…but why are we talking about it now
In 1910, when the famed Flexner Report was published, it brought about such sweeping reforms of all 155 U.S. medical schools that about half the schools ended up closing down.
Over 100 years ago, Abraham Flexner was hired by the Carnegie Foundation to visit all medical schools in the U.S. to investigate medical education. Since then, medical education has not even come close to seeing the sweeping reforms of the Flexner era.
At the June 11th Digital Health Conference, medical educators, administrators clinicians, and CEOs, came together to learn more about needed reforms in medical education.
A panel of medical experts discussed just that during the “The Making of a Clinician” session.
A visual answer to “Why are we talking about medical reforms now?” was evident when Jonathan Ravdin, M.D. president and CEO, PDS, asked how many conference attendees employed medical students, physicians or nurses? About half the room, representing diverse health care businesses and clinical practices, raised their hands. “Everyone wants their workforce to be well trained, but in terms of health care, it all starts with innovative medical education,” said Ravdin.
It’s a given that we want our doctors to be master clinicians and our health care professionals to be tops in their skills. DHC’s medical experts spotlighted changes necessary in medical education in order to keep up with the expanded role of IT in learning and in the real-world of delivery of care.
Ravdin said, “An improved model of health care, starting with how we educate our clinicians, affects all of us from providing a profound richness of patient care to improved health care delivery, safety and access.”
Behind the Scenes
Smart medical students are by and large in a lock-step program that puts them into a learning cycle as if they were in high school. “They should be learning individually to continue to support their drive and passion, similar to how grad students learn,” said Ravdin, “and not to learn just to learn in an isolated basis.”
Students have said that the basic science they learn the first two years in medical school is very important, but a couple years later they can’t remember it. Ravdin said it should be integrated throughout their education.
The following reforms were pointed out as crucial to clinical education programs, and they yield better leveraging of IT once learners become practitioners. First, reforms are needed to move from knowledge-based education to competency-based learning. That focus should include team-based, outcome and patient-based education. When learning focuses more on outcomes, it provides the opportunity for measuring a future doctor’s skill development.
Another example of where changes are needed is in the making of tomorrow’s clinicians. Both Dr. Ravdin and Jeffrey Grossman, M.D., president and CEO, UW Medical Foundation, said today’s education is more focused on disease but in our complex world of health care, there is a growing need to focus more on health maintenance.
It’s been well researched and documented that medical students start out learning with passion and drive—they are altruistic, excited and eager to learn. But by the time they have to decide what area of medicine they want to practice in, they are not as altruistic as they were earlier in their education. Ravdin blames how medical education is taught for that attitudinal change. “Often their spirit gets squashed and we drive them away from primary care. Debt drives their career choices,” he said.
What if you were asked to make a career decision (when you were in your 20s or a few years out of college) that would affect your life for about three decades? Could you do it under pressure?
That is exactly what third year med school students are asked to do. They have about 4 months—between May and September to make a 30-year (or longer) career decision about what field of medicine they want to practice in.
It’s not hard to see that there is something fundamentally challenging about this equation that makes it ripe for reform. Consider how these life-changing, life-long often stress-based decisions are made and then how they shape the face of health care years to come.
One of the biggest drivers of students’ career choices is obviously based on economics. Ravdin explained, “In public schools, med students come out with about $180,000 in debt, in private school its $240,000. Combine that as a physician couple and you can see how economics plays a role when future physicians make decisions under pressure their third year. They can switch paths later but it’s difficult. Instead, they choose higher paying specialties due to status and economics.”
Intelligent Health Care Leverages IT
Today, most U.S. medical schools are equipped with health IT, analytics and biomedical information—a huge transformation in medical education, giving learners access to simulation centers and electronic-based information. Prior to IT’s role in medicine, information was often anecdotal, sometimes lost in translation.
Barry P. Chaiken, M.D., FHIMSS, noted, “We need IT analytics to measure patient outcomes as well as financial outcomes.”
For example, he said if a surgeon is doing a hip replacement, and it takes 180 minutes but a similar surgery by another surgeon takes half the time, health IT can help modify costs and behavior as necessary, but you have to do the analysis first.
But there’s more work to be done. Take the time it requires to learn about randomized clinical trials (RCT), for example. Grossman pointed out that in 1975, when he was in medical school, if you did a little digging, you could probably find out where all the RCTs in the world were being conducted.
Discussing why it’s important to have a better way of organizing large amounts of information, he said, “Today, there are about 25,000 new RCTs in the world each year. It’s impossible for physicians, learners and others to keep up with it,” he said.
Where is IT and medical education headed? Ravdin said, “We have to utilize big data and cloud analytics. You can’t do it without this.”
This is where some of the changes in medical education and healthcare are needed and are starting to happen.
How’s this for an original thought? Today, if you are a good communicator, your medical school may see those skills as a pathway to becoming a good physician.
Doctors wear many hats and play many roles so some medical schools are starting to reduce prerequisites. Ravdin explained, “Schools are realizing that having good oral and written communication skills can be just as important as taking physics.”
At the end of the day, how do you assess the effectiveness of medical education? It may not sound like a formidable task but it’s never been done. That’s partially due to the vastly different paths doctors take—such as that of an orthopedic surgeon, family medicine doctor practicing in rural America, hospital administrator and numerous other positions.
Ravdin explained that healthcare will drive IT capabilities going forward and that requires top analytics in place.
This example further explained the premise. The panel of health experts at DHC agreed we need an “intelligent” health care system that can do many things for many people starting with educating doctors. But most learners are not getting analytical feedback shortly after an experience. Instead, they get feedback long after the moment of learning has passed, at the end of the year.
Ravdin said faster feedback, provided electronically, is first and foremost, not only fundamental to their education, but also to their future practice. “This is not a good data solution and it evolves into a life-long learning portfolio.” Other reforms needed surround the need for more intelligent search engines in clinical decision making. “We don’t have clinical decision making support yet,” noted Ravdin.
If a doctor is looking for help making a decision about a patient, he may get it from ‘processed outcomes’ 80 percent of the time. These are surrogate outcomes that ask questions like ‘did you give the patient an aspirin for this or that’.
“This is not the support we need from more intelligent search engines,” said Ravdin. “We need to provide data about a patient and then receive information like, `here are things to consider.’ That’s decision making.”
Still, Chaiken noted that while health IT is evolving, it is not evolving clinically in groundbreaking ways.
Grossman posed the question, going forward, how much of a transformation in intelligent health care can be attributed to a natural evolution? Regardless of having a specific answer at this time, he probably summed up the feelings of DHC attendees when he noted, “I hope we never go back to when IT didn’t play in important role in medical education and health care.”