In Focus: Modernizing Medical Education to Advance New Care Models and Foster Continuous Quality Improvement

By Martha Hostetter and Sarah Klein

To say medical education has not kept pace with changes in the practice of medicine would be an understatement. The last significant redesign was a century ago, based on the landmark 1910 Flexner Report, which recommended that medical students spend the first two years of four-year programs learning foundational science and the latter two applying that knowledge to clinical practice.¹ 

It was an appropriate model for the era, formalized during a time when rapidly changing discoveries in physiology and microbiology were revolutionizing the practice of medicine. Ensuring doctors could keep pace with the changes and apply them in practice was paramount. Since then, the acquisition of new scientific knowledge during medical school has become less important—not because this information isn't rapidly evolving or critical to good care, but because it's been made more accessible via the Internet, reference materials, and disease-specific decision support tools. 

What medical students can't get as easily is practice with the tools, techniques, and communication skills necessary to deliver high-quality care today—particularly as the locus of care shifts away from acute care in hospitals to the long-term management of chronic conditions in ambulatory and community settings. New payment models that hold physicians and other providers accountable for managing large populations of patients also require new skills, including the ability to lead interdisciplinary teams of providers and use sophisticated information technology and performance data for continuous quality improvement.

Recognizing this, a number of U.S. medical schools are making changes to their curricula that will affect how students spend their time, and in some cases, how much time they spend in school. Many of the innovations are in keeping with ongoing changes in medical residency programs, spurred by the Accreditation Council for Graduate Medical Education's implementation of milestones that, among other things, require residents to demonstrate the ability to investigate and use evidence to improve patient care.² 

Some of the most dramatic changes are designed to customize curricula to the strengths and weaknesses of individual students arriving with varying levels of experience in clinical settings. By tailoring coursework based on an assessment of competencies and enabling students to choose areas of specialization earlier, several schools including New York University (NYU), Texas Tech University Health Sciences Center, Columbia University's College of Physicians and Surgeons, and a handful of others enable students to graduate in three years. Administrators at Oregon Health and Science University (OHSU) School of Medicine are allowing for even more flexibility with the expectation that, over time, all students will graduate on different dates. "There's no reason we need to hold them back if they demonstrate competency, says George Mejicano, M.D., Oregon's senior associate dean for education (see this Q&A for more information about OHSU's education reforms.)

Shortening the time spent in school has the added benefit of reducing the total cost and time burden of a medical education. "These students will graduate with far less debt and earn an additional year of practice income compared to traditional students," says Mark Henderson, M.D., associate dean for admissions and outreach at the University of California, Davis, School of Medicine (UC Davis), which this year is allowing a handful of students to complete school in three years and go directly into primary care internal medicine residency programs there or at Kaiser Permanente, which is also providing this group scholarships.

Encouraging High-Quality, Value-Based Care
Anticipating that graduates will be working in systems that emphasize high-quality, high-value care, many schools are working to inculcate in students a sense of responsibility for scarce resources and the ability to recognize what constitutes high-value care. At Mayo Medical School, students will use a "clinical checkbook" tool to track all of the services provided to their assigned patients during clinical rotations and review the charges to assess whether there were redundancies or instances of unnecessary care. "It sounds simple, but when we trained, we never even thought about costs," says Sherine E. Gabriel, M.D., Mayo's dean. "Did you really need to check hemoglobin six times that week? Did the patient need an X-ray every morning? Did redundant use of resources contribute to a health problem for the patient?" 

In similar fashion, medical students at Indiana University School of Medicine will have access to resources in an electronic medical record (EMR) system that indicate the costs of ordering a particular test or procedure, patients' insurance status, and information to help them assess the potential effectiveness of that treatment. This assessment of effectiveness is part of a larger effort to prepare physicians to participate in what the Institute of Medicine has termed a "learning health care system," using large data sets that were not available to previous generations of medical students. 

At NYU School of Medicine, for example, students are working with de-identified patient discharge information from multiple New York State hospitals to not only understand the strengths and weaknesses of a particular data set and how to manipulate it, but also to test hypotheses related to the costs and quality of care. Among the questions students have asked are: Does day of admission correlate with length of stay for congestive heart failure patients? How much do charges vary across hospitals for the same payer and a given diagnostic related group (DRG)? What are the provider-level variations in length of stay, volume, and charges for a given DRG? In one such analysis, students found the data from eight New York State hospitals did not support a widely held belief that care on weekends may be of lesser quality because fewer staff are around: hospital patients admitted over the weekend actually had, on average, shorter lengths of stay.

"Physicians are going to need these skills in their professional lives," says Marc Triola, M.D., an associate professor at the school and associate dean for educational informatics. "Whether they are trying to improve quality they deliver as providers, whether they want to understand how they are using resources across a panel of patients, or whether they are understanding how a health care system is measuring them."

New York University, Indiana University, and others are using data from their health system's electronic medical records to assign students virtual patient panels as teaching tools. At Indiana University, the virtual panels reflect the mix of patients that students might encounter over the course of their careers: not only those with different health conditions but also with different types of insurance (or no insurance), urban and rural backgrounds, and differing access to providers. In class assignments, students will explore how care differs for these patients and assess how well care is coordinated. They will be able to contrast the care plan they would have created for the patient with what actually happened to the patient in the system. The "teaching E.M.R.," as Maryellen E. Gusic, M.D., executive associate dean of educational affairs at Indiana University School of Medicine calls it, "is a way to ensure they are learning about systems-based practice."

Enhancing Communication and Teamwork
Teaching communication and cross-disciplinary teamwork either virtually or in person is also a key focus of educational reforms. At the University of Missouri, for instance, student teams from the medical, health management, pharmacy, respiratory therapy, and nursing schools take part in a simulation to provide care for patients who come to an emergency department during a flu epidemic. Observers watch not just what students do but how well they work together. The experiential learning makes a difference, says Linda Headrick, M.D., senior associate dean for education at the University of Missouri–Columbia School of Medicine. "In the classroom this interprofessional stuff is nice, but here [they realize] they really need each other to meet patients' needs."

Until now, one of the biggest barriers to teaching multidisciplinary teamwork in medical schools has been the challenge of coordinating schedules across multiple schools. To surmount this, Indiana University will use a shared teaching EMR, enabling students from the different schools to log on as their schedules allow and collaborate asynchronously to create care plans for virtual patients, and then have opportunities for in-person group discussions. Similarly at the Brody School of Medicine at East Carolina University, medical and nursing students use a simulation lab to practice delivering news of a medical error.

Because some of the communication skills needed to practice medicine depend on fixed personality traits, many medical schools are changing admission criteria to reflect qualities that may not be teachable (e.g., empathy and openness to others' ideas). To test for these interpersonal skills, University of California, Davis, School of Medicine has applicants take part in 10 short interviews, using the multiple mini-interview technique pioneered at Canada's McMaster University. Each brief encounter assesses the candidate on a skill deemed critical to good doctoring, such as listening, ability to give feedback, ability to articulate a cogent argument and defend it, and cultural competency—aspects that typically aren't evaluated until students are in their third or fourth year of medical school.

Creating Earlier and More Meaningful Interactions with Patients
To give students more meaningful interactions with patients, medical schools are also putting students into clinical settings earlier—including more ambulatory settings—and over longer periods (see this Q&A to learn how Penn State College of Medicine is using medical students as patient navigators). These students are being trained to perform key tasks, such as helping to coordinate patient care, that physicians themselves may have a hard time finding time to do. 

At the University of California, San Francisco, School of Medicine, students matriculating this July will work in care teams for six to nine months to gain experience as health coaches for patients with chronic disease. (In one pilot, first-year students in outpatient cardiology clinics helped check in patients, observed physicians doing visit summaries, met with patients to review care plans, and followed up with patients by phone. Having students perform these tasks led to improved patient satisfaction and reduced the number of times patients called the clinic with questions.) Similarly, at Vanderbilt University School of Medicine, students are assigned to help clinicians with tasks such as medication reconciliation and behavioral interviewing. In the second year, they take a "transition of care" course in which they help with hospital discharge planning and follow-up care, including making home visits. "It is not shadowing," says Bonnie Miller, M.D., Vanderbilt's senior associate dean for health sciences education. "They are actually meaningful contributors to the health care delivery team."

Implications
Many of these medical schools are in the early stages of developing and testing new educational approaches, and it's not at all clear what impact these changes will have. New methods of assessing students are also a work in progress. Some schools, such as the Cleveland Clinic Lerner College of Medicine, are forgoing traditional grading and ranking systems in favor of electronic portfolios in which students and their teachers compile evidence of their progress on specific competencies. The goal is to inculcate in students an awareness of how well they're doing and to provide more frequent and specific feedback about their progress. 

However, adding new coursework and educational tools requires a lot of time and money. Many of the schools described here won $1 million grants through the American Medical Association's Accelerating Change in Medical Education program to support their efforts, but the total costs exceed grant amounts. Some of that investment is tied to faculty development, another critical element of education reform. (The Association of American Medical Colleges has called for schools to develop a critical mass of teaching faculty versed in quality improvement techniques and has launched the Teaching for Quality program to train faculty in ways to teach quality improvement and to assess students.)³ 

There are also capacity issues when it comes to finding clinical sites willing to offer students meaningful roles on their care teams over long periods. This may be easier in communities that have large integrated delivery systems, including clinics with the infrastructure needed to support students. Most schools offer some kind of "clinical bootcamp" to give students a basic understanding of clinical environments—including patient privacy and safety issues—before heading out to the field, but clinics must still offer some hands-on training to students. 

"We will not achieve the care that current and future patients deserve unless we bring together what we know about the best care and best education," says the University of Missouri's Headrick. "We are making progress, but too slowly. We are challenged by a sense of competing demands, faculty who feel ill-prepared and overtaxed, and resources that are not well matched to needs. Clinical and education leaders must find sustainable ways to integrate our efforts toward better health professions education, better health care, and improved health."

Notes