The New Tools: What 21st Century Education Can Teach Us

The educational world is becoming flat.

A quiet revolution is underway in the way teachers and students interact using recorded lectures, YouTube, and the internet. In 2004, financial analyst turned online educator Sal Khan began tutoring his niece in math using an online drawing program. As he uploaded these lectures to YouTube, their popularity grew into a social phenomenon.

Today, Khan Academy has provided over 240 million online lessons around the world in over 4000 topics. Stanford, MIT, and other universities now offer massive open online courses (MOOCs) by top professors to all comers. In fact, Harvard Business School no longer offers an introductory accounting class due to the availability of an exceptional online course from Brigham Young University. With high-quality content readily available online, the student-teacher dynamic is changing. Students are expecting excellent instruction and teachers are expecting students to be increasingly knowledgeable about subjects from online viewing. These reciprocal heightened expectations have the potential to create a more dynamic and interactive classroom experience.

These innovations can also transform patient education by bringing patients into the circle of learning. Patients already leverage YouTube and other online sources for health purposes. For example, PatientsLikeMe was started in 2004 by the family and friends of Stephen Heywood who had been diagnosed with amyotrophic lateral sclerosis. This online community helps connect patients with other similarly affected patients and aims to educate patients about the illness experience and potential treatment options. This encourages patients to think synergistically about complex problems such as outcomes, decision-making and ethics. Today, PatientsLikeMe covers more than 1200 health conditions with over 100,000 members.

Given these broad ranging developments, we need to rethink the patient–doctor encounter. The typical encounter follows the traditional pedagogic paradigm of “banking” – in which the teacher, who has the power and the knowledge, seeks to deposit knowledge assets into the learner’s bank (1). Unfortunately, though this approach induces passivity and disempowerment it is the dominant mode of patient education. Instead, imagine encounters where patients are prepared to engage in shared decision-making, allowing the office visit to center on activities that promote patient-centeredness and engagement such as confirming patient comprehension, ascertaining values, and establishing goals.

Video education in medicine: advance care planning

Consider the topic of advance care planning. All patients should discuss their goals of care with their doctors – certainly patients with advanced illnesses deserve such discussions. Yet few patients have these conversations. It seems that physicians find it difficult to broach this topic, are pressured for time, or do not acknowledge the importance of the issue. Decades of advocacy have had little impact. Yet, we have shown that videos can help promote meaningful discussions between patients and physicians (3–5).

Imagine a typical advance care planning discussion occurring today. The physician provides the details of the potential treatment options and reviews the risks and benefits involved – possibly using language that the patient does not understand. What if the patient viewed a short, simplified and standardized video prior to or during the encounter that empowered the patient by presenting possible treatment goals and illustrating the medical procedures most consistent with those goals, reviewing common risks and benefits of each? Next, the physician has a discussion with the patient reviewing the video’s content, emphasizing patient specific considerations and discussing the patient’s questions. This process can improve the patient–doctor encounter, leading to greater interaction, satisfaction and understanding.

Additionally, videos provide a crucial quality control element, widely utilized in intensive care and surgical settings to promote quality and safety, but currently lacking in patient–doctor communication. At present, what information is offered to patients isentirely dependent on which provider the patient has and whether that provider chooses to inform the patient. Standardization is critical to assuring that patients obtain the information needed for informed decision-making.

Many clinical scenarios are suitable for video assistance. Our research consortium has tackled some of them, including providing options to patients about their choices at the end of life, and imagining future disease states such as advanced dementia and the likely medical problems complicating those conditions (3–5). Our studies suggest three important findings: (1) patients often lack essential information regarding their options; (2) the lack of patient information and empowerment leads to unnecessary – and frequently unwanted medical procedures; and, (3) videos can help surmount many of the information gaps and improve out- comes by helping patients avoid unwanted medical treatments (3–6). Receiving medical care that is discordant with patients’ wishes is a medical error no different from administering the wrong medica- tion or amputating the wrong body part. Videos can help empower patients to obtain the knowledge needed to avoid such medical errors. The shifting educational paradigm using online videos and MOOCs may help bring this to fruition.

Opportunities for videos in healthcare and quality control

Consider other ripe opportunities: videos helping caregivers to navigate the health care system or MOOCs reviewing medical illnesses such as dementia and heart failure from the early to late stages. Videos can potentially inform patients and caregivers at almost every point of contact with the health care system. Clinical research validates this perspective: short, well-made and easy to understand videos are associated with a wide range of benefits including improved compre- hension, decision-making, and satisfaction (3–5).

As with all new technologies, issues regarding quality control will arise. Below, we list some of the salient issues for the new video paradigm:

  1. How can we adequately evaluate all the new videos regarding content, objectivity, point of view and authenticity? Do we have to? How rigorous should these evaluations be without becoming burdensome?
  2. What criteria should exist regarding creating the videos in regards to the use of special effects and animation versus videos that show clinicians in real clinical settings? Is one more effective than the other or a combination of the two? Do patients prefer real images of doctors and patients rather than actors, avatars, or cartoons?
  3. Should such videos primarily exist within the non-profit sector where market forces are not as paramount as in for-profit entities? Should one be preferred over the other?The ongoing debate regarding the development of decision support technologies, especially when highly subjective content and media such as video are used, is instructive: when important questions regarding quality control, standardization and objectivity are raised early and transparently then consensus can be obtained (7). The important first step is to acknowledge the questions and to create guidelines for best practices.

Transforming the healthcare landscape with video education

If necessity drives innovation, health care is certainly at such a moment. We face a “silver tsunami” of an aging population, lack of advance care planning, funding cuts, and a growing shortage in primary and palliative care. Given the complexity of the issues involved, the best solutions will address foundational aspects of care. We believe straight-forward ideas – like videos to facilitate understanding – can address these problems if implemented correctly and applied in conjunction with improved communication strategies. The profession of medicine should harness the power of video technology to reinforce the patient–doctor interaction.

Medical progress will undoubtedly add further complexity to patient encounters. New treatments may lead to important benefits but also frequently yield added conceptual complexity for patients (and clinicians). In addition, patients are increasingly bringing their own information from internet searches and online communities to the patient–doctor encounter, the content of which is often unchecked. Using standardized and critically reviewed videos are a potent tool to help clarify complexity and appropriately weigh medical evidence.

While the ideal of activated patients and clinicians has been around for decades, it has not yet been actualized. In our view, a 21st century education paradigm that leverages videos and MOOCs will move us towards this goal. It is time to learn from the rapid evolution of online video learning techniques to empower patients and clinicians with short, simple videos. The physician then becomes a guide to help patients clarify their values and goals built on a solid foundation of information and understanding. Videos are a powerful tool for the patient and physician, and have the potential to significantly improve the delivery of care in an increasingly complex health care system.

This editorial originally appeared in Volume 1, Issues 3-4 of Healthcare: The Journal of Delivery Science and Innovation (HJDSI), released today, December 11, 2013.


1. Friere P. Pedagogy of the Oppressed. New York, NY: Bloomsbury Academic Press; 2000.
2. 〈http://www.improvingchroniccare.org/〉 Accessed 10.7.13.
3. The Video Images of Disease for Ethical Outcomes (VIDEO) Consortium.

Randomized controlled trial of a video decision support tool for CPR decision- making in advanced cancer. Journal of Clinical Oncology. 2013;31(3):380–386. http://dx.doi.org/10.1200/JCO.2012.43.9570. [Epub 2012 Dec 10].

4. Volandes AE, Paasche-Orlow MK, Barry MJ, et al. Video decision support tool for advance care planning in dementia: randomized controlled trial. British Medical Journal. 2009;338:b2159http://dx.doi.org/10.1136/bmj.b2159.

5. El-Jawahri A, Podgurski LM, Eichler AF, et al. Use of video to facilitate end-of-life discussions with patients with cancer: a randomized controlled trial. Journal of Clinical Oncology. 2010;28(2):305–310http://dx.doi.org/10.1200/JCO.2009.24. 7502.

6. Rauch J. How not to die. The Atlantic. 2013 ([Accessed 10.7.13]).
7. Elwyn G, O’Connor A, Stacey D, et al. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. British Medical Journal. 2006;333:417.


19 replies »

  1. I love the work that Angelo Volandes and his colleagues have done, showing how video education really improves people’s ability to engage with advance care planning.

    It’s a bit too bad however that so far those videos are not available to the public, only to healthcare systems (see acpdecisions.org).

    Now that the Khan Academy and others are getting into health education, I hope we’ll see more high-quality information made available to individuals and families…it is certainly badly needed if we’re to scale education efforts related to aging and end-of-life, among other topics.

  2. It doesn’t matter what medical speciality you are practicing today- if you are not engaged with both individual and institutional prevention (or better yet have an MPH degree) you are not relevant to the future of medicine.

  3. It’s great to see some familiar names on this comment thread (hi Mike and Rishi) as well as other passionate commenters.

    First I’d like to thank the authors for the excellent article! Implicit in their discussion are three key factors underlying the excitement in both mobile health and online education: (1) broader access, (2) personalization, and (3) increasing engagement. We have made a lot more progress in the first area than in the other two areas.

    Increased connectivity has allowed people all over the world to consume content, and we’re just starting to see data science applications enable us to personalize the delivery of this content. This has implications for the authors’ second group of questions about the new video paradigm: “Do patients prefer real images of doctors and patients rather than actors, avatars, or cartoons?” The answer is that some patients will prefer the former, other will respond to the latter. Just as we are moving towards personalized medicine we will need to transition into personalized education.

    Personalization should contribute to improved engagement, but additional innovations will likely be necessary. MOOC dropout rates are still incredibly high because we’re basically taking the “sage on a stage” model and moving it to an online format. This is where medicine and education can learn from the recent superstar in the tech world: social media. People spend billions of hours on Facebook, Instagram, Pinterest, and Snapchat. Medical education can learn from these companies by offering similar experiences, such as social and collaborative learning as well as diverse content sources and gamification.

    As a medical student I’m excited to see this dialogue continue here and in other venues.

    Shiv Gaglani

  4. Agree with Rishi-Nice article. Rishi is being coy though–please check out the Khan Academy Healthcare and Medicine Initiative that we at the Robert Wood Johnson Foundation are very proud to support and which Rishi leads at Khan: http://www.khanacademy.org/science/healthcare-and-medicine.

    Also, see the new Robert Wood Johnson Foundation initiative called,Flip the Clinic, which we’re building with numerous collaborators across the country under the leadership of Thomas Goetz–it’s just getting started but seeks to do much of what the authors here describe: http://fliptheclinic.org/. Here’s Thomas’ THCB post on that effort from a few months back: https://thehealthcareblog.com/blog/2013/07/17/flipping-the-doctors-office/

  5. The authors bring up an important point that is prevalent in both patient encounters and in medical school education– the lack of team-based learning and planning. We are used to systems of unequal power dynamics– doctor-patient, teacher-student, among many others–and these are obstructive to good communication and varied perspective. Information asymmetry drives much of this trend- patients are expected to come in with open ears and closed mouths, but with the growth of information available through the internet, and as the authors propose, particularly through informational videos, patients can be more involved in their own health, as they should be. This is important in so many ways- in prevention, in the comprehension of treatment and follow-up, in patient comfort and the ethics of informed consent etc.. Similarly, medical education needs to be more interactive- most medical schools have podcasted lectures, so students are more often skipping class to simply watch the material on their own. There is great potential here to reform the way we teach–a system where the student comes in with a basic level of information and engages with the professor in discussion/debate. By removing barriers of hierarchy, we can push the field of medicine forward in many ways.

    Abraar Karan
    MD Candidate UCLA

  6. It’s certainly important to have health and medicine content available online to everyone for free. Increasingly, it’s important to recognize that the content has to be easy to understand, it has to offer deep conceptual learning, and it should be reviewed, maintained, and vetted by a trusted source. These issues are challenging but each one can and will be tackled in turn.

    Great article!

  7. G-mom:

    Very accurate commentary. There is a crying need for patients to have more access to information to make the best calculated decision, but as you imply some doctors have egos bigger than the state of Texas. Ala – “how dare you question my edict from upon high.”

    What I found is that when one gets into disease that is not well understood often doctors are guessing at what the best treatment is. This is understandable as how else will they learn what the fix is; however, when it’s one’s own life in the mix one kind of wants to understand as much as possible before opting for a serious and perhaps unproven treatment or operation.

    You really don’t want to be a guinea pig unless absolutely necessary.

  8. I use the email portals that a couple of my docs provide, but not all docs have them. I had two recent appointments during which I asked the physicians and they said that they could not afford to implement them. One of my doc’s nurses said that she had to print out the emails for the doc to look at them….and it would be quicker to call.

    Will all physicians have to have secure email portals soon? Is this a requirement like the EMR?

    Does the HIPAA Privacy Rule permit health care providers to use e-mail to discuss health issues and treatment with their patients?


    Yes. The Privacy Rule allows covered health care providers to communicate electronically, such as through e-mail, with their patients, provided they apply reasonable safeguards when doing so. See 45 C.F.R. § 164.530(c). For example, certain precautions may need to be taken when using e-mail to avoid unintentional disclosures, such as checking the e-mail address for accuracy before sending, or sending an e-mail alert to the patient for address confirmation prior to sending the message. Further, while the Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between health care providers and patients, other safeguards should be applied to reasonably protect privacy, such as limiting the amount or type of information disclosed through the unencrypted e-mail. In addition, covered entities will want to ensure that any transmission of electronic protected health information is in compliance with the HIPAA Security Rule requirements at 45 C.F.R. Part 164, Subpart C.

  10. FYI HIPAA doesn’t prevent the use of email and almost any doctor with an EHR can also offer you secure email as well (just goes through their portal).

  11. There is certainly a great deal of opportunity ahead of us.

    The average american has an 8th grade reading level and the medical vocabulary of a 5th grader and neither docs nor patients understand basic concepts required for informed decision making like relative vs absolute risk Very few doctors have been trained in preventive care, nutrition or end of life counseling

  12. Yes I agree. Doctors need a reeducation. They need to understand the patients can be the experts in their own disease. In addition, they need to trust patients to help. In my personal experience, patients can be experts and could even create their own videos(instead of relying on some 3rd party who knows nothing about the disease but is waiting to regurgitate the “doctors” knowledge). Check out these videos which were created by myself and my son: http://ihavefoodallergies.tumblr.com/
    I am a big proponent of participatory medicine and this personal experience has shaped that.

  13. No, it absolutely isn’t better. There needs to be collaboration between patient and doctor as well as between doctors caring for the same patient. I have tried to get my doctors to communicate with each other, but the easiest lines of communication (email) are blocked by HIPAA.

    This MUST be the future of medicine, especially for chronic/rare illness patients, but there have been very few doctors that I have encountered that accept informed interaction with their patients.

    This type of interaction also puts the onus back onto the patient, much like diet and exercise, to be informed and proactive about their own health and conditions. Unfortunately, the majority of people expect their docs to know everything about everything because, after all, the doctor is The Doctor.

    Many entrenched stereotypes on both sides of the doctor/patient encounter must change before this kind of dialog and open flow of information can help anyone.

  14. “Instead, imagine encounters where patients are prepared to engage in shared decision-making, allowing the office visit to center on activities that promote patient-centeredness and engagement such as confirming patient comprehension, ascertaining values, and establishing goals.”
    Yes, imagine how long this visit takes, because the patient knows their options and wants to discuss them.
    Yes, imagine when the patient brings up studies that contradict your out-dated, med-school knowledge of that condition.
    Yes, imagine that doctor with the “deer in the headlights” look when they see your face for an appointment.
    Yes, imagine that patient getting dropped, or labeled as being “difficult,” because they know more about their condtion(s) than the doctor.

    Knowledge is an amazing thing, many doctors are not ready for patients to have it. It takes a very confident, open-minded physician to accept this kind of interaction and I have only found a few.