Dell's Different Direction

UT-Austin Medical School's Curriculum Isn't Designed Just to Train Doctors — It's Built to Revolutionize Medicine

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Cover Story — May 2017

Tex Med. 2017;113(5):28-33.

By Sean Price
Reporter

To get a sense of how different The University of Texas at Austin Dell Medical School is from most other medical schools, you could start with first-year student Woody Green. 

The average age for allopathic medical students in the United States is 24, but Mr. Green hardly fits the fresh-out-of-college mold. Instead, he's a 37-year-old family man with a wife, a daughter, and a dog. Back when he was in college, he majored in fine arts, not pre-med or the sciences. His first career was in medicine, though: He worked for nearly a decade as a paramedic in Austin.

"It's unusual, I'll admit," Mr. Green said about his path to medical school. 

Many of Mr. Green's 49 classmates have similarly unorthodox backgrounds for first-year students. Also, 22 percent of them identify with racial or ethnic groups historically underrepresented in medicine. That's way above the 13 percent national average, according to the Association of American Medical Colleges. 

Together, they make up the inaugural class of the first medical school built from scratch by a major research university in the last 50 years. Clay Johnston, MD, Dell's inaugural dean, says their diverse makeup is just one sign of the school's commitment to change medicine by experimenting with just about everything. "It's a very different kind of experience that none of us who went to medical school 10 years ago — or even two years ago — were exposed to," he said.

How different? For openers, the school has developed a unique curriculum, one that practically does away with traditional lectures and focuses instead on solving problems. 

And the school's mission goes beyond just training doctors. It wants to "transform the way people get and stay healthy." That means, among other things, tackling the social and financial barriers that keep people away from doctors. Dell's leaders want to make Austin a "model health city" by improving health care for low-income and poorly insured people.

Dell's first class of students got started last July, and Mr. Green says he's seen the school's commitment to that mission at all levels. 

"I kind of worried that it was just what they sold to med students to get them in the door — and what they sold the public," he said. "But they seem to be following through. The problem is that these are huge initiatives. They're not only trying to build a school but also trying to build a huge enterprise."

A big piece of that enterprise will fall into place this month. Seton Healthcare Family's new $245 million teaching hospital, Dell Seton Medical Center, will open across the street from the almost-as-new Health Learning Building, where classes are held. Seton's new center will replace the 1970s-era University Medical Center Brackenridge. As more new pieces appear on the UT-Austin campus, Dr. Johnston says, Dell's impact will start being felt more and more. That's especially true of its emphasis on creating doctors who are as proficient at leadership as they are at medicine.

"A lack of physician leadership has [caused us to be] victims of changes in the health care system," he says, "as opposed to being the ones who are actually creating a system that's better for patients and better for doctors." 

Fixing Flexner

Nearly everything about Dell Medical School is unusual, including the partnership that created it. The University of Texas at Austin has been trying to get a medical school for decades. Its chance finally came about in the late 2000s when state Sen. Kirk Watson (D-Austin) proposed that UT partner with Seton, a branch of the Ascension health system, and Central Health, the health care district for Travis County. 

All of these partners, as well as the Michael and Susan Dell Foundation, agreed to make big investments in the new school. But the ongoing funding was still a problem. Normally, that would come from the Texas Legislature. Yet state lawmakers did not see an Austin medical school as a priority. To get around this, Senator Watson pushed for a local ballot initiative that uses Central Health's taxing authority to raise property taxes to help pay for the new school. Travis County voters approved the tax increase in 2012, and the school was under way. 

The work of educator Abraham Flexner largely shaped today's medical schools. In 1910, Mr. Flexner wrote a report for the Carnegie Foundation for the Advancement of Teaching after visiting all 155 medical schools in the United States and Canada. He deemed most of them "hopeless," and the reforms he called for led to the modern template: a university-affiliated institution, two years of science, and two years of clinical work with patients, nonstop lectures, and lots of memorization.  

A century later, a national movement of physicians has diagnosed the "Flexnerian" model as creaky and out of step. For instance, these physicians say, why waste student time on heroic feats of memorization in the age of the internet? 

"When it was embarrassing to pick up a textbook in front of a patient, maybe memorization made sense," Dr. Johnston says. "But it's not terribly useful in the practice of medicine today. The things you need to know, you'll know by heart, and the things you don't need to know, you'll look up. That's the way it should be." 

Under Dell's new curriculum, the normal two years of science are now packed into one, and the second year now is filled with hands-on clinical experience. The third year is a "growth" year in which students can work on a dual degree or a community project. And the fourth year is devoted mostly to exploring career opportunities and interviewing for residency positions.

Susan Cox, MD, the executive vice dean for academics, was the principal designer of Dell's curriculum. She says half of it consists of case-based learning. Students have to solve a medical problem as a group, which sometimes includes nursing and pharmacy students. This shows students the real-world value of working together with other health care professionals. It also trains them always to ask questions and look for better approaches. 

"They're not just going to do things because we've always done them that way," Dr. Cox says. "They're going to challenge."

Dell Medical School has one lecture hall, but the staff tries hard to make sure no lecturing takes place there. Student Anatoli Berezovsky, 24, says the "large-group interactives" held in the lecture hall are again based on teamwork. Speakers present cases, and students work with those around them to do research and arrive at solutions. "It's not just one person talking at you," Mr. Berezovsky says. "It's thinking through problems with people around you. It's a structured way to learn as a group."

The school's curriculum also features leadership classes each year, and Mr. Berezovsky says leadership has been woven into pretty much everything. 

"Everybody's on some sort of committee or plays some sort of leadership role," he says. "It's not mandatory, but they're pushing that everybody steps up and does that sort of thing. There are times when each of us has presented in front of the whole class, and I think they're just slowly trying to make that part of the experience."

A New Ecosystem

The emphasis on leadership touches on Dell's larger ambition: to remake modern medicine. Dr. Johnston says the current health care system is broken. He believes that's reflected in the health disparities in Travis County, where African-Americans and Hispanics suffer disproportionate rates for chronic problems such as obesity, diabetes, tobacco use, and hypertension. Dr. Johnston sees the future doctors from Dell as not just physicians but ambassadors for change. 

"What we're trying to do is create a whole ecosystem in which people rise up to find solutions," he said. 

Dell's experimental third-year projects are key to building that ecosystem. Third-year students can choose to do an independent project that focuses on health care innovation and design, population health, or clinical/translational research. Students can't just do anything they want. Each project has to be approved by the school, and students must show that someone will fund their project.

Since the inaugural class is just wrapping up its first year, nobody's quite sure what impact these projects will have. But many students, like Brooke Wagen, are ready to get started. At 40, Ms. Wagen is the oldest of the Dell students. She has raised her three children in East Austin, a historically low-income neighborhood, and delivered Meals on Wheels to elderly neighbors. Those experiences gave her an idea.

"Let's say you're hard of hearing, in your 80s, you have to go to [a Veterans Affairs clinic], you have a bunch of comorbidities, and, because you're hard of hearing, you can't call anyone on the phone," Ms. Wagen says. "Anytime you have a health care problem you have to ride the bus and go to the VA and spend the whole day there, miss your Meals on Wheels, and then maybe or maybe not get your question answered because the provider may or may not remember you, or you may or may not have a consistent provider."

Ms. Wagen says she believes this scenario could be eliminated by using health advocates who know the patients, know the doctors, and can get answers right away. That not only would improve health outcomes, she says, but it also would save doctors money and time. She plans to work with her elderly neighbors to find other ways to improve care. "I think we'll also be making health care cheaper by making it better," she said.

Students who are unsure about their projects can get help from the Design Institute for Health, a first-of-its-kind collaboration between Dell and UT's College of Fine Arts. The institute, which is led by two national design experts, uses a creative design approach to health care problems. Its job is to research and rethink everything from medical devices to local health care programs. For instance, redesigning a clinic's reception area could reduce wait times and improve efficiency. "You can do things really effectively when you redesign with the patient at the center," Dr. Johnston says.

Meanwhile, Dell has launched or is planning to launch about two dozen of its own programs designed to help low-income and uninsured people in Travis County. One of the first was a pilot project created in partnership with Seton, a local nonprofit created by Seton and Central Health, and community physicians. Its goal was to increase access to orthopedic specialists for Central Health clients. In just three months, the project cut wait times from 14 months to 28 days. 

Dr. Johnston said the orthopedic program also included a reform that Dell is keen to promote — experimenting with payment options. For instance, that pilot project based payments on health outcomes, not on the number of doctor visits or surgeries. "This is our preferred way to get paid," Dr. Johnston said. "I think we're unique in that way."

Waiting for Change

The school has earned wide applause for its willingness to innovate, but Dell has many critics who say innovation is not enough. Former state Sen. Gonzalo Barrientos (D-Austin) and two local lawyers, Fred Lewis and Bob Ozer, appeared at a February meeting of the UT Board of Regents to argue that money for Central Health should go directly to indigent care, not to pay salaries at Dell Medical School. They have demanded to see the school's financial records. 

"It is a wonderful medical school, and it's providing innovative, preventative, and transformative medicine," Mr. Lewis says. "But the money from Central Health is supposed to go to the indigent." 

Both Dell and Central Health responded that Travis County voters approved the medical school funding in the 2012 vote. This means they are also free to spend the money on administrative and operational expenses. They also argue Central Health's money will be multiplied many times because of upgraded facilities and improved care.

Dell has had some other rough patches. For instance, there was early friction with local doctors over changes in how Seton would pay physicians to train residents. The Travis County Medical Society (TCMS) mediated between Dell and the local physicians, and Dell's leadership met with community physicians to hear concerns about the graduate medical education (GME) programs. 

Robert Cowan, MD, then-TCMS president, says the society had anticipated some concerns about the new medical school. 

"The GME meeting was a result of members turning to TCMS with their concerns," Dr. Cowan said. "The challenge for us is to represent all of our membership, both academic and private, and to bring them together when issues like this arise."

As for Dell's experiment in redesigning health care, Dr. Cowan says local physicians have generally taken a wait-and-see approach. "It's going to be a few years before we know if they've been able to accomplish many of these goals," he said. 

Dr. Cox says the wait shouldn't take long. She says people will get a better feel for Dell's impact once the school's first class moves up and launches its community projects. "I guarantee you a year from their time in their third year — some time in their fourth year before they graduate — we're going to see a palpable impact on the community that these students have brought," she said. 

Ms. Wagen agrees. She says her proposed project alone could benefit up to 60 people in East Austin before she even gets out of medical school. Once she and her classmates do start practicing, she's convinced they will live up to Dell's mission. 

"It's going to take hundreds of people to solve these health disparities," she said. "I think with the minds and hearts of the people at Dell — students, faculty, clinicians — having named it as their mission, I can't see how it won't change."

Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

SIDEBAR

UTRGV School of Medicine Tackles Valley's Endemic Problems

Texas' Rio Grande Valley is one of the fastest-growing regions of the country — and one of the most medically underserved. TMA statistics show Valley counties average 102 doctors per 100,000 people, below the state average of 180 and less than half the national average of 235. So the 2016 opening of The University of Texas Rio Grande Valley (UTRGV) School of Medicine was an important milestone for the region. 

The UTRGV campus launched its 55-student inaugural medical school class at the same time as Dell Medical School and took the same reformist approach to the Flexnerian model. Almost all learning at UTRGV School of Medicine is team-based and student-directed, says Leonel Vela, MD, senior associate dean for academic affairs. Like Dell Medical School, the UTRGV medical school also gives little time for lectures.

"We cap that at most at eight hours in a week," says Dr. Vela. "It used to be medical schools would have eight hours in a day." And the lectures are not lectures in a traditional sense. They're called "resource sessions" because students enjoy considerable back-and-forth with the presenter. 

The first Texas medical school south of San Antonio has also put its own distinctive stamp on curriculum design. For instance, the first-year students don't face the normal laser-like focus on basic science. They do study science, but they also jump into outpatient clinical work and continue doing it all four years. Much of that clinical experience forces them to confront health issues endemic to the region, including chronic problems like diabetes and infectious diseases like tuberculosis. 

Dr. Vela says this is all part of a larger mission to revolutionize health care in the Rio Grande Valley through partnerships with the community. Perhaps the biggest health challenges in the region can be found in hundreds of colonias. These are unincorporated neighborhoods that typically have poor infrastructure, no schools, few jobs, and large Hispanic populations.

The school of medicine's programs include the Community-University Partnership, which operates in six colonias within three South Texas counties. Medical students team up with students from all the other UTRGV colleges to determine health needs and work with community leaders to solve them, says John Ronnau, MD, senior associate dean for interprofessional education.

Since the inaugural class of medical students is just finishing its first year, the program is still in its infancy. Also, it faces funding problems. Many of the students work on a volunteer basis. But Dr. Ronnau says the program is already helping students see health disparities face to face and deal with social determinants like low income, poor housing, and lack of education.

"It's one thing to talk about social determinants in the classroom," Dr. Ronnau says, "but it's another when you're in the community and see them and actually talk to people who are experiencing them, and then try to come up with public service programs."

SIDEBAR

See: Playing Catch-Up: Texas Medical School Class Size vs. Population, 1990–2016

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