A. J. DE ARMENDI, E. A. MAREK
and learning theories work best at the greatest cost-to-benefit
ratio. The Institute of Medicine (IOM) reported the need to
have a federal CER organizational infrastructure roadmap to set
future CER priorities and to teach CER to every student in
clinical practice. At this time, over 100 priority study topics are
on the website out of over 1250 nominated research proposals
(IOM, 2009). In addition, Crew Resource Management (CRM)
has been shown to reduce medical errors. The future is to teach
interactive dynamics, patient safety, care delivery improve-
ments, communication, and teamwork skills in these settings. In
order for this to occur, we need the convergence of curriculum
reform interests from among all major national stakeholders
(the Association of American Medical Colleges, The Institute
of Healthcare Improvement, the American Medical Student
Association, the Agency for Healthcare Research and Quality
and the Lucian Leape Institute), as well as, the international
academic community.
Present Educational Issues
At present, efforts are underway nationally and internation-
ally at health sciences’ medical centers and at conferences to
incorporate simulation technology to educate our health care
force. Among others, examples include: computer-based virtual
reality simulators, high fidelity and static mannequins, plastic
models, live animals, professional patient-actors, inert animal
products, and human cadavers. Gurusamy et al. (Gurusamy et
al., 2008) evaluated randomized controlled trials and concluded
that virtual reality training can supplement and/or replace con-
ventional laparoscopic training in surgical trainees with limited
or no laparoscopic experience. Ma et al. (Ma et al., 2011) in a
systematic review and meta-analysis of 20 studies on central
venous line catheterization, concluded that simulation-based
education was associated with significant improvement and
benefits in a) learner outcomes (performance on simulators,
knowledge, and confidence) and b) selected patient clinical
outcomes (fewer needle attempts and pneumothorax). Cook et
al. (Cook et al., 2011) in a systematic review and meta-analysis
of almost 11,000 articles prior to 2012, concluded that when
compared to no intervention, technology-enhanced simulation
training of health care professionals was consistent with large
effects for knowledge, skills, and behavior and moderate effects
for patient related outcomes. The authors also question the need
for any further studies showing the benefit of simulation tech-
nology considering that only 4% of the studies failed to show
an association when comparing no intervention to simulation
intervention. They suggest that we focus on clarifying when
and how to apply simulation most effectively and cost-effi-
ciently.
The culture of MHE is gradually changing to a new one of
accountability in quality improvement. In 2001, the IOM pro-
posed six fundamental patient care aims to be learned by health
care students: 1) safety, 2) effectiveness, 3) patient-centered-
ness, 4) timeliness, 5) efficiency, and 6) equitability. A pre-
mium needs to be placed on efficient team-oriented promoters
of quality, safety, patient’s preferences, prevention and well-
ness (IOM, 2001). In 2002, the American Board of Internal
Medicine, the American College of Physicians, the American
Society of Internal Medicine and the European Federation of
Internal Medicine chartered a professionalism creed that states,
“… improvement of quality of care, maintaining clinical com-
petence, reduce medical errors, work with other professionals,
increase patient safety, and optimize outcomes …” (ABIM,
2002). Additionally, in 2004, the IOM reported the need to
teach behavioral and social sciences to equip health care stu-
dents to respond to patients as individuals and not just symp-
toms. The expected outcome was to build better therapeutic
relationships and to be more patient-centered. At the University
of South Florida, a project addressing these issues to surgical
residents exposed to lectures, role model playing, and mentor-
ing reduced medical errors (Brannick et al., 2009). The Univer-
sity of North Carolina uses the Team Strategies and Tools to
Enhance Performance and Patient Safety (TeamSTEPPS) to
prepare medical health care providers. TeamSTEPPS has re-
sulted in physicians reporting 1) prevention in medical errors, 2)
removal of the hierarchical inhibition to speak, 3) time-outs, 4)
sign placement to protect patients, and e) utilization of team
huddles before procedures (AHRQ, 2013). [Other centers are
applying similar educational tools to address all of these areas.]
In the US, we have one of the highest ratios in the world of
physicians/population (25/10,000) trailing Europe and Russia,
30s and lower 40s per 10,000-population, respectively. Other
parts of the world, like most of the sub-Sahara Africa countries,
average about 0.5-1 physicians per 10,000-population (Chart-
Bin, 2013). With such deficiencies in underdeveloped countries,
medical and health educators must resort to preparing the health
care force in th e least expensi ve and most efficient ma nner. For
example, can we teach an adult with an eighth-grade education
to deliver anesthesia in an African country over the internet? Is
that better than having no anesthesiologists, as is the case pres-
ently, in some of those countries? For circumstances like these,
perhaps the future of health care education is global Massive
Open Online Courses (MOOC) or a high-quality online educa-
tional content course available for the international health care
community. These are not online lecture courses, but rather, an
understanding, connecting, and exchanging of ideas through
interaction with others via discussions that form the basis of the
future of education in general (Faust, 2013). Skype is such an
example today. Medical health education continues to advance
through technology by the use of evolving digital computer
innovations, which allow us to share in global knowledge. Both
MOOCs and simulations will lead medical health education in
the years ahead.
The Future
In concluding, health care delivery will change in the future.
Continuously rising costs will be curtailed as the public de-
mands make the profession accountable in quality improvement
and safety. In order to do so, medical school educators need to
change the curricula to emphasize the: 1) integration of patient
care aims to become sensitive patient-centric and customer-
focused rather than provider-centric; 2) introduction of compe-
tencies to self-evaluate, improve and develop lifelong learning
and quality-improvement skills, be system aware, be evidence-
based standardized medical practice, develop interdisciplinary
professional teamwork and evaluate efficiency, quality and
safety; 3) teaching of Comparative Effectiveness Research to
deliver the best effective, efficient, safe benefit-to-cost health
care; 4) decision-making attitudes; 5) formation of data bases to
compare efficacy of disease/treatment results; 6) acknowl-
edgement of accountability; 7) practice of human dynamics,
such as, basic communications and teamwork skills, which
coordinate care efficiently and proactively promoting wellness
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