History in the Making

He Set the Course in Medical Education

As a young physician, John Shaw Billings endured a harrowing professional trial by fire as a 23-year-old surgeon on the battlefields of Gettysburg and Chancellorsville. He would build upon these foundational experiences as he instilled his philosophical influence on medical education in a way that no one person has before—or since. 

As the architectural designer of The Johns Hopkins Hospital’s layout and interior, Billings redefined the concept of what a hospital could be, but his influence would reach far beyond physical walls. Billings would shape the early curriculum of the Johns Hopkins University School of Medicine and hand-select the first two members of the so-called Big Four founding physicians of The Johns Hopkins Hospital and school of medicine: William Welch, the first dean of the school of medicine and William Osler, the first physician-in-chief.

“Of all the men I have ever known, he was about the wisest,” Welch later wrote of Billings. “He was a man whose judgement one sought on any difficult subject, and one pinned one’s faith to him more than to any man of one’s acquaintance.”

Drawing upon his battlefield experiences and his role as the medical librarian in the U.S. surgeon general’s office, Billings saw medicine at the time as too subjective, too intuitive. Doctors, he strongly believed, were not consistently or completely trained, and they lacked proper access to medical literature. 

To remedy the latter concern, he had created The Index-Catalogue of the Library of the Surgeon-General's Office, a comprehensive cross-reference of the available medical literature to help physicians locate published research. More important, perhaps, the index was updated with newly published material each month in the Index Medicus, the ancestor of today’s MedLine.

But Billings also believed that physicians needed to improve. A good doctor needed to go beyond merely treating the conditions as experience allowed, as best he could, and instead “investigate for himself” the root causes and cures of illness and disability through a unification of medicine and science. 

Billings envisioned his hospital not just as a place of refuge and care, but also of research and teaching. His ideal physician was part investigator, part educator. He wrote in an 1875 essay that the hospital and the school of medicine should “promote discoveries in the science and art of medicine … and to provide the means of giving medical instruction.” 

That vision set in motion the Johns Hopkins University School of Medicine’s lasting reputation and laid the philosophical foundation for the school that remains firmly rooted in its character and mission.

“In his broad interests and skills, Billings was a Renaissance man, and he infused his vision both physically and intellectually through the advanced design of The Johns Hopkins Hospital and in the founding of the school of medicine,” says pathology professor Ralph Hruban ’85. “Those influences are still with us today.”

Venous thromboembolism (VTE), a blood clot deep within the circulatory system, is a condition as ominous as its name. It can strike a patient dead in an instant. vtes kill more people than aids, breast cancer and car crashes combined. 

A few years ago, Johns Hopkins surgeon Elliott Haut led a team in developing a computer program to guide medical residents when admitting patients at high risk of VTE. “More than half the time, our residents were not making the right calls on VTE, and we wanted to improve those numbers,” Haut says. 

The online tool guided residents through diagnostic factors to help them determine the proper therapeutic regimen for any given patient, based on age, weight, medical history and so forth. Soon, 85 percent of patients were receiving proper treatment. But it was not enough for Haut. “At Johns Hopkins, 85 percent is not the goal,” he says. “We needed more.” 

And that’s when clinical informatician Brandyn Lau stepped into the picture. He developed an additional application that quantified how each resident was admitting patients at risk of VTE—what drugs and courses of treatment they prescribed. Then the application matched those scores against the recommended protocols. 

“Each trainee received a personal scorecard showing exactly how they performed against their peers, where they excelled and where they fell short,” says Lau. Within a month, 96 percent of VTE patients were getting exactly the recommended course of treatment.

“We didn’t need to coach them much; their natural competitiveness took over,” Haut says. “Some of these trainees had never been in the lowest quartile in anything, much less 50th out of 50.”

The VTE success story is more than an object lesson in human motivational behavior. It is a real-world example of an entire new direction in medical education now being rolled out at the Johns Hopkins University School of Medicine. 

Known as precision education, this movement looks to harness the power of big data—the large volume of new medical information, both cohesive and disparate, that floods us daily—to provide more personalized instruction and performance assessment—not just in the clinic for residents, but also for graduate students and medical students.

Roy Ziegelstein, vice dean for education in the school of medicine, is the point person responsible for making precision education a reality. In his medical training days, he says, there was zero performance feedback beyond his grades and an occasional “good job.” (Occasionally accompanied by a high-five if you were lucky, Ziegelstein adds.)

“If you asked me how good I was at treating diabetes, I might have said, ‘very good,’ but I wouldn’t have known for sure,” Ziegelstein says. If pressed for objective metrics, he could quote the raw number of patients he saw in residency. “But there were no data to judge the care I’d given or to guide me when I needed improvement.” 

Goodbye Cookie-Cutter Approach

When precision education becomes a reality, it will mark a fundamental shift in the way medicine has been taught since 1910, when the Carnegie Foundation issued a lengthy—and damning—study on the state of medical education in the United States. The 337-page analysis, “Medical Education in the United States and Canada,” was commonly called the Flexner Report after its author, academic scholar Abraham Flexner. It identified numerous shortcomings in the training and certification of physicians. It also raised standards for entry into medical school, influenced curriculum, instilled scientific rigor and strengthened professional licensing.

In the wake of the Flexner Report, only the very best schools survived. Johns Hopkins was hailed as the model, and many other institutions were merged out of existence. Some were shuttered outright. While the number of newly minted doctors plummeted in the years after the report, those who emerged were better trained than those who went before.

While the Flexner Report has had lasting influence on medical education ever since, Ziegelstein says, it established a paradigm that trainees generally had to adapt to—rather than a model that accommodates individual learner needs and previous experience. 

“Medical education has become a somewhat cookie-cutter process. Every student gets largely the same education,” Ziegelstein says. “Precision education is the most significant change to the medical school experience since the Flexner Report.”

Inspiration for precision education comes from another much-heralded movement in health care known as precision medicine. It is predicated on the idea that more and better data about patients—particularly their genetics, family histories, specifics of their conditions and their medical histories—can lead to better medical treatment tailored to each individual patient. (See Winter 2017 issue, “It’s Personal.”)

“We hope precision education will do for our students what precision medicine does for patients—and that it will provide an experience tailored to the student, not to tradition, to improve their skills and knowledge,” Ziegelstein says. 

Enhancing Wonder and Creativity

While the groundwork is still being laid for this sea of change, biomedical engineer Harry Goldberg, assistant dean and a board member of the Institute for Excellence in Education at the school of medicine, provides a tantalizing vision of how precision education will work once it is fully implemented.

Goldberg says it starts with asking an important question: What do we want our students to become? While the school’s mission is to create the leaders of tomorrow, he wonders what that means beyond training better physicians and researchers.

“Does it mean authors, department chairs, inventors?” Goldberg asks rhetorically. “At the core, I believe, the answer is to engage and instill curiosity in our students. This is where precision education can play a role, and we need to start with personalizing the educational experience.”

The first goal is to ensure students have a common baseline of knowledge, much of which can be delivered through the use of an online content delivery system. The ability to view this core content prior to class prepares students ahead of time to actively participate when in the classroom, where they can then learn to apply core content and develop an understanding of higher-level concepts.

Goldberg and Caitlin Hanlon, a postdoc collaborator, are integrating a “scaffold” of core content with ancillary information, such as ethical discussions, case studies, new techniques, simulations and other subject matter. While not required, these ancillary materials allow students to explore complementary information, identify their interests and go beyond what might otherwise be expected of them. 

Providing different levels of ancillary content helps address the heterogeneity of student backgrounds and interests, Goldberg notes. A nonscience major or a nontraditional medical student would benefit from content that is quite different than that of a first-year colleague who has a Ph.D. in biochemistry. 

“Currently, every student receives the same information regardless of his or her academic needs. Such standardization compromises our ability to enhance creativity, wonder and academic diversity of thought,” Goldberg says.

As proof of principle, Goldberg and Hanlon piloted this approach in an undergraduate Science of Medicine course last spring. They provided students with the core content typical of most other science, technology, engineering and math courses. But then they asked the students to enhance the material with information that the students curated themselves from the web, content they developed on their own or with information that represented responses to material posted by their colleagues.

“As the semester progressed, the students became so engaged and class participation became so pronounced that [our] role soon became nothing more than catalysts for discussion. This course clearly belonged to the students,” Goldberg says, noting he continues to receive papers and links from students to add to the course for the next cadre of learners.

Goldberg and Hanlon, along with Rebecca Walter and Leah Greenspan, two graduate students in the Biochemistry, Cellular and Molecular Biology Graduate Program, then turned their attention to the graduate Principles of Genetics course. With the support of Erika Matunis, a professor of cell biology, they transformed a lecture-style course into a team-based learning environment. Ten other graduate students helped create the core content, which was vetted by faculty members. Here too, early indications show that an individualized approach resonates with today’s students and results in deeper understanding of the material and expanded interests. The group plans to publish its findings over the next several months.

Classroom of the Future

Making way for this new era of learning means that much of the curriculum will be taught not in traditional large lecture halls with dusty chalkboards, but in entirely new settings.

Enter the “classroom of the future,” known at Johns Hopkins as STILE—for Science, Transform, Inspire, Learn, Engage. It is part of a $1 million renovation of the learning space that recently took place in the graduate program at the school of medicine. 

The STILE classroom, which opened in 2016, can accommodate 72 students at eight tables, each fitted with laptops, document cameras and microphones. Faculty members and students alike can display information from their workstations for the benefit of other students. The lectern includes an electronic pencil that allows the instructor to annotate slides and other visual content that is projected for all to see. 

From this spot, an instructor can select and project the screen of any of the student laptops to any or all of four larger screens around the classroom. To further encourage student engagement, each student has access to a “clicker”—part of an audience response system that allows the instructor to check in frequently to see if students are grasping the material. 

The remaining space in the room is covered with dry-erase whiteboards where illustration and brainstorming transpire. STILE is a space meant to engage students in active learning and to inspire new teaching methods. 

“This team-based approach to learning is different, but most students seem to really enjoy it,” says Greenspan. “Having the pre-materials allows the instructor to capitalize on STILE’s technical capabilities to inspire that more active learning approach we’re looking for in the classroom.” 

Toward Tailored Career Advising

Medical students, residents and fellows aren’t the only ones whose experience will be transformed. Those in the graduate training programs—some 750 doctoral candidates spread across 14 different disciplines—will also benefit from the precision education approach, says cell biologist and associate dean for graduate biomedical education Peter Espenshade.

Where once graduate students in the basic sciences had a reasonable expectation of careers in academia, the era of austerity in research funding has meant far fewer jobs there. Espenshade aims to tap into data to help students find rewarding careers in industry through improved career counseling, targeted lab experiences and richer alumni contact networks. He describes a future where a student can express a professional goal and advisers can map their experience against those of alumni already well along in their careers.

“Precision education starts with the question: Is it the right type of education for this student?” Espenshade says. “For each student, there’s a different path to success, and data and analytics can help us guide the right outcome for each one.”

In similar fashion, associate dean for undergraduate medical education Nancy Hueppchen aims to mine existing data sources to better individualize the advising process for Johns Hopkins medical students.

In many ways, the medical school adviser is like a physician who “examines” the student, evaluating strengths, weaknesses, talents, passions and professional aspirations to help guide students toward careers they will find fulfilling and rewarding. Traditionally, such guidance has come from the adviser’s intuition and limited outcomes data on student performance.

But with sufficient data about a student’s background, learning preferences, class performance, goals and experience, an informed adviser could sit opposite a medical student and counsel him or her with greater certainty based on data from other graduates in similar circumstances years earlier.

“We would like to know where and how these graduates are making their mark on the world, but also the academic path that got them there to help guide today’s students,” Hueppchen says. 

“The goal is to uplift every student who matriculates here. It’s the scientific educator in me: I like to be able to say to those students: This works, and this is why, and here's the evidence.”

Amplifying the Vision

Though precision education is still in its nascence, Goldberg says, Johns Hopkins has the right people in place to lead the movement both here and on the national scene. “In true Hopkins fashion, we are well-positioned to work together to build and amplify this vision of what biomedical education can and should be,” he says.

Ultimately, Johns Hopkins education leaders say, the move toward precision education will pay off in the clinics and the labs with better patient care and breakthrough research.

‘‘Currently, every student receives the same information regardless of their academic needs. Such standardization compromises our ability to enhance creativity, wonder and academic diversity of thought.”

– Harry Goldberg

‘‘For each student, there’s a different path to success, and data and analytics can help us guide the right outcome for each one.”

– Peter Espenshade