Cover Story
New School of Thought
The University of Minnesota Medical School is moving away from a four-year curriculum to one where students can take time off to explore a related field or learn about health care in another country.
By Amy Snow Landa
Midway through medical school, Bryan Armitage is doing something unusual: he’s taking a year off. Having finished two years of coursework at the University of Minnesota, Armitage is putting his medical education on hold to spend a year doing research at the university’s biomechanics lab in Minneapolis. He may even take a second year off to complete a master’s degree in biomedical engineering before heading back to medical school.
Welcome to the new world of medical education at the University of Minnesota, where students are no longer locked into a four-year box for completing their medical degree. Instead, they can take up to six years, like Armitage. Or, if they prefer, speed things up and get through in just three-and-a-half years.
The latter option appeals to first-year student Travis Olives. Olives, like Armitage, has been busy assembling a broader repertoire than “just” a medical degree, earning a master’s degree in education and another in public health by the time he entered medical school. Having spent so many years in school already, Olives says he is eager to get started on a career in medicine.
Under the university’s new Flexible M.D. program, launched in the fall of 2005, students like Armitage and Olives are not only allowed but encouraged to choose their own timeframe for completing their medical degree. The school permitted a measure of flexibility before, but it was fairly unusual for students to take additional time. The new program sends a clear message to both students and faculty that stepping off the four-year conveyor belt is an acceptable option, says Armitage. “It legitimizes it.”
Students can use the extra time for a variety of purposes, such as carrying out research or gaining hands-on experience in international or community health. Several students are currently taking time to work in countries such as Zimbabwe, Tanzania, and the Congo, while others are volunteering at community health centers here in Minnesota.
That degree of flexibility is pretty unusual among medical schools. A few, such as Stanford and Yale, allow students to take five years to get through. But Minnesota is the first public medical school in the country that formally allows students to take between three-and-a-half and six years to complete their medical degree and for the same tuition cost as the standard four years.
It’s a departure from the norm, but a necessary one, says Deborah Powell, M.D., dean of the medical school. “There’s nothing sacred about four years,” she insists. More important is that students be encouraged to take advantage of opportunities that will make them better physicians and to think for themselves about how they want to structure their careers.
Armitage, who has a degree in mechanical engineering and spent five years designing medical devices, plans to become an orthopedic surgeon who also does research. His work in the biomechanics lab allows him to apply his previous experience and gain a deeper understanding of how to use his knowledge in different clinical research applications. Some of the projects he’s involved in include testing the mechanical properties of bone/implant constructs, mapping fracture patterns, and creating three-dimensional models of post-traumatic anatomic structures. “It will be difficult to take time off during residency and beyond to develop some of the skills I am trying to learn while focusing on research,” he says. “If I can finish medical school with an increased understanding of biomechanics and several papers on scapular fractures to my name, I can use this as a basis to improve my ability to care for patients and contribute to research throughout my career in medicine.”
More Changes in Store
The four-year degree isn’t the only sacred cow that’s come under scrutiny at the University of Minnesota Medical School. Under Powell’s leadership, the entire framework of medical education could be in for a massive restructuring during the next few years.
Powell says she’s not interested in simply “tweaking” the curriculum and making other small-bore changes. “We need to do something radically different,” she says. “Our current system is calcified. It doesn’t move, it’s not flexible, and we don’t know enough about the kinds of doctors we’re training and the impact they have on improving the health of their patients.”
Convinced of the need for structural change, Powell is leading an ambitious, five-year initiative aimed at transforming medical education at the university.
The initiative, dubbed “Medical Education Development 2010”—or MED 2010—was launched in 2005. The Flexible M.D. program is one component of the project, and the first to be implemented. But the overall vision is much more far-reaching. At its core is a plan to shift medical education away from the traditional paradigm, based heavily on lectures, memorization, and multiple-choice tests, to one that is more tailored to the needs of individual students and better prepares them for practicing medicine in today’s health care environment.
Kathleen Watson, M.D., the school’s associate dean for students and student learning, says moving to the new model “means asking ourselves, what do students need to learn and how do they learn it? And then asking each student, who do you want to be as a physician and how are you going to achieve that dream?”
Those kinds of questions are not often raised in U.S. medical schools, says Kenneth Ludmerer, M.D., an internist, educator, and medical historian at Washington University in St. Louis. Ludmerer authored the book, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care in 1999 and coined the phrase “learner-centered medical education” in a New England Journal of Medicine article in 2004.
Instead, most medical schools tend to emphasize faculty concerns such as research, publishing, and patient care over what students really need for their learning and development. “The education of the medical student has evolved from the central mission of a medical school 100 years ago to literally no more than a by-product of what today’s academic medical center does,” he said in an interview.
Some medical schools have begun discussing ways to change that, but the movement is still in its beginning stages, Ludmerer says. “I think it’s fair to consider Minnesota an avant-garde school for being so explicit about putting students first.”
The medical school is doing more than just talk about putting students first. It’s also putting what Powell calls “real money” into making it happen through the MED 2010 initiative.
During the next two years, the medical school will add about $1.5 million to its Office of Medical Education budget to implement changes associated with the initiative, Powell says. That’s an increase of about 20 percent over the current budget for education infrastructure. The funds will be used to hire additional staff and to compensate faculty for time spent on the project and away from other duties.
“That’s a huge investment,” says David Stevens, M.D., vice president of the Association of American Medical Colleges and the head of its Institute for Improving Clinical Care. “To be able to spin off enough [funding] to do this is pretty impressive.”
Creating a Vision
As of June, Powell and her colleagues at the medical school will have already invested a year and a half of effort in the MED 2010 initiative. They started with a “visioning process” aimed at generating out-of-the-box ideas about changes needed in medical education and convened a series of “visioning retreats” where participants were asked to consider what an overhaul of medical education might look like. More than 130 participants, including faculty, staff, and students from the medical school, representatives from other parts of the university such as the law school and the College of Liberal Arts, community leaders, and national leaders in medical education took part in these discussions. Powell says she asked the group, “Basically, if we tear apart the current system by which we educate doctors, how would we create a new one?”
Out of that process emerged the vision that now guides the MED 2010 initiative: to develop “learner-centered education for patient-centered care.”
That vision is based on a shared recognition that today’s medical school graduates are entering a complex and rapidly changing health care environment that requires a different sort of knowledge, skills, and capabilities than were needed in the past, says James Pacala, M.D., a medical school faculty member who took part in the discussions. “The U is recognizing that medical care has changed and the traditional methods for training doctors aren’t adequate to prepare our physicians for practicing in the 21st century,” says Pacala, who directs the school’s Physician and Society course for first-year students.
He says students still need to learn the basic and clinical science that is at the core of medical education—“we’re not going to stop teaching anatomy and biochemistry.” But the traditional content taught in medical school, and the traditional methods of teaching, are no longer sufficient, he says. Medical care has changed dramatically, and medical education has to catch up.
One of the most significant changes in medicine has been the explosion of information. It used to be that doctors could memorize almost everything they needed to know—a task that’s no longer possible. Now, doctors need to know how to acquire and interpret information as they need it, and not just to memorize facts, Pacala says. That requires learning effective ways to use technology such as Palm Pilots and laptop computers in a clinical setting.
Another major change in medical care has been the increased importance of teamwork. Working in interdisciplinary teams has become virtually mandatory for physicians, says Pacala. “So we have to nurture those teamwork abilities, which involves more small-group teaching, group projects, and interdisciplinary teaching.”
Today’s medical students also need to be competent in a variety of other areas if they are to provide care that is truly “patient-centered.” For example, students need to be taught and evaluated on their ability to work through the cultural dimensions of a medical case, Pacala says. This involves understanding how cultural traditions and beliefs might affect a patient’s willingness to take certain drugs or his or her acceptance of treatment. They also need to understand the ethical dimensions of a case.
In addition, students are entering a much more complex system of medical care and insurance than their predecessors a generation ago. Today, doctors don’t just need to know about prescribing drugs, they need to understand drug formularies, the cost of a brand-name drug versus a generic, and how Medicare Part D works. “Those things are every bit as core to medical education these days as knowing anatomy,” Pacala says.
Moving Toward Competency
But the challenge of the MED 2010 initiative is to figure out how to teach those things and how to assess whether students have learned them.
Powell says she hopes to move the medical school from a one-size-fits-all curriculum to a system of teaching and evaluating students based on the concept of “competency.”
That requires tailoring the curriculum to the student, for a start. Currently, all medical students at the University of Minnesota take the same courses, regardless of the particular knowledge or expertise they bring with them to medical school. So, for example, students who already have a master’s degree in biochemistry have to sit through the same course on biochemistry as their peers, even if they’ve already mastered the content.
That’s not a good use of their time, Powell says. If students can demonstrate the required level of competency in certain subjects such as biochemistry, they should be allowed to move on to other courses such as an advanced course on the biochemistry of metabolic syndrome or diabetes.
Alternatively, students should be allowed to go slower if they need additional time to get through a subject. “Students come to us with all sorts of different abilities, so we have to devise a system where we can assess those abilities when they come to school and move people through at different rates, based on their achievement of certain competencies,” Powell explains. “Everybody is going to be treated more as an individual.”
Another goal of a competency-based system is to ensure that the medical school is, in fact, teaching students to become good physicians. That’s not as easy as it sounds.
Assessing competency is a subject of great debate these days, not just at the undergraduate level but also among residency programs and certifying boards. The Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs, has been very active during the past few years in moving residency programs toward competency-based assessments. The ACGME has identified six competencies that all physicians should have, regardless of specialty, and is planning to require that programs assess their residents on them: medical knowledge, professionalism, the ability to communicate, medical care, practice-based learning and improvement, and knowledge of how to practice within a health system. Some certifying boards have also begun integrating competency-based assessments into the recertification process.
“A century ago, the task of the medical profession was to move from ‘quacks’ to qualified physicians,” explains David Leach, M.D., the ACGME’s executive director. “This movement is designed to get us from the concept of a qualified physician to a competent physician.”
Powell says she wants to bring that movement to undergraduate medical education. “If this is what is going to be expected of practicing physicians, then we should start in medical school,” she says.
A New Kind of Yardstick
Traditionally, medical schools have relied heavily on cognitive exams such as multiple-choice tests to assess students’ knowledge. But those kinds of exams, although still important, are no longer adequate for determining whether students are developing into competent physicians, Powell says. “I absolutely believe that we have to be willing to look at different ways of evaluating.”
To do that, Powell has tapped Linda Perkowski, Ph.D., the medical school’s associate dean for curriculum and evaluation, and Kathleen Brooks, M.D., assistant dean for continuing medical education, to co-chair a work group, established this spring, that is looking at making changes in how medical students are taught and evaluated.
“We set 2010 as a goal to have an educational program that’s very different from what it is now,” says Perkowski, a clinical psychologist with 30 years of experience in evaluations and assessments at medical schools. “The gist of it is that we want our students to know what they need to know,” she says. “That’s very simplistic, but it’s a challenge with a complex and changing profession like medicine.”
One of the issues the group may explore is how the medical school could make greater use of standardized patients, both in teaching and assessment, Perkowski says. “We want to look at, are students empathic? Do they know how to take a history? Are the students able to provide patient education?”
Standardized patients—actors who pose as patients in a simulated environment—are a valuable tool for teaching students to work through clinical problems and for evaluating skills that cannot be assessed on a multiple-choice test, says Perkowski, who has pioneered using standardized patients in medical schools.
Just having the cognitive skills is not sufficient for a career in medicine, she says. “You also have to be able to look that patient in the eye and talk to them.”
Getting students to that point, of course, is the purpose of all the changes underway at the medical school.
Powell, who is in her fourth year as dean, admits it will not be easy and will take significant resources over the next several years. But she is clearly committed to the effort, saying simply: “We need to do it, so we’re going to do it.”
For Armitage, who will finish medical school by the time all of the planned changes are implemented, this is an exciting period to be at the University of Minnesota. He says MED 2010 is moving the medical school in a positive direction, even if the end point remains unclear. “I think the essence of MED 2010 is to challenge both faculty and students to approach education differently so that the end goal is becoming a better physician.” MM
Amy Snow Landa is a freelance writer in St. Paul.