Toshiba America Medical Systems

Moving Towards Modern Medical Education and Training

Pt. 3A: Teaching to the Test

Anthony Mancuso M.D. - Professor and Chairman of the Department of Radiology - University of Florida - College of Medicine | November 22, 2017



Anthony Mancuso M.D. has a mission to modernize post graduate medical education.  He has  spent the last eight years developing a competency based curriculum and evaluation, based on modern learning theory, with his team at the University of Florida.  They have leveraged extraordinary Learning Technologies to deliver this platform anywhere in the world. In his essay series, Moving Towards Modern Medical Education and Training, Dr. Mancuso will examine in detail: the specific pathway to this adherence to modern learning, educational theory, and the outcome of the application of those principles in this sphere of medical education.  

“Teaching to the Test” is a far less acceptable educational behavior, as a concept in medical education and training, than it is in primary and secondary school and university education. Such tendencies either should marginalized or eliminated at all levels but most especially in medical education, both at graduate and post graduate levels. “Teaching to the Test” erodes the curriculum and significantly reduces the validity of the test of mastery; both of these circumstances are serious decrements to the goal of establishing mastery/competency in a profession that requires critical thinking and problem solving as fundamental skills. The focus of an evaluation of mastery of knowledge should be to assess the student's or trainee's ability to use that knowledge. This concept is a foundational principle in the Bloom Taxonomy of Learning 1-2 Our patients must be assured that we can actually do what we intend and represent ourselves as capable of doing. Unfortunately, current curriculum models and testing methodology are not up to a standard that can truly establish competency/mastery and, therefore, would allow us to confidently express such assurance to our patients.

In 1906, with the inspiration of the Flexner Report 3, medical education in the United States evolved to a modern standard of teaching, but over 100 years later, not much has changed with the construct of medical education.  Until we can continue the evolution of medical school education and training, we will remain in a system predominantly based on pedagogical encouragement of memorization and regurgitation, as opposed to effective adult education.  True, there have been marginal improvements in the educational system; however, it is time for more than marginal improvement.  A rethinking about the construct of our medical education system and training, is clearly in order.
 
Dr. Weed introduced transformative concepts in medical education in the 1960s. His writings on the Problem Oriented Medical record as a treatment and educational tool, as well as more recent ideas on couplers, lead us to consider merging vast amounts of knowledge and practice experience with the extraordinary acceleration of available Learning Technologies4-8 Fortunately, that rethinking is underway with the national movement toward Competency Based Medical Education (CBME) 9, an outcomes-based approach to the design, implementation, assessment and evaluation of a medical education program using an organizing framework of competencies.

Over the last 10 years, in the UF Department of Radiology, we estimate that in the realm of critical care radiology, there are likely 600 to 800 conceptual, individual competencies/scenarios that should mastered to avoid potential harm. Such potential harm is known, in clinical practice, to be produced by observational and/or interpretive error in these often highly acute clinical scenarios. In fact, we chose the critical care domain because of the predictable potential impact of reducing harm since decision-making is often hurried and, frequently, diagnostic imaging is a critical data point influencing the next step in the plan. Critical care radiology with its relatively limited number of potential scenarios also seemed to be a reasonable body of clinical work that was amenable to a complete curriculum being delivered in a reasonable period of time.

Overall, there may be as many as 2,000 or 3,000 individual concepts, or competencies/scenarios, that apply to our entire diagnostic imaging specialty. If that is true, we can assume that it would be difficult for any one individual to become truly competent in all aspects of diagnostic imaging. That argument would seem to be reasonable based on the current shift in postgraduate radiology specialty training, which is now moving toward strongly encouraging mastery of focused areas of subspecialty interest. Given the foregoing assumptions, we can develop a list of these individual competencies to establish a curriculum that presents a roadmap and related educational tools for those wishing to prove mastery in some subset of the entire domain of radiology based competencies.
 
If you are going to give a test, it is only fair to present a curriculum that lays out the fundamental knowledge and skills that will be required for success in the testing rubric. In doing so very specific behavioral objectives, clearly spelled out in the tested curriculum must be established. If CMBE is to be validated, this is an essential next major step in the evolution of medical school and postgraduate medical education. Then how do we go about producing such a curriculum and a fair and meaningful evaluation rubric to prove mastery/competency in each individual competency tested. In the previous installment (“See one, do one, teach one”), the concept of curriculum development using the ACR Appropriateness Criteria in diagnostic imaging as a partial guide was introduced 10. In that installment we defined a specific competency to be mastered as a scenario; a scenario being simply an imaging study, in the context of a specific clinical situation, where that imaging study is appropriately considered likely  to advance medical decision-making.

So back to the original question. Why are we as diagnostic imaging educators, like those educators in the primary and secondary schools and University domains, “Teaching to the Test”? Our goal and responsibility should be discovering and, systematically eliminating from our system the educational gaps that span the knowledge and reasoning skills we must deliver to our trainees.

Evaluation is a necessary part of any educational system. Testing should reflect the goal of the education, which would ideally be mastery of a meaningful curriculum that is articulated and presented to the trainee or student. In primary and secondary education the schools in many districts spend a significant part of the school year educating to the specifics of standardized testing (“Teaching to the Test”) that will be used to judge teacher competency and in many cases affect school funding.  Primary and secondary school teachers much prefer to teach to the endpoint of critical thinking and creativity.  However current school systems require “Teaching to the Test” because they are partially motivated by financial incentives. We do not have the same financial incentives in medical school education.  Our only incentive in graduate and post-graduate medical education is to produce the best care to our patient by producing proven competent physician.  We must “teach to competency” and allow the test to prove establish mastery. “Teaching to the Test” will then produce the desired result - Competent, expert professional work product.

Coming next:
Part 3B: Competency or Passing the Boards? Every patient wants an expert. 
 

 
Anthony A. Mancuso, MD 

Dr. Mancuso graduated from the University of Miami School of Medicine in 1973 and completed a Residency and fellowship training in Diagnostic Radiology, including 2 years of subspecialty Neuroradiology training, at UCLA Health. He joined the faculty at UCLA Health where he was fortunate to have a founding member of organized neuroradiology in the United States, Dr. William Hanafee, as his friend and lifelong mentor. Dr. Mancuso owes much of the professional development in his career to Dr. Hanafee both with regard to his dedication to development of effective educational methodology and a devotion to discovery of practices that make a positive impact on patient care. He is a Past President of the American Society of Head and Neck Radiology and Senior Member of the American Society of Neuroradiology.

In 1983, Dr. Mancuso joined the faculty at the UF Health to direct the development of the MRI clinical and clinical research program. In 2000, he became Chairman of the Department of Radiology and remains in that position currently. He is also the President of the Florida Clinical Practice Association at UF Health.

Dr. Mancuso is an acknowledged international expert in the area of ENT radiology having been recognized for his achievements by Gold Medals from the American and European Societies of Head and Neck Radiology and a Presidential Citation from the American Society of Head and Neck chirurgery. He has over 170 refereed publications most in the area of Head and Neck Radiology, and has written several books, most recently, a comprehensive 3 volume text covering the clinical practice of head and neck imaging.

Dr. Mancuso's current research interests have been in developing novel methodologies for radiology education, exploiting foundational and modern learning techniques and merging those techniques with IT tools that make personalized, asynchronous delivery of an effective Radiology curriculum finally possible. His clinical research interest is now focused on the development of advanced brain MRI utilizing DTI and fMRI for the evaluation of traumatic brain injury and a wide range of neuropsychiatric disorders.
 

References

1- Bloom, B., Englehart, M. Furst, E., Hill, W., & Krathwohl, D. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York, Toronto: Longmans, Green.
2-Krathwohl, D. R. Methods of Educational & Social Science Research: An Integrated Approach. 1st Ed. 1993, 2nd Ed. 1998, New York: Longman, also Long Grove, IL: Waveland Press; 3rd Ed 2009, Waveland Press
 3-Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (PDF),
Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, p. 346, OCLC 9795002,
4-Weed, L. L. (1964-06-01). "MEDICAL RECORDS, PATIENT CARE, AND MEDICAL EDUCATION". Irish Journal of Medical Science. 462: 271–282. doi:10.1007/BF02945791. ISSN 1863-4362. PMID 14160426.
5-Weed, L. L. (1968-03-14). "Medical records that guide and teach". The New England Journal of Medicine. 278 (11): 593–600. doi:10.1056/NEJM196803142781105. ISSN 0028-4793. PMID 5637758.
6-Weed, L. L. (1968-03-21). "Medical records that guide and teach". The New England Journal of Medicine. 278 (12): 652–657 concl. doi:10.1056/NEJM196803212781204. ISSN 0028-4793. PMID 5637250. 
7-Weed LL. Medical records, medical education, and patient care: the ProblemOriented Medical Record as a basic tool. 1970. Cleveland (OH): Press of Case Western Reserve University.
8-Jacobs L. Interview with Lawrence Weed, MD—the father of the problemoriented medical record looks ahead [editorial]. Perm J 2009 Summer;13(3):84–9.
9- AMA.org- Education-Creating the Modern Medical School. 
10 - https://www.acr.org/Quality-Safety/Appropriateness-Criteria