#futureofmeded: moving from “morning” to “afternoon” subjects

By: Felix Ankel (@felixankel)

When I went to college (a long time ago), “morning” classes for the most part consisted of the natural sciences such as biology, chemistry, and physics and the “afternoon” classes consisted of the social sciences such as sociology, economics, management, and communication sciences.  I focused my efforts on the morning subjects and studied for the Medical College Admission Test (MCAT) which was heavily weighted towards “morning” subjects.  Likewise, during medical school (and residency and beyond), learning and assessment was predominantly focused on medical knowledge with secondary emphasis on “afternoon” subjects such as patient and family centered communication, shared decision making, “teaming behavior”, quality and patient safety, stewardship, systems-thinking, and “fusion skills” to work with AI.

Health care and medical education are changing. 

Our relationship with knowledge, professional identity, and structure is changing.  Traditionally, in the spectrum from data to information to knowledge to wisdom, the clinicians’ space to add value resided in the information to knowledge space. Patients would come to see a clinician, share information about their symptoms, something magic would happen, and the clinician would share knowledge that would create value.  With the advent of AI and large language modules, the data to information to knowledge progression will automate and the value proposition for clinicians will shift to the knowledge to wisdom space. This is a shared space; a space shared with patients, families, other members of the health care team, the public, and machines.  How do we train for this space? How do we assess in this space?

Training for “afternoon” subjects.

Graduate medical training is based on the knowledge, skills, and attitudes necessary take care for a patient in a specific specialty. This usually involves a combination of rotation specific clinical education and curriculum specific didactic education. In the clinical setting, much of the training is experiential and under the supervision of more senior residents or board-certified faculty.  Didactic education is usually based on a core curriculum that defines a specialty and is predominantly taught by specialty specific faculty or residents.  For example, in emergency medicine, the model of the clinical practice for emergency medicine is updated on a regular basis and serves as the blueprint for the didactic education for many emergency medicine residencies. If the center of gravity for future graduate medical education is shifting from creating vessels of knowledge in morning subjects to creating navigators of wisdom with afternoon competencies, how do we train for this? Does all training to master the knowledge, skills, and attitudes of “afternoon” subjects need to occur in the clinical arena? Does all didactic education need to be taught by specialty specific clinicians?

Assessment influences training.

Assessment is a key component of the clinical learning environment. What is assessed is what is learned. In graduate medical education, healthy habits of life-long learning thrive in environments where a combination of self-assessments, workplace-based assessments (WBAs) such as daily evaluation cards (DECs), and entrustable professional activities (EPAs), and independent assessments such as the medical boards’ in-training examination exist.  How do we build assessments for “afternoon” subjects such as patient and family centered care, systems thinking, “teaming behavior”, and “fusion skills”? How do we ensure that these assessments are fair, valid, and reliable?  Do all assessments for afternoon subjects need to be done by supervising clinicians or is there benefit for assessments by non-clinical content experts? What composition of residency clinical competency committees makes the most sense to help with afternoon subject assessment analysis and synthesis?

Question to consider.

When reflecting on your educational program, consider the following:

  1. How are afternoon subjects incorporated?
  2. How are afternoon subjects assessed?
  3. How is fairness, validity, and reliability incorporated into the assessments?
  4. What is the assessment architecture for afternoon subjects?
  5. Do you have a blueprint to incorporate afternoon subjects into your learning environment?

Acknowledgement:  The author would like to acknowledge Brendan Carr for introducing them to the concept of morning and afternoon classes..

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