The future of Medical School is — almost — here.
Over my career in healthcare I have realized that as much as my clinical work had an evidence basis, how about my management practice? Do we in the healthcare "practice of management" approach our work through a basis in evidence?
Thus began my interest in teaching in both healthcare management and work within the context of learning. Technology is having a dramatic effect on healthcare teaching and service delivery...
More and more, technology is shaping what medical
schools teach, how professors teach it and how students learn.
"There are not a lot of microscopes
anymore," laughed Morgan Passiment, director of healthcare affairs for the
Association of American Medical Colleges. Cadavers could soon be on their way
out too, in favor of virtual anatomy. Instead, schools are beginning to
incorporate EHRs, simulation, data analytics and new instructional approaches
inspired by mHealth and telemedicine.
Medical school students now need to learn more
technology-based skills, which require new settings and strategies that break
from the traditional lecture hall environment. The challenge medical schools
face is in preparing students for roles that continue to shift as care models
and technologies change.
"This is a new era for medical education and it
parallels the changes that are happening in our healthcare delivery
system," says Marc Triola, MD, associate dean of educational informatics
and the director of the Institute for Innovations in Medical Education at NYU
School of Medicine.
But curriculum evolves slowly, Ms. Passiment says.
Changes are typically reviewed and formalized every eight to 10 years.
"We knew there was a consensus out there for what
had to change, but it wasn't happening," says Susan Skochelak, MD, AMA
vice president of medical education and director of the AMA Center for
Transforming Medical Education.
That's why the AMA decided in 2013 to launch its
Accelerating Change in Medical Education Program, which awarded $11 million in
grant funding to 11 medical schools. When the AMA put out a request for
applications, nearly 85 percent of American medical schools responded,
according to Dr. Skochelak.
"People want to teach IT, but they don't have the
resources or don't know how to teach it," she says.
The 11 chosen schools were tasked to form a consortium
and develop new curricula and learning strategies to share with other
institutions around the country. Through 2018, the 11 selected universities,
including Indiana University School of Medicine, NYU School of Medicine and
Vanderbilt University School of Medicine, will be in the implementation stages
of their individual curriculum projects.
The AMA's program isn't the only initiative focused on
updating medical school curriculum. The ONC sponsors a Curriculum Development
Centers Program, for example, which has awarded schools like Oregon Health and
Science University with $2.7 million to overhaul curriculum and include new
emphases, like EHRs.
While there is still not consistent integration of
health IT across medical schools, pockets are diving into technology-based
curricula, according to Ms. Passiment.
"The challenge we have right now is helping our
learners understand the role technology can play in healthcare, and focusing on
care outcomes, not on technology. Technology is a tool," says Ms.
Passiment.
The disappearing paper trail
Just as hospitals strive to integrate EHRs as a tool
for improved patient care, many medical schools still grapple with how to best
integrate EHRs into curriculum, Dr. Skochelak says. Some universities continue
to teach old-school paper record-keeping first, while others debate the use of
templates. Meanwhile, at the residency level, students are missing the
opportunity to use EHRs due to lack of training or HIPAA restrictions, she
says.
"The challenge for educators at the beginning
level and at the medical school level is we don't know the methods or the
pedagogy that work best," says Dr. Skochelak.
IU School of Medicine, based in Indianapolis, is
working to develop better methods and pedagogy to incorporate the EHR in a
learning environment. It received a $1 million Accelerating Change in Medical
Education grant from the AMA for its proposal to develop a virtual health
system and teaching EHR, which would let future physicians practice clinical
decision making in a realistic environment.
"I want our medical students to understand this.
If I just put them in a lecture hall and talk at them, they won't get it,"
says Sara Jo Grethlein, MD, associate dean for undergraduate medical education
and professor of clinical medicine in the division of hematology and oncology
at IU School of Medicine.
"It's not just about [the students]; they have a
place in a big, complex system, and they need to learn how to function and how
they are assessed in that system, so they can thrive in that system," she
says.
IU worked with the Indianapolis-based Regenstrief
Insitute, an informatics research organization, and with the support of
Eskenazi Hospital in Indianapolis it launched a fully functional teaching
version of its EHR a year into the implementation stages of the grant. The tEHR
uses real, carefully de-identified patient data from roughly 10,000 patient
charts, down to the written notes.
The tEHR stands alone, unconnected to the hospital
system, so students are free to write in orders and notes in a simulated
environment where it can't hurt anybody, Dr. Grethlein says.
Second-year students at IU will soon start using the
tEHR. They will receive 12 sessions across the year learning about
systems-based practice and big data, according to Dr. Grethlein.
Now officials are developing activity-based
assignments for third-year students to incorporate into their rotation
schedules. For example, students could be assigned a hypothetical patient in
the tEHR with cholecystitis, or a "hot gallbladder", who received
gallbladder surgery. The student will then be asked to go into the tEHR, look
at the labs and imaging tests performed during the patient stay and justify
each of them, Dr. Grethlein says. If they cannot do so, she says, they must
find out how much money was wasted on unnecessary tests.
The ideas behind the tEHR are not entirely new — Dr.
Grethlein says she used to have students write down tests that weren't
justified on index cards — but, "it's just a slicker, higher-tech way of
doing the same thing."
The most important part is showing students how to use
the EHR as a tool to better understand their role in providing care.
"It's not just how you put in notes or orders,
it's how you use it as a tool to answer clinical questions and design
intervention," says Dr. Skochelak.
Getting a hold of big data
To use EHRs as a tool, it is increasingly important
for physicians to understand how to make data from EHRs and other sources
actionable at the point of care.
"The analytics piece, just like the EHR, becomes
the tool and mechanism to provide care. Many schools are headed in this
direction, however, I don't believe it is consistent across medical
education," says Ms. Passiment with the AAMC.
Clinical informatics became a certified subspecialty
only a few years ago, in September 2011. It emphasizes data management to help
improve how providers, patients and trainees use the information to improve
overall health.
"There is a real challenge in getting people to
fill the applied analytics positions in healthcare because you have to have
some understanding and background in healthcare as well as analytics,"
says Ms. Passiment. Giving all future physicians some training in the data
analytics portion of informatics could help address this challenge.
NYU School of Medicine, which also received
Accelerating Change in Medical Education funding, is working to add data
analytics into its traditional doctoring course, called "Practice of
Medicine."
"NYU is using big data," says Dr. Skochelak
with the AMA. "And I mean big data."
Big as in 5 million de-identified patient records. NYU
students are learning to approach big clinical data sets and analyze them to
measure providers' performance. They're challenged to think critically about
healthcare and ask their own questions of the data, which is compiled from a
publically available database called SPARCS, or the Statewide Planning and
Research Cooperative System. Launched in 1979, the New York State database
houses hospital admission and discharge information, patient diagnoses, treatments
and charges, and outpatient services information. NYU combined this with CDC
nutrition surveys and NYU Langone Medical Center's own patient data, providing
students with access to millions of de-identified records.
The big data then becomes a learning tool. For
example, in a pilot class NYU launched last summer, students were asked,
"What do you think is the most likely reason a person is hospitalized in
the state of New York?"
Most guessed chest pain or pneumonia, Dr. Skochelak
says. They were surprised to learn the number one reason for hospitalization in
New York is actually childbirth. They were even more surprised when they saw
the fluctuation in cost for this service across the state. Delivering a baby
costs $2,000 to $3,000 in rural areas, but up to $22,000 in Manhattan, Dr.
Skochelak says. Students are challenged to think about why this discrepancy
exists and track their own patient and population management activities and
queries.
"What our students love most about this is the
fact that it's real," says Dr. Triola. "It's not a textbook exercise;
it's real clinical data. It's the environment students will be training in and
potentially working in."
By October 2014, administrators were so impressed by
the pilot they wanted the whole class to have the lesson, Dr. Skochelak says.
It is now a core part of the medical curriculum and the entire first year class
has taken the course, entitled "Healthcare by the Numbers."
Adding data analytics to the curriculum helps move NYU
toward competency-based education, Dr. Triola says. It helps students acquire
the tools they need to continue to learn throughout their careers. So, even
though medical students are now tackling data analytics and other IT skills in
addition to anatomy and biochemistry, Dr. Triola doesn't believe medical school
needs to be longer.
"What I do think we need to do is begin using
some of these technologies to make medical education more of a continuum,"
he says.
Applying IT to learning processes
Nashville-based Vanderbilt University School of
Medicine did just that, by not only incorporating technology into what
professors teach, but also into how students learn.
Vanderbilt calls it Curriculum 2.0.
The new curriculum applies not only to clinical outcomes
or patient records, but to students and their learning trajectories. It
documents achievements, competencies, faculty ratings and assessments in a
portfolio for each student. It is also populated with hospital notes students
enter in the EMR during their clerkships, automatically capturing their panel
of patients, so they can use it as a teaching space.
Vanderbilt provides each student with a portfolio
coach, who they keep throughout their time in school. Students are scheduled to
periodically meet with their coaches to talk about their progress and
performance.
"It allows us to ask students, 'How can we help
you be the very best that you can be?' For high performers, we can ask, 'Given
where you are, what else can you do?'" says Kim Lomis, MD, associate dean
of undergraduate medical education and associate professor of surgery at
Vanderbilt.
The advantage of this system is that it allows
students to progress through medical school in a flexible way, Dr. Skochelak
notes. Students advance through competencies based on performance, rather than
time. This works well for some students who may need more — or less — time in
medical school. Physical therapists who decide to go back to medical school,
for example, could potentially acquire all the necessary competencies in a time
frame shorter than the traditional four-year period, she says.
More importantly, it helps ensure students are
building skills like communication, skills that could potentially fall through
the cracks in a lecture hall-structured, knowledge-based curriculum, according
to Dr. Lomis.
"It's very much in the spirit of patient safety.
It's making sure people are prepared for the roles they're going into,"
she says.
Vanderbilt's Curriculum 2.0 is more focused on
team-based, active learning and puts students into the workplace sooner, Dr.
Lomis says. Instead of the traditional two years of basic science, students go
into clinics in their second year and the school weaves the remaining science
courses through all four years.
"The new curriculum is not only focusing on
content, but also on teaching students how they will learn throughout their
whole career," she says.
* * *
Technology and technology-based learning strategies
are helping medical schools like IU, NYU and Vanderbilt shift into collaborative,
interactive learning environments, which may be better suited for a new
generation of physicians.
"Students are used to a much more networked,
engaged sharing environment and healthcare is not yet like that," says Ms.
Passiment. "It's a much more structured tech environment. It's clunky for
a lot of learners. It's challenged them to create their own workaround, which
allows us to see what the next generation of care will look like."
Best,
Don
