ARE WE ROOTED OR STUCK IN TRADITION?

“Most of what I’ve learned has proven to be false or replaced,” says Wayne Samuelson, M.D., vice dean of the School of Medicine. While that degree of obsolescence may have come as a surprise to baby boomers like Samuelson, today’s generation is acutely aware that much of what they’re taught will be outdated before they even master it.

Throughout education, teachers are scrambling to figure out how to deliver meaningful knowledge in an age of information overload. The one-way didactic model designed when a motivated person could memorize and keep on top of the latest thinking is a thing of the past. Today it’s estimated that the body of medical knowledge doubles every three to four years.

“It used to be we’d just dump knowledge onto students and house staff,” says Chief Medical Quality Officer Robert Pendleton, M.D. “Now we need to teach them how to access the information they need, when they need it, and know how to communicate with each other and with patients to create shared decision-making.”

That’s not to say there haven’t been improvements. Curriculum committees are continually rolling out new ideas. But the true reforms needed are much bigger than any one committee can solve. How do we break down silos to learn how to work as a team? Why does it have to take so long and cost so much? What is the value of the training we’re providing and how are we measuring it? And what criteria are we using to select future health care providers? “A screaming GPA and awesome standardized test scores predict you’ll be an excellent test taker, not an excellent doctor,” says Samuelson. “It’s no longer going to be enough to be the top guy in organic chem.” Today, we also need to attract the most compassionate, intellectually curious, collaborative and generous students.

Our goal is not to train students to get academic credentials after their names, says Vivian Lee, M.D., Ph.D., M.B.A., senior vice president. “We want our students to be leaders—whether that’s caring for communities, making groundbreaking discoveries, teaching tomorrow’s students or immersing themselves in global health, a biotech startup or health policy. We want to prepare them to change the world.”

The solutions are not out of reach, says Kristen Keefe, Ph.D., interim dean of the College of Pharmacy. “We need to set aside time to allow ourselves to get off this treadmill long enough to think of the most creative solutions—to think deeply and broadly. And then to have the courage to make those changes now.”

A Perfect Match: Students and Community

Train in silos; practice in teams. That’s the current disconnect between tradition and progress when it comes to educating today’s health care providers. Few disagree with the ideals of interprofessional education (IPE) and early clinical experience. But for time- and money-strapped colleges saddled with packed curriculums and conflicting calendars, implementing them can often seem like scaling a logistical Mount Everest.

Thanks to the collegial relationships of the deans of our five schools and colleges and the library director, University of Utah Health Sciences has been tackling that IPE mountain and making impressive inroads. For Wayne Samuelson, M.D., vice dean for education at the School of Medicine, it just wasn’t happening fast enough. “Sometimes you can’t wait for institutional change,” says Patricia Morton, Ph.D., R.N., dean of the College of Nursing. “Wayne said, ‘To heck with all of you, I can’t sit around discussing this for another year. I’m taking a team of students with me to Midvale.’”

Midvale is a city of about 30,000, and as the name suggests, situated smack in the middle of the Salt Lake valley. Three years ago, Samuelson set up a small clinic to serve a mostly Hispanic, underinsured population. It was a one-doc shop but Samuelson’s plan was always to turn it over to the students. As he saw it, there was a community that needed health care and hundreds of students who needed experience. A perfect match. Midvale’s firecracker septuagenarian mayor, JoAnn Seghini, Ph.D., who’s been a resident for more than 70 years and mayor for almost 20, welcomed the students with open arms.

Now three to four days a week, nursing, physical therapy, medical, pharmacy, dental and nutrition students run a four-hour clinic to serve the tight-knit community. At the Midvale Community Building Community clinic, as it’s now called, students care for six to 12 patients a shift. Faculty mentors encourage them to work autonomously and at their own pace, allowing them time to take a good history and do a thorough physical. If the clinic gets behind, they’ll swoop in and see patients themselves. The slower pace allows for a different kind of mentoring. “One time Dr. Samuelson made me listen to a patient’s heart for an awkwardly long amount of time. He was convinced I would eventually figure out what was wrong . . . and I did,” says Laura Gardner, a second-year medical student. “His encouragement and patience make me feel like an important part of the team, even though I’m still learning.”

Students get to see firsthand what others do and gain an appreciation for their skill sets and knowledge. “They have this experience before being socialized with the traditional pecking orders or tensions that arise in clinical settings,” says Morton. And they quickly learn that they don’t have to have all of the answers. They can ask for a consult, or glean thoughts from other team members, says Laura Shane-McWhorter, Pharm.D., a faculty mentor and Midvale champion. From each other, students learn a more holistic view of care—for example, how to take a thorough medication history that includes the use of supplements, drugs and alcohol. “They rely on one another and realize that as providers, we’re not alone. We’re all here together to provide patient care,” she says. The experience not only breaks down traditional barriers between students, but also between faculty mentors from all disciplines, community organizers and patients.

“It’s a wonderful model of team care,” says Morton. “They are truly making an impact.” Since opening the doors two years ago, nearly 200 students have helped care for more than 900 patients in 2,000 visits. “Without these students a lot of people would be dealing with a lot of pain,” says Mauricio Agramont, Midvale’s community developer. “Our families are so grateful and feel good about creating an educational center for these students. They’re our future providers, and the skills they learn here caring for our families will go on to benefit people throughout the state.”

The lines between learner and educator blur as students find they have as much to teach as they have to learn from one another. They learn how the professional skills they need to acquire overlap and reinforce each other: clinical, diagnostic and professional. They interact with a broad range of mentors and a diverse patient population. And they can volunteer for administrative roles to learn all the behind-the-scenes magic that goes into providing nonprofit clinical services. Many students are motivated to practice Spanish and learn what it’s like to work through an interpreter. “Working with our community partners teaches us the difference between our objectives as clinicians and the values of the community,” says Katey Blumenthal, a PT student and director of the student physical therapy clinic. “At the core, our clinic explores ways to reduce health disparities by providing care to those with the most limited access to it.”

For all the good the clinic is doing for the community, Samuelson doesn’t think of it as a charity. “I look at it as a learning lab where we can explore better ways to teach and practice team health care, while teaching clinical skills to students,” he says. He’s also excited about the possibilities for clinical investigation. “We serve a stable and amazingly cooperative and adherent population that for the most part resides in one zip code.”

Samuelson and colleagues are pursuing more institutional IPE opportunities for every student, but Midvale has proven a winner. “I believe the future is bright,” he says. Slots fill up so quickly that students complain there aren’t more. Some graduates continue to volunteer as residents because they love the community and the experience. “These students are motivated and creative and so smart and they learn a ton from their experiences,” says physical therapy faculty advisor Misha Bradford, D.P.T. “I can’t help but think they’ll be better prepared to contribute to a changing health care environment.”

What Matters: Time or Talent?

For about 100 years, the framework for how we educate medical students hasn’t really changed: Two years preclinical and two years clinical—just like Abraham Flexner recommended. His 1910 report brought sorely needed rigor and standards to what were then for-profit, two-year trade schools usually run by a few local doctors.

Since then, there have been important milestones in medical education and countless improvements to the curriculum. But the basic structure—four years of medical school plus three to five years of residency training—has persisted for more than a century. Time has been the determinant of skill. “We assume that at the end of four years all medical students are competent,” says pediatric neurologist James Bale, M.D., who is collaborating on a national project to test a different path. “Maybe some are competent in three years. Maybe some need five,” says Bale. “The question is, what do we really care about: Making sure everyone spends the same amount of time in medical school or that everyone is competent?”

The University of Utah is among four institutions handpicked by the Association of American Medical Colleges (AAMC) to pilot a competency-based model of medical school that explores that question. Pediatric students advance as they master certain skills, instead of the traditional “time in place” method. Education in Pediatrics Across the Continuum, or EPAC, which selected its first cohort of students this fall, shifts the focus from time to talent, says Bale.

If the idea was simple enough, the process to make it happen was not, highlighting how deeply entrenched the ‘time in place’ tradition is. The project’s founder, former AAMC Board of Directors Chair Deborah Powell, M.D., dean emeritus of the University of Minnesota, had to get permission from the Accreditation Council for Graduate Medical Education, the American Board of Pediatrics, even the state of California, which has a law that mandates four years of medical school. The National Residency Matching Program also had to sign off on it since EPAC graduates are guaranteed a residency at their respective institutions.

The goal is not to fast-track students through training, Bale emphasizes, but rather to focus that training on an area that interests them—in this case pediatrics. EPAC prospects are identified in their first year of medical school and introduced to the world of children’s medicine through weekly seminars and clinical labs. Then, before the start of their third year, a lucky few are chosen to enroll in EPAC, effectively getting a jump-start on residency-level training. While other third-year students are doing clinical rotations in neurology and psychiatry, Leslie Jean McNaughtan will be doing hers in pediatric neurology and child psychiatry. “It lets you focus on pediatrics sooner,” says the mother of four. “Next month I’ll start working with general pediatric patients, who, theoretically, I’ll be able to follow for five years.”

The early focus allows for greater depth of training, and for developing closer ties with mentors. Most students get a week, sometimes a few days, with each physician they shadow. “They have all this expertise to share, but it’s really hard to grow and develop with a mentor who you see for such a short period of time,” says Melissa Ann Wright, who joined this year’s EPAC cohort. Students say it also helps reallocate their time. “Most students spend months and thousands of dollars traveling to interview for a residency,” says Wright. “While students are worrying about applications and letters of recommendation together, we can focus on developing the skills we need to practice.”

If the pilot succeeds, the AAMC hopes to expand EPAC to other pediatric programs across the country and eventually bring other specialties on board. There are no guarantees. “We really have no idea how it’s going to turn out,” admits pediatrician Adam Stevenson, M.D., associate dean of student affairs.

Regardless, this program is asking tough questions that haven’t been systemically asked in 100 years. And it’s challenging old assumptions about what success looks like by asking, which educational outcomes matter? “Right now accountability is based on artificial metrics, such as how many students get licensed or pass their boards on their first attempt,” says Bale. “Does that mean our graduates are good pediatricians? It means they’re knowledgeable, but that’s all we’ve had to go on.”

GME: What’s it worth?

Should the government subsidize the training of doctors when it doesn’t foot the bill for other vital professionals, such as lawyers, teachers or nurses?

Since the creation of Medicare in 1965, the answer has been yes. For half a century, the federal government has chipped in to cover a share of what it costs to train residents, called graduate medical education (GME). Every time a debate surfaced questioning the funding, Congress voted to continue the payments to encourage hospitals and clinics to keep the physician pipeline flowing. Everyone wants access to a doctor, and residency spots seemed to be the bottleneck.

Now as concerns about an impending doctor shortage are heating up, debate is stirring again. This time, the influential Institute of Medicine (IOM) weighed in with an unexpected and controversial perspective. The July 2014 IOM report recommended preserving public financing, worth $15 billion, but called on health systems to provide greater transparency in accounting for how the money is spent. The report raised provocative questions: Are the nation’s teaching hospitals training young professionals to work as teams and care for an increasingly diverse population? Are they producing enough primary care providers? Put more succinctly: Are taxpayers getting their money’s worth?

With millions of dollars at stake, many in academic medicine understandably took issue with the IOM report and immediately began lobbying to preserve the funding. The University of Utah chose a different approach. Our health care system is one of a handful of systems in the country that has the ability to drill down to the most granular level to know the true costs of providing care. So we decided to apply that same scrutiny to understand how much it costs to train residents. “Without data on the costs and benefits, how can you accurately respond to critics who wonder if a government investment is still valid or even needed?” asks Brad Poss, M.D., pediatrician and associate dean for graduate medical education.

Measuring the cost of graduate medical education is complicated, because it’s part school, part job. Residents are paid a salary while learning on the job—sometimes they slow things down and cost the system, and sometimes they speed things up and create more efficiency. How that all nets out is highly variable depending on the specialty and the year of residency—clearly a chief resident adds much more value than an intern.

To get a sense of the range, Poss and his team are analyzing three categories of care: primary care (pediatrics), surgical care (ophthalmology) and radiology (a hospital-based service). “We’re defining residents’ activities, documenting every point at which they touch patient care, and comparing their patient costs and outcomes to those of fully licensed staff working solo.”

The numbers aren’t solid enough to draw clear conclusions, but early findings suggest that ophthalmology residents enable our Moran Eye Center to perform more cataract surgeries because residents can counsel patients and prep them for surgery. Pediatrics, on the other hand, nets about $10 less per visit when a resident is involved, likely because residents can’t charge as much as an attending, and they also tend to be less consistent documenting the right billing codes.

Cost is one thing, but the IOM report’s true concern was how we measure the value of that investment. “The IOM didn’t question our ability to produce technically adept physicians,” says Poss. “It questioned whether we’re preparing our residents and fellows to thrive in a field that is rapidly changing.” In addition to analyzing cost, Poss and team are also working on developing metrics, such as patient satisfaction surveys for residents, to help quantify how residency training is translating to patient care.

“It’s a mammoth undertaking. Next we’ll tackle world peace,” jokes Poss, who will document his findings in collaboration with Harvard Business School Professor Emeritus Robert Kaplan, Ph.D., M.S. Poss is hoping that other systems will take this kind of analysis on and be willing to share their findings. “Not only will this give us valuable information to improve the quality of residency programs,” says Poss, “but it will provide us with solid data to determine if taxpayers’ investment in training tomorrow’s providers is well spent.”