embedding the knowledge in richly interactive, compelling, and engaging formats

Interactive, engaging sessions add meaning to the knowledge and solidify the learners understanding of the material. Based on the experiences at Stanford, they also note that the sessions with video-based didactic instruction must be time neutral compared to the current model.

Encouraging in-depth pursuit of knowledge in some, but not all, domains

Here, the key is “to tap into and support the individual learner’s aptitude and passion.” Deeper “dives” into the curriculum and driven by learners and areas of expertise in each school. It also respects that some students may not feel the need to do so.

This commentary is rich with ideas to embrace technology and the flipped classroom model for our learners. It is a model that was developed for K-12 education, but as the authors note, equally relevant to medical education. There are also several keys to this model which I think are worth mentioning more in depth:

  1. Collaboration – it calls for medical schools to work together to define a core content across all schools
  2. Embracing technology – using technology not only for the core content, but also the interactive sessions to reinforce key ideas and material
  3. Encouraging multiple formats – recognizing that there will need to be several videos formats to fit various learning styles.
  4. Individualism – while collaboration is key to this endeavor, medical schools maintain individualism in the style and delivery of the interactive sessions and the areas of expertise for the “deep dives” offered to students
  5. Tailored education – students may (or may not) choose to go beyond the curriculum in “deep dives” in certain areas

I am energized by this article and excited to be an educator right now!


Prober C, Khan S. “Medical Education Reimagined: A Call to Action.” Academic Medicine. 2013;88(10):1-4

An oldie, but goodie…

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As I was skimming journals for a lit search on another project, I came across this interesting article:

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This article appeared in BMJ in 2003 and it a little dated (a few paragraphs talk about the use of overhead projectors and 35mm slides) but still had some great pearls to pull out if it.

“The nature and qualities of the teaching materials that you use can have a substantial effect on the educational experience of your students.” 

Very true. This is the whole idea behind presentation design and now has research to support this idea (see articles by Dr. Issa).

“Highlighted information helps to emphasize important issues or pivotal points in a developing argument.”

Also very true. One of the most common mistakes I see in presentations is a lack of focus on key points. The presentations turn into “slideuments” that are just large amounts of text in slide format.

The other side of this point is to highlight too much…

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“It is important that both the type of educational event and the teaching materials that supplement it are targeted at what your students need to learn. Targeting, therefore, requires an awareness of what knowledge and skills your students already have.”

Perhaps the most important sentences in this article because they hit so many important points. First, this idea that we have to tailor our teaching to our learners. This is a critical first step in designing educational activities. As much as I love presentation design, there are times when it isn’t even the best way to teach, and we have to consider this first before reflexively creating a powerpoint anytime we are asked to teach anything. This also implies that the same topic may be delivered differently based on the learners and educational goals. Second, teaching materials supplement educational activities. They should never be the central focus. Third, the idea of finding out what your students know related to the educational theme of Organizing and Anchoring. Activating prior knowledge and using the zone of proximal development aids in learning.

“…remember, [technology] is just another educational tool.”

Always important to remember, especially given the explosion of technology in the last few years.

Overall, this article was a nice, quick read that hid some great pearls that are still true for presentation design, but also gave some historic perspective on presentation tools and design ideas at the time.

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HA! Numbering slides…. classic!


Farrow R. “Creating Teaching Materials.” BMJ. 2003;326:921-3

The Dr. Fox Lecture

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The phenomenon in which the style of a lecture masks its poor content is known as the “Dr. Fox Effect.”

In the 1970’s, three researchers hired an actor, Michael Fox, to “teach charistmatically and nonsubstantively on a topic about which he knew nothing.” The lecture, titled “Mathematical Game Theory as Applied to Physician Education,” was attended or rewatched via video by a total of 55 participants (physicians, educators, and administrators).

This is a video of the lecture:


This is a video of an edited version with clips added:


Table 1 from the paper shows the responses that the participants had to the survey.

  • Group 1 – 11 psychiatrists, psychologists, and social-worker educators
  • Group 2 – 11 psychiatrists, psychologists, and psychiatric social workers
  • Group 3 – 33 educators and administrators with 21 of these holding master’s degrees, 8 with bachelor’s degrees, and 4 with other degrees not specified

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The authors concluded that “style was more influential than content in providing learner satisfaction” for those participants in the study. They were specifically aiming to address the idea that student ratings of educators had more to do with personality than with educational content.

What implications does this have for us as medical educators? There are many different theories that can come from this study. The authors themselves write “there is much more to teaching than making students happy.” This is very true, but much like attention, there is an undeniable effect of “performance” on gaining interest and motivating learners. The authors note that “despite having been misinformed, the motivation of some respondents to learn more about the subject matter persisted.”

Although much more research has to be done in this area to answer the question effectively, my own answer is summarized in a quote I use frequently in my presentations:

“Successful teaching is a performance, and the sooner we make peace with that, the better.” – Tauber, et. al.


Naftulin D, Ware J, and Donnelly F. “The Doctor Fox Lecture: A Paradigm of Educational Seduction.” Journal of Medical Education. 1973;43:630-5

Tauber R, Mester C. Acting Lessons for Teachers: Using Performance Skills in the Classroom. Praeger, 2007. 2nd edition.

Key Articles in Presentation Design – Applying Multimedia Design Principles

Two key articles give us some of the first evidence in medical education that applying multimedia design principles affect learning.

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The first article is a prospective study where “traditional” powerpoint slides were compared to “modified” powerpoint slides in a 50-minute lecture on shock given to third year medical students during their surgery clerkship. The modifications were based on Mayer’s multimedia design principles. A pre-test/post-test control group was used and took a convenience sample of students (39 in the control group, 91 in the modified slide group).

The author, Dr. Nabil Issa, was gracious enough to send me the slides he used in his study. I have included the ones that appear in the two articles for comparison.





Results: Both groups showed improvements in retention , transfer, and total scores between pre- and post-tests. However, further analysis showed statistically greater improvements in retention (F=10.2, p=0.0016) and total scores (F=7.13, p=0.0081) for those students in the modified slide group. Interestingly, there was not a significant difference between the groups ability to apply the new knowledge to clinical vignettes.

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The second article is a follow-up study based on the first.

Results: The modified slide group significantly outscored the traditional slide group on delayed tests of transfer and retention given at 1 week (d=0.83, 0.83 respectively) and 4 weeks (d=1.17, 0.83 respectively) after initial instruction. The modified slide group also significantly outperformed the traditional slide group on immediate tests of retention and transfer. (see below)

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So, what does this mean for us. Well, a few things. First, we have evidence that the way we design our materials affects learning. It also means we have a lot of work to do. There are many more questions to answer to fully understand the effect of incorporating multimedia design principles. Are certain concepts taught better in certain ways? Does the length of the presentation affect retention (yes on this one, but just thought I would throw it out there)? How do we best teach others to design with multimedia principles?

Hopefully, this is the first of many studies on optimizing the delivery of content to our learners. I even hope to contribute to this body of literature myself in the coming years.

I have written previously on Mayer’s work in this blog if you are looking for more information about multimedia design principles. Click here to see the page.

Below is a diagram of the cognitive theory of multimedia learning: Screen Shot 2013-03-28 at 10.31.05 PM(Click to enlarge)


Issa, et. al. “Applying Multimedia Design Principles Enhances Learning in Medical Education.” Medical Education. 2011;45:818-26

Issa, et. al. “Teaching for Understanding in Medical Classrooms Using Multimedia Design Principles.” Medical Education. 2013;47:388-96

Lecture Halls Without Lectures – A Proposal for Medical Education

This commentary, which was published in the New England Journal of Medicine, is a must read for all educators.

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The authors make the statement that there are “…unprecedented opportunities for technological support of learners…” and we have to “…make better use of our students’ time.”

Their solution, based on Heath’s book Made to Stick is to make ideas “stickier” by capturing curiosity and using stories to create an emotional response. (click here for a great review of the book by Michelle Lin, M.D.) The third part of their solution is to embrace a flipped-classroom model (see below).

This model, which uses digital learning outside of the classroom supplemented by active learning activities during class time, has already been adopted by many programs to varying degrees. For example, the University of Wisconsin’s EM program is currently producing content from their regular didactics to be released on iTunes U. This model also has some research support, as the article itself cites. According to a meta-analysis by the Department of Education, “on average, students in online learning conditions performed modestly better than those receiving face-to-face instruction.”

I use this article in almost all of the classes, lectures, and workshops I teach about presentation design, and integrating technology into education. The challenge for most of us will be HOW do we integrate these principles into our teaching. One of the things I warn my learners about frequently is:


So, the goal isn’t to just start recording the lectures for students to watch at home. The goal is to create materials to promote learning. Presentation design principles are at the heart of this endeavor.

Embracing a flipped-classroom and developing high quality materials for learning both in the classroom and outside of class will change the educational process for the better.

“Teachers would be able to actually teach, rather than merely make speeches.”

Crazy talk!


Prober C, Heath C. “Lecture Halls without Lectures – A Proposal for Medical Education.” NEJM. 2012;366(18):1657-9

Heath C, Heath D. Made to Stick: why some ideas survive and others die. New York: Random House, 2007

Evaluation of evidence-based practices in online learning: a meta-analysis and review of online learning studies. Washington, DC: Department of Education, Office of Planning, Evaluation, and Policy Development, 2010 (http://www.ed.gov/rschstat/eval/tech/evidence-based-practices/finalreport.pdf)

Flipped Classroom

Created by Knewton and Column Five Media

Evidence-based Presentation Design: Still “Anemic”

Soon after I became interested in presentation design, I began reading everything I could find on the subject. This first led me to books like Slide:ology and Presentation Design, but I then started to find some of the original literature the principles are based on.

In March of 2007, the AAMC’s Institute for Improving Medical Education published the recommendations of a colloquium on the use of educational technology in Medical Education.

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The key finding in regards to presentation design can be summarized in the following quote:

“…participants agreed that the current evidence base for educational technology in medicine is anemic. Although numerous publications have documented the feasibility of technology to enhance learning in various settings, little is established about precisely when to employ technology during medical education, and how best to use it when it is employed.

Fast forward 3 years, and we are still looking for the answers.

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According to the author, “the majority of medical school lectures run contrary to best practices in instructional design.” I would argue this is true of the majority of ALL presentations.

What does this mean for us?

As educators, we need to challenge the current educational practices and conduct research to find the best ways to educate our learners. It also means that it is our job to incorporate best practices into our teaching. This is especially important for medical education as enhancing the learning, skills, and retention of our students may lead directly to better patient care and patient outcomes.

We can definitely cure our anemia.


AAMC. Effective Use of Educational Technology in Medical Education. March 2007. Available at: aamc.org. Downloaded May 22, 2013

Levinson, A. Where is the evidence-based instructional design in medical education curriculum development? Medical Education. 2010;44:536-7