Teaching the next generation of physicians

As a 40-year-old former driver for Meals on Wheels, Brooke Wagen is not a typical medical school student. While her classmates in their 20s might be occupied with settling into their first year of studies and debating which specialty to enter, Wagen already has a concrete vision of how she’ll use her medical education: addressing the health needs of a state-run housing complex for elderly and disabled residents.

1117_TRU_med-schools_300x201Dell Medical School at the University of Texas at Austin may be just the place to help her realize that goal. Wagen is one of 50 students in the first class at UT Dell (see photo, left). “I’m going to take steps to solve the problem,” she says. “I’m going to make this something that can be scalable, fundable, money-saving and health-improving. I’m excited to get to put my mind up against such a big problem.”

UT Dell is one of a handful of new medical schools designed to equip physicians to thrive in a health care system focused on population health and the transition from volume- to value-based care. Its ambition to train MDs to handle 21st-century health care is part of a larger trend in medical education that stresses value-based care and the health concerns of communities.

Trustee talking points

  • The fundamental structure of medical school hasn’t changed since the Flexner Report was published in 1910, establishing two years of basic science and two years of clinical experience for medical students.
  • A changing health care landscape that seeks to move from a volume- to a value-based system relies on skills such as population health, interdisciplinary teams and primary care.
  • Major medical schools are being built from the ground up to incorporate the new skills physicians need for the future of care, and established medical schools are revamping their curricula to incorporate these changes.

UT Dell owes its existence to the residents of Travis County, who — somewhat remarkably — voted in 2012 to increase their property taxes to create a medical school that would maintain a community-focused mission and improve care in the county.

“There are major systems problems in health care and, unless we train people on how to deal with these issues, we’re not going to move the system forward,” says Clay Johnston, M.D., Dell’s inaugural dean. “Future-focused systems really need to say, ‘We care about the people, and our goal is to keep them out of our clinics and hospitals — which means we need to create the programs to do that.’ ... We’re really pushing for an ideal future, and thinking about what our students need to learn in order to achieve that.”

Supporting article: Rewriting the medical school curriculum

Like a number of other colleges across the nation, Dell is upending the traditional medical school curriculum, which involves two years of basic sciences and two years of clinical experience. That’s been replaced with what school leaders call its Leading EDGE (Essentials, Delivery, Growth and Exploration) four-year curriculum. For starters, classroom-based, preclinical learning is compressed into one year instead of two, and students are placed on teams to prepare them for interdisciplinary collaboration long before residency.

In the second year, students begin 40-week immersive clinical clerkships. Early exposure to patients is a foundational change that schools, both new and old, are beginning to adopt. Dell’s third year includes a unique feature, the “Innovation, Discovery and Leadership” block. It offers students the option of pursuing a dual degree. In addition to the medical degree, students can obtain a master's in any of the following: public health, business administration, biomedical engineering and educational psychology, or they can pursue an independent discovery project in one of three areas: health care innovation and design, population health and clinical/translational research.

Value-based thinking is laced throughout Dell’s curriculum. For example, clerkships allow students to follow the same cohort of patients from admission to post-discharge. Using the traditional SOAP (Subjective, Objective, Assessment, Plan) method for making notes in patient charts, students incorporate value and safety recommendations as part of their routine.

For example, a student may suggest using an effective, low-cost drug alternative to a costlier drug that was prescribed in the patient chart. Students also are required to make at least one safety recommendation, say, assigning assistance for a weak patient when getting out of bed.

Value culture

Dell Med’s Value Institute for Health and Care guides outcome and cost-measurement efforts for the school’s clinical services. But one of its core objectives is to create a shift in the way future physicians think about value.

In particular, Dell emphasizes thinking about value in terms of patient outcomes, says Elizabeth Teisberg, executive director of the institute and a professor of medical education at Dell. “If you can get people thinking about value as improving outcomes in ways that improve health in your patient population and community, and use [those improvements] to drive down costs, that’s a big service. It’s a culturally different mindset about what we’re trying to do, both in terms of education and also clinical practice.” Teisberg co-authored the 2006 book Redefining Health Care: Creating Value-Based Competition on Results, an influential work in the value-based movement.

For Dell students, says Scott Wallace, managing director at the institute and associate professor at Dell, that translates into asking the big questions: What does it mean to think about a segment of patients? How do you define and identify groups with shared needs? And how do you design a program that meets those needs?

Supporting article: Academic leaders are valuable resources to hospitals

An integrated approach

Kaiser Permanente, with its longtime commitment to patient-centered care, is slated to open its Kaiser Permanente School of Medicine in fall 2019 to an initial class of 48 students.

“Our whole design model is based upon taking a medical school and embedding it into our system of care,” says Marc Klau, M.D., vice dean of education and clinical education. The school was designed so that Kaiser Permanente’s integrated system, which delivers on the Triple Aim, becomes the primary learning tool, says Klau.

The first class of students will be assigned to study groups and will work with care teams within Kaiser’s system. They’ll also work in the surrounding communities, including in safety net clinics outside of the Kaiser Permanente system that primarily serve the uninsured and those on Medicaid.

Students will receive the same report cards as Kaiser’s physicians. Professors and students will be able to see who they cared for, how they did and what patients thought of the care. The hope is that these data can be used to customize students’ learning plans and prepare them for the type of feedback and analytics they’ll encounter in clinical practice.

 “As the student is embedded in our system of care, they will learn it, they will see it, they will know how to do it,” Klau says.

Community-based curriculum in Nevada

Before the curriculum was formulated for the new University of Nevada, Las Vegas School of Medicine, founding Dean Barbara Atkinson, M.D., spent six months meeting with local individuals and organizations. Physicians, hospitals, businesses and community leaders, among others, all shared what they thought the community needed the most. What she learned informed the principles of the new medical school.

The first class of 60 students began studies July 17. As their first order of business, in addition to receiving emergency medical technician training, students were assigned specific neighborhoods to survey, where they identified the social determinants of health. Students are expected to visit the areas one day every week to evaluate educational opportunities, graduation rates, health care access and the availability of healthful food, and then make suggestions for improvements.

Supporting article: Pioneering population health in medical education

UNLV’s medical students will be required to perform 400 hours of community service over the course of their four years of training to strengthen their understanding of and connection with the residents.

A rural perspective

In August, Washington State University’s new Elson S. Floyd College of Medicine welcomed its first 60 students. With about 10.4 doctors per 100,000 residents in the state, the college has focused its curriculum on rural communities and underserved urban areas, says John Tomkowiak, M.D., founding dean.

One of the foundational goals of the school is to give students a deep grounding in medical technology so they are ready for the many ways it is likely to evolve.

“Part of the art of educating health care professionals for tomorrow’s practice is how we introduce them to the technologies they’re likely to be using not only five or 10 years from now, but what the landscape will look like 20 or 30 years from now, and how we prepare them to be adaptive and flexible,” says Tomkowiak.

The medical college's technology incubator will enable students to collaborate with medical technology startups to design solutions to the problems plaguing underserved populations in the state. As of July, there were more than 100 possible candidates looking to partner with the school. Final decisions will be made in January.

A feature of the incubator will be the yearly “Hackathon” hosted by the college of medicine. First-year students will form interprofessional teams of six to eight from across areas of the university. Together, they will develop solutions to rural and underserved community health issues and compete to get their solutions funded.

Supporting that approach is a Task Force on Ensuring Access in Vulnerable Communities report published by the American Hospital Association in February that spotlights virtual care approaches and identifies the social determinants of health as two of nine emerging strategies to ensure access to health care services in vulnerable communities, both rural and urban.

Financing a new medical school

Opening a new medical school takes more than a fresh curriculum and a value-based approach — it also requires immense financial support.

A voter-approved tax hike like the countywide one for Dell Medical School at the University of Texas at Austin is rare. More common is state capital funding such as that received by the University of Nevada, Las Vegas and Washington State University, largely because the schools’ focus on addressing community primary care needs was identified as “mission critical” for those states as a whole, says Eva Bogaty, vice president and senior credit officer, Moody’s Investors Service Inc., who does the credit ratings for both UNLV and WSU. “I doubt either would have gotten off the ground without state funding,” she says.

In addition to new schools that graduate physicians, 13 new osteopathic medical schools have opened since 2002-03.

Trustee takeaways

In the past, hospitals and health care systems might have paid scant attention to what was happening in medical schools. But these days, with renewed focus on population health and improving the continuum of care, it is more important for hospital leaders to work hand in hand with academic leaders, says Ryan Leslie, vice president of academics and research at Dell Seton Medical Center at the Univesity of Texas, the new teaching hospital for Dell medical students. “These changes are so big, they can’t be done in a single year — it takes a lot.”

Past literature suggests just 1 in 5 doctors has training in the social determinants of health, notes Jay Bhatt, D.O., chief medical officer of the American Hospital Association and president and CEO of the AHA’s Health Research & Educational Trust. And while hospitals are teaching physicians to work better with community partners, more training is needed. “Hospitals and health systems can really be a living lab in terms of being able to test approaches,” Bhatt says.

The AHA’s Physician Leadership Forum is expanding educational tools to help doctors develop and improve leadership and management skills. Its Physician Inclusion agenda will focus on strategies for leadership, resilience and well-being, and improving delivery of high-value care and managing populations. For more information, visit www.ahaphysicianforum.org.