Navigating the Digital Frontier: Transforming Graduate Medical Education

The world is undergoing an unprecedented surge in technological advancements, revolutionizing nearly every aspect of our daily lives. From artificial intelligence to new smartphones, the digital era has ushered in a wealth of resources at our fingertips. Medical education is no exception to this transformation. With the expansion of online resources, lectures, and educational apps, the landscape of graduate medical education (GME) is rapidly evolving, presenting both opportunities and challenges for educators and learners alike.

Incorporating a hybrid model of education that combines the strengths of traditional methods with innovative technological tools is hardly new, as evidenced by initiatives dating back over a decade. This approach has been more thoroughly explored and implemented in the realms of primary and secondary education within universities, where e-learning has become a widespread resource. It offers students the flexibility they seek and has been shown to provide an education that is at least on par with traditional approaches. In medical education, institutions such as Harvard, the University of Virginia, and Stanford made the bold move to transition away from traditional lectures in favor of case-based learning as early as 2010. This shift was in recognition of the value of a more dynamic and interactive educational approach (N Engl J Med 2012;366:1657-9). Nevertheless, it is essential to note that while undergraduate medical education may have paved the way for such innovations, GME presents its own unique set of challenges and considerations.

A study conducted within a pathology residency program compared the use of team-based learning to case-based group discussion, showing that each method was equally effective. In the case-based model, a faculty moderator guided discussions using a prewritten case designed to cover critical learning points. Conversely, the team-based learning involved a more standardized information presentation with intermittent multiple-choice questions. The study showed that although students were initially skeptical of the new learning method, they grew to enjoy and recognize the value of their peers as an educational resource. The case-based approach allowed faculty moderators to curate material and guide discussion, leading to increased student engagement and attendance. However, students subjectively felt more influenced by the teacher’s charisma and ability to moderate discussion compared to the team-based learning groups (Med Educ 2005;39:1045-55).

Central to the discussion surrounding the integration of technology and hybrid learning into GME is how program directors and educators assess the value of nontraditional resources. Questions abound regarding the validity and reliability of online resources, such as question banks and podcasts, compared to expert-authored textbooks and peer-reviewed articles. The absence of uniform editorial standards for podcasts and many online resources raises concerns about the accuracy and credibility of the information they disseminate. Without robust mechanisms for fact-checking and peer review, there is a legitimate danger in incorporating unverified content into the curriculum, potentially compromising the quality of medical education.

Fortunately, many studies have assessed the accuracy of different online resources in medical education. For instance, an evaluation by Evans et al. of open access websites for anesthesia education provides valuable insights into the relative merits of different educational platforms (Anesth Analg 2022;135:1233-44). The study evaluates 37 online open access resources in anesthesia, grading them as upper, middle, or lower tertiles based on metrics such as description of the editorial review process, author/website/institution disclosures, clinical relevance to anesthesia professionals, ease of access, interactivity levels, integration of figures, media, and modalities other than text (Anesth Analg 2022;135:1233-44). In general terms, resources sponsored by a recognized society (i.e., ASA, IARS) tend to score higher than those resources sponsored by a department or individual. There is strong evidence demonstrating that active learning and engagement can both enhance and broaden understanding; however, only 30% of the evaluated resources offer an interactive component to learners (Anesth Analg 2022;135:1233-44).

The call for active learning stems back decades, as early as 1983, with active learning defined as students engaging in material, being asked to reflect on ideas, and regularly assessing their understanding (Adv Physiol Educ 2006;30:159-67). It is important to note that both Michael and Koles acknowledge in their work that although active learning can enhance understanding, it is not passive (Med Educ 2005;39:1045-55). This challenges both the educator and the student. In Koles’ study, the bottom quartile of students was the only subset that experienced worse educational outcomes when compared to the team-based learning, possibly due to the lack of student engagement (Med Educ 2005;39:1045-55). In Michael’s work, they note that faculty development is critical in order to create a successful active learning environment for students (Adv Physiol Educ 2006;30:159-67). This research serves as a vital resource for program directors and educators seeking to make informed decisions about the integration of technology into their curriculum.

Furthermore, the era of reading textbooks cover to cover may indeed be a relic of the past. In International Anesthesiology Clinics, Dr. Kurup and colleagues discuss the ever-evolving challenges presented by each new generation of learners (Int Anesthesiol Clin 2010;48:13-25). The upcoming generations of learners in GME have grown up in a digital world, as opposed to the current generation of educators who have primarily adapted to a digital world that evolved around them. Kurup encourages educators to meet this new generation where they are, utilizing the digital resources they are so accustomed to in other areas of life (Int Anesthesiol Clin 2010;48:13-25). While textbooks have historically served as important references, the advent of online resources has fundamentally altered the way residents access and engage with educational materials. Indeed, one study showed that Google was not inferior to traditional searches of Medline and UpToDate^® (Postgrad Med J 2010;86:459-65). It is the responsibility of medical residency programs to evolve with their learners and continue to strive to create a learner-centered model.

The COVID-19 pandemic revitalized this issue, as it forced the dramatic and rapid expansion to accommodate online learning. A study of 140 medical students demonstrated that online lectures were included in 95% of their curriculum, and 85% had asynchronous e-learning as part of their medical education curriculum during the pandemic (Figure). The students rated the impact of the online pandemic curriculum experience and knowledge base on technologic skills/theoretical knowledge more positively while rating their clinical skills, lab skills, productivity, and anxiety/stress as more negatively impacted. Institutions at all levels of education are grappling with the extent to which they should revert back to prepandemic approaches to teaching versus how openly to embrace these newer platforms. Even with the knowledge that active learning and e-learning can enhance GME, the question remains: how do we assess the value and accuracy of these online resources compared to traditional textbooks and reviews? This question is paramount in ensuring that residents receive high-quality, evidence-based education.

In conclusion, while the integration of technology into GME holds tremendous promise for enhancing the educational experience, it must be approached with caution. The hybrid model of education represents a dynamic synthesis of traditional and innovative approaches, offering learners a multifaceted and personalized learning experience. However, ensuring the quality and accuracy of online resources remains paramount, requiring ongoing vigilance and evaluation by program directors, educators, and learners alike. The goal of GME for anesthesiology residents is the same as it has always been: to train the highest-quality anesthesiologists in their clinical practice and critical decision-making for eventual successful board certification and permanent licensure.