Two years ago, the American Medical Association said medical education needed a shakeup, citing "gaps between how medical students are trained and how health care is delivered," and put up $11 million to fund experiments in closing those gaps.
Now that effort is beginning to bear fruit.
The AMA gave grants of $1 million apiece to 11 medical schools, together forming a consortium called the Accelerating Change in Medical Education consortium, and using the grant money to fund creative ways to prepare students better for their physician careers.
In the first of a three-part series, MedPage Today looks at what four of those schools are doing.
Big Uses for Big Data
New York University's (NYU) School of Medicine has chosen to teach tomorrow's doctors how to make better use of health data to not only improve community-wide health but also to make a difference for their individual patients, according to Marc Triola, MD, director of the Institute for Innovations in Medical Education at NYU.
"We're at this amazing time where federal and local governments are releasing health data through initiatives like data.gov, and medical schools have access to data about the healthcare delivered by doctors in the community," he said in a phone interview. "With the changes happening in healthcare and the changing role of technology and data, teaching these [data analysis] skills seems more important than ever."
NYU medical school students are now given access to some large clinical data sets, including a database of every admission to every hospital in the state -- about 2.5 million visits per year to the state's 227 hospitals, Triola explained. The database contains information on each patient's ethnicity, reason for admission, procedures performed, and charges incurred.
"We created a website in which we downloaded all this data for two years ... so students can look at the most common reasons patients were admitted to the hospital, what medical conditions are the reason [for the admission], and how much charges can differ from one hospital to another," Triola said. "It's fun and they love it because it's real data."
Students learn about the data's power and its limitations as they work in teams to come up with a clinical question they can ask the database, such as variations in charges, or differences in quality or length of stay. Students work on the projects for five weeks.
"This exercise has been extremely eye-opening," said Triola, who notes that some students have turned their projects into manuscripts that have been submitted to medical journals. "To understand what the data mean and how to improve quality are critical skills for doctors," even down to the practice level.
Mastering the Science
At Brown University in Providence, R.I., some medical students are pursuing a new type of dual degree: an MD and a master's in population medicine, said Paul George, MD, director of curriculum for the dual degree program and associate professor of family medicine at Brown. "The master's program is comprised of nine courses integrated across four years of medical school," so students don't have to stay in school any extra time, he explained.
"The healthcare system is rapidly evolving," George said in a phone interview. "What physicians needed to know even five or 10 years ago is different than what they need to know today. So we often talk about basic science and clinical science in medical school, but a third science is emerging which is healthcare delivery, and students really need to know about that."
The nine courses include a course on healthy disparities and social determinants of health -- that course is required for all medical students -- as well as courses in biostatistics and epidemiology, the U.S. healthcare system, leadership, and two courses on the intersection between population and clinical medicine.
Those last two courses have three themes: the social and community context of healthcare, quality improvement (QI), and leadership, said George. For the first theme, students must identify a problem or need in the community and propose a project to fix that need. For the QI theme, students must devise a QI project at one of their physician mentor sites. Students also get opportunities to practice their leadership skills.
In addition to the integrated master's program option, all Brown medical students participate in a longitudinal integrated clerkship, George said. "When I was a medical student, you did your clerkship in the third year -- rotating through internal medicine, pediatrics, and so forth. So you would do 12 weeks of internal medicine, then stop, then six weeks of ob/gyn., then stop. There was no continuity with the patients or the providers you were working with."
In the longitudinal model -- which is being piloted this year with eight students -- the students participate in all their clerkships longitudinally over the course of the third year. First, the students spend three weeks each doing inpatient medicine and surgery rotations "to set them up for taking care of sick patients and knowing how hospitals work," he explained. "Then for the next 32 weeks, they spend a half-day per week with an internal medicine practice, a half-day with a family physician, a half-day with an ob/gyn, and a half-day with a pediatrician.
"So now we have put together continuity with patients -- because we hope that they'll see the same patients over and over again -- and continuity with the provider because they are working with the same physician over 32 weeks ... and also with practices, because they're in the same practice all year long."
In addition, students each follow three to five patients from each of their physician mentors, "so if one patient they're following in the medicine clinic has a cardiology appointment, the hope is that they'll go with that patient," George added.
Teaching the Teachers
One of the AMA's other grantees, East Carolina University's Brody School of Medicine in Greenville, N.C., is making the faculty part of its focus. "If you look at the literature on this, it's pretty clear one of the biggest barriers [to teaching students about the healthcare delivery system] is the generation of faculty we belong to," said Elizabeth Baxley, MD, senior associate dean of academic affairs at the medical school. "We weren't ever taught this."
"We've got faculty who are very busy caring for patients, trying to teach medical students and resident and fellows, and keep up with their own specialty, and they're having to work in a new healthcare system, and they were never taught the principles and science behind the new systems to improve them and make them safer," Baxley said during a phone interview at which a media relations person was present.
So East Carolina developed the Teachers of Quality Academy, a 15-month program whose first class started in January 2014 and finished this past April. "We used the Institute for Healthcare Improvement's model called the 'Breakthrough Series Collaborative,' where we did six different two-day learning sessions," she explained.
Baxley noted that there were 39 faculty in the first class -- but only 29 were from the medical school. "One of the new competencies we needed to teach was how to work with other healthcare professionals," she said. "If we were only teaching to physicians, we wouldn't get far, so we recruited from the College of Nursing and the College of Public Health" and other allied colleges.
In addition to the two-day learning sessions, faculty members also had to choose a clinical project in the outpatient arena, the hospital, or the emergency department, for which they had to develop an "aims statement" of what they wanted to improve and work with a team to get it done. The school also worked with East Carolina's College of Education to develop a class in medical education that trained faculty in developing new curricula and figuring out how to improve on them.
For that class, faculty members "each had to develop on educational model for health systems competency," Baxley said, adding that there was only one rule: it couldn't be in a lecture format. "They could do an exercise, a problem-based learning case, or [something else]." One nursing school faculty member even developed a game modeled after something she saw in the United Kingdom.
The school also is offering a Leaders in Innovative Care (LINC) scholars program for medical students who want to do a "deep dive" into the healthcare delivery system. Medical students who apply and are accepted to that program spend part of the summer after their first year in an eight-week immersion course and also do additional coursework in their second through fourth years of medical school.
Learning at Their Own Pace
If someone is doing really well in medical school and learning faster than other students, why should they be held back? Conversely, if students need more time to learn a particular skill, why not let them stay and keep working on it? Those are the questions raised by Oregon Health & Science University (OHSU), in Portland, which has developed a competency-based curriculum for its medical students, according to Tracy Bumsted, MD, associate dean for undergraduate medical education at OHSU.
The old model of medical school was "time-fixed" -- two years of basic science followed by two years of clinical science, which was known as the "two plus two" curriculum, Bumsted explained in a phone interview during which a public relations person was present. With that system, "we know that when [medical school graduates] get to their next stage, they're not ready; doctors getting fresh residents now say there is a really steep learning curve. Why is that? They spend a lot of time, take a lot of tests, but they aren't ready for their next job."
On the other hand, medical schools could instead start with the end in mind, figuring out what doctors need to be able to do and know. "We know what kind of physician we will need -- not just someone who will know everything [clinically], but also knows how to answer questions and find information that's out there and to be able to adeptly use that information and those skills to help patients lead healthier lives," she said. "We start by giving them those skills and allowing them to demonstrate their competencies in medical school."
Unlike the "two plus two" curriculum, the competency-based curriculum "is time-variable and outcomes-fixed," Bumsted continued. "Every student who graduates from OHSU will have the competencies we've defined; the variable will be the amount of time that it takes."
Under the competency-based system, OHSU estimates that about 10% of students will be able to graduate in less than four years, Bumsted said. "We can envision lots of people with varying backgrounds -- like former nurses, or medics from the Army -- why would we want them to have to take the same kinds of things as people who haven't had that background?" And, she said, there will be another group who will need extra time.
Because students will be going through the school at their own pace, "one way it could work is to have designated times that people could on-ramp or off-ramp," she added. "Instead of once-a-year graduations, we might have them four times a year or six times a year. And we need to make sure they have something to go to -- so residency programs need to accept people into programs more than once a year" -- an idea that OHSU is talking about with other schools in the AMA consortium.