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• W2516452516 abstract "Donald Berwick, the President Emeritus and Senior Fellow in the Institute for Health Care Improvement, delivered the keynote at the 27th Annual National Forum on Quality Improvement in Health Care (Berwick, 2016). The entire speech curiously entitled “Turtles” can be viewed on YouTube (Berwick, 2015). The message is also summarized in a viewpoint commentary in a recent JAMA (Berwick, 2016). In his talk, Berwick attempts to explain the central conflict plaguing current health care providers as a result of friction between two overlapping eras of medicine with incompatible belief systems. Berwick describes Era 1 to be an era of professional dominance characterized by the ascendancy of the profession that dated back to years of Hippocrates and Galen. In this era the medical profession was regarded as noble and humanitarian, providers were self-regulated in that they were the sole judges of quality regarding their own work, and they possessed special knowledge and privileges not available to the lay public. However, this era was inherent with problems: unexplained variations in medical practice, high rates of injury and death related to medical errors, and issues related to soaring costs of care when no one oversaw or regulated spending for tests ordered, procedures done, and so forth. Toward the end of this era, society's trust in the medical profession had seriously eroded (Berwick, 2016). Thus, Era 2 was born in response to the failures of Era 1 with rigorous attention to accountability and market theory. Era 2, as described by Berwick, is an era driven by regulation, intense bureaucratic scrutiny, and excessive measurement, incentives, rewards, punishments, and market forces (Berwick, 2016). Berwick argues that it is the collision of norms between these two subsequent Eras that creates the present climate of discomfort and self-protection among health care providers. Accordingly, health care professionals feel angry, misunderstood, and over-controlled, whereas insurance companies, governments, and consumer groups feel suspicious, resisted, and often helpless (Berwick, 2016). What can solve this conflict? Berwick proposes a 9-step plan to move toward Era 3—“the moral era.” In principle, Era 3 would reject both the unbridled paternalism of Era 1 and the exhausting reductionism of Era 2. Ideally, the moral era would aim to (1) reduce mandatory measurement; (2) stop complex individual incentives; (3) shift the business strategy from revenue to quality, (4) abandon professional prerogative when it hurts the whole, (5) use improvement science; (6) ensure complete transparency; (7) protect civility; (8) hear the voices of the people served, and (9) reject greed (Berwick, 2016). For educators in the anatomical sciences we propose that Berwick's speech might provide a touchstone for reflection as we consider the evolution of our field. There was an Era 1 in anatomical sciences education: a climate of professional dominance where anatomical discoveries and knowledge were based on ancient and medieval anatomists (Galen, Vesalius, among others). In the early era, anatomical education was special, privileged, and in high regard at every medical school. It occupied a significant portion of curricular time and served as a gate into the garden of other basic sciences and medical disciplines. A traditional pedagogical approach to lectures and laboratories dominated the educational scene for centuries. Students learned anatomy by attending lectures, by observing demonstrations of prosected specimens or from relying on their own dissection experience. The quality of the course was measured in hours spent in laboratories, the number of lectures, and also the personal prestige of professors teaching the course. Students learned by memorizing facts (often useless minutia) from textbooks, atlases, class handouts, tables, and the notes they painstakingly took during lectures. Learning anatomy was like a marathon race where the winners were individually awarded with honors, grades, and other accolades and the losers often dropped out of medical school. Competition was fierce. However, there were problems with this era. Anatomy was isolated from clinical teaching, memorization did not help students use the knowledge in the clinical environment, and students often failed to arrive at anatomical explanations for disease processes when faced with a specific clinical problem (Miller et al., 2002). At the end of this era, anatomy was in jeopardy as it was one of the most expensive courses in the medical curriculum, with the high cost of maintaining laboratories and the increasing cost of bequest programs. In addition with the way anatomy had been traditionally taught, the course was not translating into clinical relevance—making better doctors. Medical schools redesigning curricula began to cut away at the length of anatomy courses (Drake et al., 2009, 2014), and anatomists began to fret that their former position on the pedestal of medical education would not last much longer. Analogous to Berwick's assessment of the state of health care, many negative outcomes from anatomy's Era 1 triggered drastic changes by medical school administrators and curriculum committees in the last two decades. The focus of redesign seemed to feature a decrease in curricular density by cutting anatomy exposure in the curriculum, usually by decreasing or eliminating human dissection. Anatomists were pressured to implement new educational strategies, such as active learning, integration of basic sciences into clinical scenarios, and team-based approaches to learning. Many programs introduced innovations, like e-learning, to remain competitive as market forces demonstrated that medical students prefer programs that require less time in class. We would argue that Era 2 in anatomical sciences education is also driven by laws of accountability, scrutiny, excessive measurement (students and faculty evaluations), incentives, rewards, punishments, and market forces. During this paradigm shift, many anatomists lost the autonomy they once enjoyed and lost control over their courses now run by curriculum committees. Similar to the health care environment, the educational norms from Era 1 of anatomical dominance clashed with Era 2's excessive externally mandated regulations. In Era 2, we fear that the professional identity of the anatomical sciences has been lost in the integrated curriculum (Bolender et al., 2013), in the uncertainty of the future, and with the cost-cutting measures that have jeopardized so many anatomy departments. As a result, this clash has caused discomfort among educators in the anatomical sciences. For many, there is a lack of trust in the administration overseeing curricular changes, and this triggers self-protective reactions. Therefore, is it possible to think about Berwick's Era 3—a moral era—occurring in anatomical sciences education? Could compromises and solutions be found between the past and the present that would benefit not only learners in anatomy but all parties—anatomy professors, host institutions, and future patients of the graduates? Analyzing the steps in Berwick's proposed plan for the new “moral era” of medicine, we found that many apply to education in the anatomical sciences. Thus a “moral era” in anatomical sciences education could be characterized by: Students and faculty are constantly bombarded with evaluations and questionnaires related to instructors, students, and courses. Similar to the health care environment, most of them are useless, but they are imposed by administrators and accrediting agencies. The central issue is how the results of these evaluations are used to improve education. In most schools and universities, the raw percentages, Likert scale scores, and student comments are forwarded to curriculum committees or deans, and also to teaching faculty without any accompanied feedback or interpretation. Most of the evaluations end up in some bottom drawer in the instructor's desk. We would argue, too, that students are not able to realistically evaluate many aspects of the course. For instance, the clinical relevance or “usefulness” of the information presented during the course is almost impossible to assess since students likely have not yet had the opportunity to see where it is relevant in the health care environment. Often student ratings and their comments are taken out of context, often misunderstood by faculty, and misapplied by administrators to pressure faculty into making reforms. Also, students are rarely taught to provide constructive feedback, so their comments are general, of poor quality and often flippant. Determining the usefulness of evaluations and assessments as they relate to the wide context of the educational mission of the institution might be helpful. Teaching students how to give constructive feedback is imperative if assessments are to be considered reliable data. Decreasing the frequency of assessments and course evaluations may mean that those collected are of higher quality and more worth reading and considering when looking to reform aspects of a course or program. The health care point associated with payment structure could be easily translated into the reward system that students receive in the form of individual grades and progress reports. Many medical schools have abandoned letter grading systems which fuel competition among students. Simple Pass/Fail systems and portfolio approaches seem to work well in the era of ACGME competencies and milestones (Nasca et al., 2012; Byrne et al., 2016). Also with the recent incorporation of ultrasound, radiological imaging, and other non-technical skills into anatomy courses, the objective structural practical examination (OSPE) should be utilized to assess student competence. In the era of team-based health care, team-based and competency-based assessments should be introduced and used in the anatomy laboratory (Pratten et al., 2014). A few schools are already doing this and the anatomical sciences are in a position to lead the way. As some of the early courses in medical school, the anatomical sciences can set the expectation that competency is determined by team as well as individual assessments. Many decisions regarding anatomical sciences education are influenced by cost. Schools have looked to eliminate expensive gross anatomy laboratories, replacing them with online applications, 3D visualization systems or holographic simulations, out of concern for the bottom line. The push to blended learning and flipped classrooms is based mainly on financial incentives to cut program costs, and very seldom is the pressure based on improving the quality of the education. This conversation needs to be tempered by a balanced approach in which electronic media supplements traditional approaches with close attention to quality outcomes. There is no substitute for a professor's expertise and ability to design and guide meaningful learning experiences; the assumption that education can be entirely crowd-sourced is both naïve and arrogant. The teaching of anatomy and other basic sciences should not occur in silos. The old approach of having “my class” or “my course” or “my students” should be extended into an interprofessional attitude where each course is shaped and led by multidisciplinary teaching faculty. We are convinced that a partnership between clinicians and anatomists is essential for student education in all health care professional courses. A variety of input from a multidisciplinary teaching team that includes practicing clinicians, surgeons, radiologists, physical therapists, and sonographers helps students to see the real-life application of their newly acquired knowledge. In addition to interprofessional faculty involvement in the shaping and leading of a course, interprofessional education can exist among students from multiple professions (medical school, nursing school, physical therapy programs) when invited to learn anatomy together (Harden, 2015; Kirch and Ast, 2015). We have seen the benefit in mixed classrooms/mixed laboratory groups in that students also learn about the other members of the team and the expertise unique to their specialty. These environments naturally foster team approaches (Vasan et al., 2011; Huitt et al., 2015). When multidisciplinary teams of students are given a clinical problem and tasked to find a solution, within the context of a team effort, approaching the problem from a variety of theoretical and practical perspectives based on their experience with interpersonal and skill-based modalities, students learn about team-based competency. Education programs in the anatomical sciences should follow an evidence-based and competency-based approach. Featuring improvement science as a gold standard prepares students for future practice requirements that will be derived from an analysis of societal and patient-centered needs. To utilize a competency-based approach, faculty development is needed to ensure that research findings from the field of education and patient care are getting appropriately integrated into textbooks and curricula. For instance, research from the field of education should be taken into consideration in the development of multimedia modules. Didactic decision-making should be guided by sound research on the cognitive aspects of learning. We must take into consideration what we now know about cognitive overload in our students when it comes to using computer-based programs and other multimedia approaches (Wilson, 2015). Adult learning theories have generated sufficient evidence to emphasize the importance of relating how anatomical knowledge is relevant to real-life problems and realistic clinical scenarios. We know that knowledge is not well retained if it is not connected to issues of importance in the world of the student (Pawlina and Drake, 2016). Berwick emphasizes the importance of scholarship for those practicing in health care; similarly, all basic science educators (including anatomists) should actively participate in the scholarship of teaching and learning. Scholarly teaching must be open to the public, be subject to reviews, and be accessible for exchange with other educators (Collins, 2004). Objectivity, rigor, and accountability should be emphasized in all aspects of our scholarly activity (Ellaway, 2016). All curricular revisions and improvements should have in mind graduate outcomes for the future clinicians who will soon practice in the rapidly evolving health care environment. We must stay tuned to the latest developments in the field of anatomical sciences, such as various mobile applications (Küçük et al., 2016; Trelease, 2016), 3D printing (McMenamin et al., 2014), and other innovative educational technologies (Guze, 2015). In the world of anatomical sciences, transparency relates to competency assessments and student feedback. We feel that providing formative feedback to students in a one-to-one manner with a faculty mentor during the course is invaluable for student growth and professional development. Open class discussions about the culture of the institution, professional values, such as respect, integrity, compassion, teamwork, leadership, and excellence, should be conducted regularly so students realize these intangible elements of professionalism are an integral component of their competency assessment. Anatomy is one of the first subjects introduced early in the curriculum of many medical schools. Accordingly, for many students, anatomy is their introduction to teamwork in a medical environment. Teamwork experiences in anatomy should be considered a foreshadowing of performance on teams in the clinical clerkships later in the curriculum (Pawlina and Drake, 2016), and transparency of peer feedback needs to be taught early. Students and faculty must both adhere to the highest standards of professionalism, ethics, and personal responsibility—but in order to come to a common understanding of what the standard is, open discussions must take place to lay transparent groundwork for feedback. In the basic sciences, the people served are not just students, but faculty, and in the long range, all patients whose lives will be affected by what is learned in the classroom. The voices of students must be heard so that curriculum designers can balance education needs with student well-being. Faculty development is an important setting for faculty voices to be heard and to prepare the transformation from instructors and teachers to mentors and role models in the competency-based curriculum (Steinert et al., 2016). Students learning anatomy become partners, teachers and learners in the journey through the curriculum. In many programs, once yearly there is a ceremony for the families of the body donors where the voices of future patients are heard and students honor the patients who became teachers in the gift of their bodies for education (Pawlina et al., 2011; Jones et al., 2014). We imagine there are even more ways for the voices of patients to come into the classroom so that the voices of the people served may be heard as an early clarion call during the course of medical education. The moral era described by Berwick is the next logical step not only in the transformation of the practice of medicine and health care, but also in the transformation of medical education. As we have shown, Berwick's goals for the transformation to Era 3, the moral era, can guide and focus a prioritized reorganization of all basic sciences, including the anatomical sciences, in the struggle to maintain identity and relevance within the medical curriculum. Anatomists need to be part of the bigger picture and bear in mind how students will best become physicians to serve patients. There is no doubt in our minds that the competency-based transformation currently under way in many medical schools will lead to better outcomes and improved utilization of knowledge. Be a part of it and embrace the maxim that “the needs of the patient come first” when bringing your students into the new era of anatomical sciences education. Wojciech Pawlina, M.D., FAAA* Department of Anatomy Mayo Clinic College of Medicine Mayo Clinic Rochester, Minnesota Richard L. Drake, Ph.D., FAAA* Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland Clinic Cleveland, Ohio" @default.
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• W2516452516 title "Moving towards a moral era in anatomical sciences education" @default.
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