Summary: In his latest blog Professor Harden addresses Testing a new idea, Open-book examinations, and The need to think outside the box in planning for the future Description: Testing a new idea
One of the best and most satisfying ways of testing a new idea is to see its application and how it works in a different context. I was delighted to find, for example, that the concept of the OSCE was successfully adopted by the police in the UK and implemented as their national exam to assess candidates for promotion. They had been looking for an exam that assessed practical skills and could be applied on a large scale and found that the OSCE met their needs. The OSCE even featured in the TV police drama Inspector Morse.

More recently I was pleased to hear from John Dent that the Church of Scotland has adopted the Three-Circle learning outcome model I first described in 1999 and have applied it as a framework for learning outcomes expected for trainee ministers. (AMEE Guide 14)

Harden, R.M., Crosby, J.R., Davis, M.H., Friedman, M. 1999. AMEE Guide No. 14: Outcome-based education: Part 5-From competency to meta-competency: a model for the specification of learning outcomes. Med Teach. 21(6), 546-552.

Open-book examinations
A striking development in assessment during the COVID-19 pandemic has been the use of open-book examinations. The assessment of open-book examinations was the theme of a paper by Ivry Zagury-Orly and Steven Durning in Medical Teacher (2020). They argue that open-book exams allow educators to pose questions that require higher ordered cognitive skills and critical thinking beyond rote memorisation. In many ways the open-book exam is more authentic to clinical practice. How to ask the right question, where to find resources to answer the question, and how to evaluate the answer were three areas which Chuck Friedman et al argued needed more attention to be paid in the curriculum.

Zagury-Orly and Durnin proposed the future is likely to see a hybrid model, with learners assessed using a combination of open-book and closed-book examinations. A first part closed-book exam would evaluate learners on concepts they should know without looking up, and this would be followed by a second part open-book exam assessing skills that are authentic and relevant to evidence-based clinical practice.
Open-book exams are attracting attention. At the AMEE 2021 Conference (http://amee.org/conferences/amee-2021) there will be a preconference workshop on the topic of open-book exams and also a networking session where participants will be able to share their views and experiences of open-book exams.

Friedman, C.P., Donaldson, K.M., Vantsevich, A.V. 2016. Educating medical students in the era of ubiquitous information. Med Teach. 38(5), 504-509.

Zagury-Orly, I., Durning, S.J. 2020. Assessing open-book examination in medical education: The time is now. Med Teach. Epub ahead of print.

The need to think outside the box in planning for the future
There is a commitment in the UK to increase significantly the number of doctors in training. It is not clear the extent to which the proposed numbers take into account, as argued by Michael Wilkes (2018), that other health care professionals are likely to make in the future a greater contribution to meeting health care needs of the population.

Discussions as to how to meet the needs for more doctors have not unexpectedly focused on whether this is best achieved by expanding the intake of existing medical schools, creating new schools in selected areas, or by a combination of both. Regrettably, the opportunity does not appear to have been taken to look at fundamentally different approaches to medical education. Should the expansion of medical education, for example be based on an unbundling approach to curriculum development where a medical school is no longer seen as responsible for covering the wide range of specialties and learning opportunities required. Local, national, and international collaboration in the delivery of the medical education programme is likely to be part of the new norm. Ryan Craig, in his book College Disrupted: The great unbundling of higher education, described unbundling of the curriculum as a gripping vision of the likely immediate future of higher education, backed by hard data and insider insights.

At previous AMEE Conferences I argued that the present approach to medical education is not sustainable and that a fundamental change is required and merits serious consideration. At a dinner before the current lockdown an ENT surgeon argued that his 13 years of training was not necessary to equip him with the knowledge and skills needed to undertake his work as an ENT surgeon. The same argument was put forward by a cardiologist. Instead of the present system training in the future should have two tracks – the first track would be to train over a period of six years or so specialist doctors with the necessary expertise in a specific area such as, for example, orthopaedic surgery or neurology. The student would be admitted to medical school with this career aim just as dental students are admitted to train for dentistry. The second track would train generalists who completed a 10 year programme.

That such ideas or adapted versions of them have not been considered by our leaders is perhaps not surprising – it is like asking turkeys to vote for Christmas or chickens to vote for Colonel Sanders. Frederick Hess, in his book The Same Thing Over and Over: How School Reformers Get Stuck in Yesterday’s Ideas, argued that rather than attempting to improve a fundamentally outdated, outmoded structure we should explore and develop new structures. Reformers tend to pour their faith and resources into making the existing structure more effective. He argued that we tend to colour safely within the lines, largely because those lines are so taken for granted that would-be reformers don’t realise there is an alternative.



What is thought as impossible may be possible. Wayne Hodgins, a future strategist, in the book by Elliot Masie Learning rants, raves, and reflections in a chapter titled Imagine if the impossible isn’t, argued that “The future is ours for the choosing, if we can master the courage to ignite the transition from vision to reality by simply imagining that the bright future is now possible and begin shaping its design and implementation. The truth is that it will take all of us to imagine, design, and build it. If you can imagine this previously impossible dream now, you are already part of the solution.”

In planning for the future of medical education the challenge is to think outside the box and to imagine that what is thought to be impossible may be possible.

Wilkes, M. 2018. Medical school in 2029. Med Teach. 40(10), 1016-1019.