Wednesday, February 15, 2017

So where is the Creative Destruction?

Assuming the existing paradigm of medical school education is tired and in need of replacement, the next question is why hasn’t it happened? Technology change is all around us. Students have replaced memorization and note cards with the EHRs, phones, laptops and Google. Yet the system is relatively unchanged. How come?

A review of creative destruction is helpful. The original theory of creative destruction (replacement of old with new) was that downturns in the economy spurred such destruction. This “liquidation model” proposed that when things go bad people revisit resource allocation and come up with novel solutions. The application of this model to medicine would infer that the unending growth and riches of healthcare is the problem. Additionally the ability to dump more and more debt onto medical students [thus forcing students to choose high paid specialties focusing on procedures] has further enhanced the riches of the industry. The end result of all this largesse is that the healthcare aspect of the economy has been protected from from the risks (and destructive value) of recession. Without downturn there is complacency and thus stagnation.

So for us to move out the current "Normal Science" and shift the paradigm we would then need something bad to happen in terms of health care. Now since health care is 17% of GDP you can argue either way.

Option #1: No way can that happen; our entire economy will crash.

Option #2: It is inevitable. How much longer can the US remain competitive when it spends twice what any other country spends and still does not provide health care to everyone?

I wish I had the magic ball to predict which one will win. Sadly, based on the above theory we lose either way. If everything stays rosy then medical student changes. If health care in the US crashes then medical student training changes but the system is in chaos.

Thursday, February 9, 2017

The Paradigm Shift to Experiential Learning

In the discussion of innovation and paradigm shifts, it's helpful to review weaknesses in the process of challenging the existing paradigm. In this case, I am going to discuss the paradigm of a standard "academic" approach to education.

I recently got a chance to experience experiential learning first hand in a course called "Modern Marketing". The course eschewed the usual "academic" approach to education or the more trendy "case-based" approach to education. Instead it chose to teach modern marketing via participating in the Google Online Marketing Challenge (GOMC).

The experiential learning involved:
  1. Reviewing potential team members
  2. Contacting them about joining or adding them to a team
  3. Setting up communication techniques
  4. Defining strengths and roles
  5. Forming a team contract to define team expectations
  6. Identifying potential clients to work with the GOMC
  7. Deciding as a team what client to solicit
  8. Contacting clients
  9. Forming an understanding to work with that client
  10. Creating a contract that would define the expectations
  11. Negotiating that contract
Before actually investigating the use of [Google Adword] marketing for a specific client's website.

Note that the above elements are team building/personal/business skills; these are not "marketing" skills. As we migrate from the old (e.g., boring, didactic, research, academic, expert-based) pedagogy in an attempt to confer skills/competencies vs. knowledge we must challenge our assumptions. In this case the assumption is that experiential learning is more effective and even if that effectiveness comes as a cost the value outweighs the cost.

I disagree. Inefficiency is inefficiency no matter how exciting the outcome. As we alter our pedagogy to become experiential we need to be aware of the potential inefficiencies in that approach and to aggressively counteract those inefficiencies. Otherwise our learners spend time doing something they are already skilled at.

For example, if Hertz required that anyone renting a car first go through Driver's Education, that would be an excellent idea for a young kid who never drove a car before and hasn't take that course. To require that for someone who has been driving for 20 years is silly. Similarly, in the marketing class experiential learning example above the above process is a useful learning lesson at the beginning of training (assuming such skills don't exist). But putting such a process at the beginning of every course is inefficient. Not assessing if these skills already exist is lazy.

Let's say we went back to the old pedagogy. In that case the first item would probably be "complete module 1 in the online course/book and answer the questions." Perhaps that wouldn't be trendy or impactful but efficient. But at least the first action in the course would be related to marketing.

What to do if you want to deploy more active, participatory experiential learning model?

In this case the solution is quite easy. Move efforts that are "core skills" to a module focusing on "core skills development." Then identify potential inefficiencies and root them out. In this case:
  1. Assign team members to teams
  2. Deploy an efficient communication framework to all teams and refine it (alas such a product probably does not exist thanks to lameness of Blackboard and Canvas) - Come on Google do it for us!
  3. Pre select all companies to work with and ensure they have already agreed to participate and signed a contract to that extent.
Skills training/learning then occurs starting with the first hour of the first day.

As medical training moves to experiential learning it must put effort into similarly rooting out components that are unrelated to the skills development (i.e., competency creation) task at hand. And to not accept inefficiency as a necessary component of that the end goal.

So what is the core weakness in the process of challenging the paradigm? Caution. The old paradigm is alive and well in the above inefficient example. Inefficiency leads to frustration and confusion. It saps excitement and drives folks back to the old way of doing things. Most importantly it ensure that it doesn't work that well. It's a classic example of, "I want to challenge but not alter". As I interpret Kuhn, the existing paradigm is a wall and to some extend we don't want to break it down for fear of what is on the other side. I'll avoid putting in Reagan's quote to Gorbachev.

Wednesday, February 1, 2017

Micro Shifts

I'm at the Winter Conference on Brain Research (WCBR) which is full of very complicated talks about brain functioning and the underpinning mechanisms and mediators. It's Kuhn's "Normal Science" writ large. But since Kuhn focused on physics and it was 50 years ago how could he have imagined such a huge effort focused on such a small (comparatively) problem? 

Were he to be at this conference, perhaps he would have identified "Micro-Paradigm Shifts" that follow the same pattern but are limited to a smaller field. As an example genetics is slowly challenging the Bipolar Disorder I/Schizoaffective/Schizophrenia rubric and imply they are all the same. Most people say it's bunk and others simply carry along with DSM-V and ignore the debate and implications. But if these diagnostic categories are wrong then the entire field of psychiatry has been traveling down the wrong path (and misdiagnosing patients and potentially mistreating them) for eons. Certainly that would qualify for a paradigm shift.

Similarly there is probably some finding at this conference which is "upsetting" to some attendees and challenges the known order. Perhaps what we really need is a way to identify the early stages of shift where/when someone challenges "normal science."

In terms of medical student training we might look for evidence of unease. For example, the emphasis of the "new" topics (economics, big data, data analysis, communication, coordination) isn't really causing any unease. Annoyance, frustration and perhaps irritation for some, but certainly not unease. So this is still "normal science" of medical education. It's just adding topics already to crowded curriculum (which lacks coherency, recognition of unsustainability, or relevance to the actual practice of medicine - but I digress.)

In contrast arguments that medical school should be reduced to 3 years (which I find compelling) have been greeted with unease. So any challenge to the "medical school takes 4 years" paradigm [Duke's replacement of one year with a research year seems a sneaky way of implementing change without causing unease] would seems to be evidence that a shift is happening. The actual shift may not be to 3 years. It may be to an entirely new approach (distance learning, individualized curricula, varying lengths?) to medical school training. But to me identifying unease is the key to identifying potential shifts, and changes to the 4 year plan are about the only change that I see that causes unease.