Distributed Medical Education: Lessons in Change
Dave Lampron, Director Technology Enabled Learning, Faculty of Medicine, University of British Columbia
In 2002, the University of British Columbia’s (UBC) Faculty of Medicine, in partnership with the University of Victoria, University of Northern British Columbia, and B.C. provincial health authorities, accepted a mandate from the provincial government. Their task was to double the number of physicians in the province and bring doctors to areas of the province that were then badly underserved. In addressing these challenges, technology played a pivotal role. The result was a transformation, the complexity and magnitude of which cannot be overstated. Along the way, lessons were learned that will pay dividends for future changes.
Background
At the turn of the 21st century, British Columbia had a serious shortage of physicians with no change in sight. The number of specialist trainees per capita was the lowest of all the Canadian provinces. B.C. had fewer medical student spaces per capita than any other province. B.C.’s north felt the health care gap most acutely, and in June of 2000 a massive public rally and physician walkout occurred in one of B.C.’s largest northern communities; Prince George. This event brought national attention to the crisis and laid the groundwork for the expansion and distribution of UBC's undergraduate medical program.
Significant challenges existed. The province of B.C. encompasses an area larger than the states of California, Oregon, and Washington combined. The shortage of physicians in many communities translated to a lack of teaching capacity, so opening new medical schools wasn’t an option. Developing a single, distributed program for medical education and training required a new collective vision as well as detailed, collaborative and innovative planning.
While distributed medical education was not uncommon in North America for components of pre-clinical or clinical education, fully distributed campuses that delivered four years of the medical curriculum were unique. Advances in technology, particularly videoconferencing, were seen as a possible way to distribute the program. But success depended on many groups—government, faculty, students, physicians, architects, administrators, and information and communication technology experts—coming together to plan and implement the program.
UBC’s Medical Program’s Transformation
Over the last 10 years, UBC’s medical program has undergone a transformation so profound that if learners from a pre-distribution era returned to their alma mater today, they would have great difficulty recognizing the medical school they once knew.
In 2002, UBC’s undergraduate medical education program had a cohort size of 128. Today that cohort size is 288, and medical education occurs at university campuses in Vancouver, Victoria, Prince George and Kelowna and 80 teaching hospitals around the province. By the end of the 2013-14 academic year, UBC will have graduated 1,728 new physicians under the new model.
Technology Underpinning the Transformation
UBC’s MD education relies on a multitude of technologies to support distribution and ensure that learners at all sites enjoy an equivalent experience. Videoconferencing technology in particular has been vital. The year 2012 saw support for more than 45,000 videoconference hours of undergraduate, postgraduate, continuing medical education, and allied health professions education.
Reflecting on a Decade of Distributed Medical Education
The 2013-14 academic year will be the tenth year of UBC’s distributed medical program, a milestone that offers an opportunity for reflection. Over the decade since we started our expansion and distribution, I have witnessed and participated in a total organizational transformation.When we began planning the technology components of the distributed program back in 2002-03, we consulted with schools that had taken a similar path. Many had tried to use technology to enable aspects (primarily clinical) of distribution. We heard time and again how painful the process was. But why had so many previous attempts failed or involved such a struggle? After all, we were considering using many of the same technologies to distribute our own program.
Technology Cloaked as the ‘Answer’
The late Marshall McLuhan, Canada’s great communication theorist and philosopher said, “The ‘message’ of any medium or technology is the change of scale . . . that it introduces to human affairs.”[i] This statement describes B.C.’s own organizational transformation.
The implementation of technology has allowed B.C.’s underserved communities to leverage much-needed teaching capacity from specialists practicing in urban settings such as Greater Vancouver and the Fraser Valley. But it wasn’t technology itself that made the change successful. It was understanding the underlying challenge and why we needed to solve that problem. In our case: the need to train more physicians and address the rural health-care shortage. Understanding the ‘why’ allowed us to apply the most appropriate and ultimately, technology-based solution.
Organizational change is often a challenge, and technology has a way of magnifying the impact of change and sometimes masking the importance of change management in this type of transformation. The use of technology can facilitate a brilliant solution when the problem is well understood and the solution well-planned-out. Conversely, it can create an enormous mess if the underlying problem is poorly understood. If technology had simply been applied without considering the ramifications, UBC’s distributed medical education program ‘feel-good’ story could easily have been a colossal failure.
That doesn’t mean that technology was marginalized—in fact, it was treated as a strategic enabler; a tool that was the final ingredient in a successful change-management initiative. In other words, the form followed the function. Our message was that, while the technology itself can be alluring, without a cogent and well-thought-out understanding of the organizational challenges, implementation is risky.
Lessons Learned: Making the Change Stick
According to a 2008 IBM global study, “1,500 change management executives reveal that nearly 60 percent of projects aimed at . . . business change do not fully meet their objectives.”[ii] I would anecdotally add to IBM’s findings that change initiatives underpinned by technology might have an even higher failure rate.
Having the benefit of hindsight has allowed us to deconstruct the UBC Faculty of Medicine’s educational transformation. We might not have fully realized it at the time, but we were fortunate enough to have the key components to make the transformation successful. Through this experience, I have come to the conclusion that, no matter what the change, success fundamentally hinges on three primary components:
a) Understanding the objective and the reason behind the need for change
b) Having committed leadership who are ready to ‘walk the walk’
c) Planning for the change rather than jumping immediately into execution
Transformations will be successful only if these fundamental components of change are in place. Understanding the reason for a change and having the willingness and ability to change are far more important than the technology that may ultimately underpin that change.
Changing Academic Medicine
Calls for reforming medical education are becoming increasingly frequent. Some of those calls are incredibly compelling.[iii] [iv] As a result, I can’t think of a medical school, or any academic program for that matter, that isn’t considering curriculum reform. The Khan Academy (also known as ‘flipped learning’) and Massive Open Online Courses (MOOCs) are causing great disruption to the educational ecosystem. I see many schools rushing to ‘flip’ their courses or create a MOOC. However, flipped learning and MOOCs are merely tactics (the what and how) rather than objectives (the why). Too often the rationale for why the reform is required gets lost in the excitement of a shiny new approach. For many curriculum reform initiatives, the medium gets confused with the message.
Although undertaking curriculum reform is different from expanding or distributing a medical program, the ingredients for implementing successful change are not. The key is being able to separate the signal from the noise and focusing on encouraging the people involved in the change to buy into the reason for doing it in the first place. If the objective isn't clearly understood, people will not buy in, and the underlying technology and other solutions are not likely to be successful.
Finally, but significantly, we can touch on the subject of communication as part of transformation. Communication is critical to any initiative focused on change, yet is perhaps one of the most overlooked and misapplied components. Top-down communication by itself can be effective at demonstrating organizational leadership and explaining the need for change, but it might be less effective at creating understanding and engagement by those whose actions will have the greatest input in achieving success. Comprehensive, multi-level organizational communications, complemented by enlightened and progressive leadership, are key to ensuring that a dramatic organizational transformation, particularly one that is underpinned by technological change, is successful. The successful expansion and distribution of UBC’s Faculty of Medicine’s education program has taught me that strategically communicating ‘the why’ of transformation rather than ‘the what’ of technology, a true transformation that benefits all stakeholders—learners, faculty and ultimately, patients—can be effectively implemented.
Adapted from a talk presented at the AAMC 2013 Information Technology in Academic Medicine Conference
Acknowledgments
Special thanks to Katharine Casey, Anthony Knezevic, Brian Geary and Christopher Pryde
References
[i] McLuhan, Marshall, Understanding Media, 1964
[ii] IBM, IBM Global Study: Majority of Organizational Change Projects Fail, October 2008, https://www-03.ibm.com/press/us/en/pressrelease/25492.wss
[iii] Emanuel EJ, Fuchs VR. Shortening Medical Training by 30%. JAMA. 2012;307(11):1143-1144. doi:10.1001/jama.2012.292
[iv] Prober, Charles G., Heath, Chip, Lecture Halls without Lectures—A Proposal for Medical Education, N Engl J Med 2012; 366:1657-1659May 3, 2012DOI: 10.1056/NEJMp1202451