Face to Face
Overhaulin'
By Kim Kiser
Dean Keith Lindor, M.D., is tearing down the curriculum at Mayo Medical School and rebuilding it to produce graduates who are suited to 21st century practice.
Keith Lindor, M.D., is about to be petitioned by two first-year medical students, Jessica Bury and Rayna Dyck. Bury settles on the edge of a chair and pulls out a paper signed by 38 of the 42 members of their class asking for “little things that would make a big difference to us.”
She argues her case like a young lawyer before a seasoned judge—only in this case, the judge is the dean of Mayo Medical School, a man who has the power to grant their requests. Bury acknowledges that members of her class support Lindor’s plans to revamp the medical school curriculum and inject a bit more breathing room into students’ schedules, whether it’s an extra 10 minutes between classes or a few more days of spring break. Although the class that starts in July will be the first to benefit from the curriculum changes, Bury and her fellow students would like to see some of them extended to their class.
Their requests are simple: Make sure classes end on time so students aren’t late to the next one; give them a day between rotations so they have time to read ahead or just catch up on life; have more formal preparation for Step 1 of the U.S. Medical Licensing Examination; re-evaluate the attendance policy (students now need permission from their instructor and the administration to miss a class—a policy Bury says is “very demoralizing”); have clinic rotations match up with what’s being taught in class.
“Shall I go on?” Bury asks. Lindor, a willowy man with thinning blond hair and wire-rimmed glasses, leans forward in his chair and nods, telling her that most of these requests can be honored. Bury mentions a problem with instructors not knowing what students had or had not learned in previous classes and that the four-day spring break, which starts on a Friday and ends on a Monday this year, is too short. The schedule dates from the early days of the medical school, when only 10 percent of students came from outside of Minnesota. Today, students come from all over the world. “It’s almost impossible to go home,” says Bury, who hails from Alaska.
One might expect such a scene to play out on the campuses of large universities with more activist reputations, not Mayo Medical School, where suits and ties are as common as stethoscopes. However, the fact that the students feel comfortable voicing their concerns tells much about the atmosphere Lindor has nurtured since becoming dean in January of 2005. Bury turns to me and says, “Dean Lindor came to us and asked us all to be as involved as we can be.” She makes a point of saying that he is always open to meeting with them and promptly answers their e-mails. “I think that’s unusual for a medical school dean.”
Keith Lindor
At a Glance
Education: Mayo Medical School, M.D., 1979; Bowman Gray School of Medicine, internal medicine residency, 1982.
Family: Married to Noralane Lindor, M.D., a geneticist and fellow graduate of Mayo Medical School; son, Carl, 23, a recent University of St. Thomas graduate who works as an adolescent drug and alcohol counselor; daughter, Rachel, 20, a junior at St. Benedict’s who is premed.
Early career plans: Lindor followed the path of his father, an engineer, and studied chemical engineering and psychology at the University of Minnesota. “At the time, I realized most of the jobs were in petroleum. I kept thinking I can’t move to Cleveland. At the time, the Cayahoga River was burning [oil and debris from area industries had caught fire]. I liked science, and medicine seemed like a better fit.”
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After Bury finishes going through her list, Lindor lets her know he has heard her point about needing enough time to get to class by concluding the meeting 10 minutes before its official end. The soft-spoken gastroenterologist assures the students that they will see some changes soon.
“These are ideas we wouldn’t have come up with because we’re not living the life,” he explains after Bury and Dyck leave.
A Student of Students
Students have been one of Lindor’s research interests during the last year and a half. In order to better understand their concerns and find out whether what they are being taught in the classroom is on key with the way medicine is being practiced in the clinic, he has invited groups of them to his home, met individually with first- and second-year students, organized lunches for third- and fourth-years, and attended as many student events and meetings as possible, in addition to seeing patients and overseeing clinical trials for drugs to treat cholestatic liver disease.
Lindor says he didn’t go into the dean job with the idea of overhauling the way Mayo trains future physicians. In fact, he didn’t even want the job when it was first offered. “I was surprised but had the presence of mind not to say no, and that I wanted to think about it over the weekend,” he recalls of the day he got the offer. That weekend, the 52-year-old Lindor, himself a 1979 graduate of Mayo Medical School, attended his 25th class reunion. (He and his wife, Noralane Lindor, M.D., a geneticist, are among 10 members of their graduating class who are still at Mayo. “She said, ‘If I would have guessed which one of you would become the dean, you would have been the least likely,’” the reserved Lindor says with a laugh.) After reuniting with former classmates and spending time on campus with students, he started to think differently about the job. “The bottom line was that after talking to the students, I realized this was what I wanted to do,” he says, explaining that he liked the idea of getting daily doses of their energy and enthusiasm. “They have great ideas, and they think anything is possible.”
Candid yet unassuming, Lindor, who often starts his day by reading publications unrelated to medicine (Architectural Digest and Sunset are two favorites that give inspiration to his hobby, landscape architecture), comes off more like a quiet academic who would rather spend his day in the research lab or working one on one with patients than a leader who wants to revolutionize the medical school curriculum. His voice at times barely audible, he’s refreshingly honest when he admits that sitting through hour after hour of lecture can be “mind-numbing” and that Mayo pulls “a funny bait and switch” on students by granting admission to those who’ve volunteered in their communities yet giving them no time to serve the people in and around Rochester.
His willingness to acknowledge the good and the bad makes it easier for students such as Bury and Dyck to approach Lindor about the fact that they and their classmates feel as if they have no oxygen in their schedules. “In talking to students, it became clear that the curriculum was too dense. Some of the students would say things like ‘I can hardly wait to get out of class so I can finally learn something,’” he says. “There was too much lecture, too much emphasis on detail and not enough on active learning. We were spending a lot of effort on things that were no longer effective or in some cases were impediments to learning.”
For example, first-year students might spend eight hours hearing about the details of rare and complex liver diseases rather than learning about how the liver functions. They might learn about the cardiovascular system in class and later that day shadow a physician in an unrelated specialty such as dermatology or psychiatry. And if they fell behind in their studies, they had no time to remediate. “It’s a fast-moving train, and if you have to get off, it’s hard to get back on,” Barbara Porter, assistant dean for student affairs, says of the curriculum.
Such demands were taking a toll on students. Studies by Liselotte Dyrbye, M.D., an assistant professor of medicine at Mayo, published in the Mayo Clinic Proceedings in December 2005 and Academic Medicine the following April found about half of the medical students from Minnesota’s three medical schools who were surveyed suffered from burnout or depression. “We don’t always see the folks who are crashing and burning, but it seems to be a growing number,” says Porter.
Lindor knew things had to change for the sake of the students and for the sake of the patients those students would eventually care for.
Mental Blocks
Mayo isn’t the only medical school to put its curriculum and teaching methods under a microscope. “Many medical schools understand now that the way we have been teaching students is what was adequate for medical practice in the 1950s,” says Patricia Barrier, M.D., associate dean for student affairs. At the time, medical knowledge was much more limited. Graduates could expect to go into solo or small, group practices. And issues such as patient safety, whether patients had health insurance, and being sued for malpractice were not physicians’ top concerns. “We now have a medical climate where most of our students will need to practice as members of interdisciplinary teams in different types of practice settings. They won’t need to be fact memorizers but will have to learn how to manage knowledge that is ever-changing,” she says.
In other words, graduates will need to know how to access the most current information on a patient’s condition while in the exam room; deliver safe, effective care that’s backed up with evidence; find help for patients who don’t have insurance; and work in a system where decisions might be made by corporate executives rather than doctors. “It’s a far more scientifically, socially, and economically complex medical world,” says Barrier, who was part of the medical school’s administration the last time the curriculum was updated about 10 years ago.
Lindor followed leadership guru Stephen Covey’s advice to “begin with the end in mind” when he started overhauling the curriculum. That means having students interact with patients starting the first week of school, rather than after months of lecture. “We want students to see themselves as physicians, not as college students,” he says. “We want to keep that end in mind—a practicing physician with patients.”
In explaining how the redesigned curriculum will work, Lindor pulls out a large piece of posterboard that outlines the path the 42 incoming students will take starting in July. “We were thinking of having T-shirts made, but no one would buy them,” he says with a laugh of the dense chart that shows a breakdown of each academic year.
Although the plan is still a work in progress, the first two years will be made up of a series of six-week blocks that will cover topics such as molecular biology, cell structure, and principles of disease. Students will spend no more than 20 hours a week in lecture, and what they do in clinic will build on what they learn in class. Lessons on ethics, scientific foundations, professionalism, and teamwork will be integrated into the subjects covered in the blocks. Between blocks, the students will have three weeks of leadership training or two-week “selectives,” in which they can explore areas of interest such as rural health, do community service projects, remediate, or take a much-needed break. Students will spend their final two years doing clinical rotations, much the way they do now. However, after a recent lunch with fourth-year students who said they feel unprepared to do the teaching that will be required of them as residents, Lindor has been looking for ways to get them experience by helping first- and second-year students prepare for their boards.
“He’s quite the visionary,” Porter says of Lindor. “He has the ability to see things that aren’t there and to think about medicine and training and where we want to be.”
But Lindor has had to work to convince faculty, who have been used to teaching their own courses their own way, of the need for change. Although he comes across as someone who’d rather sit back and listen than deliver the hard sell, Lindor used skills he honed in his previous position—head of gastroenterology and hepatology, one of the largest departments at Mayo—to win over other physicians. “He worked very, very deliberately and very diplomatically,” says Barrier, who notes that Lindor always came to meetings armed with evidence-based arguments and answers. “It took many, many individual meetings with people and having to overcome the reaction of ‘Oh my gosh, I can’t possibly teach my course any other way,’ and of bringing people together who have not worked together before and saying ‘Here’s who’s teaching cardiovascular pathology and cardiovascular physiology. How can you all merge your courses and work together?’”
Barrier, who was part of many of those meetings, says Lindor sold them on the idea by showing examples of how it can be done. “He would give them something to work with, rather than just say ‘Do something different,’” Barrier says. “The other thing he did was engage everyone and reinforce their value and how integral they were to the process.”
Redesigned for Learning
The curriculum isn’t all Lindor plans to overhaul. He also has his eye on renovating the building that houses the medical school starting next year. Constructed by the Works Progress Administration in 1936, the Tudor Gothic–style Mitchell Student Center looks like something that was transplanted from an Ivy League campus.
The three-story dolomite limestone building, which was once home to the Olmsted County library, looks charming on the outside but isn’t conducive to 21st century learning on the inside. Lindor pulls out blueprints showing how the floor where his office is located will be cut up into classrooms, lounges, and conference rooms that can support small-group learning.
Again, beginning with the end in mind, he plans to turn the lower level of the building into space where medical students and students from the graduate school—two groups that right now see very little of each other—can interact. “The current lounge is an abysmal looking area,” he says. Lindor believes that by changing the physical space in order to bring medical students together with future researchers, it will help produce better doctors: “To me, that’s the wave of the future in medicine—incorporating basic science information into clinical practice. What better time to start doing that than with students?”
And for Lindor, medical school is all about turning good students into good doctors. Lindor recalls how he got e-mails from medical students at 1 a.m. the day after Hurricane Katrina struck, wondering how they could get to Louisiana to help those in need. The students ended up staying in Rochester, holding fundraisers and assembling 300 backpacks for schoolchildren.
“When people talk about redesigning medical education and making it more patient focused, that’s what they’re talking about—the concept of giving back to the community and helping others. That’s probably the basis for what makes a good physician,” he says. “Students need to see value in that, and we have to provide opportunities to do that versus the way it currently is where you have to be in the classroom being bored to death learning stuff you’re not going to remember.” MM
Kim Kiser is associate editor of Minnesota Medicine.