Information technology and the future of medical education
Rolf J. Sebaldt, MD, CM
Clin Invest Med 1997;20(6):419-21.
Dr. Sebaldt is Associate Professor of Medicine (Rheumatology) and Associate Professor of Clinical Epidemiology and Biostatistics, Centre for Evaluation of Medicines and Health Information Research Unit, McMaster University, Hamilton, Ont.
He is also the producer of the electronic edition of Drugs of Choice, published by the CMA, author of Fig.P scientific data graphics software, produced by Biosoft, and developer of the CANDOO system and national registry of patients with osteoporosis, osteopenia and menopause. He is currently developing physician-friendly computer interface systems and disease-specific patient database systems for point-of-care use by subspecialist physicians and surgeons.
Reprint requests to: Dr. Stuart M. MacLeod, St. Joseph's Hospital, 50 Charlton Ave. E, Hamilton ON L8N 4A6
The inevitable challenge for an academic medical education program, whether undergraduate or postgraduate, is to successfully manage the process of its own evolution. Since innovations are, by definition, untested, there are no gold standards by which to evaluate options for change. But beware the planners who are certain they "have it right." Gold standards are equally lacking for the optimal balance among innovative (creative), catch-up (adaptive) and tried-and-true (conservative) policies.
Information technology and medical informatics are related "buzzwords" of the late 20th century. They encapsulate a set of remarkable concepts and dramatic implementations in computer software. The enormous growth in the capabilities of computer hardware as well as their widespread availability and increasing interconnectedness around the planet are critical underpinnings.
Development has continued at a blistering pace for more than 15 years. This would have been dramatic enough had it meant that development has been constant (like the amount of water that flows annually over Niagara Falls). However, like compound interest, development has actually proceeded exponentially, following Moore's Law, which states that microcomputer capabilities double every 18 months, a law that has held true since 1981 or even earlier.1 The drama of such constant exponential (or geometric) growth is quite difficult for human beings to fully appreciate, since they experience their own aging at a constant (or arithmetic) rate, such that fractional increases in one's age are continually diminishing each year, in stark and happy contrast to exponential growth!
Paradoxically, as the doubling of computer power has become a routinely sesqui-annual event, and as computer hardware has attained commodity status, it is no longer helpful to see information technology as a precipitous revolution that is either under way or imminent. Rather, the continuing exponential pace has become normal, and that fact is the "revolution that has already been." It is also the basis of the enormity of the future challenge, since there is no single opportune moment that simply awaits discovery by forward-thinking planners.
The practical consequences are enormous. For example, entire personal medical records can easily be stored digitally on small portable cards, a capability that may render all existing medical information systems sadly obsolete, or at least hopelessly inefficient and ineffective. Very-high-resolution radiographic images can be converted into, or directly created in, digital form, usefully manipulated, instantly transmitted to distant locations, securely archived and easily retrieved, rendering all existing film-based storage systems cumbersome and outdated. At the moment, data transmission speed over normal Internet conduits limits the value of image transfer, but this too is changing fast.
Exponential growth in information technology ensures that today's potential wonders will be eclipsed by still greater opportunities. This applies not only to technical or operational efficiencies but also to optimal patient care in our real-world medical practices. As information technology blasts ahead, a few precious "gems" and many dull "rocks" are regularly spewed forth. Among physicians and educators alike, there will always be those who embrace the newest and the latest drugs, gadgets or procedures, and also those who prefer to ignore all innovation until the last possible moment. The unavoidable challenge for medical educators is to regularly and continually re-evaluate options for improving their teaching methods and tools. In the face of constant rapid change, they must avoid the paralysis of perpetual uncertainty while making decisions that open rather than close future options.
It behooves medical curriculum planners and faculty achievement evaluators to embrace the fact that continuing rapid change in information technology is the new status quo. All medical educators should be receiving active encouragement, incentives and even prodding from senior management to use their unique, specialized knowledge and skills to participate in the development of improved teaching tools and innovative information presentations.2 The creation, evaluation and application of these teaching methods and tools by academics, depending on the faculty members' interests, will help develop the capabilities of information technology to best advantage for learners.
Most such efforts will be so innovative in practice, however, that current criteria for "academic" excellence and achievement for promotion will fail to recognize them. A personal example of this is the creation, development and publication of Fig.P, a data graphics computer program that addressed many of the previously unfulfilled needs of biomedical researchers. This project was an enormous, unique and wonderful challenge for me. In my opinion, its ultimate success is better measured by the many thousands of copies sold worldwide than by the number of citations indexed or the number of minimum publishable units that it may be equivalent to. While academic and industrial colleagues worldwide have spent significant research dollars to obtain "reprints" of my work, this contribution was also for a time much more a hindrance than a help to me when I sought academic promotion.
To use a set of backward-looking analogies, creating innovations using information technology, such as computer software, teaching simulations, multimedia resources and other electronic publications, has many of the same aspects as such diverse activities as writing a book, developing a university course, preparing a meta-analysis, running a collaborative clinical study, designing a laboratory research program, and tutoring/mentoring a small group. The foresight of a rapid and thorough modernization of academic criteria for excellence and achievement will be mandatory at institutions that wish to provide leadership in education, research and development.
Is any academic medical program preparing its graduates to fully exploit the benefits of computer literacy in their professional lives? Is any program fostering in its graduates a respect for, and a desire to contribute to, innovations that harness the vast potential of information technology, for the benefit of medical practice and patient outcomes? Or will academic medicine fade into uninspired passivity, turning out a generation of medical professionals who are generally satisfied to evaluate and adopt existing technologies conceived and created for them by professionals in other disciplines?3
The products of information technology provide users with at least 2 basic services:
- memory, or increasingly vast storage and retrieval capacity for data of any kind, and
- processing power, or increasingly powerful computational capabilities.
Exponentially increasing "memory," in the form of larger hard disks, CD-ROMs and DVDs (digital video discs) on one's desk or accessible via the Internet or the Intranet of a local institution, makes current medical knowledge increasingly available to students, teachers and patients alike. Electronic information resources such as reviews, formularies, critical appraisals, guidelines, textbooks and original research publications allow their authors to publish updates more quickly and inexpensively than is possible in print. For information users, the latest information can be found "just in time"4 when needed at the point of learning or of clinical care in the office or hospital setting. Massive textbooks and journals that are disproportionately out of date despite their weight can be left unprinted in most cases. Successful information products and teaching resources can be a huge challenge to create and remain quite rare, but reflect mastery of a subject and the ability of the authors to communicate.
Exponentially increasing "processing power" provides increasingly sophisticated and rapid searching, displaying, retrieving, sorting, comparing and analyzing. Computational power whittles down and otherwise manages increasingly unwieldy data sets. Complex images can be processed rapidly (in "real time") and help impart 3-dimensional knowledge of anatomic structures. Virtual reality systems allow brain, eye, cardiac or orthopedic surgery to be learned. Complex system simulations with dynamically changing visual or graphic displays can increase understanding of typical and aberrant behaviour of intricate biological systems, such as physiologic or pathologic (cardiac, renal, metabolic, neuronal, immunologic, neoplastic), pharmacokinetic, epidemiologic and other systems.
Large amounts of current medical information on any subject are rapidly available to anyone through CD-ROMs, other electronic publications and the Internet. Teachers are no longer needed solely in their role as a repository and provider of current information; they are freed to help students develop an approach to exploiting electronic information resources and to critically appraising their shortcomings. Although information content is the ultimate raison d'etre for information structure, current best knowledge can be exploited as the essential but ephemeral database du jour through which students acquire durable information-structuring skills. To help instil a passion for lifelong learning, teachers should use these information resources as part of their teaching activities whenever appropriate.
Medical schools should not oblige their students to purchase a stethoscope, an electrocardiogram machine, a computer or a magnetic resonance imaging scanner. However, this does not relieve them of an obligation to offer solid grounding in the use and abuse, interpretations and limitations of each of these exceptionally useful tools. Inevitably, however, most students will find both the stethoscope and the computer to be essential purchases for their optimal learning. The promise of a technology that is beginning to cater to the unique features and fallibility of human thinking, learning, understanding, conceptualization and memory will not be easily resisted.
References
- Miller M. Looking back -- the personal computing industry by the numbers. PC Magazine 1997;16(6):128-9.
- Lapeyre AC. The World Wide Web is already changing medical education. Acad Med 1997;72:563-4.
- Friedman RB. Top ten reasons the World Wide Web may fail to change medical education. Acad Med 1996;71:979-81.
- Chueh H, Barnett GO. "Just-in-time" clinical information. Acad Med 1997;72:512-7.
