22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 3, Hansen)

We gratefully acknowledge the sponsorship of the Penn State University Hershey Medical Center Department of Family Medicine (James Herman, Chair) for funding the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

Thomas Hansen, MD; Creighton University

Thomas J. Hansen, MD, Creighton University, Omaha: Good morning! My name is Tom Hansen from Creighton University. My job at Creighton is the oversight of the curriculum for medical students.

There is a big question I ask myself when I look at the Patient Protection and Accountable Care Act (PPACA). If this bill is providing us a vision of what the physicians should be like in the future, then what should medical education look like?

PPACA’s Vision of Medicine in the Future

I’m briefly going to go through just a couple of the sections of PPACA to give an idea of how I understand the act’s vision.

PPACA envisions that  a physician will be participating in improving health outcomes through the implementation of such activities as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, in a practice that uses the “medical home” model.

Preparing the Medical School Curriculum for a Reformed Medical Practice Environment

How well are we training our medical students to participate in quality assurance and quality reporting? How do we do this?

My premise is that I don’t know what happens in their post-graduate residency programs. So, if the job of medical education in the undergraduate years really is to prepare a generalist, I have the responsibility to assure that the Creighton curriculum is preparing all my students as generalists, regardless of the what kind of residency program they pursue.

The students have to have at least some exposure to the things that they’re going to be expected to do once they are out in practice – the chronic disease management, quality reporting, medication initiatives.  These are some of the things that we can address in the curriculum now.

We implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence-based medicine, and health information technology.  We implement wellness through health promotion activities. I think all medical schools have incorporated some component of evidence-based medicine in their curricula.

Assuring a Relevant Curriculum Using Web-based Interventions and Social Media

But as I look again at our curriculum, I  ask to what extent are we preparing my students to use evidence-based medicine, and the best clinical practices? To what extent are we involving students in health information technology?  How do we the introduce wellness and health promotion activities? How do students learn to assure the quality of care?

Wellness and health promotion activities may include ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants and may include the wellness and prevention efforts described below.  (Truthfully, in the case of the web-based intervention, I’m having a lot of interaction with our students. I think the medical students are educating me on what is possible, especially in this age of social media. They are showing me how this can be done, and are being very creative. This question should be asked for medical curriculum designers:  how can we start looking at medicine based on social media and on web-based techniques?)

Teaching Use of Guidelines and Wellness Promotion

But consider a list of subjects: wellness and preventive efforts, smoking cessation, weight management, stress management, physical fitness, nutrition, heart disease prevention, healthy lifestyles support, diabetes prevention. When I review the current curriculum, I look to see how these critically important topics are covered.

In the curriculum I went through as a medical student, there was a lot of emphasis on heart disease prevention and diabetes prevention.  How well – I ask myself this question – are we teaching our students how to counsel patients on smoking cessation, weight management, stress management, physical fitness, nutrition and healthy lifestyle support? The students usually are exposed to these subjects, but what they hear about in classes may not prepare them for the clinical setting.

I look at myself and know that I’m not following a lot of the guidelines. I look at the guidelines established by the United States Preventive Services Task Force. You know what the recommendations are. Some of them are based on insufficient evidence for them even to be considered in the clinical setting, but  physicians practicing under PPACA should at least have the vision to be able to use guidelines and document outcomes.

How do we start teaching this in the course of medical school education? As an example, the Centers for Disease Control and Prevention [CDCP] promotes a healthy lifestyle through ceasing use of tobacco products, controlling or reducing weight, lowering cholesterol and blood pressure, avoiding the onset of diabetes, or improving the management of diabetes.

I think we’re doing some of the things well, some of the things we’re not. The CDCP promotes public health community interventions, screenings and clinical referrals where necessary, physical activity, proper nutrition to lower obesity, chronic disease management and mental health. Again, how are we preparing our students to do these things so that they, especially in primary care, don’t have to refer out what they can do this in the clinical setting.

Evaluation of and Participation in Practice-based Medical Research

Finally, how do we teach students how to evaluate and examine the results of medical research and of demonstration projects. How do we develop and model curricula for cultural competency, disease prevention and public health? How well are we teaching our students to involve and engage themselves in research – especially translational research – so that they know how to go from the bedside to the research lab (there is not a lot being done on that subject) and then conduct and participate in interdisciplinary education.

Incorporating Interdisciplinary Education into the Medical School Curriculum

To what extent are we engaging in interdisciplinary courses in the medical school? That’s very difficult at my institution. I try to work with the School of Nursing, We’re fortunate we have all of allied health professions – dentistry, nursing, pharmacy, physical therapy/occupational therapy. Even so, it’s very difficult for us all to come together and find what are our future goals are, in order to develop a course in which all of us are working together to achieve those goals.

Changes in LCME Standards for Medical Schools

Let’s quickly consider what the Liaison Committee on Medical Education (LCME) requires now.

In the Original Standard ED-1 [The medical school faculty must define the objectives of its educational program . . . Educational objectives state what students are expected to learn, not what is to be taught . . . The objectives and their associated outcomes must address the extent to which students have progressed in developing the competencies that the profession and the public expect of a physician], we had the “competencies”. Most medical schools are now moving towards integrating the competencies from residency education into undergraduate medical education.

We have a mandate to at least address system-based knowledge and practice-based learning. We are looking at the whole system. What do we want to do about the whole system to improve quality of care? What are we doing about our own patient population to improve care?

The revised ED-5 [The educational objectives established by the school, along with their associated outcome measures, should reflect whether and how well graduates are developing these competencies as a basis for the next stage of their training] requires us to provide a general professional education and prepare medical students for entry into graduate medical education. Are we really preparing our students to be generalists, to be primary care physicians, so that they then can specialize based on the education that we provide?

ED-6 states that the curriculum of a medical education program must develop the medical student’s ability to use problems and skills wisely in solving problems of health and disease. If we’re doing this well, then this is really helping prepare them for the vision that PPACA has for our future physicians.

In Standard ED-7 it is stated that the curriculum “must include concepts in the basic and clinical sciences, including therapy and technology, changes in the understanding of disease, and the effects of social needs and demands on care“. Even now our medical students need to be able to demonstrate that they are aware of the greater needs of the poor and of the underserved in order to provide the care to them as students, as well as in their future practice.

LCME requires that the educational objectives established by the school, along with their associated outcome measures, should reflect whether and how well graduates are developing these competencies as a basis for the next stage of their training. Standard ED-13 requires us to include “preventive, acute, chronic, continuing, rehabilitative and end-of-life care“.

Some schools are better than others. When I look at our own curriculum at Creighton University, I can see that we do acute, chronic and continuing care very well. We’re o.k. doing preventive, although we are not as good as I think we should be. But we really need to bone up on  rehabilitation and end-of-life care.

What will be expected of medical school graduates in future practice

I think it’s a real challenge, because these are the things that the medical students are going to be measured on down the road as physicians. How do we prepare them in medical school? Again, the curriculum must include clinical experience in primary care [ED-14]. We must prepare students to enter any field of graduate medical education [ED-15], including clinical experience relating to wellness determinants of health opportunities for health promotion.

The language is very broad. From what I’ve seen from a number of medical schools, this is interpreted many different ways. There is no set curriculum for any of these subjectss, but again these are things that the students need to be well-versed in as they enter into the world that is participating in PPACA.

In ED-17 we must be able to provide our students with experience in “clinical and translational research“.  How do we do this in a clinical setting when the number of hours are limited?

ED-19 requires “specific instruction in communication skills as they relate to physician responsibilities, including communication with patients, families, colleagues, and other health professionals“. This is where we’re starting to get into that interdisciplinary education. How do we improve our communication with our colleagues or nurses, physicians’ assistants others in the healthcare arena?

Then ED-20 requires that the curriculum of medical education “must prepare students for their role in addressing the medical consequences of common societal problems“. The example they give is “the diagnosis, prevention, appropriate reporting, and treatment of violence and abuse“. Maybe we need to start looking at changing the language to include smoking sensation, weight management, nutrition, physical fitness, so that it’s much more explicit about what they need to be well-versed in as they are preparing for their future.

So I ask, what is this vision that PPACA is promoting for our medical students? What does LCME require, for us to decide whether we’re doing this very well or not? Then where do we go from here?

At Creighton, our very first medical school was a dilapidated old building. The curriculum consisted of the basics of anatomy, physiology, pharmacology  – the hard core sciences. Is that the goal anymore? Or is now the goal in medical education to produce professional physicians that have these other qualities? That they’re going to be well-versed in research? That they’re going to be very well-versed in leadership?

When you look at an MBA program, they don’t focus just on accounting and financing. They’re going to look at accounting and financing for the workforce, but also make sure that you’re going to be a good leader. Perhaps that’s something we need to start integrating into a medical curriculum.

Perhaps we need to take a look at the bigger picture and ask whether we really need a full semester of anatomy? Do all physicians really need to know the degree of anatomy that’s being taught now, or do we want to say here are the important aspects of anatomy, physiology, and pathology, that we feel is important for those in undergraduate medical education? If so, let’s divert some of that time in the curriculum to smoking cessation, to leadership skills, to weight management, to nutrition, to physical activity?

The medical school’s mission and vision

It goes even deeper. What is our mission and vision? Each of us who belongs to a school that has a mission statement is provided with some guidance as to where we need to go. I look at our own at curriculum at Creighton: “We are to provide excellence in educating students, physicians and the public, advancing knowledge and providing comprehensive patient care.”

We can take from that mission statement and expand the comprehensive patient care. Don’t we really need to make sure that we have time in the curriculum for preventive medicine, instead of just kind of alluding to it? The teaching of research, clinical care, and leadership is very much a part of our curriculum’s goals and our vision. If this is our vision, then how are we articulating that vision in our curriculum?

How do we prepare students best for patient safety? How do we participate in improving health outcomes, in the prevention of falls, and of smoking, and of stress; and the improvement of nutrition and fitness? What do we base our counseling on? The United States Preventive Services task force has said that there is insufficient evidence that nutritional counseling in the clinical setting makes sense. How do we prepare students for nutritional counseling if  we don’t even have a clear consensus that it makes a difference?

There’s nothing right now that the United States Preventative Service task force has recommended with regard to prevention of falls, so what do we really teach? How do we address the teaching of a skill that’s part of the vision for our students, but which cannot be described?  Similarly, we have the vision of leadership. To what extent are our students going to be exposed to this topic in the curriculum?

Many medical schools have just one month that they’re spending in family medicine and that takes place during their clinical years. We need to say that we really need to expand the amount of time in the clinical years that they’re in primary care, and the amount of time that we are educating students on the preventive medicine aspects.

I don’t have a lot of answers. I have probably more questions than answers at this point as I;mscratching my head and saying “Alright, what is needed in our curriculum in the future?” I will end here. Hopefully, we will get some thoughts and comments from the audience.