The new basic training for next gen physicians

Last summer, Peter Nauka, 23, a first-year medical student at New York's Hofstra University's Northwell School of Medicine, was on his second night as an EMT assistant when his ambulance received its first serious medical call. Someone needed immediate help in Queens.

“How real everything is about to become,” Nauka recalled thinking as the vehicle sped along city streets, its emergency lights spinning and sirens blaring. “I was going to be expected to play a very real and vital role in patient care.”

When they arrived at the scene, the EMT, Nauka and another first-year medical student ran into the house and placed the patient—unconscious and without a pulse—onto a stretcher. At first, Nauka watched the paramedic and the other first-year apply ventilation and chest compression. After a few minutes, it was his turn.

“I was not even really thinking at this point. I just became very automatic in my task,” Nauka said. “I do remember trying not to look at the patient's face.”

Once at the hospital, the staff took over and rushed the patient into the intensive-care unit. “I was absolutely drenched in sweat at this point,” Nauka said. “I sincerely hope that they ended up surviving.”

Hofstra's decision to immerse first-year students like Nauka into the nitty-gritty of day-to-day medical care is part of a growing movement among U.S. medical schools to train the next generation of physicians in ways that will allow them to adapt quickly to changing delivery-system models. High on the list of skills the programs seek to instill in students is how to work in teams and understand the roles played by other professionals.

“When you apply to schools, they ask you if you are a team player. But that's lip service,” Nauka said. “You don't see it until you're enrolled.”

Architects of the new programs also say that by exposing students to the complex needs of patients with multiple chronic conditions, they will be more willing, once they're in their residencies and beyond, to understand the special needs of such patients and how to care for them in a more holistic manner. Proponents say immediate immersion with the seriously ill should instill greater empathy for such patients, spark interest in taking up primary care and make future doctors more attuned to helping patients navigate the complexities of a highly specialized healthcare system, which is the essence of the medical home model for care coordination being touted by Medicare and other payers.

“It can create a passion for improving the situation,” said Dr. Don Goldmann, chief medical and scientific officer at the Institute for Healthcare Improvement in Cambridge, Mass. “Walking in patients' footsteps is critical.”

At the very beginning of medical training at Hofstra Northwell, which opened in 2008 at Hofstra University in partnership with North Shore-LIJ Health System, first-year students are assigned to work shifts with local emergency medical technicians. The nine-week course results in their becoming certified as EMTs.

The course provides an overview of actions the students will learn later in medical school, including medical history-taking, CPR and responding to crises, said Dr. Lawrence Smith, dean of the Hofstra Northwell School of Medicine. “We wanted to get the students comfortable with seeing patients right from the beginning and link classroom work to what they see with patients.”

The course also teaches that the smartest person in some care-delivery environments isn't the doctor. In this case, it's the paramedic. “It is team care, and it leaves an imprint,” Smith said.

As Medicare, Medicaid and private payers move more patients into value-based payment models—the CMS has set a goal of having 85% of Medicare payments include some form of risk-sharing by 2016—medical educators are beginning to take responsibility for their role in creating the unsustainable fee-for-service payment model. Training since the famous Flexner Report of 1910 has emphasized hard sciences in the classroom and clinical exposure to highly specialized care.

But many educators today argue that model needs to be expanded to include a greater focus on patient-centered care given that access remains a problem and outcomes—despite the world-class medicine available in most healthcare settings—lag many other advanced industrial nations.

“We know from studies that compassion decreases in medical students over the arc of training and their residency,” said Dr. Frederic Schwartz, senior adviser to the dean at A.T. Still University School of Osteopathic Medicine in Mesa, Ariz. “Something has to change if we're going to create a sustainable environment that leads to community benefit.”

Some schools forgoing the traditional route are bringing first-year students face to face with their ever-changing patient population by embedding them in teams of medical workers. Four years ago, the Icahn School of Medicine at Mount Sinai in New York began offering what it calls the Longitudinal Clinical Experience course, said Dr. David Muller, dean of medical education.

Students are assigned to a clinical instructor and one of his or her chronic-care patients in September of their first year. The student follows the patient for two years, working with a healthcare team that may include a nurse or social worker, Muller said.

Students are present for every physician-patient encounter, which can include home-care appointments. They are included in all communications between the system and the patient. When a patient falls at home, for instance, the student is alerted so as to be present in the emergency room.

Patients with chronic illnesses will make up the bulk of students' work after they become doctors. “The key in this is the relationship,” Muller said.

The relatively new program has provided a welcomed and unexpected benefit for Mount Sinai. The students bring fresh eyes to larger, systematic issues at the hospital, such as cultural insensitivity, biases against some patients that exist outside as well as inside the hospital, and internal processes that can lead to safety and quality problems in the delivery of clinical care.

Their insights have led the hospital to plan to give students access to its confidential online portal, which is now used by full-time staff to report medical errors and near misses. “Students are in a unique position to spot issues related to bias and racism, as well as safety and quality, in clinical care,” Muller said. “I think the students are in a unique position because they have access to all clinical settings and they are much more sensitive to breaches in safety, quality and bias because they're seeing things through both lens—pedestrian and medical.”

The American Medical Association has endorsed the move toward earlier patient exposure for students. It has awarded $12.5 million in grants to 32 medical schools in the Accelerating Change in Medical Education Consortium, which was organized in 2013.

Dr. Susan Skochelak, the AMA's group vice president for medical education, said the schools in the consortium are committed to the idea that training future physicians involves not only following or shadowing professionals, but integrating students into healthcare teams and advocating for patients. “Patients want to be heard and understood,” Skochelak said. “Students can be an extra set of eyes and ears to make sure this happens.”

Nashville-based Vanderbilt University School of Medicine received a $1 million grant in 2013 to develop what it is calling Curriculum 2.0, which aims for deeper comprehension of the fields essential to practicing medicine.

The program seeks to integrate the patient-care experience with health professions' knowledge, and to integrate systems knowledge with patient care, said Dr. Kimberly Lomis, associate dean for undergraduate medical education at Vanderbilt. Curriculum 2.0 was a response to the fact that medical outcomes around the country could be improved. “We responded to the fact that our outcomes are not good and are costing us a great deal,” she said.

Under the program, students are anchored in a clinic site and watch how doctors take care of patients. Groups of eight students meet during the week to talk about patient cases. “The overall intent is that as much work as possible is framed as patient care from day one,” Lomis said.

Nurses, receptionists and patients grade the students, and the students must find three non-physicians at the hospital who can provide feedback, Lomis said. Students also work on medication reconciliation work for patients.

Some educators say earlier exposure to patients can improve symptoms of depression in medical school students. A recent AMA study found that 29% of young physicians suffer from depression. But educators say students will realize they're working toward a greater goal as they continue to work with patients.

“Forces upon you in medical school make it harder to be empathetic. It wasn't until I got to know my patients that I developed a level of empathy and understanding,” said Dr. Keith LaScalea, associate professor of clinical medicine at Weill Cornell Medical College in New York.

The hope is that getting to know patients earlier in their training will help students develop this vital skill. It's never too early for students to begin practicing their craft, which, like musicians, is necessary to improve.

“They too can become master clinicians over time,” LaScalea said.