There was a time when medical training consisted of following a mentor (physician), with learning based on the process of “see one, do one, teach one.” It was the gold standard in teaching medicine. The phrase isn’t exactly accurate, but it worked. You saw something more than once, and you did it more than once, before you taught it. This was especially true for learning how to perform surgery, and all medical training was surgery at one point. In fact, doctor’s offices were called “surgeries” as late as the mid-20th century. My oldest friend’s dad was a physician, and his offices were called “the surgery.”
Medical training is evolving
Medical and surgical procedures used to be simple. If you were an apprentice, you saw the procedure, you did the procedure, and then you taught the procedure to your student once you became a physician and took on your own apprentice or apprentices. “Doctoring,” along with the education of doctors, started changing in the late 1700s. We began to have formalized medical education and schools of surgery. Physicians started learning from books. From antiquity until the 1800s, all doctors were jacks-of-all-ailments, from helping those with colds to helping someone who needed an appendix removed to … well, if you can think of a medical condition, that’s what a doctor had to know how to treat.
The changes in medicine and medical training occurred as science discovered more and more about disease and how to treat it. A lot of diseases are caused by bacteria. Bacteria were first observed by Antonie van Leeuwenhoek back in the 1670s, but the little “animalcules” he saw weren’t identified as the cause of disease for nearly 200 years! Many physicians had their suspicions about bacteria and microorganisms, but it was Louis Pasteur and Robert Koch in the 1870s who correlated disease with some of the little organisms. Fast-forward 130 or so years to 2000. Medicine reached a kind of tipping point when technology truly began to assist with medical diagnoses and procedures.
Because our knowledge of medicine is growing exponentially, there is increasing specialization and division into smaller and smaller areas of practice. Medicine isn’t going to get any less complex, and this creates a conundrum. How do we train young doctors today using all the resources we have, both online through virtual reality and with living patients? Many university-based physicians who run medical training programs knew the system developed over the previous two centuries wasn’t working well enough. It wasn’t that physicians who were graduating were bad doctors, per se, but there were fewer who were going into surgery and fewer still who even stayed in the practice of medicine. The number of students who have stopped practicing medicine five years after graduation is shocking.
Over the past decade and a half, the science and education of medicine has changed immeasurably. Teaching medicine used to be quite simple. It isn’t anymore.
In the 21st century, teaching medicine has embraced both technology and patient care. Medical school curricula hadn’t changed for decades other than teaching advances in medicine. It used to be that first-year medical students sat in classrooms, dissected a cadaver (their first patient), and had a lot of “book learning” medicine. Very little time was spent with patients until the second year of medical school, and at some schools not until the third year. The fourth year of medical school was mostly clinical. Finally, students got to spend time with patients.
Medical schools can’t work that way any longer. Clinical time in front of patients is the most important training an aspiring young doctor can receive. At many medical schools, students start in clinics in their first year—in fact, in the first part of their first year. And yes, there is still a lot of “book learning” and other written material (such as HIPAA regulations in the US) that medical students and residents must absorb. That hasn’t changed, but now it’s delivered via the Internet or loaded on tablets and smartphones. Additionally, simulation has become virtual reality, and virtual reality (VR) is getting big. Really big. There are a lot more delivery systems and modalities that are very appropriate in medicine. VR is just the beginning.
In the late 1990s, I worked for the department of surgery at the University of Michigan. We decided to digitize somewhere north of 400 videos of surgical procedures. This was new territory. And although I was making a lot of video and experimenting with HD, we didn’t use the video we created for medical student or resident education. One reason was that video couldn’t be streamed yet, since there wasn’t enough bandwidth in 1999 (and the video codecs weren’t good enough to stream video). If you were going to try streaming video, it had to have small pixel dimensions (by today’s standards): about 300 pixels across by 220 down. That’s a small image, but screens and CRTs (cathode ray tubes) were 720 by 480 pixels, so these videos didn’t seem that small in relation to the screens.
After the 400 videos were digitized—a whole process that was very complex compared to today—we transferred them to a special dedicated server and used a Flash-based portal (hey, it was 16-plus years ago) where a resident user could scroll over a list for different body functions (circulatory, digestive, etc.) and a list of surgical videos available to view would pop up. Surgical residents, especially first-year residents who were scheduled into the operating room (OR) for a specific procedure, would go to the portal in a browser to look for the same procedure. It sometimes wasn’t that easy. At that time, we had digitized 16 ways to repair a hernia! The residents would view the video of the procedure right before they walked into the OR and get a basic understanding of what was going to happen. Computer video and the Internet have come a very long way since then.
And now, virtual reality
Virtual reality is the next (or rather, the right-now) big thing in medical schools. It’s also gaining traction in patient care. VR in medical training is especially good for surgery. In one of several randomized clinical trials, the investigators concluded: “Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.”
That trial is from the UK, but just as valid here. Surgery—both interventional (like open abdomen) and other non-invasive procedures—is increasingly incorporating VR components. Virtual reality, and better still interactive virtual reality, is beginning to show amazing benefits in physician, surgeon, and nurse training. Beginning early in the first year of medical school, the students used to dissect a cadaver. This no longer happens at most medical schools. The dissection is virtual. If you’re an adult, say, over the age of 45, it might not seem like it would work, but the schools have demonstrated it does. Many believe it’s as good an experience for the students, but there is no tactile sensation of what organs feel like, even though handling a cadaver isn’t the best way to know what a kidney or a stomach feels like.
Virtual reality, and VR training, is becoming a large factor in operating rooms and small surgeries everywhere. Laparoscopic robotic surgery is becoming commonplace, along with laparoscopic regular surgery, and both are certainly virtual reality. Training with a robotic surgery machine is really a virtual virtual-reality surgery. At Johns Hopkins, they’re teaching both traditional techniques and robotic techniques at the same time. The resident or surgeon uses a robotic surgery machine when there’s no real body, but a representation of one in the viewfinder. It frequently doesn’t look real… yet. The student or resident gets a feel for the machine while they’re in the early part of their medical careers. The surgeon gets to practice on the machines. When they become surgeons, students and residents are prepared to use the machines like a second set of very flexible hands.
Many surgeries are still best performed by hand. Robotic laparoscopic surgery frequently isn’t appropriate. Obviously (or maybe not so much), surgery to the limbs isn’t appropriate for laparoscopic surgery. There’s nothing to inflate to see the organs, except in the case of joint surgery (knee, shoulder, and elbow). Some of those are done laparoscopically. Most are now trained using VR. As the haptic quality of the robotic surgery machines improves, robotic surgery will be getting better. Much of laparoscopic surgery is still done manually, and the training is traditional. This is not because of resistance by surgeons, but because manual laparoscopic surgery is frequently faster. Surgeons need to work as quickly as they can while being extremely careful. Less time in anesthesia is a good thing. Maybe it’s just experience levels, and as surgical experience improves there will be more and more robotic surgeries.
One thing that was discovered early on was that the best handlers of the robotic surgery machines were younger surgeons (late 20s to early 30s) who were also good video game players. The dexterity they gained by playing with their Nintendos, PlayStations, Xboxes, etc., became invaluable. They picked up on the machines rapidly. Older surgeons sometimes struggled with them; they didn’t have the same kind of dexterity that was used in games when they were young. There are still technical limitations, especially in the haptics, but they’re getting much better.
These are just a few examples. All these techniques can be used across the board in medical schools, nursing schools, dental schools, and physical therapy and veterinary schools. There’s no field in health not benefiting from the implementation of virtual reality.
The caveat I’ve heard more than once is that VR doesn’t match the feeling of being with a real patient. And that leads us back to the beginning.
Medical education is undergoing a fundamental change, a sort of “back to the future” in medicine. Technology is one of the drivers, but a larger driver might be the patient-physician interaction. I interviewed several physicians who teach at different medical schools around the country. After some short conversations, it became obvious we’re in the midst of a sea change in how doctors are trained from the first day of medical school until they graduate. We’ve come full circle.
This, in part, is a return to a highly modified apprenticeship system. First-year medical students now routinely begin having patient contact just weeks after starting medical school. They’re most definitely at the “see one” stage, but they’re seeing—and they’re seeing patients. Students frequently follow one physician for a term of time: at one school, for an entire semester, at another for a month. There’s lots of variation. The real value is that students then become apprentices, in a real sense, to the physician they’re following around.
Two hundred and fifty or so years ago, as medical schools were beginning to form, we ended the millennia-old system of medical apprenticeship. It goes around and it comes around. When the first medical school in the colonies opened in 1765, it was to have “anatomical lectures” and a course on “the theory and practice of physik.” Apprenticeship as a more or less formal program was ending as medical schools began to open.
Apprenticeship is a good training program at the basic level. Of course, it’s different in the corporate world where we assume basic skills are known, but new skills are always necessary. Is it that different from medical training? Some companies apprentice a new employee to shadow an experienced employee for a week or so. This inculcates the new hire into the corporate culture and rhythms of daily work life for the new employee. As medicine, research, and society get more complex, maybe training should be simpler.
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Grantcharov, T.P., et al. “Randomized clinical trial of
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McConaghy, Mary D. “School of Medicine: Historical
development, 1765-1800.” University Archives & Records Center, University
of Pennsylvania. November 2010.