UT System Seeks to Reinvent Medical Training
Medical Education Feature – November 2011
Tex Med. 2011;107(11):39-42.
By Ken Ortolon
Dallas pathologist Thomas McConnell, MD, took an unusual path to medical school. In the late 1950s, he left Rice University without completing his undergraduate degree and enrolled at The University of Texas Southwestern Medical School.
Dr. McConnell says he made the decision because he was "out of money and had to shorten my education by any way possible."
He was one of a handful of students in his class at UT Southwestern who had the necessary prerequisites and who were allowed to enroll in medical school after only three years of college. He received his medical degree from UT Southwestern in 1962 after just seven years of higher education.
Now, the UT System is launching pilot programs that could make that type of accelerated advancement the norm rather than the exception.
UT's Transition in Medical Education (TIME) initiative is an effort by 10 UT System institutions to reinvent medical education and shorten the amount of time it takes to train new physicians.
"The impetus for this is the current state of affairs with medical education, namely that it's long, it's expensive, and premedical and medical education have changed little in the 100 years since the current model was developed," said Steven Lieberman, MD, vice dean for academic affairs at the UT Medical Branch (UTMB) in Galveston and cochair of the TIME initiative. "And the reality is the practice of medicine and delivery of health care have changed dramatically in that period of time."
If successful, TIME could reduce the amount of time some students spend in college and medical school to six years, maybe even less. While that piece of the project is what "grabs most peoples' attention," Dr. Lieberman says the bigger piece will be a fundamental change in the way future physicians are educated.
"What I'm most excited about is that this is really a new model of what ought to go into physician education," Dr. Lieberman said. "The old model is learn science and then learn about diseases and then go practice, applying that science to diseases with all of the knowledge that you've got. What we're looking at is a different approach that is much richer, much more complex in terms of the preparation necessary to be a physician. But it also much more accurately and fully reflects the many attributes that are critical to being the kind of physicians that patients expect."
TIME involves four separate pilot projects that partner various UT System academic institutions with UT medical schools. The UT System Board of Regents approved $4 million for the project. Each pilot is scheduled for fall 2013.
While each partnership will develop its own unique programs, Dr. Lieberman says the project will integrate premedical and medical education in four areas.
The first is a prehealth professions program that includes students interested in a variety of health care professions – including medicine, nursing, pharmacy, and allied health fields – who learn core material together, work in teams, and are exposed to an interprofessional environment.
Second is competency-based education that bases progress toward the awarding of degrees on "what students are able to demonstrate that they can do, rather than how long they've been in a course of study," Dr. Lieberman said. "The idea is to assess competencies, and once a competency is demonstrated, the student moves on toward more advanced competencies."
Third is professional identity formation, which Dr. Lieberman says is essential to competency-based education. Being a physician is "more than being able to apply knowledge and knowing how to perform clinical skills," he said. Physicians also must develop personal characteristics, demonstrate professional behaviors, and learn to integrate the values of the profession with their own personal values.
In the past, professional identity development "has been done largely unintentionally and almost by osmosis," Dr. Lieberman said. This part of the program would make professional identity formation an" intentional process" within the curriculum that involves student reflection on their experience, active mentoring, and role modeling, he says.
Finally, the new curriculum would include nontraditional topics, including humanities, social sciences, public health, quality improvement, and more.
Dr. Lieberman says these topics "have not been dealt with extensively in traditional premedical and medical curricula but are critically important to the modern practice of medicine."
While each partnership develops its own pilot programs, at least two would seek to cut one year off the typical training time for a physician.
David Henzi, PhD, is the partnership director for the Facilitated Acceptance to Medical Education (FAME) program developed by UT San Antonio (UTSA) and the UT Health Science Center at San Antonio (UTHSCSA). He says its approach is basically a "3 + 4" program, "meaning that students would attend UTSA for three years, they would have to complete certain requirements, and at the end of that third year they would go to the health science center and begin medical school."
The FAME program would prepare those students for medical school through two unique components – team-taught courses that utilize UTSA and UTHSCSA faculty to give undergraduate students a taste of the medical education environment and gateway courses that would put a medical twist on courses that traditionally would not have a medical aspect.
The gateway courses would introduce undergraduate students to diseases such as cancer, diabetes, and obesity, while also bringing in humanities components, as well, says Dr. Henzi, who also is director of the Office of Academic Enhancement in the medical school at UTHSCSA.
"So they will learn not only about the disease base but also some of the socioeconomic components of it as well, such as the ethical dilemmas associated with obesity, and professionalism and other sorts of humanities components," he said.
Students in the pilot project would receive a bachelor of science degree in biology from UTSA after completing their first year of medical school and then get their medical degree three years later, Dr. Henzi says. He says the FAME project likely will enroll 30 UTSA freshmen in 2013 and might later add an additional 20 sophomores.
A partnership involving UT Austin, UT Southwestern, and UTHSC at Houston also seeks to graduate physicians in seven years. And a partnership between UT Dallas and UT Southwestern plans to shorten training for some students to as little as six years by eliminating duplication of some basic science courses that students take both as premedical students and in medical school, and dropping courses that officials identify as no longer relevant for 21st-century physicians.
For example, some experts have questioned the need for a year of general chemistry, a year of organic chemistry, and a year of physics for future physicians, Dr. Lieberman says. While it is unlikely those topics would be eliminated entirely from the curriculum, emphasis on them might be reduced, he says.
Better and Faster
Donna Ekal, PhD, says a group of UT institutions along the Texas-Mexico border is working with UTMB and UTHSC Houston to build a better, faster, and scalable integrated medical education curriculum that other institutions can use.
"We think we can really do all three of those things by looking at the medical education curriculum together," said Dr. Ekal, partnership director for the Accelerated Professional, Relevant, Integrated Medical Education (A-PRIME) project that includes UT El Paso, UT Brownsville, UT Pan American, UTMB, and UTHSC Houston.
Dr. Ekal says the traditional approach to physician education involves "very little back and forth” between the undergraduate institution and the medical school. “So we're looking at this together. How can we make this a six- or seven-year integrated process where we all work toward creating this educational pathway for our medical professionals?"
The A-PRIME project will bring faculty from the various institutions together to develop courses that meet the needs of both the undergraduate and medical degree programs, she says.
For example, they are looking for more efficient ways to deliver biochemistry content, which students now take at both the undergraduate and medical school levels.
Attempts to put medical education on a fast track are not new. Baylor College of Medicine offered a three-year program in the 1980s and 1990s, but officials there say students found it hard to squeeze four years' worth of classes into three. Texas Tech University Health Sciences Center also recently initiated an accelerated three-year medical school program for students interested in family practice.
The Association of American Medical Colleges says some 20 medical schools across the country offer fast-track educational programs.
Dr. Henzi says one of the oldest is at the University of Missouri at Kansas City, where the undergraduate institution and medical school share a campus and offer a joint bachelor of science and medical degree program.
Where's the Humanity?
TIME has drawn some criticism from those who believe a six- or seven-year training cycle would eliminate humanities and social sciences from a student's education.
"It is certainly true that the core facts of a medical education can be learned in less than eight years. However, the six-year education of such a physician would leave gaping holes in that doctor's understanding of the human condition, and that lack of knowledge would significantly affect the way future patients are treated and the way that doctor would practice medicine throughout her or his career," Austin psychiatrist Stephen Sonnenberg, MD, wrote in an opinion article published in August by the Austin American-Statesman.
But Dr. Lieberman says that concern is why UT is incorporating humanities, social science, and cultural competency in the nontraditional topics component of the new medical school curriculum.
Dr. McConnell wholeheartedly supports shortening the training period. He says he "didn't find that I suffered any" in his medical career by not completing his fourth year at Rice.
Meanwhile, the Association of American Medical Colleges (AAMC) supports the project. Henry Sondheimer, MD, AAMC senior director of academic affairs, sees real value in integrating the undergraduate and medical school curricula, as well as the competency-based training approach.
"Different people reach different levels of competency in different areas at different rates of speed," he said. The assumption that all schools have been under -- that everyone progresses at the same rate of speed -- is obviously not correct."
Dr. Sondheimer also says accelerating the pipeline for new physicians and cutting the amount of debt they graduate with also could be important outcomes of the TIME project. The median medical school debt now stands at approximately $160,000 he says.
"If you can take a cohort of young people and get them through medical school with $90,000 or $100,000 or even $110,000 in debt, that's substantial to them," he said.
Less debt could increase career options for those new physicians, making it more likely some graduates would choose primary care specialties that traditionally earn less money, he says. And, it might prompt some bright students to choose medicine who are now entering other carriers, he adds.
"We have some pretty good data right now that there's a group of very qualified students who are interested in medicine but are not applying to medical school because of the debt issue," Dr. Sondheimer said. "If we can see these types of programs, then hopefully that group of students will apply."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
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