Deborah C. German, MD, Julia Pet-Armacost, PhD, Richard D. Peppler, PhD, and Juan Cendan, MD suggest that if medical students are taught through “behavior activation” approaches, such a change can have a profound impact on improving the quality of care provided by our future doctors.
Progress in medical knowledge has followed a sequence inexorably linked to the technologies available to clinical researchers. First, beginning in Renaissance Europe and into the early 19th century, new medical knowledge related largely to gross anatomic processes. With the advent of microscopy and chemistry laboratories, medical knowledge in the late 19th and 20th centuries became ever more focused, first on organ-specific activities, then on cellular and genetic code dimensions. Although work in the areas of genetics and understanding disease causes still has tremendous promise, and will continue to be the focus of large-scale research with strong financial support, there is a dissonance between the hyper-focus on the causes and treatment of diseases as compared to the tremendous possibilities of large-scale public health interventions facilitated by modern technologies.
For example, medical science now recognizes that: (1) alcohol consumption leads to permanent hepatic damage; (2) genetic markers near the GABRG3 gene on chromosome 15 are related to alcoholism; (3) even young alcoholic patients will demonstrate reduced parieto-temporal activity on fMRI when challenged with a memory task; and (4) genetic predispositions to alcoholism are borne out by adoption and twin studies. Like alcoholism, there are myriad examples in which current medical knowledge is quite rich, however, the ability to prevent and avoid the conditions has not received as much research interest or funding.
Preventive & Behavioral Approaches
Although the cellular, molecular and genetic research must continue, the authors propose that the next generation of medical practitioners needs to consider methods to prevent and redirect patients from engaging or maintaining destructive behaviors. Much of the necessary behavioral information is already available: what to eat, how much to exercise, the need to avoid smoking and the like. Physicians have largely relegated these activities to public health officials and legislators. Medical trainees need a curriculum that advances the biological sciences behind disease, and also promotes research into practical interventions to enhance the health and welfare of populations (either through prevention or intervention).
Medical education should explore the relationships between disease and the patient’s context, in order to elucidate factors promoting an individual’s disease. It is not enough, today, for doctors to know the half-life of oral hypoglycemic agents being used to manage an obese patient with type II diabetes – clinicians must investigate the entire social, cultural and dietary context of that patient in order to manage the disease and effect a change. Further, in order to prevent the disease, the research questions should frame the environmental factors that contribute to the condition, and concentrate on deliverable interventions that may lead to improved personal and community health.
Employing Technology to Change Behavior
It is in the spirit of preventive medicine that the 21st century’s technological promise may be leveraged. The technologically-disruptive forces we are now witnessing must be harnessed to enhance community health. Consider these possibilities: can physicians utilize mobile technology to ensure that a known alcoholic does not have a drink? How can we leverage social networks to keep a dieter on a schedule, or move him or her to exercise? Many applications such as FitPal, FitBit, etc. have been developed. Future physicians and other professionals need to be able to work with their patients in using such technologies to change behavior. How do we create communities of people who are at risk for the same disorder, which can serve as mentoring platforms? The mobile technology revolution places the effector in the patients’ hands and is already largely in place. Behavioral scientists and education and game theorists have done much of the work to understand individuals’ motivations for participation and avoidance in similar platforms. However, medicine has been slow to investigate and create scalable interventions; research funding remains largely linked to basic molecular science and therapeutic clinical trials.
Determination of behavioral drivers will be critical in the future of medical education, and creative solutions will demand that multidisciplinary teams conjure the possible interventions; for example, it may be necessary to pay a “pre-diabetic” a modest amount to enforce better dietary behavior now, rather than paying a huge bill for her amputation or obesity 20 years later. This type of approach may be considered anathema to pure science, but it may work, and it may be financially reasonable for a government, or even an insurance company, to pay a patient to lose weight.
A New Approach
A two-pronged approach to large-scale public health is reasonable. The established basic science approach should continue to be the scaffold upon which our medical students learn pathophysiology. However, the intervention and prevention side should address not only the individual patient, but also the context in which that individual lives and, even more importantly, the conditions which enabled the patient to arrive at the disorder. Internet search engines currently use data mining to identify that the person working the computer, for example, has an interest in purchasing a new puppy. Within microseconds, the addresses for all pet stores within five miles of that IP address show up on banner flags.
Why shouldn’t there be a method to identify when a patient with a known propensity to purchase large volumes of chocolate is searching the Internet for sweets, and offer that person advice or even a direct communication with a health mentor?
Current medical students should be driven and encouraged to pursue preventive health as a line of investigation; furthermore, they should work with their colleagues in the social sciences, engineering and gaming disciplines to consider these approaches. No medical student will be able to create technological tools alone. Also, medical college leadership will need to recognize faculty participation in design of technology to help patients prevent illness (efforts which are currently largely underfunded), as viable and valuable contributions to their institutions.
The responsibility of medical educators is to develop modern medical curricula that investigate applications of technology to preventive health, and facilitate the interaction between medical students and other professionals in health-related and other disciplines who can bring expertise to the process. The authors believe that this approach also considers the reality that a standardized curriculum cannot prepare the student for all of the changes the field of medicine will undergo during our students’ professional careers. We concur with the 2010 Lancet commission report noting that 20th century medical education and training will not work in the 21st century. The report suggested six educational reforms, one of which was to exploit the power of information technology for learning through “development of evidence, capacity of data collection and analysis, simulation and testing, distance learning, collaborative connectivity, and management of the increase in knowledge.”
University of Central Florida Example
The curriculum at the University of Central Florida College of Medicine has embraced these concepts by encouraging medical students to pursue research projects for which they demonstrate passion. An article in The Chronicle of Higher Education discussed programs at the University of Maryland School of Medicine and at the University of Pittsburgh School of Medicine. The University of Central Florida College of Medicine faculty supports this “spirit of inquiry” by encouraging students to reflect on existing data and providing the necessary review and supervision for student development. The projects students delivered have ranged from traditional bench science to educational materials and population-based research for medically underserved communities. When faculty allow the student to create a novel project or suggest an innovative approach, the student will begin to see him or herself as part of the solution to a medical question, a process termed “behavioral activation.”
In an effort to model this creative process, the University of Central Florida College of Medicine has provided support for a number of simulation and technological initiatives in an effort to stimulate independent and point-of-use education. For example, in standardized patient areas, students can use their miniature tablet computers to scan images on a poster (like a QR code) which augments their experiences with standardized patients. Preparing these platforms takes coordination of the curriculum and engagement of faculty, with a small risk that the approaches may not succeed. However, the students recognize that novel approaches can have tremendous possible “upsides,” and by seeing the faculty as creative, trainees will hopefully model their teachers’ creative approaches and understand that knowledge and approaches are not, and should not ever be, static.
Medical progress has always been linked to the advances in other technical fields. The current expansion in mobile processing technologies will undoubtedly have an impact on the care of our patients. Medical educators should encourage current students to embrace these technologies, not just so that students can watch a lecture at their leisure on their cell phone or laptop, but to lead them to think of constructive ways in which they can employ the technology to improve the health of patients and communities. We suggest that changing the way in which students are taught through the use of behavior activation approaches can have a profound impact on improving the quality of care provided by our future doctors, and on their ability to stay current with continuing changes in health care.
About the Authors
Deborah German, MD is vice president for Medical Affairs at the University of Central Florida and the Founding Dean of UCF’s College of Medicine. She is working to develop a premier 21st century research-based medical school that anchors a new medical city.
Julia Pet-Armacost, PhD is the former associate Dean for Planning and Knowledge Management at the University of Central Florida. She is now an associate Dean Emeritus.
Richard Peppler, PhD is the associate Dean for Faculty and Academic Affairs in the University of Central Florida, College of Medicine. He was a faculty member at the LSU Medical Center, Quillen College of Medicine at ETSU and at the University of Tennessee Health Science Center before coming to UCF in 2007.
Juan Cendan, MD is the assistant Dean for Simulation and associate Professor of Surgery at the UCF College of Medicine. He supervises the clinical skills and simulation program at the college. His educational and research interest has been in the use of simulation for both medical students and surgeons. He works closely with experts in computer sciences to develop communicative virtual human avatars and flexible laparoscopic training modules.