For all its traditional successes, the current model of medical education in the United States and Canada is being challenged on issues of quality, throughput, and cost, a process that has exposed numerous shortcomings in its efforts to meet the needs of the nations' health care systems. A radical change in direction is required because the current path will not lead to a solution.The 2010 publication Educating Physicians: A Call for Reform of Medical School and Residency identifies several goals for improving the medical education system, and proposals have been made to reform medical education to meet these goals. Enacting these recommendations practically and efficiently, while training more health care providers at a lower cost, is challenging.To advance solutions, the authors review innovations that are disrupting higher education and describe a vision for using these to create a new model for competency-based, learner-centered medical education that can better meet the needs of the health care system while adhering to the spirit of the above proposals. These innovations include collaboration amongst medical schools to develop massive open online courses for didactic content; faculty working in small groups to leverage this online content in a "flipped-classroom" model; and digital badges for credentialing entrustable professional activities over the continuum of learning.

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Just imagine: new paradigms for medical education.

Physician-patient communication is considered a fundamental aspect of medical care; yet, research shows that patients commonly have difficulty in understanding medical instructions from physicians.1,2 Physicians often use medical jargon, deliver too much information at a time, and do not confirm patients' understanding of what was discussed.3,4 At the end of the medical encounter, patients remember less than half of what the physician tried to explain, and they may be uncertain about what steps to take next.3,5,6

Low health literacy contributes to the communication gap between physicians and patients.4,7 Patients with low health literacy may have less familiarity with medical concepts and vocabulary, and they ask fewer questions (S. Kripalani, unpublished data). They may also hide their limited understanding out of shame or embarrassment.8 Research shows that physicians commonly overestimate patients' literacy levels, and they rarely consider limited literacy skills in their assessment of whether patients understand what they need to do.9,10 Furthermore, when provided information about patients' literacy levels, physicians appear ill-prepared to communicate effectively.11

In their reports on health literacy, the American Medical Association (AMA) Ad Hoc Committee for the Council on Scientific Affairs, the National Work Group on Literacy and Health, and the Institute of Medicine each called for greater efforts to educate physicians and other health professionals about issues related to health literacy, including techniques to communicate more clearly.12–14 In this article, we describe effective strategies for teaching about health literacy and clear communication. We highlight the most important educational content areas and discuss methods for teaching about health literacy through both clinical precepting and more formal curricula. While the focus of this article is on teaching medical students and residents, its lessons could be applied to developing programs for practicing physicians. Indeed, some of the methods outlined in this article are used in the AMA's health literacy training program for physicians.15 The approach described in this article is also applicable to the training of students and practitioners in all of the health care professions.

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Teaching about health literacy and clear communication.

Despite widespread endorsement of competency-based assessment of medical trainees and practicing physicians, methods for identifying those who are not competent and strategies for remediation of their deficits are not standardized. This literature review describes the published studies of deficit remediation at the undergraduate, graduate, and continuing medical education levels. Thirteen studies primarily describe small, single-institution efforts to remediate deficient knowledge or clinical skills of trainees or belowstandard-practice performance of practicing physicians. Working from these studies and research from the learning sciences, the authors propose a model that includes multiple assessment tools for identifying deficiencies, individualized instruction, deliberate practice followed by feedback and reflection, and reassessment. The findings of the study reveal a paucity of evidence to guide best practices of remediation in medical education at all levels. There is an urgent need for multiinstitutional, outcomes-based research on strategies for remediation of less than fully competent trainees and physicians with the use of long-term follow-up to determine the impact on future performance. Acad Med. 2009; 84:1822–1832. Medical educators and accrediting organizations have shifted their emphasis from what is taught in the curriculum to what a medical student, resident, or practicing physician can perform. Whereas most trainees and practicing physicians can demonstrate competence in clinical and communication skills, a minority fail to meet the expected standard and require remediation. Despite widespread endorsement of the expectation that physicians-in-training and practicing physicians be assessed for their competence, it remains challenging to identify accurately and reliably those trainees and physicians who are incompetent or less than fully competent and to remediate their deficiencies effectively. Less than fully competent physicians or trainees fail to maintain acceptable standards in one or more areas of professional physician practice, whereas incompetent physicians lack the abilities (cognitive, noncognitive, and communicative) and qualities needed to

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Remediation of the Deficiencies of Physicians Across the Continuum From Medical School to Practice: A Thematic Review of the Literature

Teaching health care professionals about health literacy: a review of the literature.

In 2000, the Accreditation Council for Medical Education introduced a new initiative that substantively changed the method by which residency programs are evaluated. In this new competency-based approach to residency education, assessment of performance became a main area of interest, and direct observation was offered as a tool to assess knowledge and skills. Despite being an inherent part of medical education as faculty and learners work together in clinical experiences, direct observation has traditionally been an informal and underused assessment method across all specialties. Residents and students report rarely being observed during their educational process, even though they value the experience. Reasons for this include a lack of faculty time, a lack of faculty skills, a potential stressful effect on the learner, and a perceived lack of validation of the assessment. This article examines the literature regarding the use of direct observation in medical education with a focus on validity evidence. We performed a PubMed search of articles pertaining to direct observation, using key words such as direct observation, performance observation, clinical observation, students, and residents. A subsequent search was conducted in known articles, focusing on variations of the term observation in the titles of articles and introducing the concept of clinical competence. In conclusion, direct observation is a unique and useful tool in the assessment of medical students and residents. Assessing learners in natural settings offers the opportunity to see beyond what they know and into what they actually do, which is fundamentally essential to training qualified physicians. Although the literature identifies several threats to its validity as an assessment, it also demonstrates methods to minimize those threats. Based on the current recommendations and need for performance assessment in education and with attention paid to the development and design, direct observation can and should be included in medical education curricula.

Direct Observation in Medical Education: A Review of the Literature and Evidence for Validity

PurposeTo determine how often students report that they are observed while performing physical examinations and taking histories during clerkship rotations.MethodFrom 1999–2001, 397 students at the University of Virginia School of Medicine were asked at the end of their third year to report

Direct observation of students during clerkship rotations: a multiyear descriptive study.

This resource includes four standardized patient cases intended to address prominent low health literacy topics. In addition to the standardized patient cases, this resource also includes ...

William G. Wilson

Papers

Direct observation of students during clerkship rotations: a multiyear descriptive study.

Utilizing Standardized Patients to Enhance Health Literacy Communication Skills