Keywords

This concluding chapter of Mastery Learning in Health Professions Education aims to chart new pathways for health sciences education and evaluation research. Unlike the first chapter in this volume, “Clinical education: origins and outcomes,” which presents a detailed critique of the signature pedagogy of clinical education in the health professions, this chapter sets forth an optimistic agenda about twenty-first century education and evaluation research.

We begin by presenting six education and education research opportunities in health professions education. The six education and research opportunities include the following: (a) expand mastery learning curricula to include a broader range of skills training in medicine, nursing, and other health professions; (b) spread mastery learning curricula into patient education and education for family members and patient caregivers; (c) develop and test mastery learning curricula to better address training of clinical team skills; (d) widen education models where one’s peers and other professionals serve as teachers and assessors; (e) enlarge mastery learning domains to cover a much wider range of non-technical clinical skills in addition to breaking bad news and difficult conversations; and (f) improve the quality and reporting of mastery learning research to ensure that future research programs are thematic, sustained, and cumulative and address translational science goals.

There are also many challenges on the mastery learning education and research horizon. We choose to name and amplify seven challenges that are now prominent: (a) assessment of complex clinical problems as a mastery learning base; (b) achievement of adaptive competencies in patient care; (c) the limits of mastery learning; (d) evaluation apprehension; (e) cultural and organizational questions; (f) mastery learning in the context of new and emerging technologies; and (g) in the USA, a lack of federal funding for mastery learning health professions education research.

Opportunities

Expand Mastery Learning Curricula

Current use of the mastery learning model in health professions education has focused chiefly on preparing physicians and nurses to perform invasive clinical procedures (Chaps. 12, 13, and 14). Mastery learning education and research has also been conducted on improving physicians’ communication skills, especially breaking bad news and having end-of-life conversations with patients and families (Chap. 10). There is now an acute need to expand mastery learning curricula to a much broader range of clinical skills and a larger sample of health professions beyond medicine and nursing. Clinical curriculum development, faculty training, and creation of assessment programs that yield reliable data for learner advancement and entrustment decisions are needed to extend mastery learning across the health professions continuum.

Patient, Family, and Caregiver Education

Rigorous patient, family, and caregiver education is needed to boost patient quality of life, reduce morbidity and mortality, and lower patients’ hospital length of stay and readmission rates. Mastery learning holds promise to address each of these healthcare goals.

To illustrate, physician Jeffrey Barsuk leads an interdisciplinary team of advanced heart failure physicians, nurses, and health services researchers at Northwestern Memorial Hospital (NMH) in Chicago. This team uses simulation-based mastery learning (SBML) to educate patients with advanced heart failure and their [usually family] caregivers who rely on ventricular assist devices (VADs) for survival while awaiting a heart transplant. Barsuk and colleagues report, “VADs are mechanical heart pumps that are implanted into a patient’s left and/or right ventricle. An electrical cord (driveline) exits from the pump through the abdomen and is attached to a small computerized controller (that controls the actions of the pump) which is connected to a power source. VAD self-care . . . requires a high level of knowledge and meticulous skill performance by patients and caregivers. Adverse events related to VADs include driveline infections . . . and strokes that lead to a high readmission rate. Patients and their caregivers must be able to change the dressing at the driveline exit site using a sterile technique, change the controller if it malfunctions, change power sources . . . learn new medications, troubleshoot controller alarms, and, overall, adjust to a new daily lifestyle to help prevent those adverse events” [1].

This ambitious VAD mastery learning curriculum was developed as an education program for advanced heart failure patients and their caregivers to reduce complications associated with VAD. Educational rigor is important because under usual conditions preventable driveline infections occur at a rate of 1.31 per patient month after implant placement. Also, the overall mortality of patients with a VAD is 19% at 1 year [2]. Early results from the NMH mastery learning curriculum for VAD patients and their caregivers from a randomized trial are encouraging. Expressed in translational science terms (Chap. 16), T1 education results in the controlled simulation education laboratory and T2 clinical care results due to reduced bedside complications show that a powerful simulation-based mastery learning (SBML) education intervention “. . . provided superior VAD self-care skills learning outcomes compared to usual training. This study has important implications for patients due to the morbidity and mortality associated with improper VAD self-care” [3].

This early work with VAD heart failure patients and their caregivers suggests that the mastery learning model can be used to address many other patient education problems in a variety of healthcare settings. Other potential targets for patient mastery learning education include outcomes that healthcare educators want patients to acquire to minimize the risk of morbidity and mortality. Potential topics include self-administered peritoneal dialysis; home central venous catheter (CVC) management; wound, ostomy, and drain care; and taking complex medication regimens including intravenous infusions such as antibiotics, total parenteral nutrition, and injectable medications such as insulin, epinephrine, and anticoagulants.

Mastery Learning for Clinical Team Training

Chapter 11 of this book makes a strong case that in the health professions no one works alone anymore. In nearly all settings, today’s healthcare is delivered by professional teams, not by individual providers working in isolation. This practical situation underscores the importance of developing and testing mastery learning curricula for health professions team training. Team training means that the focus of education and assessment practices must shift from persons to groups. Team training and assessment also means that mastery learning curricula will need to address team composition including teams with consistent members versus those that are interchangeable as in the US Army trauma training teams (Chap. 11). Team assessment will require minimum passing standards (MPSs) set for individual learners that are applicable to team-based mastery learning. Our multi-year experience with advanced cardiac life support (ACLS) team responses shows us that this work is substantially different than mastery learning for an individual clinical skill [4].

Peer Teaching and Assessment

Management and delivery of mastery learning curricula in the health professions can be labor intensive (Chap. 7). Learners engage in focused, deliberate practice to improve clinical skills and knowledge representations. The faculty workload is also intense because instructors need to set learning and practice conditions, document interrater reliability, monitor learner progress, provide feedback and debriefing, coach for learner improvement, and assess learners for professional entrustment decisions. The education workload in mastery learning is substantial for everyone.

There are many opportunities in health professions mastery learning curricula to engage learner peers as instructors and assessors. Peers are defined broadly and may include professional school classmates or other healthcare providers. For example, the concept of “near-peer teaching” has gained traction as an instructional strategy in health professions education. This approach uses senior learners, usually several years ahead of learners in the same health profession, to serve as facilitators for junior learners. Near-peer teaching is effective because junior student learners and senior student teachers share a common language, knowledge base, and social role [5]. The technique has been used in problem-based learning, clinical education, simulation, and other small group medical education sessions. Near peer teaching is valued by students because senior learners can leverage their recent educational experiences and add clinical context for younger peers [6].

Professional school classmates can contribute to peer teaching as a result of formative assessments within instructional units. Learners who meet or exceed the MPS quickly can work as peer coaches to help others who need more deliberate practice time to reach the goal (Chap. 2). This assumes, of course, that the education environment is governed by a spirit of cooperation and psychological safety among learners and faculty (Chap. 8).

Health professions educators should also consider the contribution that healthcare providers who have a different healthcare role than learners may add to education experiences. One successful example is the key contribution that respiratory therapists made during education of nurses and physicians in ACLS (Chaps. 3 and 4).

Non-technical Clinical Skills

Mastery learning curricula in health professions education have a strong record of helping learners acquire such procedural skills as endoscopic surgery, lumbar puncture (LP), CVC insertion and maintenance, thoracentesis, paracentesis, and other invasive maneuvers (Chaps. 12 and 13). Team-based clinical skills including ACLS can also be taught and learned to mastery standards (Chaps. 3 and 11). Evaluation research also shows that non-technical clinical skills such as communication (breaking bad news and end-of-life discussions with patients and families), situation awareness, and task allocation can also be addressed effectively using the mastery learning model (Chap. 10).

The opportunity to expand the mastery learning model to a broader range of non-technical clinical skills including patient handoffs [7], interprofessional communication, team leadership, resource management, and elements of clinical reasoning depends on educators’ ability to assess outcomes reliably [8]. Creating mastery learning curricula is relatively easy for what Ericsson and Pool call a “highly developed field” where educational outcomes can be measured objectively and where there is professional consensus about correct answers [9] (Chap. 4). However, non-technical mastery learning curricula are much harder to develop because these professional practice behaviors do not fit the Ericsson and Pool definition. Progress toward developing and testing non-technical clinical skill mastery learning curricula will be slowed until consensual outcome assessment programs are created and tested (Chap. 5).

Mastery Learning Research

The mastery learning bundle is a set of seven complementary elements: (a) baseline, or diagnostic testing; (b) clear learning objectives, sequenced as units usually in increasing difficulty; (c) engagement in educational activities, e.g., deliberate skills practice, calculations, reading, etc.; (d) set MPSs for each educational unit; (e) formative assessment; (f) advancement to the next educational unit given achievement at or above the MPS; and (g) continued practice or study on an educational unit until the mastery standard is reached [10] (Chap. 2). The power of mastery learning resides in use of the complete package, the inseparable seven element bundle. However, each of the seven mastery learning pieces warrants research study and refinement.

To illustrate, Coughlan and colleagues performed a study involving Gaelic football [soccer] players that dissected, “How experts practice: a novel test of deliberate practice theory” [11]. These investigators found that experts “practiced the skill they were weaker at and improved its performance across pre-, post- and retention tests.” “In contrast, . . . participants in the [comparison] group predominately practiced the skill they were stronger at . . .” [11]. Coughlan and colleagues conclude, “Findings provide support for deliberate practice theory and give some insight into how experts practice and improve their performance beyond its current level” [11]. The Coughlan et al. study is a research example about how to understand and improve one of the seven features of the mastery learning bundle. Research studies addressing the other six mastery learning bundle features are needed.

Longitudinal mastery learning research is needed at all levels across the health professions to better understand the sources and timing of clinical skill decay [12] and why clinical experience is not a proxy for quality of healthcare [13]. Early results are encouraging. A mastery learning study of clinical skill acquisition and maintenance shows that ACLS skills acquired to a mastery standard are retained without decay for up to 12 months [14]. Mastery learning of invasive clinical procedures such as central venous catheter insertion [15] and critical care skills (e.g., ventilator and hemodynamic parameter management and treating septic shock) [16] shows that these skills are resistant to decay over at least 12 months. More research is clearly needed, especially studies that compare mastery learning education interventions to other training methods, to determine if these early skill retention results can be replicated.

Beyond individual research studies, the utility and impact of mastery learning curricula in health professions education will be advanced by evaluation research programs that are thematic, sustained, and cumulative [17]. A prominent example of such a mastery learning clinical education and research program is the systematic series of CVC insertion and maintenance studies led by Jeffrey Barsuk with an interdisciplinary Northwestern team. The T1 to T4 (Chap. 16) studies are a series of CVC education and research reports that address mastery learning of (a) CVC skill acquisition in a medical simulation laboratory (T1) [18], (b) systematic setting of a CVC MPS by an expert faculty panel [19], (c) a demonstration that patients receiving CVC care from mastery trained medical residents experience fewer complications than patients cared for by residents trained traditionally (T2) [20], and that (d) mastery learning of CVC skills is responsible for an 85% reduction in central line-associated bloodstream infections (CLABSIs) in a medical ICU (T3) [21]. Collateral (T4) effects from this mastery learning CVC education and research program include (e) a demonstration of long-term retention of CVC skills [22]; (f) cost savings expressed as a 7:1 return on financial investment [23]; (g) unexpected yet welcome systemic educational improvement [24] that prompted a MPS increase [25]; (h) successful dissemination of the mastery learning CVC program from a tertiary care medical center to an academic community hospital [26]; and (i) educating attending physicians and ICU nurses in CVC patient care to mastery learning standards [27, 28].

One-off, stand-alone mastery learning education and evaluation research studies will have little impact unless they are connected to other thematic investigations that demonstrate translational, downstream patient outcomes (Chap. 16). Research connections contribute to a sustained and cumulative body of work that will enrich, improve, and extend the boundaries of the current mastery learning model in health professions education.

Uniform reporting of mastery learning evaluation research studies according to standardized reporting conventions is another opportunity to advance scholarship [29]. Standardized research reporting conventions shape and inform mastery learning curriculum development and research in all phases beginning with design, intervention character and intensity, deliberate practice features, pretest and posttest development, timing, data reliability estimation, and program management. Uniform research reporting contributes to clear understanding of procedures and results, continuity of data sets, opportunities for research synthesis, and the general progress of mastery learning in health professions education [29].

Challenges

Complex Assessment

Patient care delivered by health professional individuals and teams is a complex enterprise with many moving parts. Diagnosis, patient management, teamwork, procedural skill, medication reconciliation, image and diagnostic test interpretation, communication with the healthcare team and families, patient handoffs, navigating an electronic medical record (EMR), responding to crises, perceiving and responding to ethical issues, addressing ethnic and cultural matters, and a host of other competencies are all potential mastery learning targets in health professions education. However, as pointed out in Chaps. 4 and 5 on Instruction and Assessment in Mastery Learning, educators simply cannot teach and assess the complete universe of eligible knowledge, skill, and professionalism attributes. Instead, health professions educators teach and assess carefully selected samples of professional behavior shaped by accreditation requirements, professional practice guidelines, local preferences, habit, restricted time schedules, and many other influences.

Decades of behavioral science research on expert performance, summarized by Anders Ericsson and Robert Pool in their book, Peak: Secrets from the New Science of Expertise, are distilled in a key statement, “. . . a crucial fact about expert performance in general [is]: there is no such thing as developing a general skill” [9]. This indicates that attempts to measure and assess such general clinical attributes as “medical decision making,” “cultural competence,” and “interpersonal skill” will fail without clear operational definitions of their key elements.

The professional education and assessment needed to address complex clinical situation present a real challenge. Medical conditions of patients and families change rapidly, management of health problems may have more than one correct answer, and experts often disagree about the best course(s) of clinical action. How can health professions educators create and manage a mastery learning curriculum to prepare physicians, nurses, and other providers to manage complex clinical and social problems?

The answer, we believe, is to break down the complex clinical situation into a smaller set of education and assessment operational units—for example, a curriculum—on mastery learning in, say, geriatric care. The units will serve as an approximation to a “highly developed field” where outcome assessment is objective, “or at least semiobjective,” that permit formative and summative decisions about learner progress and entrustment [9]. The set of operational units will cover knowledge and skill facets of geriatric care that are teachable and testable to mastery standards yet will never represent a census of the competencies needed to address all complex clinical cases. Such a deliberate sampling approach encourages health professions educators to develop curricula; teach, measure, and assess key features of complex clinical cases very well; learn from the experience; and find ways to improve continually. These smaller units can then be united as parts of a larger curriculum to assess overall care performance for multiple healthcare professionals.

This problem with complex clinical assessment is highlighted by the teaching message of surgeon Atul Gawande in his book, The Checklist Manifesto. Gawande states, “There are . . . all kinds of steps that checklists do not specify. They are not comprehensive how-to guides. They are quick and simple tools aimed to buttress the skills of expert professionals” [30].

Adaptive Competencies

Adaptive competence is a hallmark of professional practice. Cognitive psychologist Keith Holyoak asserts a professional with adaptive competence is one . . . “who can make an appropriate response to a situation that contains a degree of unpredictability.” This contrasts with “routine experts who are able to solve familiar types of problems quickly and accurately” [31].

Intra-operative decision-making and procedural adjustment by a surgeon is one example of adaptive competence. To illustrate, if a colon cancer surgeon observes that a tumor not seen on imaging has invaded a patient’s liver she may have to modify the operation. Adaptive competence is seen among health professionals every day in complex and simple situations: a pediatrician who changes an epileptic patient’s seizure medicine due to an unexpected side-effect; the family physician who refers an elderly cancer patient to hospice rather than more aggressive chemotherapy; a nurse who needs to decide whether to call a stroke code or an on-call physician when a patient becomes slightly altered with slurred speech; a psychiatrist who prioritizes cognitive behavior therapy as an adjunct to medications to care for a patient with depression. Adaptive competence is a cornerstone of expertise in the health professions. How can educators increase the probability that their learners will acquire adaptive competencies and use the competencies effectively in patient care?

Health professions education clinical learning objectives change—sometimes quickly—due to time, setting, patient acuity, disease severity, advancing technology, and many other personal and interpersonal variables. Fluid clinical conditions prompt educators to prepare learners to expect the unexpected, respond to uncertainty, and develop adaptive competence. Ericsson and Pool present strong evidence that attests to the highly adaptive capacities of the human species [9]. These scientists point out that after much deliberate practice with continuous refinement of mental representations, “When an actual surgery diverges from the surgeon’s mental representation, he or she knows to slow down, rethink the options, and, if necessary, formulate a new plan in response to the new information” [9].

A recent example from the aviation profession is a case study about the importance of adaptive competence and the training needed to reach that goal. Captain Chesley “Sully” Sullenberger, the pilot who performed the “Miracle on the Hudson” by safely landing a commercial airplane on the Hudson River in 2009 with no loss of life, testified recently before a US congressional panel. The panel was investigating simulation training for flight safety. Sullenberger stated, “We must make sure that everyone who occupies a pilot seat is fully armed with the information, knowledge, training, skill, and judgment to be able to be the absolute master of the aircraft and all its component systems and of the situations simultaneously and continuously throughout the flight” (emphasis added). “Pilots need physical, firsthand [simulation] experience to be prepared for emergencies.” Sullenberger concluded his testimony with the statement, “Reading about it on an iPad is not even close to sufficient” [32]. The congruence of Captain Sullenberger’s congressional testimony and principles of mastery learning with deliberate practice is evident.

Ericsson and Pool suggest that general adaptive clinical competence cannot be taught and assessed [9]. However, a sample of the component parts of clinical adaptive competence for specific situations or conditions can be operationalized and become the foundation of a mastery learning curriculum.

Limits of Mastery Learning

Health professions educators need to acknowledge that despite its utility in many training curricula, mastery learning is not a panacea. Mastery learning is not a cure-all for educational problems in the health professions. A “one size fits all” or “just add water” mentality simply cannot drive the use of mastery learning in health professions education.

We believe that mastery learning is most useful to help health professions learners acquire and maintain core or essential clinical skills that really matter in everyday clinical practice (Chap. 3). We also believe that curriculum developers, teachers, and assessors can never educate health professionals about all of the complex clinical conditions they will encounter in their careers, especially as healthcare changes and technology improves. Thus mastery learning should focus on carefully selected samples of clinical skills, reasoning, communication, and other learning outcomes (Chap. 5) that connect directly to patient care practices and patient outcomes (Chap. 16). After more than a decade of experience we identify several additional benefits of the mastery learning approach. These include high satisfaction among learners, receptivity to feedback, and the idea that additional deliberate practice is a necessary part of education and not a penalty. These features not only develop expertise but also imprint learners with the knowledge that lifelong skill development and assessment is necessary to practice at the highest level [33].

Evaluation Apprehension

Evaluation apprehension is ubiquitous throughout the health professions. The term refers to the widespread fear among health professionals in training and practice to be revealed as having an insufficient fund of knowledge or poor clinical skills. Evaluation apprehension produces a variety of dysfunctional behaviors including failure to ask for help with uncertain clinical problems and impression management, defending one’s professional image in clinical and professional settings at all costs [34, 35].

Rosenbaum writes, “… the perceived need for impression management to protect one’s professional image is extremely high in medicine.” Rosenbaum also describes the “tacit calculus” common in clinical environments, “balancing the need to seek help against the likelihood of looking stupid” [35]. McGaghie contributes to the discussion, “… much of everyday clinical education and learner evaluation is an intricate kabuki play involving a fear of failure, impression management, the importance of portraying an image of competence, face saving, the power of subjective evaluations, and the value of establishing and maintaining one’s clinical reputation. Objective, reliable data have no role in these performances” [34].

Evaluation apprehension is a powerful source of resistance to the development and implementation of mastery learning curricula in health professions education. Mastery learning pretests, for example, are specifically designed to detect learning and clinical deficiencies. The measured deficiencies, in turn, are used to give learners specific, actionable feedback; provide focus for deliberate practice; guide formative assessment toward the MPS; and finally inform summative entrustment decisions once the MPS is met or surpassed. This can only happen in mastery learning settings that are psychologically safe, when assessment data are used as a tool, not as a weapon—and everyone understands and lives by the rules.

There is a clear need to devise mechanisms to reduce evaluation apprehension in health professions mastery learning settings. Health professions educators who endorse mastery learning must engineer and operate safe and supportive learning environments that mitigate its influence, such as presimulation briefing [36]. In addition, early evidence suggests that learners who undergo successful mastery learning experiences simply “get over it.” Successful mastery learning experiences boost student self-confidence, lower anxiety, and increase motivation for more skill and knowledge acquisition. The learners grow accustomed to mastery learning curricula so steps of baseline assessment, deliberate practice, feedback, regular formative assessment, and more practice to reach a mastery standard become a new normal for education [33].

Cultural and Organizational Questions

The culture of health professions education has historically judged the learning and performance of students and healthcare providers as norm-referenced accomplishments. Competitive student selection, progress through basic science education, acquisition of clinical skills, and professional certification and licensure have all been judged in comparison to other learners, usually on a normal distribution of performance metrics. Academic achievement and clinical performance are judged by “grading on the curve” rather than in comparison to a MPS expected for all learners (Chaps. 5 and 6). The common result of this widespread cultural policy is uneven knowledge and clinical skill acquisition among nurses, doctors, physical therapists, pharmacists, midwives, and other health professionals (Chap. 1). A growing body of evidence shows that uneven skill sets among health professionals is a key source of substandard patient care (Chap. 16).

The idea that learning and professional practice in the health professions is “good enough” based on norm-referenced performance is no longer good enough. Health professions educators and certification and licensure bodies need to expect more from students and practicing professionals to ensure patient safety. Setting high education achievement and professional practice standards, and enforcing the high standards via accountability, represents a cultural paradigm shift in health professions education.

Another cultural and organizational challenge (also an opportunity) in the health professions concerns the introduction of mastery learning into continuing professional education (CPE) and maintenance of certification (MOC) programs (Chap. 18). There are two key barriers to the use of mastery learning in CPE and MOC. The first is an abiding ideology within the health professions about the value and utility of internal self-regulation; self and peer assessment; and stiff resistance to limits on post-certification scope of practice and income opportunities. Rigorous MOC requirements frequently meet opposition. This ideology has deep historical roots [37] and contemporary expression in what Susskind and Susskind term, “status quo bias,” a preference for continuing to do things as they are done today [38]. A recent example of status quo bias is the report of a 2020 Task Force of the American Board of Internal Medicine which after 2 years of MOC deliberation recommended only modest changes in the focus and frequency of multiple-choice tests for MOC in that specialty [39]. This is troublesome for at least two reasons. First, continued reliance on multiple-choice examinations to certify and license healthcare professionals as competent to practice covers a very small sample of professional behavior. Psychometrician Brian Clauser and colleagues state, “. . . a passing score on a licensing examination may be seen as a prerequisite for acceptable practice but not a guarantee of acceptable practice” [40]. Second, issues of great importance to the public including clinical skill assessment, adaptation of new technology into practice, interprofessional collaboration, and team science have not yet been adequately addressed over the lifespan of continuing health professions education, certification, and licensure [38].

The second key barrier to introducing mastery learning into health professions MOC is the evaluation apprehension problem, discussed in the previous section. Clinical skill, knowledge, and professionalism attributes simply cannot be improved without reliable baseline assessment and feedback (Chap. 5). A climate of psychological safety and assurance that assessment data will be used as a tool, not a weapon, are essential to address this cultural and organizational barrier [34,35,36].

New and Emerging Technologies

The EMR; automated reading of digital MRI and dermatology images; personal, automated monitoring of such physiological metrics as blood pressure, hemoglobin A1c, and kidney function; robotic surgery; point-of-care ultrasound; educational simulations; genomic testing; DNA manipulations, and a host of other new and emerging technologies will challenge health professionals and the systems that govern their behavior throughout the future. Technological advancements in biology, computer science, nanotechnology, and other fields are advancing at a breathtaking pace. This not only means that most health professionals will likely narrow their scope of practice but also that patients will assume independent responsibility for more of their own healthcare. Cardiologist Eric Topol anticipates in his 2015 book, The Patient will See You Now, “. . . [we] are embarking on a time when each individual will have all their own medical data and the computing power to process it . . . from womb to tomb . . . even to prevent an illness before it happens” [41].

We find it ironic that in this day of rapid and continuing changes in all aspects of healthcare that the methods of educating and assessing health professionals have changed very little in the past century (Chap. 1). As the chapter authors of this volume have pointed out in many locations, we simply must improve health professions education practices to keep current and deliver quality patient care. New and emerging technologies will always challenge health professions educators to keep pace and to use the advancements intelligently. Mastery learning is only one educational approach to reach this goal.

Federal Funding

Healthcare research in the USA is funded chiefly through federal agencies including the National Institutes of Health (NIH) [42] and the Agency for Healthcare Research and Quality [43]. These agencies have a long historical record of financially supporting excellent basic and applied biomedical research to advance bioscience and inform healthcare clinical practice. However, funding for research in health professions education has been deficient or absent [44,45,46,47], despite strong evidence that financial support is linked directly to the quality of medical education research [48].

This circumstance prompted several members of our health professions education research group to criticize federal funding research priorities and call for reform. The research group asserts, “[NIH and AHRQ] statements about [research funding] policies and priorities focus on biomedical research, education of biomedical scientists, and conventional treatment options. They do not address the value of a skilled workforce in the clinical medical and health professions and the importance of rigorous clinical education for the delivery of effective healthcare. We assert that human capital, embodied in competent physicians and other health professionals, is an essential feature of [clinical science] even though NIH, Institute of Medicine, and AHRQ policies and priorities are silent about the contribution of clinical medical education to health-care delivery” [49].

We continue to endorse this statement because a growing body of research evidence shows that powerful health professions education grounded in mastery learning with rigorous assessment has direct effects on improved patient care practices and patient outcomes (Chap. 16). Financial support from US federal agencies will boost the health professions education research agenda and improve healthcare for the patients we serve.

Coda

The challenges we have outlined are real. However, we have learned that mastery learning can be a vital component of health professions education. Mastery learning is an invaluable tool to tackle the challenges of individual and healthcare team clinical competence and excellent patient care.

Despite mastery learning being in its infancy within health professions education, there are already many successful examples across a spectrum of translational outcomes from improved bedside performance to better patient outcomes (Chap. 16). We are responsible to build on these early successes while addressing new opportunities and challenges in health professions education. This will take sustained hard work. The good news is that long-run integration of mastery learning into health professions education will ensure that all learners achieve a high and uniform level of performance that leads to improving the care and outcomes for all of our patients.