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Medical School 2.0

07/31/18

A New Way to Train Physicians

JeffMD
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Deborah Ziring, MD, associate dean for Academic Affairs/ Undergraduate Medical Education, is responsible for leading the design, implementation, administration, and evaluation of JeffMD.

When Deborah Ziring, MD, attended medical school in the 1980s, she sat in large lecture halls day in and day out while professors at the head of the class spewed information in steady streams. There was anatomy lab, microbiology lab, and a few other labs, and she paired up with fellow students to practice physical examinations, injections, and blood draws. Her first interaction with real patients didn’t come until her third year.

That was then. This is now »

It’s 10 a.m. at the Sidney Kimmel Medical College’s Dorrance H. Hamilton Building, room 212.  

Eight students sit around desks arranged in a U shape facing a screen. One student takes
the clicker and begins a PowerPoint presentation on hepatitis; Ziring interjects a few bits of additional information, then gives the floor to another student who continues the session.
A box of donuts is passed around, and the students snack as they discuss infections, treatments, and outcomes.

The next day, some of those students will interview patient actors to learn communication skills; a few will go to the anatomy lab; and others will spend the afternoon in the emergency department or outpatient clinic helping patients understand medical tests, discussing health concerns, and arranging follow-up care.

Welcome to a new age of medical education. Welcome to JeffMD, a method of instruction that replaces the traditional lecture-based courses with a curriculum that integrates hands-on medicine and basic science with interactive case-based seminars, problem-based tutorials, presentations by students, scholarly inquiry opportunities, and skills and communication training.

Specifically, it means placing future physicians into patient care settings almost immediately for early clinical exposure, optimizing learning through small groups and varied instructional formats, and encouraging students to develop special interests through individual projects. It also means putting a high priority on compassionate interaction with patients—in other words, bedside manner.

“The idea behind CBL [case-based learning] is that knowledge is really important, but knowledge is not enough to practice medicine,” says Ziring, associate dean for Academic Affairs/Undergraduate Medical Education at SKMC, who is responsible for leading the design, implementation, administration, and evaluation of the revised medical curriculum.

She came to Jefferson after spending 12 years at Drexel University College of Medicine overseeing two tracks within the school—one traditional lecture track and one CBL track. “What we found was that students in the case-based track felt better prepared for their clerkships than the traditional students,” she says. “They had been learning about cases and thinking about patient problems from the start;

they already integrated and built their knowledge in a way that they could easily apply
to clinical practice instead of getting a siloed approach of learning where they hadn’t put information into real-world patient context.”

Ziring calls the “data dump” approach of the traditional lecture method a “one-way street” that isolates the student and their learning. In contrast, small-group CBL that is monitored and mentored by a facilitator allows students to investigate and learn from each other while building collaborative skills—which are just as important as academic proficiency.

“When you’re sitting in a lecture hall nobody’s evaluating your ability to work well with others, which is critical in clinical wards where you have to work together as a team all the time,” she says.

SKMC

Medical Education Past, Present, and Future

The evolution of medical education over the past century from lecture-based learning to hands-on case-based learning was inevitable, says Mark L. Tykocinski, MD, provost and executive vice president for Academic Affairs at Thomas Jefferson University, and the Anthony F. and Gertrude M. DePalma Dean of the Sidney Kimmel Medical College. 

“The 1910 Flexner Report placed science front and center for the medical student,”
he says of the extensive study of medical education in the United States and Canada.
“The 2010 centennial report from the Carnegie Foundation built on it, bringing a focus on competencies, problem-solving skills, collaborative learning environments, early clinical immersion, and interprofessional education. JeffMD addresses all of them head-on, setting the stage for creative and flexible training toward a broader set of career pathways for
the 21st-century physician.” 

The radical shift in how future doctors are educated took hold about five years ago, when technological advances and public expectations forced educational institutions to go back to the drawing board and take another look at potentially outdated methods of training physicians. Beginning in 2013, the American Medical Association (AMA) instituted the Accelerating Change in Medical Education (ACE) program to update medical school education, starting with 11 schools across the country, including University
of California San Francisco and Vanderbilt. Each was awarded $1 million to restructure and revise the medical education curriculum. In 2015, the AMA added another 21 schools, including Jefferson.

The impetus to change the delivery of healthcare education is both internally and externally driven, says Ziring. “The internal driver is the learner, who has so much information at their fingertips because of technology—the internet allows them to look up anything at any time.” External drivers are the public’s expectation of the healthcare provider to be more patient-centered, and the move toward outpatient care. 

“Doctors not only need to have the knowledge, but also to be good at communicating and helping to navigate a complex healthcare system,” she says. “Also, in the old days, it was all about acute care in the hospital. You either solved the illness or you didn’t. Today, a lot of medicine is about managing complicated chronic diseases as a medical team in an outpatient setting. Now you have the focus shifting to also handling the socioeconomic and environmental aspects that need to be addressed.”

Because of these changes, about 75 percent of medical schools across the nation currently are undergoing or have undergone some degree of curriculum reform. The dominant trend—and the future of medical education—is a movement toward integrated curricula with active learning modalities.

“I’ve felt this is a direction Jefferson should have been moving toward for many years,” says Steven Herrine, MD ‘90, vice dean for Academic Affairs and Undergraduate Medical Education. While he is grateful for the excellent education
he received, Herrine admits that he always felt there was a “better way” to train physicians.

“The emphasis was on knowledge acquisition, and medicine is so much more than being able to recall knowledge—it’s clinical situations, critical thinking, reasoning, being aware that patients are from different backgrounds than your own,” he says. “This change provides a more hands-on, experiential approach that accentuates humanism in medicine.”

In June 2017, when Jefferson awarded white coats to the first cohort of JeffMD students, Somnath Das was “excited to be a guinea pig.” Das, 23, of Warner Robins, Georgia, hadn’t originally planned to attend SKMC; in fact, he had already been accepted to his state school. But when he interviewed at Jefferson, he was “blown away” by the program.

“I didn’t know anything about the new Jeff curriculum, but when I heard about it my first thought was, ‘Well, shouldn’t medicine be taught this way rather than just learning a bunch of information at once and then not getting the chance to use it until the very end of school?’” He said the “learning from a holistic perspective … the early clinical exposure … and flexibility in the development of areas of interest” sold him on Jefferson. “I really appreciate all the critical knowledge I’ve gained in the first year, and also the scholarly inquiry component. Traditional programs can’t offer that.”

The scholarly inquiry program tracks provide students with academic and research opportunities outside of the traditional medical curriculum. The connection to other Jefferson institutions and programs gives SKMC students access to coursework not usually found in medical school. Guided by a mentor, the students work to complete independent projects appropriate for their concentration. For example, a student might work with faculty and other students at the East Falls campus to create a better football helmet or design a better clinic space; at the College of Population Health a student can research how to plan and implement solutions to the current challenges facing healthcare or focus on patient safety and quality of care; the Clinical and Translational Research track helps educate the next generation of physician scientists and researchers.

Das says he agrees with the “spirit of the program” and its holistic approach to learning, and he is not about national standardized testing. “As far as the boards are concerned,
I know I will have to teach myself a lot of facts regardless of the program,” he says. “The curriculum’s goal is not to teach us to take the test, but how to practice medicine and be better doctors.”

While it is too soon to assess the success of the JeffMD curriculum, the first cohort of ACE schools across the country report that board scores have remained the same  or increased slightly.

A Different Path

JeffMD covers all of the traditional medical school education—
fundamental science, anatomy, biochemistry, etc.—but there is a stronger focus on case studies and problem-solving. Relevant science instruction is combined with increasing clinical experience, as putting theory into practice helps to solidify the knowledge. While first-year students only interact with patients as support staff, as their knowledge increases, so do their responsibilities. 

Tykocinski says the program takes education beyond competencies to the cultivation of clinical intuitions and judgment. “It develops cross-cutting ways of thinking, reengaging the Oslerian art of medicine alongside Flexner’s science of medicine.”

The program employs the same methods that progressive schools are using across the country. But what sets JeffMD apart from other schools transitioning away from the traditional training curriculums is an emphasis on the humanities and bedside manner.

“We are bringing back the art of medicine,” explains Ziring. “During the period when scientific knowledge exploded, emphasis in instruction was put on the memorization of information. The art of conversation, communication, and building patient trust all became secondary to that. Now, with all the technological support to help retrieve factual information, physicians are free to pursue the other aspects of a healing relationship.”

Students in JeffMD are required to take humanities courses such as Healing Art, Medical Spanish, and Art Appreciation. While a class that requires medical students
to visit an art museum might sound strange, Ziring explains that viewing and discussing paintings helps future doctors understand nonverbal behavior and improves their ability
to process nonverbal communication.

“There is a growing recognition that no matter how much technology we have, healing really comes back to the relationship between the people receiving care and people giving care—how fundamental a caring relationship is to healing.”

And while JeffMD is very focused on the care of the patient, there is also a wellness component for the student built into the curriculum. Studies show that medical students come into school with less depression, and are better adjusted, than their age-match peers. However, by the third year they surpass their age-match peers in depression. The American Foundation for Suicide Prevention reports that medical students suffer from depression at rates 15 to 30 percent greater than the general population; in addition,
a study published in the Journal of the American Medical Association

in 2016 found that 1 in 10 medical school students experience suicidal thoughts.

“The small-group setting allows for a more robust support  network—it helps them form close relationships with their fellow students and allows the facilitators to notice if someone is struggling so they can reach out and ask ‘are you okay … can I help you?’” Ziring says. “That kind of thing wouldn’t happen in a large lecture hall setting.”

Change Is Hard

While Ziring enthusiastically calls the program “shiny and new,” not everyone was immediately open to the change. “There’s been a lot of pushback,” she says. “For some students it’s the fear of the unknown, and for many faculty members, there has been the attitude ‘the old way was good enough for me, so it’s good enough for someone else.’” 

Nevertheless, as the first cohort finishes the academic year, the program is winning over both faculty and students alike. “Some people say, ‘If it ain’t broke don’t fix it.’ I say, ‘Okay, it wasn’t broken, but do you really think it was as good as we could make it?’” Ziring says. “This is an amazing opportunity to do better—and we are taking full advantage  of that opportunity.”