Precision Education: The Future of Lifelong Learning in Medicine.

ABSTRACT: The goal of medical education is to produce a physician workforce capable of delivering high-quality equitable care to diverse patient populations and communities. To achieve this aim amidst explosive growth in medical knowledge and increasingly complex medical care, a system of personalized and continuous learning, assessment, and feedback for trainees and practicing physicians is urgently needed. In this perspective, the authors build on prior work to advance a conceptual framework for such a system: precision education (PE).PE is a system that uses data and technology to transform lifelong learning by improving personalization, efficiency, and agency at the individual, program, and organization levels. PE "cycles" start with data inputs proactively gathered from new and existing sources, including assessments, educational activities, electronic medical records, patient care outcomes, and clinical practice patterns. Through technology-enabled analytics , insights are generated to drive precision interventions . At the individual level, such interventions include personalized just-in-time educational programming. Coaching is essential to provide feedback and increase learner participation and personalization. Outcomes are measured using assessment and evaluation of interventions at the individual, program, and organizational levels, with ongoing adjustment for repeated cycles of improvement. PE is rooted in patient, health system, and population data; promotes value-based care and health equity; and generates an adaptive learning culture.The authors suggest fundamental principles for PE, including promoting equity in structures and processes, learner agency, and integration with workflow (harmonization). Finally, the authors explore the immediate need to develop consensus-driven standards: rules of engagement between people, products, and entities that interact in these systems to ensure interoperability, data sharing, replicability, and scale of PE innovations.

Exploring the role of community health organizations in promoting public health during a health crisis: a qualitative study of COVID-19 responses in South Africa and Zambia.

While the COVID-19 pandemic amplified the need for accurate and actionable health information, uncertainty and the proliferation of misinformation have contributed to significant mistrust in public health messages, especially among marginalized communities. Community health organizations can play an important role in creating trust and providing targeted health information to vulnerable groups. This qualitative study, which is focused on community health organizations supporting vulnerable populations in South Africa and Zambia, finds that during the pandemic, community health organizations expanded their roles and leveraged their established access and trust to support the communities they serve with health education and services. However, the reliance on external support limits the organizations' ability to respond in an effective and efficient manner during health crises.

Building Bridges With School Boards-An Understudied Seat of Health Equity.

This Viewpoint describes the role of school boards in both education delivery and health outcomes and the importance of clinician involvement in effecting health-promoting policies for all students.

Changing Mindsets About Side Effects of the COVID-19 Vaccination: A Randomized Controlled Trial.

BACKGROUND: Side-effect concerns are a major barrier to vaccination against COVID-19 and other diseases. Identifying cost- and time-efficient interventions to improve vaccine experience and reduce vaccine hesitancy-without withholding information about side effects-is critical. PURPOSE: Determine whether a brief symptom as positive signals mindset intervention can improve vaccine experience and reduce vaccine hesitancy after the COVID-19 vaccination. METHODS: English-speaking adults (18+) were recruited during the 15-min wait period after receiving their second dose of the Pfizer COVID-19 vaccination and were randomly allocated to the symptom as positive signals mindset condition or the treatment as usual control. Participants in the mindset intervention viewed a 3:43-min video explaining how the body responds to vaccinations and how common side effects such as fatigue, sore arm, and fever are signs that the vaccination is helping the body boost immunity. The control group received standard vaccination center information. RESULTS: Mindset participants (N = 260) versus controls (N = 268) reported significantly less worry about symptoms at day 3 [t(506)=2.60, p=.01, d=0.23], fewer symptoms immediately following the vaccine [t(484)=2.75, p=.006, d=0.24], and increased intentions to vaccinate against viruses like COVID-19 in the future [t(514)=-2.57, p=.01, d=0.22]. No significant differences for side-effect frequency at day 3, coping, or impact. CONCLUSIONS: This study supports the use of a brief video aimed at reframing symptoms as positive signals to reduce worry and increase future vaccine intentions. CLINICAL TRIAL INFORMATION: Australian New Zealand Clinical Trials Registry: ACTRN12621000722897p.

Side-effect concerns are a major barrier to vaccination against COVID-19 and other diseases. Therefore, the purpose of this study was to determine whether a brief symptom as positive signals mindset intervention could improve vaccine experience and reduce vaccine hesitancy after the COVID-19 vaccination. Participants were recruited during the 15-min wait period after receiving their second dose of the Pfizer COVID-19 vaccination and were randomly allocated to a treatment as usual control condition or to a mindset intervention condition which entailed watching a 3:43-min video explaining how the body responds to vaccinations and how common side effects such as fatigue, sore arm, and fever are signs that the vaccination is helping the body boost immunity. Compared with participants in the control condition, participants in the mindset intervention condition reported significantly less worry about symptoms at day 3, fewer symptoms immediately following the vaccine and increased intentions to vaccinate against viruses like COVID-19 in the future. No significant differences emerged for side-effect frequency at day 3, coping, or impact. These finding provide initial support for cost- and time-efficient interventions to improve vaccine experience and reduce vaccine hesitancy without withholding information about side effects.

Medical School Admissions: Focusing on Producing a Physician Workforce That Addresses the Needs of the United States.

The aging population, burnout, and earlier retirement of physicians along with the static number of training positions are likely to worsen the current physician shortage. There is an urgent need to transform the process for selecting medical students. In this Invited Commentary, the authors suggest that to build the physician workforce that the United States needs for the future, academic medicine should focus on building capacity in 3 overarching areas. First, medical schools need to develop a more diverse pool of capable applicants that better matches the demographic characteristics of health care trainees with those of the population, and they need to nurture applicants with diverse career aspirations. Second, medical schools should recalibrate their student selection process, aligning criteria for admission with competencies expected of medical school graduates, whether they choose to become practicing clinicians, physician-scientists, members of the public health workforce, or policy makers. Selection criteria that overweight the results of standardized test scores should be replaced by assessments that value and predict academic capacity, adaptive learning skills, curiosity, compassion, empathy, emotional maturity, and superior communication skills. Finally, to improve the equity and effectiveness of the selection processes, medical schools should leverage innovations in data science and generative artificial intelligence platforms. The ability of ChatGPT to pass the United States Medical Licensing Examination (USMLE) demonstrates the decreasing importance of memorization in medicine in favor of critical thinking and problem-solving skills. The 2022 change in the USMLE Step 1 to pass/fail plus the exodus of several prominent medical schools from the U.S. News and World Report rankings have exposed limitations of the current selection processes. Newer approaches that use precision education systems to leverage data and technology can help address these limitations.

"The Videos Gave Weight to Our Work": Animated mHealth Videos and Tablet Technology Boost Community Health Workers' Perceived Credibility in Khayelitsha, South Africa.

Mobile health (mHealth) interventions are increasingly used to support community health workers (CHWs) in low-and middle-income countries. As near-peers within their communities, the credibility of CHWs is sometimes questioned-a recognized barrier to their efficacy. Nested within a large, randomized-controlled trial, this qualitative study captured the experiences of South African CHWs, called "Mentor-Mothers," using tablets and animated videos to promote exclusive breastfeeding. We conducted in-depth telephone interviews with 26 tablet-carrying Mentor-Mothers. We analyzed interview transcripts using a Grounded Theory approach, then developed a theoretical framework, based on an emerging theme, for understanding how tablet technology boosts the perceived credibility of CHWs. Tablet-carrying Mentor-Mothers described an increase in their perceived credibility, which they attributed to overt and signaling effects related to enhanced credibility of (1) their messages, (2) themselves as messengers, and (3) the program employing them. Mobile technology investments in CHWs could enhance their credibility, translating into meaningful investments in the health of under-served communities.

Managing Difficult Conversations: An Essential Communication Skill for All Professionals and Leaders.

Managing difficult conversations is an important skill to develop and refine for all professionals and future leaders, particularly for those in health care where difficult situations with high stakes are prevalent. The intensity and frequency of these types of conversations will predictably increase as one's professional responsibility grows. In this article, the authors discuss their interprofessional course, Managing Difficult Conversations, developed 15 years ago for medical and graduate students at Stanford University. The course facilitates the practice of managing difficult conversations through role play in a low-risk, safe classroom setting among peers. The role-played difficult conversations are based upon a series of case studies and are facilitated by faculty and guest experts. There is no single communication style that suits everyone, but the authors offer resources from the course that can be applied for effective difficult conversations, including 12 guiding principles and a 3-stage framework for planning, beginning, and conducting the conversation. Preparing and practicing for difficult conversations will enhance the likelihood of conveying the necessary information with professionalism, directness, clarity, empathy, and warmth. Although unsettling news will always be difficult to receive, the method of delivery should be a source of comfort and hope, not one of discomfort and pain.

Digital Education for Health Professionals: An Evidence Map, Conceptual Framework, and Research Agenda.

BACKGROUND: Health professions education has undergone major changes with the advent and adoption of digital technologies worldwide. OBJECTIVE: This study aims to map the existing evidence and identify gaps and research priorities to enable robust and relevant research in digital health professions education. METHODS: We searched for systematic reviews on the digital education of practicing and student health care professionals. We searched MEDLINE, Embase, Cochrane Library, Educational Research Information Center, CINAHL, and gray literature sources from January 2014 to July 2020. A total of 2 authors independently screened the studies, extracted the data, and synthesized the findings. We outlined the key characteristics of the included reviews, the quality of the evidence they synthesized, and recommendations for future research. We mapped the empirical findings and research recommendations against the newly developed conceptual framework. RESULTS: We identified 77 eligible systematic reviews. All of them included experimental studies and evaluated the effectiveness of digital education interventions in different health care disciplines or different digital education modalities. Most reviews included studies on various digital education modalities (22/77, 29%), virtual reality (19/77, 25%), and online education (10/77, 13%). Most reviews focused on health professions education in general (36/77, 47%), surgery (13/77, 17%), and nursing (11/77, 14%). The reviews mainly assessed participants' skills (51/77, 66%) and knowledge (49/77, 64%) and included data from high-income countries (53/77, 69%). Our novel conceptual framework of digital health professions education comprises 6 key domains (context, infrastructure, education, learners, research, and quality improvement) and 16 subdomains. Finally, we identified 61 unique questions for future research in these reviews; these mapped to framework domains of education (29/61, 47% recommendations), context (17/61, 28% recommendations), infrastructure (9/61, 15% recommendations), learners (3/61, 5% recommendations), and research (3/61, 5% recommendations). CONCLUSIONS: We identified a large number of research questions regarding digital education, which collectively reflect a diverse and comprehensive research agenda. Our conceptual framework will help educators and researchers plan, develop, and study digital education. More evidence from low- and middle-income countries is needed.

Evaluation of a community-based mobile video breastfeeding intervention in Khayelitsha, South Africa: The Philani MOVIE cluster-randomized controlled trial.

BACKGROUND: In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs ("mentor mothers"). METHODS AND FINDINGS: We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants' median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers' time use and eliciting their subjective experiences through in-depth interviews. At both points of follow-up, we observed no statistically significant differences between the video intervention and the control arm with regard to EBF rates and other infant feeding practices [EBF in the last 24 hours at 1 month: RR 0.93 (95% CI 0.86 to 1.01, P = 0.091); EBF in the last 24 hours at 5 months: RR 0.90 (95% CI 0.77 to 1.04, P = 0.152)]. We observed a small, but significant improvement in maternal knowledge at the 1-month follow-up, but not at the 5-month follow-up. The interpretation of the results from this causal impact evaluation changes when we consider the results of the nested mixed-methods performance evaluation. The mean time spent per home visit was similar across study arms, but the intervention group spent approximately 40% of their visit time viewing videos. The absence of difference in effects on primary and secondary endpoints implies that, for the same time investment, the video intervention was as effective as face-to-face counseling with a mentor mother. The videos were also highly valued by mentor mothers and participants. Study limitations include a high loss to follow-up at 5 months after premature termination of the trial due to the COVID-19 pandemic and changes in mentor mother service demarcations. CONCLUSIONS: This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs' direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services. TRIAL REGISTRATION: The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27, 2018.

Design preferences for global scale: a mixed-methods study of "glocalization" of an animated, video-based health communication intervention.

BACKGROUND: Designing health communication interventions for global scaling promotes health literacy and facilitates rapid global health messaging. Limited literature explores preferences for animation prototypes and other content characteristics across participants in different global regions. Prior research underscores an urgent need for health communication interventions that are compelling and accessible across culturally and geographically diverse audiences. This study presents feedback from global learners on animation design preferences and other key considerations for the development of educational video content intended for global adaptation and scaling. METHODS: We used a mixed-methods, sequential explanatory design, with a qualitative descriptive approach to the analysis of the qualitative data. We recruited participants from an international group of learners enrolled in a massive open online course. Through an online quantitative survey (n = 330), we sought preferences from participants in 73 countries for animation design prototypes to be used in video-based health communication interventions. To learn more about these preferences, we conducted in-depth interviews (n = 20) with participants selected using maximum variation purposive sampling. RESULTS: Generally, respondents were willing to accept animation prototypes that were free of cultural and ethnic identifiers and believed these to be preferable for globally scalable health communication videos. Diverse representations of age, gender roles, and family structure were also preferred and felt to support inclusive messaging across cultures and global regions. Familiar-sounding voiceovers using local languages, dialects, and accents were preferred for enhancing local resonance. Across global regions, narratives were highlighted as a compelling approach to facilitating engagement and participants preferred short videos with no more than two or three health messages. CONCLUSIONS: Our findings suggest that global learners may be willing to accept simplified visuals, designed for broad cross-cultural acceptability, especially if the content is localized in other ways, such as through the use of locally resonating narratives and voiceovers. Diverse, inclusive portrayals of age, gender roles and family structure were preferred.

Learning Alone or Learning Together: Is It Time to Reevaluate Teacher and Learner Responsibilities?

Medical schools across the United States and Canada constantly consider how to improve their curricula and their pedagogical strategies. The authors found it informative to compare how students in 2 professional schools, medicine and business, are taught. The authors believe that creating the best future physicians requires students and faculty to be physically together to learn essential skills. Increasing student interactions with peers and faculty enhances learning, and the classroom is a natural place for these interactions to take place. Requiring medical students to attend teaching sessions in the preclinical curriculum should help foster their development of core competencies, including critical decision making, clinical reasoning, and patient-centered care.

Expansion of simulation and extended reality for undergraduate health professions education: A call to action.

In the spring of 2020, the COVID-19 pandemic limited access for many health professions students to clinical settings amid concerns about availability of appropriate personal protective equipment as well as the desire to limit exposure in these high-risk settings. Furthermore, the pandemic led to a need to cancel clinics and inpatient rotations, with a major impact on training for health professions and interprofessional health delivery, the long-term effects of which are currently unknown. While problematic, this also presents an opportunity to reflect on challenges facing the traditional clinical training paradigm in a rapidly changing and complex health care system and develop sustainable, high-quality competency-based educational models that incorporate rapidly progressing technologies. We call for pilot studies to explore specific simulation-based inpatient and outpatient clinical rotations for professional and interprofessional training.

The Philani MOVIE study: a cluster-randomized controlled trial of a mobile video entertainment-education intervention to promote exclusive breastfeeding in South Africa.

BACKGROUND: In South Africa, rates of exclusive breastfeeding remain low and breastfeeding promotion is a national health priority. Mobile health and narrative entertainment-education are recognized strategies for health promotion. In-home counseling by community health workers (CHWs) is a proven breastfeeding promotion strategy. This protocol outlines a cluster-randomized controlled trial with a nested mixed-methods evaluation of the MObile Video Intervention for Exclusive breastfeeding (MOVIE) program. The evaluation will quantify the causal effect of the MOVIE program and generate a detailed understanding of the context in which the intervention took place and the mechanisms through which it enacted change. Findings from the study will inform the anticipated scale-up of mobile video health interventions in South Africa and the wider sub-Saharan region. METHODS: We will conduct a stratified cluster-randomized controlled trial in urban communities of the Western Cape, to measure the effect of the MOVIE intervention on exclusive breastfeeding and other infant feeding practices. Eighty-four mentor-mothers (CHWs employed by the Philani Maternal Child Health and Nutrition Trust) will be randomized 1:1 into intervention and control arms, stratified by neighborhood type. Mentor-mothers in the control arm will provide standard of care (SoC) perinatal in-home counseling. Mentor-mothers in the intervention arm will provide SoC plus the MOVIE intervention. At least 1008 pregnant participants will be enrolled in the study and mother-child pairs will be followed until 5 months post-delivery. The primary outcomes of the study are exclusive breastfeeding at 1 and 5 months of age. Secondary outcomes are other infant feeding practices and maternal knowledge. In order to capture human-centered underpinnings of the intervention, we will conduct interviews with stakeholders engaged in the intervention design. To contextualize quantitative findings and understand the mechanisms through which the intervention enacted change, end-line focus groups with mentor-mothers will be conducted. DISCUSSION: This trial will be among the first to explore a video-based, entertainment-education intervention delivered by CHWs and created using a community-based, human-centered design approach. As such, it could inform health policy, with regards to both the routine adoption of this intervention and, more broadly, the development of other entertainment-education interventions for health promotion in under-resourced settings. TRIAL REGISTRATION: The study and its outcomes were registered at clinicaltrials.gov ( #NCT03688217 ) on September 27th, 2018.

A Multi-Institution Collaboration to Define Core Content and Design Flexible Curricular Components for a Foundational Medical School Course: Implications for National Curriculum Reform.

Medical educators have not reached widespread agreement on core content for a U.S. medical school curriculum. As a first step toward addressing this, five U.S. medical schools formed the Robert Wood Johnson Foundation Reimagining Medical Education collaborative to define, create, implement, and freely share core content for a foundational medical school course on microbiology and immunology. This proof-of-concept project involved delivery of core content to preclinical medical students through online videos and class-time interactions between students and facilitators. A flexible, modular design allowed four of the medical schools to successfully implement the content modules in diverse curricular settings. Compared with the prior year, student satisfaction ratings after implementation were comparable or showed a statistically significant improvement. Students who took this course at a time point in their training similar to when the USMLE Step 1 reference group took Step 1 earned equivalent scores on National Board of Medical Examiners-Customized Assessment Services microbiology exam items. Exam scores for three schools ranged from 0.82 to 0.84, compared with 0.81 for the national reference group; exam scores were 0.70 at the fourth school, where students took the exam in their first quarter, two years earlier than the reference group. This project demonstrates that core content for a foundational medical school course can be defined, created, and used by multiple medical schools without compromising student satisfaction or knowledge. This project offers one approach to collaboratively defining core content and designing curricular resources for preclinical medical school education that can be shared.

Human-Centered Design of Video-Based Health Education: An Iterative, Collaborative, Community-Based Approach.

Drawing on 5 years of experience designing, producing, and disseminating video health education programs globally, we outline the process of creating accessible, engaging, and relevant video health education content using a community-based, human-centered design approach. We show that this approach can yield a new generation of interventions, which are better aligned with the needs and contexts of target communities. The participation of target communities and local stakeholders in the content production and design process fosters ownership of the content and increases the likelihood that the resulting intervention will resonate within its intended primary audience and be disseminated broadly. Ease of future adaptation for additional global audiences and modification of the content for multiple dissemination pathways are important early considerations to ensure scalability and long-term impact of the intervention. Recent advances in mobile technology can facilitate the dissemination of accessible, engaging health education at scale, thereby enhancing the potential impact of video-based educational tools. Accessible and engaging health education is a cornerstone of health behavior change. Especially in low- and middle-income countries, increasing access to effective health education can contribute to improved health outcomes. Prior research has identified several characteristics of effective health education interventions. These include the integration of pictures, narratives, and entertainment-education, in which the health messages that make up the educational content are embedded. However, the effectiveness and long-term impact of health messages ultimately depend on how well the end users can identify with the content that is presented. This identification, in turn, is a function of how well the messages correspond to user needs and wants and how this correspondence is communicated through the design characteristics of the health education intervention.

The Match: To Thine Own Self Be True.

The residency match process, culminating with the Match Day celebration, plays out in medical schools across the United States and Canada every year. The process may seem strange and mysterious for observers outside of medicine. The notion that each graduating student's employer for the next several years is first revealed to thousands of people, all at the same moment, through the opening of an envelope is surreal. The emotional reactions accompanying the process range from jubilance to deep disappointment. Much attention and care have been given to developing the algorithm underpinning the Match, and the process seems just: Optimization favors applicants over training programs. Witnessing students as they progress to their next stage of medical training is special for those involved in medical education. Faculty are filled with pride. But the process is far from perfect. The author of this Invited Commentary notes several concerns about the Match: the arduous process that students undergo to maximize their chances of success; the costs attendant to the travel and related expenses of multiple, geographically dispersed interviews; and the metrics that students and their medical schools use to judge the outcomes. The author worries that for some students, the "ideal" match may not be the one driven by their dreams and aspirations but, rather, by an amalgamation of those of many well-meaning friends, family members, and faculty. Medical students should seek advice and guidance, but the author hopes that, ultimately, students follow their own drumbeat and are true first to themselves.

A Proposal for a Shared Medical School Curricular Ecosystem.

New digital platforms are transforming learning in higher education and providing high-quality education content at little or no cost. Educators can now reach large, even global audiences. Yet, many medical schools continue to develop and maintain custom but duplicative curricular content despite having limited faculty and financial resources. In addition, medical students are faced with a multitude of potentially unaligned curricula driven by the school, national licensing exams, and the students' own perceived clinical training needs. The authors propose the creation of a common curricular component ecosystem that is developed around consensus-built foundational learning objectives aligned with core competencies that must be acquired by all students graduating medical school. Identifying and developing common curricula with standardized learning outcomes ideally should involve leading medical education, accreditation, and certification bodies in the United States. Curriculum component standards will be necessary to enable curriculum development, sharing, and adoption at scale. A shared medical curriculum ecosystem would free up faculty time to develop high-value teaching activities at individual medical schools. Students would benefit from a consistent education experience that better aligns with national licensure exams. A shared, core curriculum system could begin to bend the cost curve for medical education in the United States and scale internationally to help address the increasing global shortage of health care workers.