Playing the Long Game: How the University of New Mexico is working to improve public health

Host: We're broadcasting live at the AAMC in Baltimore 2015, and this year's conversation is about change. What needs to change in health care? I know there's a ton of things, but we're asking each person what specific thing is on their mind right now.

Announcer: Asking questions, seeking solutions. Algorithms for Innovation live from Baltimore at the AAMC 2015.

Cosgrove: Hi, I'm Ellen Cosgrove, Vice Dean for Academic Affairs and Education at the University of Nevada Las Vegas School of Medicine.

Host: And Ellen, tell me about something at your institution that you were at that had to change?

Cosgrove: I'd like to talk to you today about an experience that I had with colleagues at the University of New Mexico in which we undertook a complete transformation of our entire basic science and clinical curriculum to put the focus on health equity to improve the status of health care in the state of New Mexico.

Host: And what was the situation like before you implemented the program?

Cosgrove: New Mexico is a land of enchantment but a land of many challenges because of the poverty, the vastness of the state and the challenges of people who have not had the access to education and other opportunities. New Mexico ranks near the bottom of the states in many health indicators, and so the senior leadership of the school, under the direction of Paul Roth, the Dean and Vice Chancellor for Health Sciences, decided to make a commitment to improving the health of the community in New Mexico by 2020.

One part of that involved changing our curriculum so that students who would graduate from the school would have a greater understanding of why New Mexico had these disparities in health and health outcomes, and what they could do to address those disparities.

Host: And what exactly did you teach the students to help them understand what the problem was in a way that they could go out, then, and actually make a difference?

Cosgrove: New Mexico had been blessed for a long time with very dedicated faculty and students who had been involved in a volunteer effort and establishing free clinics and immigration clinics and the like. But the sense was that we needed to transform the physician outlook so that the physicians that we graduated would realize that their patient was not just the person sitting in front of them, but the whole family and community, so in a sense marrying the tools of public health with the tools of medicine, and in so doing, being able to think of new or novel ways to address patient problems.

Host: Was there a barrier? I'm sure there were probably a lot, but let's talk about a couple of barriers that you had to implementing this program and how you overcame them.

Cosgrove: Those of us in the profession of medicine as well as those in the profession of public health are very entrenched in our own viewpoints, and trying to marry those viewpoints and curricula together, as in any marriage there is sometimes joy and sometimes friction. I'd say moving away from that perspective. Anytime you talk about changing the curriculum in medical school you come up against the idea that it's easy to add things in, but very hard to remove things.

We're really looking at we can't get around that barrier that there are 24 hours in a day, and our students need time to be able to integrate what they're learning, so all of the barriers that everyone in medical education faces when thinking about how do we really transform rather than just tweak our curriculum?

Host: And how did you overcome those barriers in this instance?

Cosgrove: This was truly a group effort. I was inspired by Tom Gilmore who's a change agent at the Wharton School, and using some tools that I learned from his approach, looking at transformational change as a campaign in which it's important to identify not only allies but even more important, to identify who are the people who object to the change and why. Because it's in working with the people who are not sure that they want to sign on to the change that you can actually make your program better.

This is not about getting "buy-in". This is really about listening to what people who object to the change are saying as an opportunity to refine your ideas and make the change program even better than you had first imagined it.

Now, that said, there are going to be some people who no matter what you do are just going to dig in their heels forever, and at some point you just have to figure out how to drive around those blocks in the road.

Host: So it sounds like you laid some groundwork before you actually started to implement anything. How long did it take to establish those relationships and get that feedback?

Cosgrove: We're talking about an eight-year process from the time that we started thinking about this change, laying the groundwork and bringing in important speakers who talked about the social determinants of health and disease, thinking about going across the board to all departments and bringing in identifying people in different specialties who would have a public health perspective and being able to bring that to forums such as Grand Rounds, and then getting people engaged in working on pieces of the change.

So that's another important part of Gilmore's thinking, finding the pockets of where what it is you'd like to see happen are happening already and encouraging the growth and development of those both as pilots to an overall change and to also recognize the other people who are having good ideas and doing good work, and bringing them forward into leadership within the institution.

Host: So this was not an overnight story. This was a long game that you were dealing with right here.

Cosgrove: This was a long game, for sure.

Host: And it's paying off.

Cosgrove: It's paying off. Since 2010 when the change went into place, every student who enters the University of New Mexico School of Medicine graduates both with an M.D. and a certificate in public health. Those credits for the certificate were developed not by doing an add-on, not by doing an online module that students had to do, but by changing the content of each and every required course and clerkship to include both didactic and experiential opportunities for students in public health

Host: Is it too early to see if it has impacted the health of the community?

Cosgrove: It's too early to see if it's impacted the health of the community because the first students who graduated with this curriculum are just now in their internship here.

Host: So what would you have changed in this process if you could go back and do it again, meaning what could you make happen a little bit more easily?

Cosgrove: I think that I did not fully appreciate the power of small bits of support for faculty time to actually work on this, and for the first six or seven years it was all about things that people were doing in the evenings and weekends and on their own time. It doesn't have to be a lot, but some of those bits of supported time for faculty are an important signal that they can take to their division directors and department chairmen to show that their work is valued by the school.

I think that thinking about that reality would have helped earlier. I think also having many more groups, eventually we got to many, many small groups working on various aspects of the transformative change, but I think for too long I stuck with one major committee which was too limiting. So in retrospect there are definitely things that I could have done better, and I'm trying to put some of those ideas into effect as I build the new curriculum at the University of Nevada Las Vegas which is going to be a brand new medical school opening up in July of 2017.

Announcer: Reimagining health care. Explore more at AlgorithmsforInnovation.org.