TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION, VOL.

126, 2015

USING TECHNOLOGY TO MEET THE CHALLENGES OF

MEDICAL EDUCATION

PHYLLIS A. GUZE, MD, MACP

ABSTRACT
Medical education is rapidly changing, influenced by many factors in-
cluding the changing health care environment, the changing role of the
physician, altered societal expectations, rapidly changing medical science,
and the diversity of pedagogical techniques. Changes in societal expecta-
tions put patient safety in the forefront, and raises the ethical issues of
learning interactions and procedures on live patients, with the long-stand-
ing teaching method of “see one, do one, teach one” no longer acceptable.
The educational goals of using technology in medical education include
facilitating basic knowledge acquisition, improving decision making, en-
hancement of perceptual variation, improving skill coordination, practic-
ing for rare or critical events, learning team training, and improving
psychomotor skills. Different technologies can address these goals.
Technologies such as podcasts and videos with flipped classrooms, mo-
bile devices with apps, video games, simulations (part-time trainers, inte-
grated simulators, virtual reality), and wearable devices (google glass) are
some of the techniques available to address the changing educational
environment. This article presents how the use of technologies can provide
the infrastructure and basis for addressing many of the challenges in
providing medical education for the future.

INTRODUCTION
The use of technology in medical education has been developing over
many years. The trend in the use of technology has primarily devel-
oped in response to the challenges facing medical education. These
challenges to medical education are numerous (Table 1). The changing
healthcare environment, with the movement of medical care from the
traditional hospital setting to ambulatory medicine, has necessitated
the ability to provide care in a much shorter period of time and
requires changes in documentation with all information, including
both health knowledge and medical records, becoming digital. Empha-
Correspondence and reprint requests: Phyllis A. Guze, MD, MACP, University of Califor-
nia, Riverside, School of Medicine Education Building, Riverside, CA 92521, Tel: 951– 827-
4564, Fax: 951– 827-7688, E-mail: [email protected].
Potential Conflicts of Interest: None disclosed.

260
 USING TECHNOLOGY 261
TABLE 1
Challenges of Medical Education
Changing healthcare environment
Changing societal expectations
Patient safety
Ethics — “see one, do one, teach one”
Changing curricular emphasis — competencies and milestones
Explosion of medical knowledge
Need for life-long learning
New generation of learners
Rapidly changing technology

sis on cost-containment and evidence-based use of resources is a na-

tional imperative. There are changes in societal expectations so that
patient safety is a focus at all levels of medical education. This has also
raised the ethical issues of learning interactions and procedures on live
patients, with the long-standing teaching method of “see one, do one,
teach one” no longer being acceptable.
There is also the change in curricular emphasis, both in undergrad-
uate and post-graduate training, from simple knowledge acquisition to
the need to demonstrate competencies in the learner (1). The explosion
of medical knowledge no longer allows physicians to keep in their mind
all knowledge that is necessary to provide quality patient care. It is
estimated that more than 600,000 articles are published in biomedical
literature every year. If a student attempted to keep up with the
literature by reading 2 articles per day, in 1 year this conscientious
individual would be more than 800 years behind (2). Although the
profession has long held that physicians need to be life-long learners,
this concept is now an imperative. There is also a new generation of
learners; “digital natives,” a phrase termed by Prensky (3). These are
young people born into the digital world who speak the language of
technology fluently. They expect their education to reflect their exper-
tise in different levels of technology integration and are accustomed to
technology-enhanced learning environments. Finally, medicine is ex-
periencing a rapidly changing use of technology in the delivery of care.
The educational goals of using technology in medical education in-
clude facilitating basic knowledge acquisition, improving decision
making, enhancement of perceptual variation, improving skill coordi-
nation, practicing for rare or critical events, learning team training,
and improving psychomotor skills. Different technologies can address
these goals. The task of medical educators is to use these new technol-
ogies effectively to transform learning into a more collaborative, per-
sonalized, and empowering experience. Bonk captures the essence of
262 PHYLLIS A. GUZE

this new age of technology tools for education by stating “Anyone can
learn anything from anyone at any time” (4).

TECHNOLOGY AND MEDICAL EDUCATION

There are many technologies currently being used in medical edu-
cation. Although the following attempts to present these as individual
approaches, the applications overlap in terms of technological compo-
nents and instructional possibilities.

Computer-assisted Learning
Education of undergraduate medical students can be enhanced
through the use of computer-assisted learning. One example is the use
of “flipped classrooms” in which students review an online lecture
before the lecture session, and come to the classroom to have an
interactive session with the teacher. This time can now be spent on
further exploring complex issues or discussing and solving questions in
a more personalized guidance and interaction with students, instead of
lecturing. Research in this area has not been extensive. Although
randomized trials in education suffer due to difficulty with standard-
ization, contamination between two arms, inability to blind the par-
ticipants, and difficulty measuring outcomes, a few randomized trials
have been conducted asking outcome questions about flipped class-
rooms with some success (5, 6). These studies showed a positive effect
in the areas of student involvement, satisfaction, and knowledge ac-
quisition. Bridge et al conducted a 5-year retrospective study of
streaming video use at Wayne State University School of Medicine and
found the student response to be overwhelmingly positive, with just a
small percentage of students reporting that they rarely or never used
streaming video of lectures (6).

Mobile Devices
Personal digital assistants (PDAs) are routinely used by students for
medical questions, patient management, and treatment decisions.
Medical apps for iPhones and Android devices are numerous. Although
many focus on anatomy and physiology, some address medical problem
solving, diagnosis, and treatment. The website iMedicalApps.com (7)
provides recommendations for the best apps for students and residents
and links to online app stores for purchases. Stanford University, as
one example, has a “Student App” webpage and Stanford apps that can
be obtained from the Apple store. Many medical apps are also available
to be used on tablets as well as phones.
 USING TECHNOLOGY 263

Digital Games
The application of digital games for training medical professionals is
on the rise. The so-called “serious” games provide training tools that
provide challenging stimulating environments, and are often used for
training for future surgeons (8, 9, 10). Use of serious games for surgical
training improves eye-hand coordination and reflex times (10). At
Florida State University College of Medicine, students in geriatric
clerkships play ElderQuest, a role playing game in which players work
to locate the Gray Sage, a powerful wizard in poor health that each
player must nurse back to health (11). One published assessment of
this tool was used to teach geriatric house calls to medical students.
The investigators found that this method provided medical students
with a fun and structured experience that had an effect not only on
their learning, but also on their understanding of the particular needs
of the elderly population (12).

Simulation
The aim of simulation is to imitate real patients, anatomic regions,
or clinical tasks, and/or mirror the real-life circumstances in which
medical services are rendered. Simulations can fulfill a number of
educational goals (Table 2). A qualitative, systematic review by Issen-
berg et al, spanning 34 years and 670 peer-reviewed journal articles,
found that the weight of the best available evidence suggests that
high-fidelity medical simulations facilitate learning under the right
conditions (13). The learning characteristics identified included pro-
viding feedback, repetitive practice, curriculum integrations, range
of difficulty levels, multiple learning strategies, capture of clinical
variation, individual learning, and the ability to define outcomes or
benchmarks. Issenberg et al concluded that although research in
this field needs improvement in terms of rigor and quality, high-

TABLE 2
Education Goals for Simulation
Provides effective feedback
Repetitive practice
Range of difficulties
Multiple learning strategies
Capture clinical variation
Controlled learning environment
Individualized learning/mastery and team training
Defined outcomes and benchmarks
Effective method for team training
Simulator validity
264 PHYLLIS A. GUZE

fidelity medical simulations are educationally effective and simula-

tion-based education complements medical education in patient care
settings (13). Bradley has published a review on the history of
simulation and Lane et al, a comprehensive review of simulation in
medical education (14, 15).
The use of simulation spans a spectrum of sophistication, from the
simple reproduction of isolated body parts through to complex human
interactions portrayed by simulated patients or high-fidelity human
patient simulators replicating whole body appearance and variable
physiological parameters (14,15). One of the earliest simulators, a
mannequin named Rescusi Anne, was developed 35 years ago when
mouth-to-mouth resuscitation protocols were introduced (16). About
the same time, Harvey, a simulator to teach cardiac examination
skills, was developed and is still used worldwide in medical schools and
hospitals (17).
Part-task trainers consist of 3-D representations of body parts/
regions with functional anatomy for teaching and evaluating proce-
dural or psychomotor skills, such as plastic arms for venipuncture or
suturing. Palp-Sim (18) is an example of a program that uses a
haptic system which provides simulation for placing a cannula in the
femoral artery. Haptic systems refer to those simulators that repli-
cate the kinesthetic and tactile perception and produce a feeling of
resistance when using instruments within a simulated environment
(14, 19, 20).
Integrated simulators combine a mannequin (usually a whole body)
with sophisticated computer controls that can be manipulated to pro-
vide various physiological parameter outputs that can be physical
(such as a pulse rate or respiratory movements) or electrical (presented
as monitor readouts). These simulators are often used as the core
platforms of simulation centers. Simulation centers attempt to repli-
cate fully functioning operating rooms, intensive care units, emergency
departments, or patient rooms (15). A well-structured case in the
simulation center can teach and assess many, if not all, of the patient
and process-centered skills, as well as team involvement and manage-
ment.
Virtual Reality (VR) simulation refers to the recreation of environ-
ments or objects as a complex, computer-generated image. In VR
simulations, the computer display simulates the physical world and
user interactions are with the computer within that simulated (virtual)
world. There are a number of VR programs used in medical education.
One example, MIST VR (Minimally Invasive Surgery Trainer–Virtual
Reality), has been specifically designed to provide trainees with a
 USING TECHNOLOGY 265

realistic and assessable environment for developing skills, particularly

in the area of laparoscopy (21, 22).
The LINDSAY Virtual Human Project, a computer-generated 3-D
anatomy and physiology model, permits the user to visualize anatomy
and other human components in a 3-D simulation using 2-D computer
interfaces, including mobile devices, and provides an immersive ap-
proach to anatomy and physiology (23, 24). Use of anatomy simulation
models have not been well studied although computer-generated 3-D
models to teach anatomy have proliferated. One randomized study by
Nicholson did show that the 3-D computer-based anatomical model
enhanced students’ learning of anatomy of the ear (25).
Second Life is an online virtual world, developed by Linden Lab (a
company based in San Francisco, CA) and launched on June 23, 2003,
as of 2014 has approximately 1 million regular users. Within any
Second Life simulated environment, users exist through avatars which
interact realistically with other avatars online. Islands or areas of
learning can be established where avatars can visit, interact with
other avatars, and also interact with information provided by institu-
tions such as the CDC, NLM, PubMed, and medical schools to mention
a few (26). Second Life currently features a number of medical and
health education projects (27, 28) and educators are in the process of
evaluating the value of Second Life in different aspects of medical
education (26, 29, 30).

Wearable Technologies
Google Glass is being tested as a new layer of technology that makes
education more realistic and potentially more effective. At the Univer-
sity of California, San Francisco (UCSF) School of Medicine, a cardio-
thoracic surgeon, Pierre Theodore, MD, has used Glass in more than 20
surgeries. He uses Google Glass to project radiologic images (CTs,
MRIs, etc) into the field of vision as he operates to assist in cases where
he can use additional clinical data to help guide activity (31).
The role of Google Glass and other devices will become commonplace
across the healthcare continuum and provide an essential clinical tool,
from use by the paramedic on location to advanced care and consulta-
tions (32). The University of California, Irvine School of Medicine may
be the first to integrate Google Glass into the curriculum (33). Educa-
tors believe that students will benefit from Glass’s unique ability to
display information in a smartphone-like, hands-free format, being
able to communicate with the internet via voice commands and being
able to securely broadcast and record patient care and student training
266 PHYLLIS A. GUZE

activities using proprietary software compliant with the 1996 federal

Health Insurance Portability & Accountability Act (31).

DISCUSSION
Medical education is rapidly changing, influenced by many factors
including the changing healthcare environment, the changing role of
the physician, altered societal expectations, rapidly changing medical
science, and the diversity of pedagogical techniques. Societal influ-
ences and the changing healthcare environment are influenced by the
internet, globalization, cost containment, aging of society, increasing
public accountability, a medically informed public, demands of person-
alized care, population diversity, expansion of healthcare delivery by
non-physicians, and changing boundaries between health and health-
care. Physicians now work in teams, are salaried, part of a complex
organization, and must be highly accountable. Challenges of preparing
the future doctor involve emphasis and standardization of competen-
cies and learning outcomes, integration of formal knowledge and clin-
ical experience, patient-centered care, population health, cost-con-
scious⫺high value care, and understanding the organization of health
services.
Use of technologies for undergraduate, postgraduate, and continuing
medical education has become increasingly prevalent. There are a
number of educational advantages that are listed in Table 3. These
modalities facilitate knowledge acquisition, improve decision making,
enhance perceptual variation, improve skill coordination, and provide
an educational environment that engages the learner and allows learn-
ing that does not endanger the patient. Use of computer technologies
has the additional benefit of being able to assess competencies and
milestones, and provide the student, at any level, with the tools to
continue to access the medical knowledge necessary to deliver quality
care and be a life-long learner.

TABLE 3
Educational Advantages of Technology
Safe, controlled environments that eliminate risk to patients
Enhanced, realistic visualization
Authentic contexts for learning and assessment
Documentation of learner behavior and outcomes
Instruction tailored to individual or group needs
Learner control of the educational experience
Repetition and deliberate practice
Enhance perceptual variation and improve skill coordination
Standardization of instruction and assessment
 USING TECHNOLOGY 267

The use of technology in medical education should be to support

learning; it should not be a replacement for face-to-face learning.
Educators must still focus on the principals of teaching, not on the
specific technologies. Technologies are just one tool in the educational
toolbox. The task of medical educators is to use these new technologies
effectively to transform learning into a more collaborative, personal-
ized, and empowering experience. To paraphrase Confucius: “Tell me
and I will forget, show me and I may remember, involve me and I will
understand” (34).

REFERENCES
1. Sherwin J. Competency-based medical education takes shape. Association of Ameri-
can Medical Colleges, April 2011. Available at: https://www.aamc.org/newsroom/
reporter/april11/184286/competency-based_medical_education.html. Accessed Octo-
ber 12, 2014.
2. Barnett OG. Information technology and medical education. J Am Med Informatics
Assoc 1995;2;285–291.
3. Prensky M. Digital Natives, Digital Immigrants. On the Horizon (MCB University
Press) 2001;9(5):1– 6.
4. Bonk CJ. The World is Open: How Web Technology is Revolutionizing Education. San
Francisco, CA: Jossey-Bass, 2009.
5. Greenhalgh T. Computer assisted learning in undergraduate medical education.
BMJ 2001;322(7277):40 – 44.
6. Bridge PD, Jackson M, Robinson L. The effectiveness of streaming video on medical
student learning: a case study. Med Educ Online 2009;14:11. Available at: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC2779626/.
7. Husain I, editor. Medical Application, 2014. Website. Available at: http://
www.imedicalapps.com/.
8. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for
medical education and surgical skills training. Br J Surg 2012;99(10):1322–30.
9. Rosser JC, Lynch PJ, Cuddihy L, et al. The impact of video games on training
surgeons in the 21st Century. Arch Surg 2007;142:181– 6.
10. Rosenberg BH, Landsittel D, Averch TD. Can video games be used to predict or
improve laparoscopic skills? J Endourol 2005;19(3):372– 6.
11. Community and Continuing Education, Utah Valley University, 2013. Elderquest.
Web site. Available at: http://www.uvu.edu/ce/elderquest/. Accessed October 13,
2014.
12. Duque G, Fung S, Mallet L, Posel N, Fleiszer D. Learning while having fun: the use
of video gaming to teach geriatric house calls to medical students. J Am Geriatr Soc
2008;56(7):1328 –32. Epub: http://www.ncbi.nlm.nih.gov/pubmed/18482292.
13. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and
uses of high-fidelity medical simulations that lead to effective learning: a BEME
systematic review. Med Teach 2005;27(1):10 –28.
14. Bradley P. The history of simulation in medical education and possible future di-
rections. Med Educ 2006;40(3):254 – 62.
15. Lane LJ, Slavin S, Ziv A. Simulation in medical education: a review. Simulation
Gaming 2001;32:297;297–314. Available at: http://sag.sagepub.com/content/32/3/
297.abstract.
268 PHYLLIS A. GUZE

16. Resusci A. Advanced Cardiac Life Support Training guides. Dallas, TX: American
Heart Association, 1971.
17. Gordon MS, Ewy GA, Felner JM, et al. Teaching bedside cardiologic examination
skills using “Harvey,” the cardiology patient simulator. Med Clin North Am 1980;
64(2):305–13.
18. John N. Bangor University, Istituto Italiano di Technologia, Royal Liverpool Uni-
versity Hospital, “Palp Sim” Online video clip. YouTube. YouTube, April 16, 2011,
Web. Available at: https://www.youtube.com/watch?v⫽JkytZWiKPrA. Accessed Oc-
tober 10, 2014.
19. Clapan ES, Hamza-Lup FG. Simulation and Training with Haptic Feedback – A
Review International Conference on Virtual Learning, 2008. Available at: http://
www.academia.edu/3820500/Simulation_and_Training_with_Haptic_Feedback_-_
A_Review. Accessed October 12, 2014.
20. Hamza-Lup FG, Popovici DM, Bogdan CM. Haptic feedback systems in medical
education. JADLET J Adv Distributed Learning Tech 2013;1(2);7–16.
21. Wilson MS, Middlebrook A, Sutton C, Stone R, McCloy RF. MIST VR: a virtual
reality trainer for laparoscopic surgery assesses performance. Ann R Coll Surg Engl
1997;79(6):403– 4.
22. McCloy R, Stone R. Virtual reality in surgery. BMJ 2001;323(7318):912–5.
23. Tworek JK, Jamniczky HA, Jacob C, Hallgrimsson B, Wright B. The Lindsay virtual
human project: an immersive approach to anatomy and physiology. Anat Sci Educ
2013;6:19 –28.
24. Jacob C, von Mammen S, Davison T, et al. LINDSAY Virtual Human: Multi-scale,
Agent-based, and Interactive. In: Kolodzieg J, Khan SU, Burcznyski T (editors).
Advances in Intelligent Modelling and Simulation: Artificial Intelligence-Based
Models and Techniques in Scalable Computing. First Ed. Heidelberg, Germany:
Springer, 2012:327– 49.
25. Nicholson DT, Chalk C, Funnell WR, Daniel SJ. Can virtual reality improve anat-
omy education? A randomised controlled study of a computer-generated three-di-
mensional anatomical ear model. Med Educ 2006;40(11):1081–7.
26. Spooner NA, Cregan PC, Khadra M. Second life for medical education. ELearn
Magazine September 2011. Web site. Available at: http://elearnmag.acm.org/
featured.cfm?aid⫽2035934. Accessed October 5, 2014.
27. Boulos MN, Hetherington L, Wheeler S. Second life: an overview of the potential of
3-D virtual worlds in medical and health education. Health Info Libr J
2007;24(4):233– 45.
28. Beard L, Wilson K, Morra D, Keelan J. A survey of health-related activities on
second life. J Med Internet Res 2009;11(2):e17.
29. Wiecha J, Heyden R, Sternthal E, Merialdi M. Learning in a virtual world: experi-
ence with using second life for medical education. J Med Internet Res 2010;12(1):e1.
30. Melús-Palazón E, Bartolomé-Moreno C, Palacı́n-Arbués JC, et al. Experience with
using second life for medical education in a family and community medicine educa-
tion unit. BMC Med Educ 2012;12:30.
31. Pelletier SG. Technology in Academic Medicine: Medicine Takes a Closer Look at
Google Glass. AAMC Reporter, April 2014.
32. Nosta J, How Google Glass is changing medical education. Forbes Technology, June
27, 2013. Web. Available at: http://www.forbes.com/sites/johnnosta/2013/06/27/
google-glass-teach-me-medicine-how-glass-is-helping-change-medical-education/.
Accessed October 12, 2014.
33. UC Irvine, UCI School of Medicine first to integrate Google Glass into curriculum –
wearable computing technology will transform training of future doctors. UCIrvine
 USING TECHNOLOGY 269
News. May 12, 2014. Web. Available at: http://news.uci.edu/press-releases/uci-
school-of-medicine-first-to-integrate-google-glass-into-curriculum/. Accessed Octo-
ber 12, 2014.
34. Confucius quote, GoodReads. 2014. Web. Available at: http://www.goodreads.com/
author/quotes/15321.Confucius. Accessed October 13, 2014.

DISCUSSION
Weinberger, Philadelphia: One of the things with education is the whole regula-
tory environment surrounding it; the LCME for medical schools, ACGME for graduate
medical education, and so forth. Have they taken a stand in terms of promoting or
restricting — obviously you are talking about changing a lot in the educational environ-
ment — and I am wondering what the regulatory bodies are doing in terms of incorpo-
rating this new type of technology?
Guze, Riverside: The accrediting bodies are very conservative. However, what they
overwhelmingly use as outcomes are usually things like test exams. They also use
student satisfaction, because they use student surveys. So far their silence has been
basically that if you get to the end and can demonstrate competence in whatever you do
then they have been accepting of it.
Zeidel, Boston: We have actually developed at our place simulations for physiology
which make the physiology dynamic rather than static. Of course, this seems like a great
idea. I would urge that as we apply these technologies that we actually develop the
ability to test whether they work. There is an awful lot that has gone on in education
since Flexner, actually where we change the way we educate, and we don’t measure
whether it makes any difference. All of us who have lived in suburbs have recognized
that every 5 years there is a new math curriculum. We have no idea whether it is any
better than the old math curriculum, but everyone has to learn it. I would urge that we
try with the developing field of measuring efficacy in educational interventions to
measure whether these things improve things or not, so that we can try to be a bit
rigorous about what we are doing. Of course, all the medical schools in the country are
probably going to flip their curriculum in the next several years, and probably I fear
there will be no effort to figure out if it is any better than what we were doing before.
Guze, Riverside: It’s a very good point. Fortunately or unfortunately, in this area
the major research is really qualitative research and not quantitative research. There
have been a few studies that have looked at exam rates and shown that students who
are more actively involved, through using some simulation technologies, have done
better.
Katz, Boston: My comment has to do with ultimately the binary characteristics of
technology, which is, there is a right answer and there is a wrong answer in general. Just
this week, I heard that there were complaints about our otherwise very good co-training
simulation session. That there was sort of always a right answer, but they rarely got
beyond that. They very rarely got into the variability of the real situations. It gets to this
issue of sort of ambiguity; the value of being able to hold multiple right answers at the
same time without an exact correct answer. That’s one of my concerns about some of this
technology. Although I readily acknowledge the many, many advantages. I was wonder-
ing if you could talk about that. How does this affect the learners ability to be open
minded in a situation where there is often time a right or wrong answer?
Guze, Riverside: I don’t think this is a substitute for a certain amount of face-to-face
interaction that has to go on. There is the art of medicine that we can’t ever, from my
perspective, leave behind. These are tools that actually get a student, I believe, more
270 PHYLLIS A. GUZE

actively involved. But without the modeling I think by the physicians who apply the art
and are able to say, “This may be right in this individual but may not be right in others,”
we then would be missing an important component of education. I think what the
technology does is take advantage of the fact that as adults we do much better if we are
actively involved in doing something.
Bradsher, Little Rock: When my son graduated from medical school a few years
ago, he was distraught that his intern coat wouldn’t fit his IPad, so my communal wife,
who is home economics major, took one of my coats and harvested a pocket and put inside
his coat an iPad pocket. He showed it to his intern mates who said, “You are such a nerd.”
Then about 20 minutes later they said, “Can we get one of those?”