Many medical students do not attend lectures during their first two years, opting instead to watch recorded sessions on their own time.
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Tom Fox/Getty Images
Many medical students do not attend lectures during their first two years, opting instead to watch recorded sessions on their own time.
Tom Fox/Getty Images
During my first two years as a medical student, I almost never attended lectures. Neither did my peers. In fact, I estimate that less than a quarter of the medical students in my class are always in person. One of my professors, Dr. Philip Gruppuso, said that in his 40 years of teaching, attendance for in-person classes was the lowest he had ever seen. Even before the COVID-19 pandemic, first- and second-year medical students were routinely skipping classes. Instead, they chose to watch the recordings at home on their own time. The pandemic has accelerated this shift. This absence has many in the medical education system wondering how this will affect future physicians and sparked widespread discussion in the medical establishment. Medical education is changing rapidly, and that change is being driven by students—so how can schools incorporate the realities of virtual learning while adequately training them to take on the enormous responsibility of patient care?
The first two years of “flipped” classroom
The first half of medical education (traditionally the first one to two years, sometimes called the pre-clerkship years) prepares students for success in the second half of medical school, the clerkship, where students work directly with patient care teams. Prepractice medical education is where students learn the technical elements of being a doctor before seeing patients. It includes lectures in the medical sciences – anatomy, embryology, physiology, pathology and pharmacology – as well as the health systems sciences – ethics, professionalism and public health. It goes beyond lectures. It includes dissecting the human body in an anatomy laboratory, practicing how to interview patients and conduct medical examinations (often using patient actors), and many group discussions related to specific lectures.
Virtual learning has had some glaring downsides for me during these critical first two years. I can’t ask a question to a pre-recorded lecturer. The teacher-student relationship is one of the parts of medical education I look forward to the most, but it’s getting harder to cultivate. It is sometimes isolated.
Dr. Gruppuso and I started our conversation with some ideas on how we could change the medical education system to mitigate these disadvantages while supporting students in the decisions they had already made to study on their own time.
Our recommendation: Widespread use of the “flipped classroom” model in pre-practice medical school lectures.In this model, face-to-face lectures all but disappear, and students learn most of the classroom-type material on their own forward Face time – hence the flip. We recommend starting with a series of virtual modules in preparation for case-based group sessions held face-to-face. Activities such as anatomy labs, patient interviews and physical exam exercises, as well as guest lectures will remain on-site. Essentially, this contains virtual lecture tracks, but physical attendance is required for small group hands-on learning.
A Medical Student’s Perspective – Alexander Philips
Let me start by saying that I do enjoy the advantages of virtual lectures. Pausing, rewinding, rewatching, and speeding up the conversation was a great way to focus on my weak spots and save time, which is my most valuable resource as a medical student given the sheer amount of information to be learned. Virtual learning also makes it easier for me to incorporate non-lecture resources into my study plan, such as flash cards, web tutorials, or third-party lectures.
In a flipped classroom scenario, my typical day might consist of a morning watching short, focused medical science modules with pauses in between so I can draw diagrams, study online flash cards, and read and watch other resources. I will then engage in an hour or two face-to-face case-based group discussion with my professors and classmates, where we focus on the clinical application of this medicine by discussing hypothetical patient cases. Other time will be devoted to anatomy labs, clinical skills exercises with standardized patients (patient actors) under the direct supervision of faculty members, observations in the hospital, and unstructured time for other activities such as research, advocacy, and community service.
In addition to allowing discussions and meeting professors and classmates, it also brings order to my schedule. In the current system, with the convenience of recording lectures, I’m left to keep up with the material on my own, making it easier to fall behind.
A Professor’s Perspective – Dr. Philip Gruppuso
I have taught medical students for almost 40 years in many settings – hospital rounds, patient appointments, small group discussions and large class teaching. I have spoken on topics ranging from biochemical pathways to lifestyle diseases (diseases related to physical inactivity) to nutritional science and the biology of aging.
The most satisfying part of teaching is teaching the less tangible aspects of being a doctor – how to respect all patients and be a true caregiver. I do this by telling the story of my clinical experiences in lectures, and my takeaway is the interaction with the students. The pandemic and the resulting shift in how students learn has changed all that.
Fully virtual learning for the first two years of school may be necessary during the pandemic, but continuing to do so will leave young people unprepared to become doctors.
Medicine taught in clinical skills courses or human anatomy is inherently personal in nature and cannot be captured in essentially impersonal forms of learning. There is more to preprofessional education; other enablers of overall physician training, such as research, specialty exploration, and volunteer work, are nearly impossible to achieve with virtual learning.
Finally, changing the role of the physician teacher is a very real threat to the medical education enterprise. Physicians are unusual among walks of life in that they are expected to teach no matter where they practice their profession. Take away the satisfaction that comes with face-to-face teaching, and we risk losing the commitment of teachers, much of which is often done on an entirely voluntary basis.
Medical Education at an Inflection Point – Our Together Efforts
In discussions of what medical education might look like post-pandemic, some have called for the years leading up to internships to be entirely virtual. Promotion to a trainee position will be based on ability (i.e. whether you have mastered the coursework) rather than time. But we are in favor of a less extreme combination of virtual learning that relies on such flipped classrooms.
Brown University’s Warren Alpert School of Medicine and other schools are increasingly implementing this approach. Interacting with peers, asking questions, and building relationships with faculty are of greatest value and save time when students have a solid understanding of the basic framework and key concepts of the basic sciences. This framework can often be built more effectively in a tailored virtual environment, where students can actually work on their weaknesses, freeing school staff to focus on helping students apply that knowledge to caring for patients. Faculty can also supplement these discussions by sharing their experiences of how they diagnose and treat specific patients working in the organizations and communities that medical students serve during their clerkships. Eliminate larger in-person medical science lectures and focus on developing or sourcing high-quality virtual content to take advantage of virtual learning; use the time and resources saved to optimize regular face-to-face case group meetings with faculty and other students, which can ease Disadvantages of virtual learning.
Medical education is at a turning point. The traditional versus flipped pre-practice medical science classroom is just one of several decisions we face when considering how to train the next generation of physicians. For example, the following issues are closely related to the role of virtual learning in medical education and are simultaneously being debated in schools across the country.
- What is the role of the medical science curriculum in medical education? The USMLE Step 1 exam is the first licensure exam to become a doctor and tests medical science concepts. The recent move to pass/fail the exam will only hasten the process of shortening the duration of pre-service education. Encouraging students to start looking at medicine from a clinical perspective early in their training is a good thing, but the reduced time spent on gaining insight into disease mechanisms and treatments could undermine the foundations of clinical education.
- To what extent can or should preprofessional medical science education integrate external resources to effectively teach content? For years, medical students have embraced the shift to outside resources through self-directed courses to supplement or replace lectures in medical school. This mostly happens independently of faculty or administration input.
- If the cost of delivering lectures is reduced based on reusable or easily updatable virtual content, and potentially standardized across schools, the resulting efficiencies could conceivably reduce the cost of education. If this can be done, should medical tuition be reduced to reflect this? If so, it could mean broader access to medical education, less student loan burdens, and fewer barriers to pursuing careers in low-income specialties like primary care. Conversely, the time and teacher-intensive nature of more small group sessions may increase the cost burden for schools.
- Will the benefits of these education reforms reach everyone? For students entering medical school from disadvantaged educational backgrounds, including students with neurological differences or students from underrepresented groups in medicine (URiM), online courses may lead to poorer educational outcomes. Conversely, neurodivergent learners may benefit from individualized learning modules; URiM students and those who traditionally have less access to teachers may have more face-to-face learning time. As education moves to virtual formats, it is critical to assess its impact on the entire student population.
These questions are harder to answer than the question of whether flipped classrooms should play a larger role in preprofessional medical education. But these options are not all or nothing. Changes should be made with an understanding of the trade-offs and with the foresight to mitigate the negative effects of those changes.
Medical school needs to get the right trainee medical education. The solid foundation I (Alexander Phillips) built during my first two years of medical school helped me diagnose, admit, treat, and discharge my first patient, just a few weeks ago as a third-year medical student serving as My first internship job. We believe the next step in premed medical education is clear. The flipped classroom is a promising model, so virtual learning plays an increasing role in the years leading up to medical school internships. Can we preserve the broad goals of preprofessional medical education while supporting medical students in making decisions to learn on their own time? We believe the answer is yes.
Alexander P. Philips, a third-year medical student at Brown University, tweets @AlexPPhilips. Dr Philip Grupso is a former associate dean for medical education and currently teaches at Brown University.This article represents only the views of the two authors, thanks Dr. B. Star Hampton and Dr. Sarita Warrier Work with Brown University and ask for their input.
