Med­i­cal schools aim to make cur­ricu­lums mir­ror the real world

Modern Healthcare - - PHYSICIAN COMPENSATION - By Maria Castel­lucci

Dr. John Ray­mond, CEO of the Med­i­cal Col­lege of Wis­con­sin in Mil­wau­kee, thinks there is a crit­i­cal el­e­ment sorely miss­ing in the train­ing of as­pir­ing physi­cians: com­pas­sion.

Since there is an as­sump­tion that all doc­tors are in­her­ently com­pas­sion­ate and car­ing in­di­vid­u­als, tra­di­tional med­i­cal ed­u­ca­tion doesn’t out­right ad­dress its im­por­tance in pa­tient care, he ar­gued.

But re­cently com­pas­sion seems to be get­ting lost as doc­tors face more ad­min­is­tra­tive bur­dens and an in­creased em­pha­sis on clin­i­cal pro- duc­tiv­ity. “Th­ese pres­sures can de­hu­man­ize medicine,” he said.

Ray­mond isn’t the only one con­cerned that the grow­ing bur­dens doc­tors face are harm­ing their cru­cial re­la­tion­ships with pa­tients. Lead­ers from six other med­i­cal schools have joined the Med­i­cal Col­lege of Wis­con­sin to form a net­work aimed at ad­dress­ing this co­nun­drum well be­fore doc­tors be­gin their ca­reers.

Through the Na­tional Trans­for­ma­tion Net­work, which of­fi­cially launched in June, the schools will work to­gether to de­velop a cur­ricu­lum fo­cused on three com­po­nents: char-

A big chal­lenge is that teach­ers are still learn­ing and adapt­ing to changes in the in­dus­try.

ac­ter, com­pe­tence and car­ing. The net­work was es­tab­lished with the help of a $37.8 mil­lion grant from the Kern Fam­ily Foun­da­tion, a not-for­profit that funds ed­u­ca­tional ini­tia­tives. The other par­tic­i­pat­ing schools in­clude the Mayo Clinic School of Medicine, Geisel School of Medicine at Dart­mouth, UCSF School of Medicine and Van­der­bilt Univer­sity School of Medicine.

Ray­mond quickly ac­knowl­edged that clin­i­cal com­pe­tence isn’t lack­ing in med­i­cal ed­u­ca­tion, em­pha­siz­ing that med­i­cal schools do an ex­cel­lent job of equip­ping fu­ture doc­tors with the sci­en­tific back­ground and clin­i­cal skills needed to treat pa­tients. What’s lack­ing is mak­ing sure as­pir­ing doc­tors have the right in­ten­tions and mind­set to care for the na­tion’s vul­ner­a­ble or sick.

The lack of fo­cus on th­ese qual­i­ties dur­ing med­i­cal school ul­ti­mately hin­ders ef­forts in the health­care in­dus­try over­all to pro­vide care that is more pa­tient-cen­tered. “We need to make (med­i­cal school) feel more real and more di­rectly re­lated to the pa­tient,” Ray­mond said.

How ex­actly the Na­tional Trans­for­ma­tion Net­work will change cur­ricu­lums is still be­ing worked out, but there will be a strong em­pha­sis on en­sur­ing stu­dents ap­pre­ci­ate and un­der­stand the im­por­tance of com­pas­sion to pa­tients, Ray­mond said. This will likely take the form of more oneon-one time with pa­tients and an em­pha­sis on per­sonal well­ness and burnout, which plagues a ma­jor­ity of physi­cians to­day.

The tran­si­tion won’t be with­out chal­lenges since it re­quires not only a change in cur­ricu­lum but a change in mind­set. “You re­ally can’t change stu­dents with­out chang­ing the fac­ulty and cur­ricu­lum and even the cul­ture, which is prob­a­bly go­ing to be the hard­est part,” Ray­mond said.

The net­work isn’t the only ma­jor col­lab­o­ra­tive aim­ing to re­vamp med­i­cal ed­u­ca­tion. Med­i­cal schools across the na­tion are re-eval­u­at­ing how they pre­pare fu­ture doc­tors for their ca­reers. Yet the lead­ers be­hind this push read­ily ad­mit change isn’t easy. Be­cause there is so much up­heaval in health­care—whether it’s new pay­ment mod­els, in­creased use of tech­nol­ogy, the push to con­sumerism, and more—fac­ulty mem­bers have a hard time keep­ing up with it all and find­ing the best ways to teach new con­cepts. At the same time, tra­di­tional men­tal­i­ties on what med­i­cal ed­u­ca­tion should look like can be tough to break.

“There is this feel­ing of, boy you’re im­ped­ing on my ter­ri­tory,” said Dr. Jed Gon­zalo, as­so­ciate dean for health sys­tems ed­u­ca­tion at Penn State Col­lege of Medicine, re­gard­ing how some fac­ulty re­act to re­forms in med­i­cal ed­u­ca­tion. Gon­zalo has been work­ing with the Amer­i­can Med­i­cal As­so­ci­a­tion to drive more in­no­va­tion in med­i­cal ed­u­ca­tion cur­ricu­lum. He said he hears from skep­ti­cal pro­fes­sors who say change isn’t nec­es­sary. But Gon­zalo ar­gues that it is. When he was in med­i­cal school roughly 15 years ago, less than eight hours of his ed­u­ca­tion was ded­i­cated to work­ing with elec­tronic health records and in­for­mat­ics. And, he ad­mit­ted, he only truly un­der­stood the dif­fer­ence be­tween Medi­care and Med­i­caid af­ter nearly 10 years of school­ing. “We are not pre­par­ing physi­cians,” he said.

Penn State is one of 32 schools that are part of the AMA’s Ac­cel­er­at­ing Change in Med­i­cal Ed­u­ca­tion Con­sor­tium, which launched in 2013. The AMA has given about $12.5 mil­lion in grants to the schools to fund their in­no­va­tive ap­proaches to cur­ricu­lum re­form.

The par­tic­i­pat­ing schools also em­brace an evolv­ing dis­ci­pline dubbed health sys­tems sci­ence by the AMA. The as­so­ci­a­tion re­cently re­leased a text­book aimed at help­ing schools that are not part of the con­sor­tium adapt the new cur­ricu­lum, which fo­cuses on as­pects of health­care de­liv­ery not cur­rently ad­dressed in-depth dur­ing tra­di­tional med­i­cal ed­u­ca­tion. Top­ics range from pop­u­la­tion health man­age­ment, health­care fi­nanc­ing and re­form, to be­hav­ioral and so­cial de­ter­mi­nants of health.

The ap­proach is in­tended to be ap­plied along with the sci­en­tific and clin­i­cal com­pe­ten­cies al­ready es­tab­lished in med­i­cal ed­u­ca­tion, said Dr. Su­san Skochelak, group vice pres­i­dent for med­i­cal ed­u­ca­tion at the AMA. She co-au­thored the text­book with Gon­zalo and four oth­ers.

The text­book can help med­i­cal schools that want to re­vamp cur­ricu­lum but don’t know how or where to start, Skochelak said. A big chal­lenge is that teach­ers are still learn­ing and adapt­ing to changes in the in­dus­try. This learn­ing curve can make it hard to know the best ways to

teach stu­dents new skills, she said.

The Brody School of Medicine at East Carolina Univer­sity, one of the schools in the AMA con­sor­tium, used its $1 mil­lion, five-year grant to pre­pare its fac­ulty for cur­ricu­lum changes be­fore they were adopted.

In 2013, the school im­ple­mented an ed­u­ca­tion pro­gram for fac­ulty called the Teach­ers of Qual­ity Academy. The fac­ulty par­tic­i­pated in group and on­line cour­ses that ad­dressed qual­ity im­prove­ment strate­gies, pop­u­la­tion health, in­ter­pro­fes­sional team work and lead­er­ship.

“We rec­og­nize that health­care is chang­ing and we need all of our fac­ulty to un­der­stand the ba­sics of health sys­tem sci­ence to lead change,” said Dr. Luan Law­son, as­sis­tant dean of cur­ricu­lum, assess­ment and clin­i­cal aca­demic af­fairs at Brody.

The move­ment doesn’t stop with large, multi-school col­lab­o­ra­tions. Med­i­cal schools new to the scene have also adopted in­no­va­tive cur­ricu­lum. Th­ese schools have the ad­van­tages of a fresh per­spec­tive and the op­por­tu­nity to learn from their more es­tab­lished peers.

Th­ese ef­forts by East Carolina, Penn State and the Med­i­cal Col­lege of Wis­con­sin are no longer unique. “There is no school that hasn’t change their cur­ricu­lum sub­stan­tially,” said Alison Whe­lan, chief med­i­cal ed­u­ca­tion of­fi­cer of the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges, which rep­re­sents all 147 ac­cred­ited U.S. med­i­cal schools.

Take the Cooper Med­i­cal School of Rowan Univer­sity in Cam­den, N.J., for ex­am­ple. The school, which opened in the sum­mer of 2012, re­searched and reached out to the most for­ward-think­ing med­i­cal schools across the coun­try to es­tab­lish a cur­ricu­lum they hope will pre­pare its stu­dents for the fu­ture of pa­tient care, said Dr. An­nette Re­boli, in­terim dean of the school.

Dur­ing their first two years at Cooper, stu­dents only have about six hours of lec­tures a week. The rest of their time is spent in small groups where they work to­gether to solve a fic­ti­tious pa­tient case meant to mimic a real-life sce­nario.

The stu­dents not only work to­gether to de­ter­mine the di­ag­no­sis and best treat­ment for the pa­tient, but so­cial de­ter­mi­nants of health are also ad­dressed. A case might fea­ture an unin­sured di­a­betic pa­tient with poor ac­cess to trans­porta­tion. “The stu­dents learn how to nav­i­gate the health­care sys­tem,” Re­boli said.

Team­work is em­bed­ded through­out the cur­ricu­lum. As part of the am­bu­la­tory clerk­ship pro­gram, med­i­cal stu­dents work with the phar­ma­ceu­ti­cal, nurs­ing and so­cial work stu­dents to run a clinic that’s within Cooper Univer­sity Health Care, the health sys­tem af­fil­i­ate of the school.

Re­boli said the Cooper Med­i­cal fac­ulty felt it was im­por­tant for med­i­cal stu­dents to be ex­posed early on to dif­fer­ent health­care pro­fes­sion­als and their roles be­cause that’s where the in­dus­try is headed. Doc­tors in­creas­ingly find them­selves work­ing in teams with nurses, phar­ma­cists and oth­ers to achieve co­or­di­nated care, yet that ex­pe­ri­ence is sorely miss­ing in tra­di­tional med­i­cal ed­u­ca­tion.

The school also em­pha­sizes the im­por­tance of pop­u­la­tion health by re­quir­ing each stu­dent to com­plete 40 hours of com­mu­nity ser­vice a year. This can take many forms, Re­boli said. For ex­am­ple, one stu­dent coached a soc­cer team while an­other helped teach English as a sec­ond lan­guage. The ex­pe­ri­ences al­low stu­dents to un­der­stand their pa­tients and the com­mu­nity of Cam­den bet­ter, Re­boli said.

At the Kaiser Per­ma­nente Med­i­cal School, slated to open in 2019, stu­dents will be asked to come up with so­lu­tions to a va­ri­ety of com­plex health is­sues such as low im­mu­niza­tion rates or falls in the in­pa­tient set­ting.

“Part of what we have to do is show med­i­cal stu­dents how to be lead­ers of change,” said Dr. Ed­ward El­li­son, board mem­ber of the school and co-CEO of the Per­ma­nente Fed­er­a­tion, a Kaiser sub­sidiary con­nected to its med­i­cal groups.

The stu­dents will also ben­e­fit from the school’s af­fil­i­a­tion with Kaiser Per­ma­nente, the not-for-profit health sys­tem based in Oak­land, Calif., El­li­son said. Stu­dents are ex­pected to shadow doc­tors, work in the more than 30 safety-net clin­ics that are part of the Kaiser sys­tem, and visit pa­tients in their homes af­ter dis­charge.

Kaiser’s move to open a med­i­cal school rep­re­sents a grow­ing trend in med­i­cal ed­u­ca­tion. Health sys­tems are in­creas­ingly work­ing with their af­fil­i­ate med­i­cal schools to brain­storm how stu­dents should be trained, said Leah Gas­sett, a prin­ci­pal at ECG Man­age­ment Con­sul­tants with an ex­per­tise in med­i­cal ed­u­ca­tion.

“Health sys­tems are rec­og­niz­ing they would like a seat at the ta­ble so the grad­u­ates are pre­pared to be ef­fec­tive clin­i­cal lead­ers of their sys­tems,” she said.

But El­li­son said Kaiser’s fore­most goal wasn’t to fos­ter a pipe­line of fu­ture doc­tors to work at the sys­tem—though they ex­pect some stu­dents to stay at Kaiser to pur­sue their res­i­dency. In­stead, the main driver was a de­sire to be part of the changes hap­pen­ing in med­i­cal ed­u­ca­tion.

“We want to con­trib­ute to the broader evo­lu­tion of med­i­cal ed­u­ca­tion,” he said. “We see this as a way to learn and share out­side our sys­tem.”

Cooper Med­i­cal School of Rowan Univer­sity has a pro­gram called Week on the Wards, when stu­dents dur­ing their first and sec­ond years ven­ture into the hos­pi­tal en­vi­ron­ment and in­ter­act with physi­cians and pa­tients.

Stu­dents at Penn State Col­lege of Medicine serve as pa­tient nav­i­ga­tors be­gin­ning their first year. They work oneon-one with pa­tients in var­i­ous clin­i­cal set­tings to help guide them through the com­plex health­care sys­tem.

The Cooper Sprouts’ Com­mu­nity Gar­den, run by stu­dents at Cooper Med­i­cal School of Rowan Univer­sity and Cam­den, N.J., res­i­dents, of­fers fresh pro­duce at no cost. Stu­dents are re­quired to com­plete 40 hours of com­mu­nity vol­un­teer­ing per year.

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