Commentary

Medical Education Reimagined: A Call to

Action
Charles G. Prober, MD, and Salman Khan

Abstract
The authors propose a new model students can apply their newly mastered to define a core curriculum that can
for medical education based on the knowledge. meet learners where they are in a
flipped classroom design. In this digitally oriented world, enhance the
model, students would access brief The authors argue that the modern relevance and retention of knowledge
(~10 minute) online videos to learn new digitally empowered learner, the through rich interactive exercises,
concepts on their own time. The content unremitting expansion of biomedical and facilitate in-depth learning fueled
could be viewed by the students as knowledge, and the increasing by individual students aptitude and
many times as necessary to master the specialization within the practice of passion. The creation and adoption
knowledge in preparation for classroom medicine drive the need to reimagine of this model would be meaningfully
time facilitated by expert faculty leading medical education. The changes that enhanced by cooperative efforts across
dynamic, interactive sessions where they propose emphasize the need medicalschools.

Today, more than 100 years after the the requisite course quizzes and national Flipping the Classroom
Flexner Report sparked major reforms examinations. And, unfortunately, In The One World School House:
in U.S. and Canadian medical schools, because the results of national board Education Reimagined, one of us (S.K.)
the general format of medical student exams, especially the United States described a new model of education,
education remains more or less the Medical Licensing Examination informed in part by ongoing work
same. A period of didactic-heavy (USMLE) Step 1, have taken on so with K12 students.1 In this model,
preclinical education (typically two much emphasis in the selection of which uses the leverage of computer
years) is followed by a series of clinical residents, students feel compelled to technology, students acquire basic
experiences of similar total length. memorize all preclinical material so that knowledge and facts about a subject
Medical education is constantly evolving they canobtain a high score on a test through a series of short videos hosted
at most of our schools, leading to many originally designed to be binary, pass online. Young learners watch these
innovations in teaching strategies, such or fail. videos on their own schedule and as
as problem-based learning, team-based
many times as necessary to master
learning, and the use of simulation.
Notwithstanding these issues, the the content. Students demonstrate
However, the net effect of all these efforts
current system of medical education mastery by providing a consecutive
on the way we educate physicians has
has resulted in the training of a series of correct responses to a number
been limited.
superb workforce of physicians, who of embedded questions. In subsequent
contribute to the health and welfare classroom sessions, students engage
The introduction to a life of medical
of society through a broad range of with their teacher in problem-solving
education often is not as compelling
professional activities. This system, exercises. There is a flipping of
as it could be. Especially during
however, is generally inflexible and not the classroom: Lessons previously
their preclinical education, students
sensitive to the skills and aspirations taught in class are learned at home,
frequently ponder the relevance of
of individual learners. Furthermore, and homework is performed in the
what they are being taught. Absent a
biomedical knowledge continues to classroom in collaboration with peers
clinical context, the information may be
difficult to embrace and retain beyond accrue at an exponential rate, and the and guided by teachers. The pace of
complexity of patients and the health learning is guided by the individual
care system continues to increase. It is student, and the relevance of the
neither possible nor desirable for all material is underscored through in-class
Dr. Prober is senior associate dean for medical students to deeply explore all aspects of problem solving.
education and professor of pediatrics, microbiology,
and immunology, Stanford School of Medicine,
biomedical knowledge. Our belief is that
Stanford, California. medical students should be provided
a framework on which knowledge can Reimagining Medical Education
Mr. Khan is founder and executive director, Khan
Academy, Mountain View, California. be built over a lifetime of learning. We believe that the model for
And students who have aptitude and reimagining K12 education is equally
Correspondence should be addressed to Dr. Prober,
Office of the Dean, 291 Campus Dr., Stanford, CA passion for developing a focus in a relevant to medical education. In fact, the
94305-5101; e-mail: [email protected]. specific area of biomedicine or medical flipped-classroom model is already widely
practice should pursue this area more used in medical education through
Acad Med. 2013;88:14071410.
First published online August 21, 2013 deeply.Our proposed model reflects gross anatomy courses. Students learn
doi: 10.1097/ACM.0b013e3182a368bd this belief. anatomical facts in lectures (or videos)

Academic Medicine, Vol. 88, No. 10 / October 2013 1407

Commentary

and from textbooks. The embedding influenced by the expertise and interest of these examinations during curriculum
of the information occurs in the gross the schools faculty. planning, students, irrespective of
anatomy lab during dissections. Most of their own medical schools curriculum,
those who have attended medical school, Building a framework of core knowledge typically prepare for these examinations
even in the distant past, continue to The central element of our medical by using third-party review material
remember these learning experiences in education proposal, depicted at the rather than their course syllabi. Students
the anatomy laboratory. top of Figure1, is the core preclinical often express a high degree of frustration
curriculum. This curriculum should and stress when they recognize that their
Figure1 depicts the three key focus on medical knowledge that is schools curriculum does not mirror
components of our proposed model foundational and known to be true the content of standardized national
for medical education: building (evergreen). Students often are told examinations. In a recent survey of
a framework of core knowledge; at the beginning of medical school that preclinical students at Stanford, 73%
embedding the knowledge in richly much of what they will be taught over identified this perceived misalignment
interactive, compelling, and engaging their time as students will prove to be between curricular content and what
wrong. Perhaps we should not spend they needed to know for USMLE Step
formats; and encouraging in-depth
our most valuable asset, time, on what 1 as one of their major sources of stress
pursuit of knowledge in some, but not all,
may not be true. Rather, a goal should be (Porwal A, Newell G. Unpublished data.
domains. These deep dives reflect the
to identify a limited amount of critical June 2012).
passion of the individual learner and the
material that serves as the building blocks
strengths of the specific medical school. This is not to suggest that medical
for subsequent lessons. It is striking that
For example, some medical schools school curricula should be designed to
such a core curriculum is not defined on
are recognized for strengths in basic a national basis. Core curricula tend to be teach to the test. Rather, there needs
science, health policy and economics, organic, arising and growing over time at to be a conscious alignment between
and biomedical engineering. Other each medical school, even though a high those responsible for creating medical
schools are recognized for strengths in proportion of core content will be similar school curricula and the National Board
primary care, immigration health, and between schools. of Medical Examiners. To that end,
population-based research. Although we propose the creation of a medical
most medical schools can support and The one unifying driver of medical school collaborative, charged with the
nurture the full range of student interests, schools core curricula appears to be identification of material that would
invariably the depth of educational the content of the USMLE. Although represent a consensus opinion on the core
opportunities at a school will be some schools pay particular attention to content of the curriculum.

Identify Minimal, Foundational, and Evergreen Material

Facilitate student access to material using:
Building the Short videos
Framework Textbooks
Online resources
Lectures

Based upon each schools unique methodologies

Science-Based, Interactive, Compelling, and Patient-Centered Exercises

Embedding
Gross anatomy laboratory
the Knowledge Dynamic classroom experiences
Clinical scenarios
Simulations

Based upon schools and students specific areas of interest and emphasis

Encouraging
In-Depth Pursuit Personalized Deeper Dives
of Knowledge
Figure 1 Key components of a proposed model for medical education. Adapted with permission from: The Blue Ridge Academic Health Group.
Report 17. Health Professions Education: Accelerating Innovation Through Technology. Figure 2 (p 14). Atlanta, GA: Emory University; Spring 2013.
http://whsc.emory.edu/blueridge/publications/archive/blue-ridge-2013.pdf. Accessed July 1, 2013.

1408 Academic Medicine, Vol. 88, No. 10 / October 2013

 Commentary

Following the identification of the core value unless learners use the knowledge more in-depth experiences are fueled by
content, we further propose the creation gained from them in meaningful students specific learning objectives and
of a library of short (~10 minute) exercises with faculty and peers. These passions, linked to the areas of expertise
videos that learners can use to access the videos are, in fact, only a fraction of our represented in their medical schools.
content in an order consistent with the overall Stanford Medicine Interactive Examples of deep dives include, but
organization of their schools curriculum. Learning Initiative (SMILI).3 Our are not limited to, what we currently
The content could be viewed by the SMILI working group includes faculty, offer students for their scholarly
students as many times as necessary to students, educational scientists, learning concentration pursuits at Stanford:
master the knowledge in preparation for specialists, and information technology bioengineering, biomedical ethics and
their flipped classroom experiences. experts. Our central goal is to support humanities, informatics and data-driven
Ten-minute videos have the advantages faculty who want to evolve their classes medicine, clinical research, community
of being sensitive to the typical peak into a more student-centric, interactive health, health services and policy,
learning period for adults and being format. Problem- and team-based molecular basis of medicine (a range of
easily archived and searchable. Content exercises are prominently represented basic sciences), and medical education.
could be revisited in the context of in many of our interactive sessions. The need to complement medical school
subsequent patient encounters, allowing Other interactive strategies capitalize on with in-depth and focused experiences
foundational knowledge to become even simulation resources, patient encounters, may not be felt by all students or by all
more deeply embedded. role-playing, and debates. The ideal schools. This should be respected. For
ratio of students to teachers varies by many, completing medical school in as
We have been experimenting with the format of the sessions, ranging from short a period as possible and entering
different video formats, including the use about 4:1 to about 25:1. These sessions the physician work force is critical
of a blank slate (much like a blackboard), often benefit from the participation and should be supported. For others,
inserted images, onscreen text (like a of faculty with different types of beginning to build an area of special
PowerPoint slide), embedded quizzes, the expertise, as when a clinician and a basic expertise that will help to drive changes
ability to alter the speed of presentation, scientist cofacilitate a session on the in biomedical science and health care
the ability to view the instructor, and clinical presentation and management delivery is critical. The key is to tap into
dialogue versus monologue. Different of children with metabolic disorders. and support the individual learners
formats appeal to different faculty and These interactive sessions also may be aptitude and passion. We believe that
different learning styles. We believe that facilitated through the use of movie clips our model of medical education is
it would be advantageous for multiple and bedside visits. sensitive to this need.
schools to produce videos on the same
core content. Students could select Our current first- and second-year A recent editorial, authored by Bruce
the version of the presentations most medical students have been exposed to Alberts,4 the editor-in-chief of Science,
consistent with their learning style. a few of our early efforts in the flipped- underscored the failure of skin-deep
Videos could be voted up or down by classroom style of education, including learning. Alberts argues that we need to
learners in a manner analogous to Yelp content in biochemistry, genetics, health replace the current overview of subjects
reviews. Over time, the best videos policy, biomedical ethics, endocrinology, with a series of deep explorations. He
would emerge. and womens health. Although the cites research that demonstrates that the
students identified a number of most meaningful learning takes place
Material would need to be updated opportunities for improvement in course when students are challenged to address
over time, although this need would evaluations, 82% of 141 respondents an issue in depth.4
be minimized through the selection favored this model of instruction when
of core content that has withstood compared with a primarily lecture-
the test of scientific validation. The based format (Ransohoff K, Xie J. Effecting Change Through
short video format would facilitate the Unpublished data. December 2012). The Multi-Institutional Collaboration
timely introduction of contemporary most common concern expressed by In summary, the convergence of the
discoveries. Instead of creating an our students was time management. The modern digital native5 learner,
entire new one-hour lecture, critical students expressed concern about simply exponentially growing biomedical
supplements could be added to the video adding interactive sessions without knowledge, and a dated medical
library with relative ease. However, we concurrently reducing the amount of education delivery system compel a
caution against the premature inclusion time allocated for didactic instruction (by need to change the way we educate
of new discoveries in the medical video). We acknowledge that the process contemporary physicians. The change
curriculum because many new facts needs to be at least time-neutral. that we propose defines a core curriculum
turn out to be wrong.2 that can meet learners where they are
Encouraging in-depth pursuit of specific in a digitally oriented world, can embed
Embedding knowledge through knowledge knowledge through rich interactions, and
interactive formats The third defining element of our can facilitate in-depth learning fueled
The second defining element of our medical education proposal is depicted by individual students aptitude and
medical education proposal is the at the bottom of Figure1. Students passion. The creation and adoption of
creation of dynamic interactive sessions. are encouraged to take deep dives our proposed model could be enhanced
The 10-minute videos have limited beyond their core curriculum. These by cooperative efforts among medical

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Commentary

schools. Perhaps the result would not be Ethical approval: Not applicable. 3 Stanford School of Medicine. Stanford
a one-world medical school house but a Medicine Interactive Learning Initiative.
http://med.stanford.edu/smili/. Accessed June
collaborative, multi-institutional effort to References 18, 2013.
reimagine medical education. 1 Khan S. The One World School House: 4 Alberts B. Failure of skin-deep learning.
Education Reimagined. New York, NY: Science. 2012;338:12621263.
Funding/Support: None. Twelve; 2012. 5 Prensky M. Digital natives, digital
2 Prasad V, Cifu A, Ioannidis JP. Reversals immigrants. In: On the Horizon. Vol. 9,
Other disclosures: Sal Khan is the founder of the of established medical practices: Evidence to No. 5. Bingley, UK: MCB University Press;
Khan Academy. abandon ship. JAMA. 2012;307:3738. October 2001.

Cover Art
Artists Statement: #646 (Indian Summer)

The very act of walking through nonverbal way. Art can shift ones health
hospital doors takes many people care experience to a more positive sense
away from their comfort zone of of well-being and can support greater
predictability, into a vulnerable state of healing. Many health care facilities are
uncertainty. When entering a building, including art as a part of the healing
most people immediately recognize solution, and I have been fortunate to
a space that inspires confidence and display my own artwork in the health
trust. Whether one is on the giving care setting.
or receiving end of health care, the
inherent risk around personal health The piece featured on this months
can provoke loaded, challenging, cover is from the series Indian Summer.
stressful thoughts. A positive impression Vermont often enjoys a grace period
makes a difference. between summer and fall that celebrates
the flowers just showing their seed
There are few places where art has #646 (Indian Summer) petticoats, the light changing to a cooler
capacity to impact people more than in a shade, the rich greens starting to dry
When a person has the opportunity
health care facility. People must process and hint at a rustling in the breezes. The
to look at and connect with art, a
deeper and more significant thoughts inevitable rhythms of nature provide so
private internal exploration occurs.
when faced with medical interventions. much material to ponder and work with
Perhaps an unnamed fear or unvoiced
By designing a welcoming environment question surfaces in the exchange. in the human experience.
filled with art that is both contemplative Perhaps a memory is awakened or a Casey Blanchard
and inspirational, an enlightened love remembered that brings healing
health care space can support and relieve to the moment. This exchange can be Ms. Blanchard is an artist living and working in
emotional stressors. powerful and meaningful in a nonlinear, Shelburne, Vermont; e-mail: [email protected].

1410 Academic Medicine, Vol. 88, No. 10 / October 2013