A kidney transplant surgery. Photo: Flickr/Tareq Salahuddin

Now Streaming: How to Do a Kidney Transplant

As medical schools seek to expand their reach and capture the attentions of smartphone-prone students, class is getting increasingly virtual

Apr 8 2016, 1:00pm

A kidney transplant surgery. Photo: Flickr/Tareq Salahuddin

As medical schools seek to expand their reach and capture the attentions of smartphone-prone students, class is getting increasingly virtual

Laura van Leeuwe Kirsch was in the middle of her course on kidney transplantation when she answered another email from me. She typed out her response, hit send, and returned to watching a surgeon's hands wrest open an incision on a patient's abdomen.

Or at least, that's how I imagined it. In reality, my only window into the university student's life was through our screens, even though only a few Dutch city blocks separate us. It's not her fault, though: As a first-year biomedical science major at the University of Leiden, she's overwhelmed with coursework and makes time for little else other than absorbing information.

Lately, van Leeuwe Kirsch has been spending more of that time at her screen: in January, she enrolled in "Clinical Kidney Transplantation," the world's first MOOC, or massive open online course, to offer instruction in the surgical procedure. She had already spent two hours per week over five weeks of school learning from her laptop, digesting short, pre-filmed interviews with doctors and a kidney donor, playing games that quizzed her on human anatomy, and realistic videos detailing the surgical process on a computer-generated patient.

After an introductory video, van Leeuwe Kirsch watches a series of six to seven additional clips, each of which typically runs under 10 minutes. At the end, there are one or two interactive activity modules, called "E-tivities" and a quiz to complete, along with optional videos. Some weeks, she also gets assignments. Because she took the class out of curiosity and to supplement her regular biology course load at Leiden, Van Leeuwe Kirsch opted not to pay the optional 43 Euro fee for a certificate of completion, and she skipped the interactive activity modules to save time.

"The E-tivities help you start a discussion with your fellow 'classmates' in a way that you can learn from each other," van Leeuwe Kirsch said. "However, I didn't participate in any of these discussions since I only had time to follow the course itself."

The course is among the world's few clinical MOOCs, but it isn't intended to replace real-life education with a professor and a hospital patient. Nor is it likely to prepare van Leeuwe Kirsch to conduct a kidney transplant anytime soon. ("Not that I'm allowed to anyway," she said.) But it's part of a growing digital push among medical schools seeking to educate a generation of students raised on smartphones and to expand their audiences to virtually anyone with a computer and an internet connection.

The university encourages non-medical students to register for its medical MOOCs, but an introductory background in biology and physiology is recommended. Since it began in January, more than 3,500 students from 90 countries enrolled, and 200 students completed it on time. Five percent of enrolled students chose to pay the 43 Euro fee for the digital certificate of completion.

"I have not taken a MOOC before," said van Leeuwe Kirsch, "but I am definitely considering taking another one."

"We see this MOOC as a way to help other countries that don't have the same resources."

Immersive online training began at a global group of med schools in the early 2000s with very limited success. But in recent years, services like YouTube and digital learning platforms designed by companies like Udacity, edX, and Coursera have helped schools across the globe experiment with online learning again as a way to expand the reach of their educational brands and overturn the traditional lecture-exam-lecture format. Supporters of the idea say that MOOCs' interactive learning elements are designed to increase knowledge retention, while their nearly limitless size allows more students to learn from scenarios that wouldn't normally accommodate large classes.

"We usually cannot get all of the people involved in a kidney transplantation together into one lecture room," Dr. Marlies Reinders, a nephrologist and one of the instructors of the kidney transplant MOOC, explained. "It would almost be impossible."

Leiden has made bold strides into the MOOC era. In 2013, it became the first Dutch university to partner with Coursera, the for-profit Mountain View-based company that, with thirteen million registered users and 1,500 courses, leads the pack among massive online education platforms. Last year, the university's Coursera offerings—on topics like global terrorism, tax law, linguistics, and urban mining—reached about 200,000 enrollments from 196 countries. Out of those, 11,000 exams were submitted and over 12,000 Statements of Accomplishment were awarded, according to the university, which has a real-life student body of 25,800 students.

Photo: University of Leiden

The kidney transplantation MOOC is already available independently of its curriculum, but the school intends to integrate it into two courses in its medical curriculum: the first in April and the second in September. And this week, the school launched a new medical MOOC: "Anatomy of the Abdomen and Pelvis, a journey from basis to clinic."

While MOOCs that cover theoretical coursework in physiology, biology, and pathology are more common, other medical schools are experimenting with more clinical MOOCs too. Meanwhile, schools in the U.S. and abroad are still determining how best to mix in-person learning with virtual lessons. Stanford, Yale, and Harvard have all to varying degrees implemented a so-called "flipped" classroom approach, in which students watch lectures at home and work on problems in groups and with professors during class time.

In September, Harvard Medical School's incoming class became its first cohort to learn through its flipped classroom curriculum. Alongside video lectures and interactive activities, students now spend time with patients earlier, with a weekly session starting in year one, and do clinical rotations in year two, moved up by a year. "My job, in the time that we're together, student and teacher, is to teach you what you can't Google," Richard M. Schwartzstein, a Harvard professor who helped develop the new curriculum, told the Boston Globe.

The upside of online

The office of the course's lead instructor, Dr. Reinders, feels practically inaccessible behind an unmarked security door. She did not hold office hours during the MOOC, and she didn't meet any of the enrolled students during the course, but a few arranged to meet her after the course finished, she said. (The class was assisted by four graduate student instructors and five moderators, who were available to answer questions on the course's online forum.)

Like van Leeuwe Kirsch, Reinders is busy—very busy—which is one reason she likes the idea of virtual learning. "As academic doctors we have clinical, research and education duties," she explained. "We are in charge of the hospital," and "with regular courses we give classes personally." But "teaching online saves a lot of time for the teachers. Time saved now can be spent on the other duties. It is a little difficult to express [the benefits] in money."

Dr. Reinders, who is helping the university develop a new medical curriculum and novel teaching methods, stresses that MOOCs like hers will not only save time for teachers and students: they can raise the sophistication of medical instruction too.

Preparing for, performing, and following up after a kidney transplant requires at least 13 different departments, she said. Instead of limiting a lecture to one professor, MOOCs let each of these 13 practicing physicians teach students directly through short videos. (A team of three animators helped to design the 3D animations that accompany these videos; the university did not disclose the cost of producing the course materials.)

Dr. Marlies Reinders, lead instructor of "Clinical Kidney Transplantation." Photo: Marc de Haan

At Leiden, the choice of topic for its first major medical MOOC was no accident. The university specializes in transplantation research and technology, owed in large part to the work of a former faculty member, the Dutch immunologist Jon van Rood. Van Rood made significant contributions in the 1960s and 1970s to understanding HLA typing, the technology that determines how well patients will accept foreign cells into their bodies. Van Rood was also one of the founders of Eurotransplant, which coordinates the international organ trade among eight European countries and is run from the University of Leiden's campus.

Medical experts expect the number of kidney transplants to rise sharply in the next decade as the proportion of patients with end-stage renal disease increases. To Dr. Reinders, that makes expanding access to information about kidney health and transplantation imperative. The class is "designed for (bio) medical students, health care professionals and anyone interested in research and knowledge on clinical transplantation," said a post on the school's Facebook page.

Providing instructions for performing a kidney transplant to anyone could, in theory, impact the dangerous black market for organs: kidneys are one of the most widely sought-after organs. In Europe, there were more than 68,000 people on the waiting list for a kidney transplant in 2012. Reinders, however, sees the course as a positive force in the international arena. "We see this MOOC as a way to help other countries that don't have the same resources," she said.

MOOCs can also help schools like Leiden improve both virtual and in-person learning via the reams of data that their participants generate. "Each one of these courses generates a wealth of behavioral data by which we can evaluate teaching methods, improve on-campus education, and offer a platform for academic research to investigate learning behavior of students with different educational and cultural backgrounds," wrote Jasper Ginn, a data analyst at the university's Online Learning Lab, in a blog post last year.

Some of that raw data can be found in the ratings and review section on the course's Coursera page. There, among the class's reviews, one student wrote that the mentors, who are graduate students from the University of Leiden, communicated well with students. Other students lauded the 3-D graphics and up-to-date information.

A student who indicated he or she had advanced knowledge of kidney transplantation was slightly less positive. "Very useful for all the users who are not still working in the transplantation field," they wrote. "For those people this course is perhaps too superficial." This student still rated the course with the maximum five stars; the course received 4.6 stars overall.

The Leiden University Medical Center. Photo: Dfmalan / WikiCommons

While none of the University of Leiden's MOOCs requires payment, the school receives a percentage of the fees students pay for certificates of completion, part of Coursera's "Signature Track." The certificates aren't accepted as credit at academic institutions, but they're endorsed by both Coursera and the institution offering each course, said Daphne Koller, co-founder and president of Coursera.

"Learners are given digital copies of their certificates that they can print, and they also have the option to easily publish certificates on their LinkedIn profiles." Koller said that Coursera's certificates are one of the most popular types of certificates to share on LinkedIn. If a student wants to receive a certificate but can't afford to pay the fee, Coursera promises need-based financial aid.

Coursera is also expanding past its certificate programs to full-blown degree programs. At the end of March, the company announced a partnership with the University of Illinois to allow Coursera users to earn a master's degree in data science from the school. This is the first degree-earning opportunity that Coursera has offered and the first that any traditional higher education institution has recognized on a MOOC platform.

"We expect to launch a number of additional degree programs in the coming year and onward," Koller wrote. "We would be excited to explore options in medicine or another health-related field."

Some of the types of teaching modules used in Leiden's MOOCs

The University of Leiden did not say what percentage of fees it receives from its MOOCs, but Coursera says it splits revenue 50-50 with universities. In addition to paid certificates, Coursera and its university partners have also sought new sources of revenue. In a report published in March, the university endorsed new paths toward monetization, and said it would experiment with crowdfunding, pay it forward, and pay-what-you-wish models this year.

"We are not opposed to experiments with new monetization models as a financially healthy platform provider and the continuity of the platform are important for Leiden University," says the report. "Also, the share the university receives helps financing MOOC updates and to keep them running on-demand."

For all of her enthusiasm about MOOCs, Reinders is more interested in a hybrid model. "I really believe that, from the start, the approach has to be blended," she said, alluding to the "flipped" classrooms that other medical schools are beginning to implement.

This Time It's Different

In 2002, 50 medical schools from around the world banded together to form the first-of-its-kind International Virtual Medical School. Led by the University of Dundee, and including Brown and Wake Forest, IVIMEDS encouraged participating schools to offer the same online coursework during the first two years of their programs. In the final two years, IVIMEDS contacts would oversee the students' clinical experiences at local hospitals.

Ultimately, all but a few universities had the technical capabilities to create and share content, and most weren't committed to streamlining a uniform curriculum on the internet.

"Many universities had only joined because they felt like they were missing out on something," said Natalie Lafferty, head of the Center for Technology and Innovation in Learning at the University of Dundee, over Skype. By 2010 the program had dissolved.

That year, however, a book by a group of medical educators, Educating Physicians: A Call for Reform of Medical School and Residency, helped inspire new thinking around medical curricula, which had changed little since the beginning of the 20th century.

Meanwhile, Lafferty credits the rise of the open access movement in the education industry with making virtual learning tools more acceptable in medical schools this time around. Online platforms like Coursera facilitate sharing, and more people own digital recording devices and know how to operate video and graphics editing software. Mobile phones have put educational and informational tools in students' hands even when they're roaming the hospital floor. In addition to browsing video archives and doing web searches, they can access MOOCs on mobile devices.

Advances in graphics simulations and, now, virtual reality could enhance these MOOCs even more. Software advances have already made it possible to develop an entire virtual patient. Virtual reality is beginning to help practicing physicians better diagnose conditions in patients. Virtual reality software can piece together existing MRI and CT images into 3D visuals that doctors can rotate around and inspect from any angle without having to open up a patient.

Yet another digital learning experiment from Harvard and MIT shows that medical MOOCs might not follow a completely linear trajectory into the virtual realm but rather settle into a some hybrid of open-closed and digital-in-person instruction. In 2013, Harvard and MIT started a program of small private online courses, called SPOCS, on their proprietary platform, edX. SPOCS are designed for a single classroom of tuition-paying students who attend the physical lectures. Neither massive, nor open, a SPOC is essentially a recorded lecture that a student watches before going to class, the heart of the flipped classroom approach.

From a 2014 worksheet on MOOCs by the American Academy of Medical Colleges

That human touch

But the flipped classroom approach can come with downsides, say some educators, especially when schools can't match technology with its pedagogical needs. "Except for introducing myself in the course, I didn't have any contact with the teachers whatsoever." van Leeuwe Kirsch told me. "I can imagine that other students that participated in discussions had more contact [with the teachers]."

Despite the visual and practical appeal of medical MOOCs, students still crave personal interaction. "A lot of people think MOOCs are the future," Lafferty said. "But students like interacting with the teacher and interactive small group learning."

Over the last two decades, medical education thought leaders have promoted team and problem-based learning curricula in the pre-clinical years. According to a study published this year in Medical Teacher, pediatrics students retained knowledge better over the short-term using these interactive, in-person methods when compared to students following traditional lectures. Still, the study found, this curriculum change had no impact on long-term knowledge retention.

Medical schools that offer a wide range of MOOCs also recognize digital learning's limits. Harry Goldberg, assistant dean of the Johns Hopkins School of Medicine, began making taped lectures available to students in his cardiovascular physiology course 15 years ago. Today the university's Bloomberg School of Public Health offers a MOOC catalog that more than two million students have followed on Coursera. But as Goldberg told the medical journal BMJ in 2013, medical teaching often requires more interaction than a MOOC can provide. "MOOCs have a role in medical education," he said. "I think that role is a lot smaller than people hope it will be."

Some medical students express a general distaste for flipped classrooms. In February a reddit user commented on Stanford's flipped classroom approach on a forum titled "Dear Stanford Medical School":

Go fuck yourselves.
You couldn't contain your dumb flipped curriculum to your school. You just haaaaaad to talk other deans into picking it up.
Fuck you, go fuck yourselves. Please Die.
Fook Yu
P.S. If you were wondering why 30% of your students
leave medicine... this is it.

On another online medical student forum last September, a first-year medical student who attends a school with flipped classrooms described being "broken down" by his performance so far. "I get out of class at 3 usually and have 8 hours of videos to watch so it doesn't leave me with much time to do anything." He wrote. "I feel that my biggest mistake was studying alone [and] not doing any problems." One respondent suggested that he watch the videos at 1.5 times their normal speeds.

To some, MOOCs may be a sign of how patient-student-doctor interaction in the medical system has changed. Hospitals are discharging patients more quickly after surgery than they have in the past, in line with research that shows that fewer post-operative interventions lead to better patient outcomes. And many patients that would have been treated in hospitals twenty years ago are now treated elsewhere, at outpatient clinics, or at home.

Interns, too, spend less time in the hospital. In 2013, a study in the Journal of General Internal Medicine found that US medical interns only spend around eight minutes with each of their patients per day—around 12 percent of their working shift, down from 18 percent in the early nineties.

Meanwhile, medical students, like most everyone else, are already spending increasing amounts of time with screens. In addition to learning and updating electronic medical records systems, medical students now use Google as a de facto learning tool, and special social networks have evolved to let doctors share medical information in real-time. A group of doctors called FOAMed shares medical visualizations and case studies on Twitter and Periscope. In 2014, the venture capital firm Union Square Partners backed a company called Figure 1, that also lets clinicians share case studies through its app. Figure 1 says 30 percent of medical schools in the US use its app, while it is available in 19 countries and has 150,000 users.

Once they leave medical school, doctors may still be inclined to spend still more time at computers than face-to-face with their patients. More doctors now accept Skype consultations, and major US health insurance providers support telemedicine apps, like MDLive and Teladoc.

Already, online medical courses are proving useful for present-day doctors, as a way of maintaining certification or continuing education for those who don't have the time to attend medical conferences or read new journal papers. For undergraduates like van Leeuwe Kirsch, MOOCs are offering a taste of what's to come. She hasn't yet decided if she'll enroll in a medical master's program after graduation, but if and when she does, van Leeuwe Kirsch may not simply be better equipped for kidney transplants: she'll be more prepared for a curriculum that's only going to get more virtual.

Correction: An earlier version of this article said that Coursera's revenue sharing agreements with universities give it up to 15% of course revenues. In fact, the split is 50-50.