Leaders in Medical Education

Dr. Rachel Ellaway, Northern Ontario School of Medicine

Osmosis Team
Jul 18, 2014

Dr. Rachel Ellaway has dedicated her career to improving medical education. She is both an Associate Professor and the Assistant Dean for Curriculum and Planning at the Northern Ontario School of Medicine. Dr. Ellaway's research focuses on the use of technology in medical education, specifically learning platforms and mobile technologies. We were fortunate to speak with Dr. Ellaway about her expertise in medical education.

How did you decide on a career in medical education?

I don’t think there was ever a point where I made this choice. Back in the mists of time I was appointed as a typographer in Medical Illustration at the University of Edinburgh. This developed into computer graphics and then into an educational multimedia role and then into education and what we came to call ‘e-learning’. My role became increasingly academic as I completed my PhD. I guess you could say that I never decided not to have a career in medical education because it is such a rewarding field to be working in. Here I am two decades later, still loving this work even though it’s changed and I’ve changed so many times since I started.

What do you consider most important in designing the MD curriculum at the Northern Ontario School of Medicine?

At the outset, just to be clear, the Northern Ontario School of Medicine (NOSM) MD curriculum was largely in place by the time I joined the School in 2007 so my answer talks to the key principles we employ rather than my own specific contributions.

I’d suggest that there are three essential factors in our MD program:

First, we recruit a particular kind of student. We don’t use the MCAT or have any basic-science requirements; we look for learners that have commitments to Northern Ontario and to the North in general, as well as to medicine, and then we complete selection using a multiple mini-interview (MMI). We admit around 3% of our applicants each year so we have a good selection to choose from to fit our model and our mission.

Second, NOSM was established to address the health needs of the peoples of Northern Ontario, a culturally and geographically diverse people who have had generally poorer health outcomes and less access to healthcare services than those in the South of the province. The argument for having a School for, of, and in the North drew on research showing that doctors who trained in underserved areas were a lot more likely to come back and practice in them. The MD program, like the School, is community engaged, oriented and based and is profoundly distributed across a multitude of community sites in the 800,000 km2 of Northern Ontario. Students spend 1 month in a First Nations community at the end of first year, two 1-month placements in small communities in second year and 8 months in one of 14 mid-size communities in third year (our Comprehensive Community Clerkship). These experiences profoundly shape the way our students develop as doctors and make them very attractive to residency programs across Canada.

Third, NOSM has an integrated curriculum based on 5 Themes that span all four years of the program. The program is broken up into modules and phases, but assessment is based on the Themes at every stage of the program. Although all 5 Themes have a Northern Ontario focus, Theme 1 ‘Rural and Northern Health’ is a particularly distinct component of our program as it covers many of the specifics of our region, and this kind of focus is found rarely in other programs.

How do you foresee medical education changing in the next few years?

I just gave a presentation on this topic to a group from Western University in SW Ontario so this is still very much in my mind. I think that there are three levels or forms of change we need to recognize:

  1. There are already many existing changes percolating through the systems of medical education. For instance, the move to competency-based medical education is a major change, which, if fully realized, means a move to individual progress and the fragmentation of a class or cohort based model. The adoption of digital technologies has slowed in recent years but as it becomes the norm to use technology we are challenged as to the changing role of knowledge acquisition and application in medicine and medical education.

  2. There have also been many calls for change at the conceptual and policy level, particularly following the centenary of the Flexner Report a few years back. A particularly significant change is the growing attention to medical schools’ social missions, in particular their relations with and responsibilities to the communities they serve – often collected in the concept of social accountability. I also think that we are going to be more aware of and engaged in the growing diversity of contexts of care, teaching and learning; in response we are starting to explore the role of contextual competence in medical education.

  3. Change from outside of medical education also needs to be considered, for instance the globalization of medicine and medical education, the changing demographic and social forces in our societies, and the economics of education and healthcare.

Clearly there are a great many factors likely to change medical education significantly. However, medicine and medical education tend to be fairly (small ‘c’) conservative and as such they tend to resist the pressures and impacts of change. To paraphrase Chomsky; although the institutions may persist, the underlying values may change more than we expect.

It can be difficult for medical students and physicians to keep up with changes in the medical field. Fortunately, E-learning allows new research to be uploaded immediately. However, it also allows information to be revised and even deleted. What changes do you think will be made to make E-learning more valuable to the medical community?

First off let me say that I don’t like using the term ‘e-learning’. It confuses and conflates many practices that are to my mind quite distinct. E-learning, if we accept that the use of technology makes things different (which I’m not sure it really does), should refer to what learners do. However, e-learning is more often concerned with what teachers do so we might more realistically call it e-teaching. In the end there are still human beings learning, the only difference being the media they use to support their learning. We should more accurately use the term technology-enabled learning (TEL) or technology-enhanced learning (also TEL).

TEL is already incredibly valuable to the medical community, reflected for instance in the move in the past few decades from knowledge acquisition to knowledge application as the primary goal of medical education. I have previously argued that digital technologies are more usefully considered as cognitive prosthetics (extensions of our mentalities) than as tools that are separate from us. The role of TEL as cognitive prosthesis is simple; how do we make best use of different media and how can they help us to be better practitioners? To be able to answer these questions health practitioners need better levels of information literacy. I think that is the primary challenge. The fluidity of information and its representation and use (and misuse) can then be addressed from within medicine rather than relying on others, who do not necessarily understand the field, to find solutions to challenges as they arise.

In your paper, "Left to their own devices: Medical learners' use of mobile technologies," you found that the use of mobile devices for educational purposes depended on the type of learner, device, and/or teacher. What changes do you think need to be made to make students more comfortable with using their mobile devices as learning resources?

I would like to see a greater degree of deliberate practice for preceptors around the use of mobile technologies in medicine and medical education. Our study described how those learners whose preceptors used mobile technologies had a better time of it than those whose preceptors did not. That’s not to say that mobile technology is intrinsically good, students need to learn when to set it aside as well as when to use it, and we need to assess their ability to practice with a mobile device (as a cognitive prosthetic) and without one. This clearly has implications for our current model of exams that ban any access to mobile technologies.

The affordances of the technologies are also an important concern. Size and usability of the device, availability of particular tools, and total cost of ownership are critical issues, but it also really helps if you are using the same technology as your peers use; the ability to share ideas and learn together is a real enabler.

I also think we need to better appreciate the spread of interest in and happiness in using mobile technology. Not all contemporary medical students are confident and competent using mobile technologies, many have concerns that they can easily become over-dependent on their devices. Deliberate practice of mobile technologies by doctors needs to be critical and reflective rather than seeking the latest and coolest technologies to use.

We also need to acknowledge that this is a fast-moving field and that contemporary practices will quickly become quaint anachronisms. For instance, Eric Topol and others are exploring the use of mobile technologies for sensing and recording patient information, while others are rapidly developing patients’ use of devices in supporting their health care regimes. The Qualcomm Tricorder XPRIZE (www.qualcommtricorderxprize.org) is particularly notable in pointing to a future where mobile devices are one of the primary tools physicians use.

To quote Miranda in the Tempest; “O brave new world, that has such people in't!”