For those who have never been to medical school, the idea of learning to be a physician often conjures up thoughts of students in white lab coats eagerly following professors on their rounds through the hospital. But these days, the patients being examined are just as likely to be avatars.
Recent advances in medicine have vastly increased the pool of knowledge that medical students need to know. But with the human capacity to hold that knowledge not increasing any time soon, medical schools have been looking for new ways to give students the tools they need as physicians. Many creative approaches have evolved over the past few years, utilizing new technology and focusing on behavioral sciences more, while putting less emphasis on memorization of medical facts. The ultimate goal of these changes is to encourage medical students to see patients as complete people, not collections of symptoms and conditions.
"Medicine has moved away from the focus on curing disease to wellness and prevention, so the patient is considered in a holistic way," said M. Brownell Anderson, senior director of educational affairs at the Association of American Medical Colleges. "It's not looking at the diabetic ulcer of the foot, [for example], but saying 'this is Ms. Jones and she has problems maintaining her diabetes.'"
Coinciding with a recent study by the AAMC urging colleges to move toward competency-based outcomes for medical learning  rather than assessing students' knowledge of specific facts, many medical curriculums are seeing tangible shifts in the way they deliver education.
"There has been tremendous change in the curriculum. It's never been that every curriculum has been the same, but [it started] to diversify 25 or 30 years ago," Anderson said. "It's a constantly evolving thing ... It's the recognition that there has been a disconnect from what the physicians are learning and the health care system in which they see patients."
One tool to help deliver this education has been the use of virtual simulations, wherein students work with avatars for whom they act as primary physicians. The University of Central Florida Medical School, which was founded in 2006 and is about to induct its first class this fall, has developed a program in which each student will be introduced to a virtual patient at the beginning of his or her medical school tenure and then work with it throughout the entire four years.
"Usually [students] get a 'snapshot' approach [to working with patients], but we are starting in the first couple of years of school," said Lynn Crespo, assistant dean for undergraduate medical education at Central Florida. "As the students gain more knowledge, what the patient presents becomes more involved."
During their time in medical school, students will treat their personal avatars from birth to death, with the virtual patient becoming more emotionally complex and prone to difficult diagnoses as time progresses. The avatar can be "time-warped," so students can zoom backward and forward in their patients' medical histories. Furthermore, the avatars can change races and sexes, allowing students to expose themselves to biases they may not know they had and further develop their communication skills.
"Although we have been talking about sensitivity in medicine for quite some time, the ability to have a tool to train the students and give them constructive feedback really hasn't been done before," Crespo said.
This specific technology, which is being used for the first time at Central Florida, was developed in collaboration with the University of Florida, Medical College of Georgia, and University of Georgia. Its creators hope to share the technology with other medical schools, where it will join a broad array of avatar-based medical technologies already in existence.
As students become more developed, their use of avatars will be pieced together with treating real patients who share similar symptoms in a "mixed reality" scenario.
Crespo maintains that being a new medical school was a huge benefit when devising the Central Florida curriculum. She said that starting with few preconceptions of how medicine should be taught allowed for more dramatic changes, rather than depending on methodologies that had already been in use for years.
"The only thing I can say with any certainty is that the new schools have it easier because they are starting with a clean slate," Anderson said.
Vanderbilt University, though it has been around for over 100 years, revised its medical school curriculum beginning in 2006 after school administrators recognized that they were not effectively utilizing technology as a learning tool. Part of the shift in the curriculum involved the development of an electronic health record that now allows students to access all patients' records from mobile devices. The information is further linked to curriculum information from the classroom, so students can refer to topics they have learned previously while working with the patient. This new technology network, says Bonnie Miller, associate dean for medical education at Vanderbilt, reflects the fact that students will never be able to remember every factoid they learn in class.
"There is so much knowledge that physicians need to know in that they need to understand social and behavioral sciences," Miller said, "and even less time to teach it," noting the reasons why Vanderbilt is utilizing this new technology.
Southern Illinois University changed its curriculum nearly 10 years ago to give students what it calls a "hybrid problem-based learning" experience. The teaching style mixes multiple methodologies, including work with virtual simulations, standardized patients, and real patients to help students learn diagnosis and treatment and cross-disciplinary classroom learning to give students more traditional scientific skills. The hope is that students will become "information managers, not information memorizers," according to Debra Klamen, associate dean for education and curriculum, so that they leave with broad knowledge of how medicine works rather than its specific, easily retrievable details. (Note: This article has been updated from an earlier version to clarify facts.)
"The whole medical philosophy is based on constant reassessment. We look at an entire curriculum and then look outside at what we think is coming down the pike," Klamen said. "We have added issues of population health and well-being, and patient safety. They are hot topics in that students will need to know about that when they graduate, [so we] put that into the curriculum in the last few years."
Other schools have have also re-imagined their curriculums:
- Florida International University, which will begin teaching its inaugural class next month, has come up with a four-year approach to community outreach called NeighborhoodHELP . The program will pair medical students with nursing, public health, and eventually law and business students to reach out to specific low-income neighborhoods and provide medical care. Students will work with their identified group throughout their four years in order to learn about and provide for their constituents' medical needs. NeighborhoodHELP is one attempt to reduce the number of emergency room visits through preventive care.
- At Harvard University, the medical school is in the process of undergoing a curriculum reform started in 2006 to bring together clinical education, small-group tutorials and problem-based learning. Now, students start their Principal Clinical Experience at a teaching hospital earlier than in the past, allowing them to experiment with different disciplines to figure out where their passions lie. In the 1980s, Harvard shifted its focus towards problem-solving and critical thinking, a change that is now being bolstered this year by a new approach to teaching critical thinking through lectures, according to Jane Neill, associate dean for academic programs in medical education at Harvard Medical School.
- Columbia's College of Physicians and Surgeons requires students to take classes in Narrative Medicine , where they learn about the emotional aspects of working with patients through humanities readings, seminars and artistic expression. Classes include topics like "The Philosophy of Death" and "Faith in the Practice of Medicine." The program is meant to help students learn to work with patients better as well as gain the ability to work as professionals.
- The School of Medicine at University of California San Francisco is beginning to use a system of portfolios  to help its students assess their progress in completing competencies. Students keep track of how well they are doing by collecting "artifacts" from their learning and using that to reflect on and assess their goals. Mentors review the portfolios to decide whether students are ready to advance to the next level of education.
With so many approaches to imbuing students with the ability to treat patients, medical school curriculums are sure to get even more diverse. Technological and curriculum innovation will produce a generation of physicians prepared in a very different manner from ever before. But school officials say some facets of medicine will never change.
"It's difficult to say how much do you have to know verses how much you can look up. I think we'll never be in a world where you don't need to know anything," Miller said. "I think that's a question that all of us struggle with. A conceptual understanding of human biology is necessarily, but you don't need to know the origin of every insertion in every vessel."