Med​ schools​ aim​ to​ train​ new​ breed​ of​ physician

Medical students at New York University shape their own curriculums.

NYU School of Medicine at NYU Langone Health arms students with a trove of de-identified public data—type of procedure; length of stay; race and age of patient; payers; variation of charges across markets; outcomes by market and individual providers; and more—provided by the university, the New York State Department of Health and the Centers for Disease Control and Prevention.

They can also analyze NYU's fictitious healthcare organization—Lacidem Care Group—which aggregates patient access barriers and visit types from de-identified data drawn from electronic health records, payers, demographics and laboratory tests and measurements. Lacidem presents them in three different practice models.

The students sift through the information, come up with research questions and work with a medical librarian and faculty member to determine if it's feasible and then hone the focus.

The students ideally can find treatment gaps, eliminate medical waste, better coordinate care and improve quality with the tools to treat not just individuals but an entire population, said Dr. Marc Triola, associate dean for educational informatics at NYU. They are more engaged because they can pursue topics that pique their interests, he said.

"We are giving them the power to ask questions that align with their goals or personal experiences or thoughts that they can turn into a research project they're motivated and interested to pursue, as opposed to a homework assignment," Triola said.

"We want to arm them to look out for system, policy and environmental issues that explain a fair amount of the differences in outcomes," said Dr. Mark Schwartz, professor of population health at NYU.

NYU School of Medicine is one of the schools reforming its coursework to fill gaps in traditional programs to better prepare students. Today's physicians are tasked with adapting to new technology, payment models, leadership roles and collaborative approaches to care delivery. But they are often unprepared if their medical school offers an outdated curriculum.

In response, schools are offering opportunities like NYU's that seek to engage in or simulate the environment in which medicine is headed, not where it's been, including such approaches as putting students to work as patient navigators or giving them access to practice EHR systems.

"We think about teaching the science of medicine, but we have some students leaving medical school who don't know the difference between Medicaid and Medicare—and that's not on them, it's on us," said Dr. Susan Skochelak, group vice president of medical education at the American Medical Association. "If you are going to be a real leader, you have to understand some of these real basics so you can influence change."

NYU Langone is one of 11 founding medical schools that received $1 million grants in 2013 through the AMA's Accelerating Change in Medical Education Consortium. The schools are working with 22 other medical schools that joined the consortium in 2015 to largely implement curriculum projects created by the original members. The goal is that the ideas will catch on throughout the country and they will be tweaked and refined to best deliver care.

The AMA effort advocates teaching students health system science, which emphasizes the role of human factors in value-based care delivery, collaboration throughout systems, leadership and patient improvement strategies.

"Once upon a time, the physician could get away with focusing on patient care and letting someone else worry about insurance and the economics of it," AMA President Dr. David Barbe said. "Those times are way past."

Medical schools often don't teach future physicians how to function and communicate in a coordinated-care environment, particularly in ambulatory settings, Skochelak said.

"The other part that we haven't talked about is chronic care—how to direct changes in lifestyle and how to deal with some of the current problems like the opioid epidemic," she said.

Students often leave medical school without enough clinical experience, experts said.

Penn State College of Medicine, a member of the AMA consortium, created a patient navigator program that immerses students in a clinical site for nine months. Student navigators guide patients through healthcare continuums at the university or partner systems—spanning primary-care clinics to nursing homes— where they educate patients, offer emotional support and help coordinate care.

It presents a patient-centered approach to students who have been taught to think of the disease or diagnosis first, said Jed Gonzalo, associate dean for health systems education at Penn State. Students work in teams and with social workers, nurses and other non-clinicians to grasp how the system is interconnected and to best use community resources to keep patients healthy. They also get to work with more complicated patients with chronic conditions or barriers to access, which was atypical, he said.

"We start with patients of high need who don't have access to cars, have high no-show rates, low education levels or someone with six chronic conditions who has coverage gaps," Gonzalo said. "It's a whole different ballgame."

Yet, the new direction has met some opposition from students and teachers. Some students say they are overwhelmed by juggling clinical work and their classes, while care coordinators are reluctant to step into an entirely new teaching or mentorship role, Gonzalo said.

But it creates a collaborative culture and gives students the chance to be leaders, skills that many physicians traditionally lacked, he said.

"A lot of the teaching role has been M.D.-centric," Gonzalo said. "In reality, we are a learning organization. We are all in this together."

Some​ of​ the​ big​ EHR​ system​ vendors​ are​ reluctant​ to​ let​ students​ use​ their​ platforms,​ so​ Indiana​ University​ created​ its​ own.

Indiana University School of Medicine, in collaboration with its affiliate the Regenstrief Institute, developed a teaching EHR system that helps students navigate clinical data.

The teaching EHR system renames real patient data and allows students to follow treatment through each clinic visit and hospital stay. Students can become familiar with different EHR formats that they will interact with daily and figure out how to use them to coordinate care within and outside of the organization.

The aim is for students to learn how EHRs can best aid their practice as well as what barriers the systems can present, whether through inaccurate information or lack of functionality, said Dr. Bradley Allen, IU senior associate dean of medical student education. IU, another member of the AMA consortium, hopes the teaching EHR will help students recognize the impact of social factors in addressing the needs of individual patients and patient populations, he said.

"Many of the large EHR vendors were reluctant to allow learners access into their EHR prior to them getting to the later stages of their career," Allen said. "We felt it was important to create a platform where they could feel free to experiment with an EHR in a nonthreatening manner."

Several other medical schools across the country are using or considering IU's teaching EHR platform, he said.

"We are capturing the voices and input of a generation of future users on how we can improve communication between all parties that deliver patient care," Allen said.

Related​ story:​ "Med​ school​ leadership​ tools​ prepare​ students​ for​ new​ world"