Preparing Doctors to Meet the Demands of the Nation’s Changing Healthcare System
Critics have long faulted U.S. medical education for being hidebound, imperious and out of touch with modern health-care needs. The core structure of medical school—two years of basic science followed by two years of clinical work—has been in place since 1910.
Now a wave of innovation is sweeping through medical schools, much of it aimed at producing young doctors who are better prepared to meet the demands of the nation’s changing health-care system.
At the new Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y, students spend their first eight weeks not in lecture classes but becoming certified emergency medical technicians, learning split-second lifesaving skills on 911 calls.
At Penn State College of Medicine in Hershey, Pa., first-year students work as “patient navigators,” helping the ill, injured and their families traverse the often-confusing medical system and experiencing it from their perspective.
At New York University School of Medicine, one required course delves into a database that tracks every hospital admission and charge in the state. Discussions center on why, say, the average tab for delivering a baby is $3,000 in a rural area and $22,000 in New York City.
“This isn’t a textbook exercise. This is real life and students love it,” says Marc Triola, NYU’s associate dean for educational informatics.
Medical educators say such innovations are long overdue. The U.S. health-care system is rapidly becoming ever more data-driven, evidence-based, patient-centered and value-oriented. But for reasons having to do with tradition, accreditation concerns and preparing students for national board exams, the designers of medical-school curricula have been slow to shift their focus.
“The reality is that most medical schools are teaching the same way they did one hundred years ago,” says Wyatt Decker, chief executive of the Mayo Clinic’s operations in Arizona, which include a medical school in Scottsdale, Ariz., that is scheduled to enroll its first class in 2017. “It’s time to blow up that model and ask, ‘How do we want to train tomorrow’s doctors?’ ”
Doctors today are well schooled in the science of medicine, says Susan Skochelak, the American Medical Association’s vice president for medical education. “What’s been missing is the science of health-care delivery. How do you manage chronic disease? How do you focus on prevention and wellness? How do you work in a team?”
To encourage med schools to move their curricula in that direction, an AMA initiative called Accelerating Change in Medical Education is giving $1 million to each of 11 schools to help fund novel programs. Of the nation’s 141 medical schools, 118 competed for the 11 grants.
The push for change comes at a time when medical educators are also trying to address a critical shortage of physicians. No new med schools opened in the U.S. from 1985 to 2000, amid fears of a doctor glut. More recently, however, predictions of a shortfall of 90,000 physicians by 2020 have sparked a building boom: Some 17 new schools have been accredited since 2002 and nine more have applied for accreditation.
A few of the new schools have made it their mission to address acute shortages of primary-care physicians in certain areas. Texas Tech University’s Paul L. Foster School of Medicine, which opened in El Paso in 2009, emphasizes community medicine and Spanish-language skills. The University of Kansas School of Medicine’s new branch in Salina takes just eight students a year—all with a strong desire to practice medicine in rural areas.
Med schools old and new are looking for a broader range of qualities in applicants—particularly students who are empathetic and have experience relating to diverse kinds of people.
To that end, in April, a new MCAT—the Medical College Admission Test—will be administered, the test’s first major revision since 1991. The new version is 2 hours longer (6 hours and 30 minutes) and tests knowledge of behavioral and social sciences as well as biology, physics and chemistry. One sample question has applicants read a passage, then asks which of four statements “is most consistent with the sociological paradigm of symbolic interactionism?”
Some schools have replaced the traditional one-on-one interview with a series of simulations in which applicants are asked to show how they would make a tough judgment call or deliver bad news. At the University of California, Davis, School of Medicine, community residents join faculty members in rating the applicants, providing a broader range of views.
Styles of teaching and learning are also changing.
“We’ve replaced ‘the sage on the stage’ with ‘the guide on the side,’ ” says Richard Zimmerman, a neurosurgeon and medical director for education for the new Mayo med school in Scottsdale.
At both the new school and Mayo’s existing medical school in Rochester, Minn., much of the material traditionally taught in lecture classes will be converted to electronic formats that students can absorb on their own, leaving class time for discussions and case studies.
Mayo also is creating a new course of study, called the Science of Health Care Delivery, which will run through all four years and include health-care economics, biomedical informatics and systems engineering. With a few additional credits, students can graduate with both an M.D. and a master’s in health-care delivery from Arizona State University.
In a course called Checkbook, Mayo students will track all of the services provided to their assigned patients during clinical rotations and look for redundancies or routine tests that add little value.
Focus on Teams
Learning to work in teams is a main focus at Mayo—and a sharp departure from traditional training for doctors.
“The old model was, you’d go on rounds; the attending would ask a question, and the young resident had to get the right answer,” says Dr. Decker in Scottsdale. “In the new model, you’re part of a team, and somebody else might have the right answer.”
To understand the roles of team members who aren’t doctors, first-year Mayo students spend half-days shadowing clinic schedulers, registered nurses, nurse practitioners and physician assistants. They also assist in managing a panel of patients, as care coordinators do. For example, they review records to see which diabetes patients aren’t managing their health well; they call the patients on the phone to discuss why they are struggling; then the students consult with the patients’ primary-care doctors to determine the next steps.
In another departure from med schools past, Mayo is making an organized effort to help students avoid burnout. Classes in the first two years are pass/fail, not graded, and students can evaluate their level of stress, fatigue and risk of suicide in a confidential Med Student Well Being Index, which also offers resources for help.
“When I went to med school 30 years ago, I don’t remember anybody asking how we were doing,” says Michele Halyard, vice dean of Mayo’s medical-school programs. “But you can’t heal the health-care system if you’re sick yourself.”
What’s being left out of medical education to make room for the new material?
Some schools are placing far less emphasis on memorizing facts, such as which drugs do what and how they interact with other drugs. Such information is now readily available electronically.
“The fund of medical knowledge is now growing and changing too fast for humans to keep up with, and the facts you memorize today might not be relevant five years from now,” says NYU’s Dr. Triola. Instead, what’s important is teaching “information-seeking behavior,” he says, such as what sources to trust and how to avoid information overload.
Technology is also changing how med students learn. Simulators that look like patients and can be programmed to go into cardiac arrest, have strokes, spike fevers, cry, vomit and eliminate are particularly useful for teaching.
“Some schools don’t use cadavers anymore,” says the AMA’s Dr. Skochelak. “But others think it’s an important way to learn respect” for the real human body. “They tell students, ‘This is your first patient.’ ”
Some schools are condensing the typical four-year curriculum into three years, to let students start their residencies sooner and graduate with less debt. The Association of American Medical Colleges is also studying ways to let students master needed skills and competencies at their own pace—an innovation that has come to medical residency programs as well.
“We should have done this 10 years ago,” Dr. Decker says of the many med school changes. Then he quotes a Chinese proverb: “The best time to plant a tree is 20 years ago. The next best time is tomorrow.”
Ms. Beck is a health reporter and columnist for The Wall Street Journal in New York. She can be reached at firstname.lastname@example.org.