There was a time when medical training consisted offollowing 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 phraseisn’t exactly accurate, but it worked. You saw something more than once, andyou did it more than once, before you taught it. This was especially true forlearning how to perform surgery, and all medical training was surgery at onepoint. In fact, doctor’s offices were called “surgeries” as late as the mid-20thcentury. My oldest friend’s dad was a physician, and his offices were called “thesurgery.”
Medical training is evolving
Medical and surgical procedures used to be simple. If youwere an apprentice, you saw the procedure, you did the procedure, and then youtaught the procedure to your student once you became a physician and took onyour own apprentice or apprentices. “Doctoring,” along with the education ofdoctors, started changing in the late 1700s. We began to have formalized medicaleducation and schools of surgery. Physicians started learning from books. From antiquityuntil the 1800s, all doctors were jacks-of-all-ailments, from helping thosewith colds to helping someone who needed an appendix removed to … well, if youcan think of a medical condition, that’s what a doctor had to know how to treat.
The changes in medicine and medical training occurred asscience discovered more and more about disease and how to treat it. A lot ofdiseases are caused by bacteria. Bacteria were first observed by Antonie vanLeeuwenhoek back in the 1670s, but the little “animalcules” he saw weren’tidentified as the cause of disease for nearly 200 years! Many physicians hadtheir suspicions about bacteria and microorganisms, but it was Louis Pasteurand Robert Koch in the 1870s who correlated disease with some of the littleorganisms. Fast-forward 130 or so years to 2000. Medicine reached a kind oftipping point when technology truly began to assist with medical diagnoses andprocedures.
Because our knowledge of medicine is growing exponentially,there is increasing specialization and division into smaller and smaller areasof practice. Medicine isn’t going to get any less complex, and this creates aconundrum. How do we train young doctors today using all the resources we have,both online through virtual reality and with living patients? Many university-basedphysicians who run medical training programs knew the system developed over theprevious two centuries wasn’t working well enough. It wasn’t that physicianswho were graduating were bad doctors, per se, but there were fewer who weregoing into surgery and fewer still who even stayed in the practice of medicine.The number of students who have stopped practicing medicine five years aftergraduation is shocking.
Over the past decade and a half, the science and educationof medicine has changed immeasurably. Teaching medicine used to be quite simple.It isn’t anymore.
In the 21st century, teaching medicine hasembraced both technology and patient care. Medical school curricula hadn’t changedfor decades other than teaching advances in medicine. It used to be that first-yearmedical students sat in classrooms, dissected a cadaver (their first patient), andhad a lot of “book learning” medicine. Very little time was spent with patientsuntil the second year of medical school, and at some schools not until the thirdyear. The fourth year of medical school was mostly clinical. Finally, studentsgot to spend time with patients.
Medical schools can’t work that way any longer. Clinicaltime in front of patients is the most important training an aspiring youngdoctor can receive. At many medical schools, students start in clinics in theirfirst year—in fact, in the first part of their first year. And yes, there isstill a lot of “book learning” and other written material (such as HIPAAregulations in the US) that medical students and residents must absorb. Thathasn’t changed, but now it’s delivered via the Internet or loaded on tablets andsmartphones. Additionally, simulation has become virtual reality, and virtualreality (VR) is getting big. Really big. There are a lot more delivery systemsand modalities that are very appropriate in medicine. VR is just the beginning.
Some examples
In the late 1990s, I worked for the department of surgery atthe University of Michigan. We decided to digitize somewhere north of 400videos of surgical procedures. This was new territory. And although I wasmaking a lot of video and experimenting with HD, we didn’t use the video wecreated for medical student or resident education. One reason was that videocouldn’t be streamed yet, since there wasn’t enough bandwidth in 1999 (and thevideo codecs weren’t good enough to stream video). If you were going to trystreaming 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 thatsmall in relation to the screens.
After the 400 videos were digitized—a whole process that wasvery complex compared to today—we transferred them to a special dedicated serverand used a Flash-based portal (hey, it was 16-plus years ago) where a resident usercould scroll over a list for different body functions (circulatory, digestive,etc.) and a list of surgical videos available to view would pop up. Surgicalresidents, especially first-year residents who were scheduled into the operatingroom (OR) for a specific procedure, would go to the portal in a browser to lookfor the same procedure. It sometimes wasn’t that easy. At that time, we had digitized16 ways to repair a hernia! The residents would view the video of the procedureright before they walked into the OR and get a basic understanding of what wasgoing to happen. Computer video and the Internet have come a very long waysince then.
And now, virtual reality
Virtual reality is the next (or rather, the right-now) bigthing in medical schools. It’s also gaining traction in patient care. VR inmedical training is especially good for surgery. In one of several randomizedclinical trials, the investigators concluded: “Surgeons who received VR simulator training showedsignificantly greater improvement in performance in the OR than those in thecontrol group. VR surgical simulation is therefore a valid tool for training oflaparoscopic psychomotor skills and could be incorporated into surgicaltraining programmes.”
That trial is from the UK, but just as valid here. Surgery—bothinterventional (like open abdomen) and other non-invasive procedures—is increasinglyincorporating VR components. Virtual reality, and better still interactivevirtual reality, is beginning to show amazing benefits in physician, surgeon, andnurse training. Beginning early in the first year of medical school, the studentsused 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 wouldwork, but the schools have demonstrated it does. Many believe it’s as good anexperience for the students, but there is no tactile sensation of what organsfeel like, even though handling a cadaver isn’t the best way to know what akidney or a stomach feels like.
Virtual reality, and VR training, is becoming a large factorin operating rooms and small surgeries everywhere. Laparoscopic robotic surgeryis becoming commonplace, along with laparoscopic regular surgery, and both arecertainly virtual reality. Training with a robotic surgery machine is really a virtualvirtual-reality surgery. At Johns Hopkins, they’reteaching both traditional techniques and robotic techniques at the same time. Theresident 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 theearly part of their medical careers. The surgeon gets to practice on themachines. When they become surgeons, students and residents are prepared to usethe machines like a second set of very flexible hands.
Many surgeries are still best performed by hand. Robotic laparoscopicsurgery frequently isn’t appropriate. Obviously (or maybe not so much), surgeryto the limbs isn’t appropriate for laparoscopic surgery. There’s nothing toinflate 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 usingVR. As the haptic quality of the robotic surgery machines improves, roboticsurgery will be getting better. Much of laparoscopic surgery is still donemanually, and the training is traditional. This is not because of resistance bysurgeons, 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, andas surgical experience improves there will be more and more robotic surgeries.
One thing that was discovered early on was that the besthandlers of the robotic surgery machines were younger surgeons (late 20s toearly 30s) who were also good video game players. The dexterity they gained byplaying with their Nintendos, PlayStations, Xboxes, etc., became invaluable.They picked up on the machines rapidly. Older surgeons sometimes struggled withthem; they didn’t have the same kind of dexterity that was used in games whenthey were young. There are still technical limitations, especially in thehaptics, but they’re getting much better.
These are just a few examples. All these techniques can beused across the board in medical schools, nursing schools, dental schools, and physicaltherapy and veterinary schools. There’s no field in health not benefiting fromthe implementation of virtual reality.
The caveat I’ve heard more than once is that VR doesn’tmatch the feeling of being with a real patient. And that leads us back to thebeginning.
Full circle
Medical education is undergoing a fundamental change, a sortof “back to the future” in medicine. Technology is one of the drivers, but alarger driver might be the patient-physician interaction. I interviewed severalphysicians who teach at different medical schools around the country. Aftersome short conversations, it became obvious we’re in the midst of a sea changein how doctors are trained from the first day of medical school until theygraduate. We’ve come full circle.
This, in part, is a return to a highly modifiedapprenticeship system. First-year medical students now routinely begin havingpatient contact just weeks after starting medical school. They’re mostdefinitely at the “see one” stage, but they’re seeing—and they’re seeingpatients. Students frequently follow one physician for a term of time: at oneschool, for an entire semester, at another for a month. There’s lots ofvariation. The real value is that students then become apprentices, in a realsense, to the physician they’re following around.
Two hundred and fifty or so years ago, as medical schools werebeginning 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 “anatomicallectures” and a course on “the theory and practice of physik.” Apprenticeshipas a more or less formal program was ending as medical schools began to open.
Apprenticeship is a good training program at the basiclevel. Of course, it’s different in the corporate world where we assume basicskills are known, but new skills are always necessary. Is it that differentfrom medical training? Some companies apprentice a new employee to shadow anexperienced employee for a week or so. This inculcates the new hire into thecorporate culture and rhythms of daily work life for the new employee. Asmedicine, research, and society get more complex, maybe training should besimpler.
References
Cavanaugh Simpson, Joanne. “The Cutting Edge.” Johns Hopkins Magazine. April 2003.
https://pages.jh.edu/jhumag/0403web/robot.html
Grantcharov, T.P., et al. “Randomized clinical trial ofvirtual reality simulation for laparoscopic skills training.” British Journal of Surgery, Vol. 91, No.2. February 2004.
https://onlinelibrary.wiley.com/doi/10.1002/bjs.4407/full
McConaghy, Mary D. “School of Medicine: Historicaldevelopment, 1765-1800.” University Archives & Records Center, Universityof Pennsylvania. November 2010.
https://www.archives.upenn.edu/histy/features/1700s/medsch.html
https://www.youtube.com/watch?v=VcfwKYtux7E
