Revamping Medical Education
Cover Story — December 2013
Tex Med. 2013;109(12):20-34.
By Amy Lynn Sorrel
Even before entering medical school, Keeley Ewing-Bramblett, MD, knew she wanted to practice family medicine. Her mother is chronically ill and "just knowing the impact family medicine made in our lives, I didn't even consider anything else."
That made the three-year medical degree for students committed to primary care at Texas Tech University Health Sciences Center (TTUHSC) School of Medicine a perfect fit for the native Texan. Instead of spending the typical fourth year of medical school searching for a specialty, she jumped into a guaranteed residency training spot through the Family Medicine Accelerated Track (F-MAT).
Clay Buchanan, MD, also gravitated toward the program after trading in a law career to pursue family medicine.
They were part of F-MAT's first graduating class of eight who started their residencies in July. When they finish, that's eight doctors who will join the Texas physician workforce one year sooner than most and with less medical school debt. In Texas, the average four-year student graduates with about $170,000 in loans, according to Association of American Medical Colleges (AAMC) data.
"Am I happy I did it? Heck yes. I graduated sooner, and being an older student, I wanted to get out and practice sooner. I was guaranteed a residency and not as much debt," Dr. Buchanan said. "However the future of medicine shakes out, we can use innovative ways to get people to go into medicine and, more importantly, primary care."
In today's health care system, many of those doctors work in teams. So the University of North Texas Health Science Center (UNTHSC) developed a course that trains its aspiring physicians at the Texas College of Osteopathic Medicine (TCOM) alongside those from its pharmacy, physician assistant, and physical therapy schools, and a nearby nursing program.
"Across the health professions, there's a tendency and a history of training in silos. Even in the clinical years of training, students often observe teams functioning, but they don't get much instruction," said David Farmer, PhD, who oversees the program. Meanwhile, research continues to show that effective health care teams are a big factor in improving patients' health and reducing medical errors. "Health care as we've known it is not going to be the same, and there's going to be a need for collaboration."
The Tech and UNTHSC programs are part of a movement to adapt medical education to today's evolving health care system. Changes in care delivery and technology, coupled with impending physician shortages, are squeezing medical schools to produce not just more doctors, but physicians who are well-prepared to practice in an ever-changing clinical environment.
Texas medical schools are trying to get ahead of the curve with innovative approaches to meeting the current physician workforce demands. TMA policy generally supports such efforts as long as they ensure high-quality medical education and meet national accreditation standards. Also, the Texas Legislature set aside $2.1 million for medical school primary care innovation grants in 2014-15 to encourage schools to develop primary care pipeline programs like F-MAT and increase the number of primary care physicians in the state.
The movement spans beyond Texas' borders: This year, the American Medical Association gave $11 million in grants to test new undergraduate medical education models in nearly a dozen medical schools across the country. Schools nationwide also are preparing for a new AAMC proposal encouraging them to focus more on students' competency — what they can do versus what they can memorize — a concept already emerging in the residency, licensing, and ongoing components of physician education and practice.
"Medical schools are looking at their role in society and in the health care system and changing how they do medical education based on the needs of the health care system," said Steven L. Berk, MD, dean of TTUHSC's medical school and chair of the Texas Medical Association's Ad Hoc Council of Medical School Deans.
Schools implemented incremental changes over the past decade or so as reports from organizations like the Institute of Medicine, the Carnegie Foundation, and AAMC called for medical education reforms.
But the recent and more rapid changes in health care delivery demand a wholesale shift, says Vice Speaker of the AMA House of Delegates and former TMA President Susan R. Bailey, MD, of Fort Worth. That's the idea behind the AMA's Accelerating Change in Medical Education initiative, which seeks to facilitate "innovative structural change that prompts a significant redesign of undergraduate medical education that can be duplicated across the country."
Still, while medical educators tend to agree with the need for change in medical education, they acknowledge it won't happen overnight.
"All of these innovations have rarely been tested in a research model," cautions Stephen B. Greenberg, MD, dean of medical education at Baylor College of Medicine and a member of TMA's Ad Hoc Council of Medical School Deans. He says medical education research is more prepared now with the technology to test whether the new approaches are working. "But it's not easy."
Bright Ideas in Texas
It may not be easy, but it's necessary, Dr. Berk says.
AAMC predicts a national shortage of 90,000 physicians across various specialties by 2020; primary care alone will see a shortage of 45,000 physicians. Texas still ranks near the bottom at 43rd in the state ranking of patient care physicians per 100,000 population. (See "Texas Needs More Doctors.") Meanwhile, the confluence of health care reform and an exponential growth in the Texas population continue to stress the physician pipeline in the state.
"When you talk about the future of health care, there are a lot of patients, especially in Texas, who need a primary care physician. That's the most cost-effective way of taking care of people," Dr. Berk said. "As medical schools, it's our problem and our responsibility to produce more primary care physicians," which his F-MAT program aims to do in three years instead of four.
The modified curriculum, modeled after a 1990s Accreditation Council for Graduate Medical Education (ACGME) pilot, is faster paced: The program condenses students' courses by eliminating summer breaks and electives in favor of exposing them to clinical training sooner. Students begin a concentrated family medicine clerkship in year two — a year earlier than in the traditional four-year curriculum — and spend their third year doing rotations and a sub-internship to prepare for residency.
"That's where the program really exceeded and succeeded in preparing me," Dr. Buchanan said. "I got to see patients sooner, do more clinical training sooner, and have continuity with my patients. [In four-year programs] it's usually all first-time exposures somewhere in the arc of care, and you don't get the whole picture."
Whereas students typically spend the fourth year of medical school in electives and extra rotations to choose their specialty and applying for residency slots, that step is unnecessary for F-MAT students.
Dr. Berk says there were challenges to starting the program, like getting approval from accrediting bodies so students' licensure was unaffected. But there was no shortage of students eager to sign up for the program, whose individual United States Medical Licensing Exam (USMLE) scores are on par with national averages. And one year less of medical school, plus a Texas Tech scholarship designated for F-MAT students, adds up to only half the usual amount of medical debt.
He acknowledges the program is rigorous and not for every student, part of the reason eligible students are screened to test their maturity level. "We're not in favor of all medical schools going to three years. We're just advocating that if a certain group can do medical school beautifully in three years, we want to encourage them to do primary care."
In fall 2012, The University of Texas System began piloting a similar initiative that aims to better coordinate students' transition from college to medical school and shorten that total time in school by one to two years. Steven Lieberman, MD, who oversees the initiative as senior dean for administration at the UT Medical Branch at Galveston, says those segments "are very disjointed, and there's not a lot of intentional integration. That introduces inefficiencies and makes things longer and more expensive than they have to be."
Under the so-called Transformation in Medical Education (TIME) initiative, 11 UT institutions, both undergraduate and medical schools, experiment with different formats that expose students to medicine and clinical training much sooner. Rather than requiring extended study in chemistry in college, for example, schools merge those courses and allow students to take more classes in biomedicine or even a pharmacology class. In addition to revised general science requirements in the premedical phase, students begin to learn some basic principles of patient safety and quality improvement and to practice teamwork.
"If we ask them to memorize a whole bunch of chemistry and regurgitate it to get into medical school, that's what they will do. If, on the other hand, we ask them to take a patient history and communicate with patients and demonstrate that before they transition to medical school, they can be a contributing member of the health care team from day one," Dr. Lieberman said.
Recognizing that young college students may lack the personal and professional maturity to handle more clinically focused training, schools integrate professional development into their training.
"Traditionally, students are invited to come and hang out with us [doctors] and see what we do and learn to act like us through imitation or osmosis, and we expect them to grow up to be good doctors like we are," Dr. Lieberman said. "This is about making that maturation an explicit and intentional process."
Those students also could get lost in growing classrooms as Texas medical schools meet AAMC's call to increase enrollments 30 percent by 2015. UT Southwestern wants to make sure students leave just as prepared without getting left out, says geriatrician and professor of internal medicine Lynne M. Kirk, MD.
For the seventh year, faculty have formed mini-colleges within each class, now around 240 students. On day one, students are assigned to one of six colleges that they stick with throughout their four years of medical school, where they can interact more closely with other students and faculty. In each college, students are broken up into groups of six and assigned a mentor, usually a clinician, so they can discuss, observe, and practice skills such as communication, taking a patient history, and ethics.
"Our classes are very large, and we wanted to make sure that our students had relationships with faculty and that we facilitated as much mentoring as possible," said Dr. Kirk, who is also a member of the AMA Council on Medical Education.
Focusing on Competency
Schools may take different approaches to revamping medical education, but they have one thing in common: They all are moving toward competency-based training.
"Instead of assessing whether students can memorize the different causes of spasms of jaw muscles — as I was asked to do years ago — what we really want to know is, are they able to take care of patients?" AAMC's Chief Medical Education Officer Carol A. Aschenbrener, MD, said. She believes today's health care changes aren't the last ones young practitioners will see in their careers, "so we need them to be able to shift how they practice, and a competency-based approach makes it easier to do that. No physician can practice the same way for a lifetime."
She says the current century-old Flexnerian model of physician education focuses largely on putting in a certain number of hours, courses, and lectures before getting practical experience to complete a medical degree. Educators say the model served its purpose well in redefining and standardizing medical education since that time. But given the ongoing expansion of medical knowledge, technology, and physicians' role in health care, the model is hard-pressed to keep up.
Competency-based training still includes education in basic sciences, but focuses less on memorization and written exams and more on regular feedback during hands-on training in skills like communicating with patients, integrating medical knowledge with practice, and training in teams, Dr. Aschenbrener explains. Given students' penchant these days for mobile technology, for example, some schools have begun to "flip" their classrooms: Lectures are posted on the web as students' homework, and class time is spent discussing and applying it. And the USMLE may be able to test students' knowledge about diabetes, but not their professionalism or skills talking to patients about the disease.
The big difference, says Dr. Aschenbrener, is that competency-based education "is based on outcomes: What should the physician actually be able to do? And the second big change is, those outcomes are grounded in evidence of what is needed in the population, not what a group of smart physicians or faculty sitting around a table thinks everyone needs."
The third component, which Dr. Aschenbrener acknowledges is tricky, is figuring out the progression of competencies and how to assess them — something her organization is working on defining. In November, AAMC was expected to release a preliminary list of a dozen or so core professional activities that she says "every single medical graduate ought to be able to do the first day of residency." The organization also is testing such activities in a national pilot project with students interested in pediatrics.
Competency-based training would then allow schools to tailor the length of students' training, although that's not the primary focus of the approach. Only as students master the core competencies are they able to advance through their education at different speeds. Drs. Berk and Lieberman also emphasized that key component of their programs.
UNTHSC meanwhile recognized that team-based training was quickly becoming a fixture in health care delivery and a core competency for young physicians when it created the Department of Interprofessional Practice in December 2012. It takes after the Interprofessional Education Collaborative, a consortium of six national health professions associations — including AAMC, the American Association of Colleges of Osteopathic Medicine, and nursing, pharmacy, and public health associations — that developed recommendations for core competencies for team-based practice.
Several times a year, Dr. Farmer, director of interprofessional practice, helps gather 600 first-year students from its medical school and various health professions schools into integrated health care teams. Through exercises like code simulation, faculty teach various competencies, including effective team development, communication, and roles and responsibilities within a health care team.
Traditionally, schools "teach how to communicate with patients, but there's no time spent on communication with each other. And one of the things that makes teams effective is a common language. We also look at what are those roles and responsibilities for each of the professions, and which stay the same and which shift based on patients' needs," he said. "Our philosophy is, if we train them together — which is going to be more commonplace when they get into residency and practice — they will be more comfortable with collaborative practice."
In fact, in the AAMC's 2013 Medical School Graduation Questionnaire, nearly three-quarters (73.4 percent) of medical students graduating this year reported that their education included training in teams with other health care professionals. That's up from 65.6 percent in 2011, the first year AAMC began tracking the topic.
New medical schools certainly have an advantage in that they can leapfrog into competency-based teaching and other 21st-century education models. Former UT Vice Chancellor for Health Affairs Kenneth Shine, MD, says the new UT medical schools he is helping launch in Austin and South Texas will probably have fewer science departments compared with existing schools, and right off the bat, the schools' curricula will emphasize factors such as flipped classrooms, small group learning with other health care professionals, and elements of the TIME initiative.
Whether starting from scratch or revamping existing curricula, putting such innovations into practice isn't easy.
Part of the reason it has taken this long, says Dr. Shine, is "medical education is very expensive, very complicated, and it involves huge numbers of people."
Dr. Farmer says the sheer logistics of coordinating with other schools and making sure 600 students get the experience they need posed certain obstacles. And students should get those experiences throughout all years of their education. It also took some work to train faculty and find practicing physicians versed in competencies that were not a part of earlier teaching models or everyday medical practice.
That's where TMA and other medical professional organizations can play a role, says Dr. Kirk. "In my own career, I had very little training, for example, in interprofessional teams when I was doing inpatient rotations. TMA and AMA have done a lot of work around how physicians can facilitate teams to help patients get the best care. So those are skills we can really be building the groundwork for in medical education."
A September New England Journal of Medicine commentary also warned that shortening medical education could mean shortchanging students and the public, but agreed that overall reforms are necessary. According to the article, 33 schools had three-year MD programs in 1974, most of which disappeared until now. The reasons for creating such programs then were the same that some schools put forth now in that they sought to address predicted physician shortages.
However, "given the growing complexity of medicine, it seems counterproductive to compress the curriculum into three years," the authors wrote. "The limited opportunity for students to participate meaningfully in patient care in their undergraduate careers is the problem that needs correction; the solution is not to rush students into residency after allowing them even less involvement with patients."
Baylor abandoned a three-year medical degree program it started 30 years ago after students found it too rigorous, and most ended up opting for the four-year track, Dr. Greenberg says. But whether students who completed a three-year medical degree are better or worse off, "no one has studied it, and there's no data on what the outcomes have been," which he says is a sticking point with implementing many of the medical education innovations proposed today.
Part of the problem, he says, is there are few cooperative studies among medical education institutions to find best practices. To fix that, this year, he and TMA for the first time brought together a group of Texas schools interested in such research. Their first project was surveying Texas medical students on how to use social media in medical education. They planned to present their experiences cooperating on the study at AAMC's annual meeting in November.
"If we can get a consortium of Texas schools to agree, some of these questions can be answered" about the feasibility of new medical education approaches, he said.
That includes factors such as what tools should be used to evaluate students' performance in various competencies, something no one has quite figured out yet. Until now, "achievement has been defined by passing a written exam. It's not the same with the core competencies we are seeing now. It's easy to do a written test on medical knowledge. It's difficult when you're evaluating things like professionalism and communication," Dr. Greenberg noted.
Meanwhile, the cost of new technologies or other resources schools would need to implement many of these ideas remains an unknown.
Dr. Kirk says her training at a three-year medical school was "a challenge, I must admit, but I came out the other side. So it can be done. But we do have to make sure that if we truncate, we are not shortchanging the public."
She and Texas Tech's Dr. Berk added that the three-year programs emerging today, including F-MAT and others proposed in the AMA projects, are about more than simply eliminating the fourth year in that they include competency-based teaching that was absent in earlier models.
AAMC's Dr. Aschenbrener also cautioned that the trend toward shortening medical education is not just about time. "The trend is about flexibility." Fighting physician shortages certainly could be a side benefit of graduating some students earlier. Regardless of when students graduate, however, "our job is to produce the best-trained and most people-oriented physicians that we possibly can."
She acknowledges it could take the next decade to realize systemic change in medical education, adding that part of the problem is a lack of federal funding dedicated to medical education research. "Even though we don't know how to assess all of this yet, there's a lot of good work going on. It will give us more information than we currently have."
Eventually, educators say accrediting bodies would have to allow for more flexibility in granting medical schools exceptions to try new programs, while at the same time maintaining their standards for what makes a good medical school.
Dr. Kirk, an advisor to the AMA initiative, says the experiments also could start to provide answers to some of those questions by giving schools seed money to experiment and then share best practices. Schools around the country are discussing the issues "and this is all a work in progress," she said. Because every medical school is unique, however, "I don't think there's a one-size-fits-all answer."
Nor do medical educators imply that the current system has been turning out less-than-prepared physicians.
Dr. Shine said the Flexner model worked "very well for 100 years, and there's nothing to be unhappy about. Only in the last several years did it become clear the model is no longer applicable in the 21st century. Science has to be connected with how we take care of patients."
Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Texas Needs More Doctors
As Chapter 1 of TMA's Healthy Vision 2020 points out, Texas has a shortage of both primary care physicians and other specialists, ranking behind the other most-populous states in the number of patient care physicians per capita.
To evaluate this shortage across specialties, TMA devised a metric that compares the number of Texas physicians per 100,000 population with the U.S. average. It's called the "Texas Specialty Ratio." The closer this ratio is to 100 percent for a given specialty, the closer Texas is to the national average.
Other points worth noting:
- Texas has fewer physicians per capita than the national average for 36 out of 40 medical specialty groups.
- Texas needs both more primary care physicians and more other specialists. A number of specialties have acute shortages.
- Psychiatry and child/adolescent psychiatry are among the specialties with the lowest Texas Specialty Ratio.
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