Medical schools overhaul curriculum to better prepare future docs

Brooke Wagen didn’t have a typical third-year medical school experience.

Instead of going through the clinical rotations students usually are exposed to, Wagen spent the year interviewing elderly residents who lived in the housing developments close to her home in Austin, Texas. 

Wagen talked to 30 residents over age 65 to try to understand how they viewed their health and social situation. 

“I always passed by these older adults who made me curious and made me want to know more and do more. Now I have gotten the amazing privilege of getting to interview some of them.”

Wagen’s yearlong qualitative research study was part of a unique curriculum approach at Dell Medical School at the University of Texas at Austin that flips the traditional third-year experience on its head.

The school, which welcomed its first class in 2016, encourages students to spend a so-called growth year taking what they have learned so far and pursuing a passion focused on health. Students can pick research, population health, design, entrepreneurship or a dual degree like engineering or business administration. The goal is to build a pipeline of doctors who want to be agents for change.

“We try to emphasize there are major issues around health and health systems,” said Dr. Clay Johnston, dean of Dell Medical School. “We are trying to create a cadre that is actually driving changes to ensure our health system is better aligned with society’s interest and people’s interest. Right now, that is missing. The changes are being done to the system and not for the system.” 

Wagen, who chose to pursue population health, said her growth year experience taught her the importance of listening to patients’ needs and challenges.

“I’m going to have a voice as a physician to continue to advocate for my patients,” she said.

Dell Medical School is one of a growing number of institutions reimagining the traditional medical education curriculum. Leaders are throwing out long-held practices in hopes of creating a pipeline of doctors armed with skills typically not learned until years in the profession, if ever. The end goal is to have a workforce of physicians who are innovative and patient-centered, concepts that traditional medical education doesn’t promote very well. 

“When I was in medical school, I did 10 weeks of obstetrics. I delivered six babies. It’s one of the highlights of medical school, but I never saw the women again. The message there wasn’t that I was here to serve the patient, you were here to deliver the baby,” said Dr. Steven Scheinman, president and dean of Geisinger Commonwealth School of Medicine, Scranton, Pa. 

Virtually all U.S. medical schools have modified their curriculums, but the extent of changes vary, said Dr. Susan Skochelak, group vice president of medical education at the American Medical Association.

Generally, newer medical schools are more easily able to take an entirely innovative approach to the curriculum, but Skochelak said there are legacy schools that have done it too. 

The AMA has been a vocal advocate for revamping medical education through its Accelerating Change in Medical Education Consortium. The initiative, which launched in 2013, currently involves 37 schools that have received a total of $14.1 million in grants to develop new curricula at their institutions.

That’s not to say there aren’t those resistant to changing  medical education. When leaders at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia started to consider overhauling the curriculum in 2015, the faculty was skeptical. 

“There was a lot of faculty who had cause to wonder, ‘Why make a change if it’s working?’ ” said Dr. Steven Herrine, vice dean for undergraduate medical education at the college. 

The leadership did “a lot of ground work” with the faculty to get their support, he said. Meetings were held to discuss the plans and involve them in the changes. 

“There has been tremendous buy-in from both the science and clinical faculty; it’s extremely gratifying,” Herrine said. The school officially changed its curriculum in 2017. 

Modern Healthcare spoke with officials from six medical schools to understand how they addressed some of the shortcomings in traditional medical education that ultimately leave future doctors ill-equipped for the rapidly changing healthcare landscape. The schools—four relatively new and two with long histories—took different approaches to their curriculum changes but share common principles aimed at ensuring that today’s students will become better doctors of tomorrow.

Ensuring students understand that patients face unique personal and social challenges that influence their health has become a key component of medical education for some schools. 

Geisinger Commonwealth School of Medicine—which opened 10 years ago as the Commonwealth Medical College and was acquired in 2016 by Geisinger Health—requires students to complete 100 hours of community service before they graduate. 

“We give the message to our students that their mission is to serve,” Scheinman said. 

Cecelia Strauch, a second-year student at Geisinger, has already completed her required hours of service but still volunteers with the National Court Appointed Special Advocate Association, an organization that advocates for children who experienced abuse or neglect in foster care. 

“Working so closely with a family that is going through so much turmoil and socio-economic crisis, it’s a humbling experience. It gives me a new perspective, a really in-depth look at the kinds of challenges that people from these backgrounds experience,” Strauch said. 

Geisinger also sets up students during their first year with a patient who has a chronic condition. The student, along with another classmate, follow that patient to their appointments and visit them at their home throughout medical school. 

The objective is for students to witness firsthand the challenges of living with a chronic disease and how social conditions impact following a care plan. It mirrors the emphasis many payers and providers are starting to put toward addressing social determinants.

Hackensack Meridian School of Medicine at Seton Hall University implemented a similar approach. The school, which opened just last year in Nutley, N.J., with a class of 60, introduces students to multiple families who they will follow throughout their time at school. Students ask questions about barriers the families face in healthy eating or going to see their doctors. 

Additionally, students need to advocate for ways to help the family address those challenges. 

“We want our students to recognize that whenever they are seeing the patient they must be thinking of the community from which the patient comes,” said Dr. Bonita Stanton, founding dean of the school.

Some schools are exposing students to clinical experiences earlier so they can better apply classroom teachings.

“Medical students learn best when they learn the basic sciences along with the clinical approach. It’s hard to say you need to memorize this if you don’t know there is a clinical application for it or a clinical need,” said Dr. Sue Cox, executive vice dean of academics at Dell Medical School. 

Students at Dell get introduced to their clinical clerkship in their second year at the school instead of the third year. All of the clinical blocks last eight weeks except for primary care, which goes on every week for two years. 

Since there is a primary-care shortage in Austin, the hope is more students will be interested in pursuing that as a specialty if they are given longer exposure to it, said Dr. Elizabeth Jacobs, a professor of internal medicine and population health at Dell. 

“We wanted to make sure students could see the value of primary care, which is hard to see if you just spend a month doing it,” she said.

Each student is set up in a local federally qualified health center or community clinic where a physician has agreed to mentor the student, allowing them to sit in on clinical visits and ask questions.

For third-year Dell student Anatoli Berezovsky, the experience has solidified his intent to pursue family medicine instead of oncology, his initial choice for a specialty. “It was cool for me to see that family medicine is more than just diabetes and high blood pressure—you can help your patients in other ways,” he said. 

Hackensack Meridian also hastened when students are exposed to clinical experiences, but with a slightly different twist—offering an option to graduate in three years instead of the traditional four. 

Like Dell, Hackensack Meridian students begin their clinical clerkships in their second year.

Stanton said the three-year graduation has a dual benefit: to reduce education debt and entice more students to pursue residency at the affiliated health system, Hackensack Meridian Health. New Jersey, like many states, is facing a shortage of physicians. 

The idea is that the students will be interested in staying at Hackensack’s health system, which has 13 hospitals, for residency because they are familiar with the organization. Third-year graduating students also won’t have as much time to seek out many other residency options. A big chunk of the fourth year is usually dedicated to that time-consuming, stressful process. 

“We feel that the students who are going to do a residency program here in New Jersey will be more likely to stay in New Jersey to practice medicine,” Stanton added. 

Some medical schools are offering courses that go beyond medicine. 

The doctors of the future will need “other tools” in their bag, said Dr. Bon Ku, assistant dean at Sidney Kimmel Medical College. 

The medical school implemented a component called the scholarly inquiry track in which students select one of eight disciplines they are going to pursue throughout the four years separate from medicine, such as population health research and digital health. 

One of the disciplines, design, teaches students to flex a muscle they don’t usually get to in medical school: creativity.

“There is an under-representation for the skill of creativity in medicine,” Ku said. “We need doctors who not only have the technical skills but also who can be creative.” 

Students choose the track they want to pursue in their first year and about 25 students per class are in the design track. They learn design principles like architecture and systems engineering and then how to apply them to common problems in healthcare. 

For Terry Gao, a third-year student at Sidney Kimmel, involvement with the design program led her to the Philadelphia neighborhood of Kensington where she—along with other students—interviewed residents about the socio-economic factors that affect their overall health.

Gao said it changed her view about interacting with patients, saying, “It’s not enough for me to say you need to eat healthier. For me, that means something different than for someone who comes from Kensington.” 

She’s now working on a series of initiatives in the neighborhood through the school including offering health screenings and cooking classes for food-insecure residents.

At Rush Medical College at Rush University in Chicago, students don’t sit in large halls with a professor lecturing for hours. Instead, students watch lectures on their own time—usually via video—and come to class prepared to work with their peers on a clinical case study that applies the lecture’s concept. 

The idea—dubbed a “flipped classroom”—comes from literature that shows lectures are usually an ineffective way to retain important concepts, said Ranga Krishnan, dean of the college. 

“It has been shown in well-done studies that lectures don’t work if you don’t use the material,” Krishnan said. He led the conversion of the school to a flipped-classroom model in 2017. 

Some faculty were initially skeptical. It required them to change how they spend time with students in the classroom and to video-record their lectures. Rush brought in content creation experts to help the professors redesign their lectures so they would be engaging for students to watch at home. 

Krishnan said faculty came around once they saw how much it improved student engagement in the material. 

Kaiser Permanente School of Medicine, which will open to its first class of students in the summer of 2020, will be using a similar approach. 

Rather than lectures, classes will focus on case studies designed by Kaiser that integrate many concepts like health systems science, the role of the physician as an advocate, social determinants of health, and costs along with the clinical concepts. 

“They will understand the continuum of what matters,” said Dr. Mark Schuster, founding dean of the school.

Surveys show that burnout, which affects roughly half of U.S. physicians, starts in medical school. Institutions are starting to give students the tools to handle it early on. 

For example, at Kaiser Permanente School of Medicine, each student will be assigned a physician mentor who will check in with them every few weeks to see how they are getting along with classes and the curriculum. The relationship is meant to prevent students from falling behind academically. 

“It can be emotionally challenging to be working with patients and brought into their lives so intimately,” Schuster said. “So we want them to be well supported.”

Kaiser also plans to offer cooking and art classes to help the students relieve stress. 

In addition to providing counseling services like many schools do, Sidney Kimmel Medical College has an aspect of its new curriculum dedicated to practitioner wellness. First-year students also engage in a week where the importance of wellness is highlighted, Herrine said. 

“Medical school is hard, the responsibility to take care of people’s health is enormous, and that needs to be taken seriously; that said, we also need to look after our own health,” he said.