I am a medical student, and I do not attend lectures. Given the sheer volume of information medical students are expected to learn (or memorize for examination purposes), attending a lecture can be very inefficient. Obviously, not all students share my habits, but anecdotal evidence (of my peers in medical programs across North America) suggests that a significant proportion of students (if given the option) do not attend lectures in person. Most students read the instructor’s slides (to become familiar with the learning objectives, again for examination purposes), and listen to audio or video recordings of the lectures (often at 2x normal playback speed) in the weeks leading up to an exam.

So how are medical students learning if they are not interacting with their instructors?  Many have turned to third-party educators. Resources like Pathoma (a pathology education/review system), board review series publishers like Kaplan, and condensed review guides such as First Aid are becoming replacements rather than supplements. Their usage is so pervasive that I’m certain anyone who is starting their second year of medical school in the U.S. probably uses at least one of these resources to study. And it’s not just books anymore. For the basic sciences, studying all the “bugs ‘n’ drugs” can be so painfully tedious that websites like SketchyMicro and Picmonic are making a name for themselves because of how efficiently they help students remember information that can only really be memorized (by creating a tableaux for any given concept, that aids in the retention of critical information), due to the sheer volume of knowledge and the short time allotted to learning it.

Medical students aren’t slackers, they’re hackers.  They are finding and using the resources that teach most effectively. For example, I use Pathoma to learn any given organ system pathology. The videos are short, the explanations clear and concise. How much did this comprehensive educational package cost me? $90 for 18 months of access and an accompanying textbook. Of course, the tuition for a single year of medical school is a wee bit more than that; to put this into perspective, pathology is by far the longest running topic in the two academic years. With the emergence of such invaluable resources, some could argue that the first two years of the traditional four year medical program are now superfluous. In the end, all students take the same board exams, and it’s possible that students could learn those first two years of information in a more time-efficient and cost-efficient manner.

Most medical programs use either traditional “basic science-based” or more modern “systems-based”curricula. In the former most of the first two academic years is spent learning the sciences that concern medicine (biochemistry, physiology, genetics, etc), whereas in the latter, courses are designed around organ systems (neuromusculoskeletal, endocrine, GI, etc).

The advantage of systems-based courses is that information is organized by an overlying structure, and is more easily applied to a clinical scenario. When we see a patient, they come in with a chief complaint. We have them elaborate on this complaint, and throughout the interaction we are honing in on the main cause by asking key questions related to organ systems (referred to as a “Review of Systems”), and performing a physical exam with specific tests that allow us to determine possible causes. Given that most of medical care starts with these crucial steps  (referred to as the History and Physical, or H&P), it makes sense that we would learn the medical sciences within an organ systems framework rather than the alternative. Furthermore, it appears that medical education is converging toward systems-based courses. Over the years there has been a surge of schools changing their curricula to systems, and new schools which are starting up with this model. But what’s next? How does medical education continue to improve? And why does this concern JoMI?

When I first came across the Journal of Medical Insight, it was in its infancy – there were only two published articles, and I chose to watch Dr. Yelena Akelina’s demonstration of a femoral artery anastomosis on a rodent. I was pleasantly surprised by the quality of the video and the clarity of the instruction. As I watched more videos, I became more impressed with the opportunity presented before me. At first, I did not understand the potential there, but I certainly knew that this was something special. As I write this diatribe on the state of medical education, my favorite video on JoMI is Dr. Matthew Provencher’s arthroscopic bankart repair. After attentively watching the video, I was struck by how brilliantly educational it was. I had never before seen a medical video, lecture, or seminar that was so clear, thorough, engaging and easy to understand. Dr. Provencher went through every detail that a surgeon must know and consider, from patient examination to diagnosis, treatment and post-op care. I felt like I could perform the operation myself. But more realistically, I bet I wouldn’t be completely useless in assisting during the procedure…

After thinking more about what JoMI is, and keeping up with their publications, I came to a realization. JoMI is part of the evolution of medical education. What systems-based curricula did for the basic medical sciences, JoMI-esque services will do for the systems curriculum.

As a second year student, burdened with the volume of information that needs to be learned, I am often reassured by upper year students who are doing their rotations. They say that although it’s very difficult to reliably retain all this information, once one begins working in a hospital setting and seeing actual patients, it becomes easier.  The retention of knowledge is easily cemented by real interactions with people. Personal involvement and attachment to a case or patient significantly helps in the retention of the details and nuances of a given condition.

This is where I see JoMI creating an impact in medical education. When you watch a surgical video from JoMI, you immediately notice how immersive an event it really is. The viewer is effectively brought into the operating room and given multiple perspectives on an operation that even a resident at the side of the table would covet. Then, you have the benefit of watching a real person undergo a procedure, which in itself is striking if you are used to staring at textbooks or animation. Finally there’s the academic exercise involved. The doctors in these videos are superb educators because JoMI has a strict selection process and perhaps surgeons willing to have their operations filmed for educational purposes may be more pedagogically inclined. Returning to the example of Dr. Provencher’s bankart repair, the video presents an overview of the case (including the patient presentation, relevant tests and imaging, diagnosis, surgical preparation), the entire operation (intervened with discussion about tools and techniques), post-op, possible complications, pros and cons of the technique employed and the rationale for its use.

Throughout these videos, information concerning anatomy, physiology, and pathology, as well as possible vascular, neurological and infectious complications are discussed. From an educational perspective, what we are witnessing is a shift from the segregation of classroom and clinical teaching to a more unified experience. As any student who takes part in case discussions will tell you, it is very intellectually demanding – requiring a sort of mental gymnastics in which various perspectives (health care provider vs patient) are finely balanced, and all our knowledge of medicine is filtered, distilled, and consolidated into what is relevant for the patient. In the same way that systems curricula prepare us to think clinically for our clerkship years, JoMI allows medical students to practice these mental gymnastics, and in the process, bridge the gap between the academic and clinical fronts of surgery. Once we have developed a JoMI equivalent for internal medicine, well…only time will tell.

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This is a guest post by a medical student.