After more than 40 years of stasis and stability, US medical schools are entering a period of transformation. A growing awareness that young doctors are coming out of training unprepared to meet the needs of 21st-century patients and communities has forced a profound rethinking of how people are taught to practice medicine.
This transformation is taking a variety of forms: Medical schools are changing curricula, instructional methodologies, and how they recruit students. And in some cases, new medical schools are being created from scratch both to address the perceived failings of the current educational framework and to replenish the ranks of primary care physicians, who are in short supply across the country.
Kaiser Permanente, the venerable Oakland-based integrated health plan and delivery system, has chosen to address these challenges by building its own medical school in Pasadena. It will admit 48 students to its first class in 2019.
"We think students could be embedded in a system of health care delivery as their educational home. That is the fundamental concept of the Kaiser Permanente School of Medicine," said Christine Cassel, MD, the newly appointed planning dean for the school. Because of that, the new medical school will not affiliate with an existing university. "We will become a degree-granting institution ourselves. It's one extra step, but we think it's worth it because of this unique model."
Cassel spoke as part of an April 9 panel on "reinventing medical education" at the annual conference of the Association of Health Care Journalists in Cleveland, Ohio.
Training students in systems of health care delivery is quite a switch from how medical students have been educated until very recently, said panelist Nathan Moore, MD, a 2009 graduate of the Washington University School of Medicine in St. Louis and coauthor of The Health Care Handbook.
Medical school hasn't changed much since 1965, he said. There is too heavy an emphasis on basic sciences and on memorizing biochemistry or genetics, with multiple-choice tests at the end of the second and fourth years — "various things that are useful but not that handy in the day-to-day practice of medicine."
He recalls "sitting there being lectured at for hours on end, as opposed to applying critical thinking or teamwork" — which he thinks doctors really need. Among medical students, depression rates and burnout are high. Among practicing physicians, burnout is so pervasive that two-thirds of them say they would not recommend medical school for their children.
The "sage-on-the-stage" tradition of medical training saps inquisitive students of their initiative and desire to learn, said Pamela B. Davis, MD, PhD, dean of Case Western Reserve University School of Medicine in Cleveland. "We got 'em for four years. The public's got 'em for 40 years. We need to teach them to think."
Current physician training doesn't prepare med students for skills that will be essential in the rapidly evolving health care landscape, said Jesse M. Ehrenfeld, MD, an associate professor of anesthesiology, surgery, biomedical informatics, and health policy at Vanderbilt University School of Medicine in Nashville, Tennessee. Those include leading teams of health care professionals, being good stewards of resources, and focusing on improving population health rather than just an individual's health.
"While technology is transforming health care, the vast majority of students are not being taught how to use electronic health records or telehealth platforms in medical school," he said.
The revamp of medical education has been given extra impetus by the American Medical Association (AMA), which elevated the modernization of physician training to one of its top three strategic initiatives. Starting in 2013, the AMA committed $11 million to a series of demonstration projects at 11 medical schools, including Vanderbilt — $1 million to each program — to develop new curricula and styles of learning that could be disseminated more widely if they were shown to work.
The University of California medical schools at San Francisco and Davis are members of the original consortium. The UCSF Bridges program is geared toward improving population-based health outcomes. The Davis program, linked to the Kaiser Permanente Northern California division, emphasizes medically underserved populations, workforce diversity, and workforce gaps.
American Medical Association Expands Medical Education Initiative
In 2015 the AMA expanded the initiative to include another 21 medical schools, among them Case Western.
Ehrenfeld is both the co-investigator at Vanderbilt's "Curriculum 2.0" program and an AMA trustee. The goals of the AMA program include competency-based assessment and flexible individualized learning plans, exemplary methods to achieve patient safety, performance improvement, patient-centered team care, and an understanding of the health care system and financing.
At Vanderbilt, Ehrenfeld said, the goal is to create "master adaptive learners," defined as physicians who will learn, engage in guided self-assessment, and adapt throughout their careers to the evolving needs of their patients and the health care system.
Vanderbilt's new curriculum lets students advance based on personal competency. If they can place out of coursework, they can move along faster and possibly graduate in less than four years. Students who are not deemed to pass the competency thresholds will get more time and instruction until demonstrating mastery of the material.
AMA grants also support Indiana University's "teaching Electronic Medical Record" (tEMR), where students work on digitized patient charts from the beginning and see the costs of the treatments they order, and Penn State's "Patient Navigator," which embeds med students as patient navigators at clinical sites across central Pennsylvania.
Adopting the "Inquiry Group" Model
The Penn State approach has been adapted in part at Case Western. "What's the point of pouring in factual knowledge?" Davis said at the panel discussion. "We moved to an inquiry group model. Medical students have to be able to access information and winnow it to what is the useful information. They need to be able to process it."
Case Western is constructing a building to house the schools of medicine, nursing, and allied health professions so graduates become accustomed to solving problems as teams across the care continuum.
"We are very much at the early stages of this," said Cassel, speaking of both the Kaiser Permanente school as well as the overall reform of medical education. More than most insurers or delivery systems, KP understands the social determinants of health and the importance of creating healthier communities, she said.
"We'll be training clinicians in this environment," Cassel said. "Some of those students may decide to stay in KP, but we are explicitly going to be teaching change agent, management, and leadership skills. We want these students to be able to go wherever they want to go to practice and help accelerate these kinds of health system changes."