Commentary
Reshaping Physician Education
Fragmented care delivery is the product of an outdated approach to medical education.
By Frank B. Cerra, M.D.
Mr. Jones is an elderly male with insulin-dependent diabetes, coronary artery disease, and metastatic colon cancer that has responded poorly to chemotherapy. He sees different doctors for these conditions, and he takes multiple medications. He does not understand what each of the drugs does. When Mr. Jones experiences side effects, he isn’t sure who to call—one of his doctors, the doctor’s nurse, or the pharmacist. When he does reach one of the prescribing doctors, he is not sure which medication the doctor is talking about and what is being recommended regarding dosing. Because he is being seen at multiple clinics, tests are often repeated. His specialists do not communicate with each other or with his primary care physician. When he does see his primary care physician, his visit lasts only nine minutes—not nearly long enough to really address his problems and concerns. Mr. Jones is progressively becoming unable to take care of himself, and his caretaker is his elderly wife. They do not understand his health insurance plan and whether he qualifies for in-home care.
The fragmented care delivery portrayed in this story is, unfortunately, a byproduct of our medical education system. For decades, medical schools emphasized science and taught students that their primary duties as a physician were to make a differential diagnosis and decisions about medical care. The result was that doctors were prepared to function in a physician-centric system, where they were to pay attention to the patient’s most-pressing medical problems and not worry about his or her other struggles within a complex health care system.
This approach to medical education may have been appropriate for simpler times. But it’s not for today. A knowledge explosion that spawned a spate of specialties and specialists and a payer system made up of a web of public and private insurers has made health care so complex that patients need more than just someone to make an initial diagnosis and write a prescription. In addition, society’s expectations of physicians have broadened. Today, we want physicians to be good communicators, to be culturally competent, and to take a more holistic approach to health. As a result, there is a gap between what medical schools teach and what doctors need to know in order to practice medicine. The problems we have with patient safety are one manifestation of this gap.
That gap began to widen during the era of managed care, when we began to see medical school graduates who had medical knowledge and skills but did not necessarily know how to do the things HMOs were requiring them to do: to hand off care to colleagues, offer preventive care, or think about lowering costs and improving quality. Over time, as the emphasis on access, quality, and cost shifted to a focus on the Institute of Medicine’s Triple Aim of enhancing the patient experience, improving the health of the population, and reducing or containing the cost of care, the gap became even more evident. In addition, patients began demanding more from their doctor. They started to expect their physician to be their partner in helping them achieve and maintain good health, to be available to address their concerns and answer their questions, to focus on what is right for them, and to not be influenced by insurers and other outside forces. These changes have prompted those of us who are leading medical schools to realize that health care delivery and medical education need to coalesce so that what is being taught reflects what’s happening in medical practice.
In 2005, we began reshaping the educational experience at the University of Minnesota to better reflect the changes in practice. As a first step, we discussed what medical students needed to know to practice. We identified seven domains of competence for our graduates: medical knowledge, clinical and patient care skills, scientific and clinical inquiry, professionalism, interpersonal and communication skills, systems of health care, and continuous improvement of care through reflective practice. We also identified the specific competencies that must be achieved in each domain. For example, in order to be able to acquire and appropriately apply clinical skills, students must spend time in hospitals and clinics learning about patient care as well as the influence of culture on patient behaviors, the importance of using evidence, being a member of an interprofessional team, the ethical dilemmas physicians face, patient safety concerns, and the role of technology in health care.
Taking into account these newly defined competencies, the faculty, through the Education Policy Committee, identified attributes that would distinguish graduates of the University of Minnesota Medical School from graduates of other institutions. They called for them to be professional, ethical, and curious, and to approach clinical problems in a way that is patient- centered and informed by literature. They noted that graduates should be thoughtful practitioners who are willing to assess and improve their practices through lifelong learning. In addition, they wanted to see the university graduate compassionate individuals who are dedicated to providing the best possible care to their patients and also to fulfilling their responsibility to society as a whole.
We designed our curriculum around these goals. Work toward achieving them starts in the first year of medical school, when we emphasize professionalism during the White Coat Ceremony and through clinical experiences in a variety of inpatient and outpatient and culturally diverse settings such as the Phillips Neighborhood Clinic and the Community-University Health Care Center. It continues as students take self-directed online courses, participate in simulations, and take part in small-group discussions of cases with their mentors. In all, our emphasis is on helping them solve more that just medical problems. For example, we try to show them that helping a patient understand how to take a medication is as important as prescribing it.
Basic and clinical sciences are integrated into the curriculum across all four years of medical school rather than just the first two. More clinical experiences occur in interprofessional settings and involve other health professionals such as nurse clinicians and clinical pharmacists. And each student has an advisor who assists in and monitors their professional development.
The extent to which students attain competency in the seven domains will be assessed through mentor evaluations, performance in real and simulated clinical settings, and examinations. If a student is found to be deficient in a particular area, he or she will have another opportunity to master the needed skills. In addition, new content is being added to the curriculum on topics such as health systems, quality improvement, informatics, population health, care navigation, and the generation and use of evidence in decision-making. New educational approaches are also being used. These include having students do exercises that require creative problem solving and that promote interprofessional teamwork, and classes that are taught both online and in the classroom.
The major challenge in reshaping medical education, however, is cultural. Because so much of medical training occurs during clinical rotations, changing medical education requires changing the culture of medicine itself. Medical education spans seven to 10 years. Yet only a small portion takes place in the classroom. The rest occurs in hospitals and clinics in the community. Thus, for medical education to change, medicine itself must change. And for medicine to change, physicians constantly need to be learning themselves so they can adapt to the evolving circumstances of practice. We need to place our students at clinical sites where they can witness physicians working in teams, taking a patient-centered approach to care, using technology in the most efficient and appropriate way, and improving processes and outcomes. We need to place them in clinics and hospitals where health improvement and prevention are regular topics of conversation, care innovation and leadership are evident, and cost-effective care is practiced. We need them to see firsthand how a patient such as Mr. Jones would be cared for not only by a physician but also by a nurse practitioner and clinical pharmacist who would keep him functioning as best as possible by regularly meeting to discuss his care plan and progress, making appropriate revisions to his medication regimen, communicating with his other physicians, helping him connect with outside support such as home health services, and keeping in touch with him by email.
Changing medical education is a huge undertaking requiring more than what a few of us in academic medicine can do. It requires hard work on the part of all physicians and all health professionals. To make it happen, physicians need to be dedicated to improving their skills, to adding to the knowledge they gained while in medical school, and to adapting to a health care environment that will inevitably change throughout their careers. MM
Frank Cerra is senior vice president for health sciences and dean of the medical school at the University of Minnesota. He also holds a McKnight Presidential Leadership Chair.