Professor Harden gives his thoughts on some of the session themes from the AAMC 2016 Meeting in Seattle, Entrustable Personal Activities and the further development of the ASPIRE initiative.
Well, not quite! Despite the eight-hour time difference and with the help of melatonin and a busy schedule I managed to sleep reasonably well. I was in Seattle for the AAMC 2016 Annual Conference. Conveniently there is a direct British Airways flight from Heathrow to Seattle. BA now keep a back record of their travellers’ history. I was interested to see that since BA started their personal records I have visited 72 cities in 40 countries. They offer an interesting metric for the distance travelled – the proportion of journeys to the moon! Apparently I have travelled the equivalent of 11.5 trips to the moon.
At the meeting the recent election of Donald Trump dominated many of the discussions. Darrell Kirch and Atul Gawande, both powerful speakers, highlighted the role of academic medicine as a partner in fostering community health at a time of eroding trust in institutions and deep division about the role of government in supporting the public good. Each of us, they suggested, can make a difference in our own setting. The importance of caring for ourselves and wellbeing was a theme that ran throughout many of the sessions in the meeting along with issues relating to resilience and discrimination. Atul Gawande introduced his new book “Being Mortal”, which tackles how medicine can improve not only life but also the process of its ending. He challenges us to think of how do we define good care? Medicine, Gawande argued, has become more complicated with more than 60,000 different diagnoses, 6000 drugs and 4000 medical and surgical procedures possible. What among these should a student be expected to learn?
Entrustable Professional Activities (EPAs) was another theme for the sessions. In one paper Olle ten Cate, who first initiated the concept, described five EPAs as the basis for a new curriculum at Utrecht. In each EPA is nested additional EPAs. What surprised me was that the six-year curriculum, which is divided into a three-year Bachelor Programme and a three-year Masters Programme, appears to have a preclinical/clinical divide with most of the teaching slots in the first three years labelled as non-clinical. This is very different to the five year curriculum in UK medical schools where there is vertical integration and clinical experience from year one.
We had an AMEE stand at the meeting and this was a great opportunity to meet existing AMEE members and encourage others to join. MedEdPublish attracted a lot of attention. Many visitors to the stand indicated that they will be participating in the AMEE Conference in Helsinki.
One of the sessions at the meeting featured Excellence in Medical Education: Standards for Best Practice. Dan Hunt chaired the session and there were contributions from ASPIRE award winners Anna Cianciolo and Pedro Greer and from James Rourke, Chairman of the Social Accountability Panel for ASPIRE. I reviewed the establishment of the ASPIRE initiative and concluded with lessons learned and possible further developments. Two suggestions for additional ASPIRE-to-Excellence topics made by participants were the Learning Environment and Innovation and Change Management in the Medical School. These and the other suggestions we have received will be put to the ASPIRE Board at its meeting in Singapore in January. The session was very well attended with more than 400 participants and a number of schools subsequently expressed interest in applying for an award.
In my opening ASPIRE-to-Excellence presentation, I referred to the move in the UK to evaluate universities in relation to excellence in teaching. The results will determine what level of fee increase English universities are allowed to make. In the initial plans the rating categories were “Meets expectations”, “Excellent” and “Outstanding”. “Excellent” and “Outstanding” were, however, thought to be potentially confusing and the categories have been changed to “Bronze”, “Silver” and “Gold”. I believe that one can differentiate “Excellent” and “Outstanding”. In the ASPIRE-to-Excellent initiative many medical schools will demonstrate excellence in the different areas assessed but there may be, perhaps, only a few who are internationally outstanding.
I participated in another session at the conference where six editors of medical education journals gave their views as to the priorities for their journal. As editor of Medical Teacher I argued that there was a need to remove the disconnect between research in medical education and teaching practice. Even in medical schools with internationally recognised centres for medical education, the curriculum frequently does not demonstrate best practice. Perhaps more provocatively I argued that there was at present an elitism in having articles published and that as Richard Smith, formerly of the British Medical Journal, had suggested the fact that the editor and a small number of referees decide what should be made available to the journal readers is not desirable. Each week we receive 30-35 manuscripts for Medical Teacher of which only three or four can be accepted because of space constraints. AMEE’s new journal, MedEdPublish, has been established to tackle this problem with all manuscripts published usually within days of their receipt, following only a minimum vetting procedure and with reviews of the papers taking place in public following their publication. An advantage is a more dynamic interaction between the authors and the medical education community. As editors we were also asked what we saw as missing in the medical education literature. I argued that insufficient attention is sometimes given to work that simply replicates what has already been done or reports failures. The need for more replication studies has been highlighted in the education literature and a commentary in the Journal of Graduate Medical Education (October 2016) by Picho and Artino argues that “replication remains an underappreciated and relatively uncommon enterprise”. They express concerns over the validity of scientific research with “considerable evidence indicating that most published research findings in the biomedical sciences are false”. Because of the lack of replication studies these mistakes are not corrected. I find it unhelpful to read systematic reviews of the literature which simply conclude “further research is required.” I also suggested that in medical education we are too conservative and traditional in our approaches and this is reflected in the articles published in our journals. We need to challenge current practice in medical education, addressing for discussing questions such as “do we need 13 years to train an ENT surgeon?” or “should the medical school of the future be very different from the medical school as we know it today?”
Walking in the streets in Seattle as in most other cities, one can’t help notice that people don’t just walk anymore. They are making calls, sending messages, following maps or listening to music. Writing in the November issue of Business Traveller, Tom Otley describes Google’s new Pixel phone and Google Assistant which answers questions you ask. It does this in two ways. It learns about you as you interact with it and it also scans your emails and calendar, knows your google searches and restaurant choices and locations and has metadata on your photos and information on your friends and colleagues. I find this slightly frightening.