Mind and Body

Creating the med school of the future

Consortium of 32 medical schools convenes at Warren Alpert Medical School to consider the best ways to expand and reshape how future physicians are trained

Photo by Richard Asinof

Dr. Jeffrey Borkan, Dr. Susan Skochelak, and Dr. Allan R. Tunkel.

By Richard Asinof
Posted 4/23/18
The Warren Alpert Medical School is playing a critical role in reshaping medical education, expanding the science of health care to include health systems.
How responsive will health systems be to the new educational curriculum being developed in medical schools? Will efforts to screen for depression as part of primary care integration of mental health and behavioral health have unintended consequences? How can better integration of nursing education into medical training further the development of a team approach in medicine?
The movement toward population health and reimbursements based upon accountable care and value-based care has been a driver of larger and larger consolidations of health systems and insurance companies. At the same time, the development of health equity zones and neighborhood health stations are innovations that often do not become part of the discussion when talking about investments in health care delivery. Where do patients and consumers get to participate in these conversations, about what they want?

PROVIDENCE – “Consensus” was the key word in the closing remarks by Dr. Susan Skochelak, the group vice president for Medical Education at the American Medical Association, at a two day meeting held on April 9-10 involving representatives of 32 medical schools at the Warren Alpert Medical School at Brown University.

And, judging from the murmurs of approval of the participants, there was a sense of general agreement that medical educators agreed that the changes introduced into the curriculum for medical students five years ago in 2013 were moving in the right direction.

The conference focused on the efforts now underway as part of the AMA’s Accelerating Change in Medical Education Consortium to ensure that future physicians across the country are better prepared to care for patients in the changing health care landscape.

The Brown medical school has played a key role in developing new curriculum aimed at expanding the two existing pillars of medical education – basic and clinical science – with a third pillar, known as “health systems science.”

In 2013, with a $1 million grant from the AMA, Brown created a first-in-the-nation program designed to train future physicians with a focus on population and public health, creating future leaders in the community-based primary care at the local, state and national levels.

The new curriculum served as an integral part of Brown’s Primary Care-Population Medicine program, launched in 2015, to help medical students learn how to deliver care that meets the needs of patients in modern health systems, particularly as the nation’s health care system moves toward value-based care.

A key component of that effort has been the development of a new textbook, Health Systems Science, which was released in 2016 and is currently being used by medical schools across the country.

In terms of impact, the new innovative models for medical school education have been adopted by 32 medical schools, supporting training for an estimated 19,000 medical students, who are projected to provide care for some 33 million patients a year.

Talking about the future
Following the conference, ConvergenceRI sat down with Skochelak, Dr. Allan R. Tunkel, associate dean of Medical Education at the Warren Alpert Medical School, and Dr. Jeffrey Borkan, chair and professor in the Department of Family Medicine and assistant dean for Primary Care-Population Medicine at the Warren Alpert Medical School, to talk about changes in medical education curriculum as a result of the initiative.

ConvergenceRI: Coming out of the conference, I was listening to your last remarks, and you talked about trying to achieve a consensus about the best ways to move forward with medical education. What is the process for doctors and educators to arrive at consensus?
SKOCHELAK:
I don’t think it is all that different than the way most of all us come at consensus. The AMA is here for this meeting because Brown is one of our flagship schools in changing the way we are training our young physicians, because we’ve identified gaps, and those gaps came from a consensus process over almost a decade of people saying, there’s a lot good about medical education, but there’s a lot that’s missing.

When we saw that there was a consensus in what was missing, we said: Let’s do what we can to try and support schools with good ideas about how to fill those gaps.

ConvergenceRI: Is it hard to get doctors to agree?
SKOCHELAK:
Depends on the subject, doesn’t it?

TUNKEL: It does depend on the subject, but I don’t think it is as difficult as we all think. I think if we concentrate on why we are doing all of this, I think we can come to consensus.

I think this came out at the end of the meeting. It is about providing wonderful care to our patients, first and foremost. That we want to ensure that they are getting great care, that we’re making discoveries that are going to benefit patients and populations, moving forward.

And also, thinking about that in the context of our students and trainees, and how to get them to the point where they are going to provide this wonderful care and help our patients and communities moving forward.

BORKAN: And I think, Susan, you put it in the summary that on one hand, we would love it to be linear, and I think Allan’s plan for the conference was to come to some conclusion.

I loved your analogy to the pebble in the water, that ripples are in some ways unpredictable and will be determined in part by the people who are in control of the organizations now but also the students who will then go forth in the next generation.

But I was thinking that, in some ways, the change comes differently in medical education. So, as a big part of this consortium, one of the products was to think about the third science of medicine, which is health systems science.

In getting there, one has to actually name all the things that are not part of basic or clinical science. And, then, to come up with domains, and then coming up with curriculum.

And simultaneously, coming up with assessments, so that the questions which are on a high-stakes and lower-stakes exam begin to require students and schools to think about [the concepts]. You begin to have a multi-pronged approach.

ConvergenceRI: There seems to be a reaction by some students and by some residents that the world of medicine isn’t what they thought it was going to be. They want to be able to help patients, but they often find themselves frustrated by the world that they then enter.
Do the changes in medical education teach them that they are going to be more responsible for shaping their own world, and that they are going to be involved in a rapidly changing future landscape of health care? Did I ask that question properly?
SKOCHELAK:
I liked the last part of the question, going forward. Because in your anecdote, whether it is cynicism or disappointment or whatever, the answer is to have tools that empower you.

When I recently sat in at Penn State, when they did their white coat ceremony, and the first lecture was: welcome to our health care system; you’re part of our team now.

You’re only a student, you might not be able to make a change, but if you see a problem speak about it. Because it is all of our jobs to change the system to make it the best that it can be.

It is not about just imparting the content of what is going on in the health care system, but also learning leadership skills, and these are different leadership skills. It’s not being the captain of the navy anymore; it’s how do you lead a team of people.

To help a student who says: this isn’t what I thought it would be, you have to say, here’s how you can make a change.

TUNKEL: I would echo something that Jim Madara [AMA CEO and executive vice president] said in his keynote address, who presented some information about what are the things that dissatisfy physicians. A lot of the dissatisfaction is anything that takes them away from caring for their patients.

And it may relate to the electronic health records.

Doctors want to be able to spend more time with their patients.

BORKAN: I was also thinking about Jim Madara, who has helped the AMA to move its focus to try and improve some of the elements that are currently plaguing health care and physicians.

Some of them are the unintended consequences; we created electronic health records to help us communicate with one another, and it created the unintended consequence of requiring a restructuring of patient visits, spending lots of hours on what’s not necessarily productive time.

So, we have lots of unintended consequences that we have to address.

ConvergenceRI: Has the AMA conducted research on the qualitative and quantitative response by physicians to electronic health records? Is it a generational thing, in that older people are having a harder time adapting and adopting?
SKOCHELAK:
The AMA has done a lot of quite a bit of research on the electronic health record. It is the number-one [cause of dissatisfaction]; it is not based on age or technological savvy.

Younger people are just as dissatisfied; the time-motion studies have shown, physicians are spending more time with the EHRs and data documentation than they are with patients. It’s spilled into their nights and evenings.

That’s not to say that there haven’t been good parts of EHRs. But the human design elements can be improved. What we’ve done at the med school level is to say: here is this tool that’s going to be with you for your practice life, day in and and day out. Now, here’s what it can do for you, and you should know what you can expect from it, so you know how to improve it. That is the way to empower change that will make it better.

BORKAN: When you think about it, the EHR is an outsized player in health care. It is becoming a major element of almost any interaction. The third person in the [exam] room is the EHR. It begs the question: the stethoscope was never the third person in the room, nor was the EKG, so why is the EHR?

It is like a 1930s airliner, it probably gets you there, but it is a little rough, and it crashes on occasion.

ConvergencRI: We’re in the midst of an epidemic of drug overdose deaths that have been linked to prescription painkillers, which in turn have been linked to the decision to include pain as a vital sign. The next similar kind of screening question may be about depression. Is medical education prepared for that?
TUNKEL:
I think the problem with pain, and the pain scores, is that it somehow was linked to how hospitals got paid. That was really the problem; it became part of patient satisfaction.

And if, you got a lower satisfaction score because your patient was in pain, the hospital would get less money in reimbursements from Medicare and other payers as well. I do believe that led to a lot of over-prescribing.

And, I think that’s a huge issue; I worry about things being introduced without a lot of study that become part of payments to physicians and hospitals, things that should be studied in a more comprehensive way before they are introduced.

SKOCHELAK: There will be a conference here soon, because Brown and Warren Alpert have been leading the nation in training on new ways to address the opioid epidemic. We’re all looking to you all for your expertise.

Similarly, Allan and Jeff have added new educational materials for physicians that were missing before, it’s under a large umbrella of health systems science, to say that the whole health system matters, when you talk about opioids and depression.

The way we think about that is to teach two things: one is about the social determinants of health, that you can’t take a patient out of their context. The second is to make sure that people are really understanding about teams.

BORKAN: I think the whole pain scale will go down as one of the bigger debacles of organized medicine. It ignored the issue of function; it didn’t have teams, and it didn’t have interventions.

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