Canon Medical Systems USA

Moving Towards Modern Medical Education and Training

Pt. 2: "See one, do one, teach one”: Changing our approach to post graduate medical training.

Anthony Mancuso M.D. - Professor and Chairman of the Department of Radiology - University of Florida - College of Medicine | November 17, 2017

Anthony Mancuso M.D. has a mission to modernize post graduate medical education.  He has  spent the last eight years developing a competency based curriculum and evaluation, based on modern learning theory, with his team at the University of Florida.  They have leveraged extraordinary Learning Technologies to deliver this platform anywhere in the world. In his essay series, Moving Towards Modern Medical Education and Training, Dr. Mancuso will examine in detail: the specific pathway to this adherence to modern learning, educational theory, and the outcome of the application of those principles in this sphere of medical education.

“See one, Do one, Teach one.” Most everyone has heard this expression during some aspect of their medical education. Examined carefully it appears to be somewhat romantically attractive; perhaps as a cavalier or swashbuckling approach usually quoted during procedural training often by someone who, in reality, knows better.  Hidden in the concept is a bit of unintentional cynicism that somehow medical training, whether it’s decision-making or procedural, can be approached simply and in the absence of demonstration of true mastery and competency. Most often, the concept is not true to the real training paradigm; however, it does reflect a potential attitude that most of our patients would find unacceptable. 

Such an attitude is in direct conflict with the spirit and transformative nature of the 1906 Flexner Report.1   If truly practiced it would also be incongruous with the equally revolutionary concepts expressed by Dr. Lawrence Weed about 60 years later in his seminal work with regard to the Problem Oriented Medical Record, as both a tool for clinical care and education. 2-5   Take a moment to think about how that might square with the very important observations made by Dr. Weed in a 2008 interview: 
Today, students are recruited on the basis of how well they memo­rize and regurgitate facts. In the future because knowledge will be in infor­mation technology tools instead of in heads, students should be trained in the reliability of performance of given tasks that will be part of a complete medical care system. Students should be selected for their hands-on skills and interpersonal skills and not on the basis of their memory and re­gurgitation of facts. They should be required to acquire competence in discrete skills and procedures, and their licenses to practice should be correspondingly limited. Medical education should become a system of Medical education should become a system of teaching a core of behavior instead of a core of knowledge.” 6
Our system of medical education and training must do much better than perpetuating the memorization/regurgitation cycle of the past as well as the simplistic embodiment of an educational attitude that might be expressed as some by “See one, Do one, Teach one”. This cries out for a written down curriculum and evaluation rubric for true Competency Base Medical Education (CBME) in both the realms of medical decision-making and treatment as well as procedural practice.
In keeping with the idea of establishing individual competencies to be trained and tested the ACR has in its Appropriateness Criteria efforts, over the last several decades has, perhaps unintentionally, created at least a partial  backbone for a comprehensive diagnostic imaging curriculum. That ACR resource has more recently been expanded into many scenarios directed at informing utilizes of imaging resources what might be the most efficient and effective pathway of incorporating diagnostic imaging into the medical decision-making process. The concept of an episode with the patient as a scenario can then be expanded to construct a curriculum in a CBME approach to education and training in diagnostic imaging both at the graduate and postgraduate level.7

In our department, we define a scenario, for the purpose of curriculum development, as an imaging study together with a specific clinical problem for which the imaging study is appropriate and is likely to be efficient and effective by to informing and advancing medical decision-making. I would challenge anyone to find a radiology curriculum that enumerates these types of individual competencies, with specific defined skill sets, which that layout a clear pathway to mastery, and then test that mastery with an adequate competency evaluation rubric.

The current evidence base that has been accumulated in the last 50 – 70 years now allows us to identify, in any sphere of medical practice, reasonable though not robotic, behaviors in a given clinical scenario. These courses of action, given a particular clinical situation and dataset for decision-making, can then be identified as individual competencies in any particular general or specialized practice of medicine. It follows that the competencies in each scenario can be evaluated by component behavioral objectives; this strategy can build a curriculum that defines a specific competency and sets forth the goals to prove mastery of that competency. If those assumptions are true, then the practice of radiology can be thought of as a set of individual competencies that must be mastered so that our patients can reasonably assume that we are experts when we provide interpretations and consultations about imaging studies and procedures that affect medical decision-making and/or provide therapeutic options.

This concept is roughly in line with Dr. Weed’s concept of couplers, which can be organized in an artificial intelligence/machine learning like manner, to focus the medical decision-making pathway along its most likely effective course. This has direct benefit to the patient and physician involved in decision-making as well as more global implications for the socioeconomics of resource utilization in medicine. The practice of medicine will change enormously with the coming and necessary modification of our educational and training practices. In closing, I will end with another of Dr. Weed’s insightful quotations from a 2008 interview; the quote is worth some serious contemplation:
“The practice of medicine must become a defined and coordinated system of tasks and reliable performers—just like the airline system is a combi­nation of pilots, mechanics, radar-skilled performers, and others, along with educated consumers who learn their roles from childhood on. The present system of medical schools teaching knowledge and graduating physicians performing as they do now will become an anachronism.”
This ideal is certainly appropriate in thinking about the future of postgraduate medical training in diagnostic imaging and many other medical disciplines.
Coming next:
Part 3A:  Teaching to the Test

Anthony A. Mancuso, MD

Dr. Mancuso graduated from the University of Miami School of Medicine in 1973 and completed a Residency and fellowship training in Diagnostic Radiology, including 2 years of subspecialty Neuroradiology training, at UCLA Health. He joined the faculty at UCLA Health where he was fortunate to have a founding member of organized neuroradiology in the United States, Dr. William Hanafee, as his friend and lifelong mentor. Dr. Mancuso owes much of the professional development in his career to Dr. Hanafee both with regard to his dedication to development of effective educational methodology and a devotion to discovery of practices that make a positive impact on patient care. He is a Past President of the American Society of Head and Neck Radiology and Senior Member of the American Society of Neuroradiology.

In 1983, Dr. Mancuso joined the faculty at the UF Health to direct the development of the MRI clinical and clinical research program. In 2000, he became Chairman of the Department of Radiology and remains in that position currently. He is also the President of the Florida Clinical Practice Association at UF Health.

Dr. Mancuso is an acknowledged international expert in the area of ENT radiology having been recognized for his achievements by Gold Medals from the American and European Societies of Head and Neck Radiology and a Presidential Citation from the American Society of Head and Neck chirurgery. He has over 170 refereed publications most in the area of Head and Neck Radiology, and has written several books, most recently, a comprehensive 3 volume text covering the clinical practice of head and neck imaging.

Dr. Mancuso's current research interests have been in developing novel methodologies for radiology education, exploiting foundational and modern learning techniques and merging those techniques with IT tools that make personalized, asynchronous delivery of an effective Radiology curriculum finally possible. His clinical research interest is now focused on the development of advanced brain MRI utilizing DTI and fMRI for the evaluation of traumatic brain injury and a wide range of neuropsychiatric disorders.

1 - Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (PDF), Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, p. 346, OCLC 9795002,
2 - Weed, L. L. (1964-06-01). "MEDICAL RECORDS, PATIENT CARE, AND MEDICAL EDUCATION". Irish Journal of Medical Science. 462: 271–282. doi:10.1007/BF02945791. ISSN 1863-4362. PMID 14160426.
3 - Weed, L. L. (1968-03-14). "Medical records that guide and teach". The New England Journal of Medicine. 278 (11): 593–600. doi:10.1056/NEJM196803142781105. ISSN 0028-4793. PMID 5637758.
4 - Weed, L. L. (1968-03-21). "Medical records that guide and teach". The New England Journal of Medicine. 278 (12): 652–657 concl. doi:10.1056/NEJM196803212781204. ISSN 0028-4793. PMID 5637250.
5 - Weed LL. Medical records, medical education, and patient care: the Problem-Oriented Medical Record as a basic tool. 1970. Cleveland (OH): Press of Case Western Reserve University.
6 - Jacobs L. Interview with Lawrence Weed, MD—the father of the problem-oriented medical record looks ahead [editorial]. Perm J 2009 Summer;13(3):84–9.
7 - Education-Creating the Modern Medical School.