Written in August 1999 by Myra M. Hurt, Ph.D
Then Associate Dean, College of Medicine
Director, Program in Medical Sciences (1992-2000)
As we face a future in which human embryos can be genetically manipulated, or cloned, a future in which the sequence of the human genome is completely known, we are faced with the ironic situation that academic medical centers are not producing the physicians our society needs. In the late 20th century, the well-trained physician is equipped to treat Degos’ disease but not shoulder pain, eosiniphilic fasciitis but not the much more common condition plantar’s wart. The medical textbooks used to train these physicians are written about the most unusual cases of disease known to man, not the common medical conditions upon which most of medical care is based. Internists leave their medical center training sites having not been exposed to a single case of osteoarthritis, early-stage diabetes or allergic asthma; never having examined a normal geriatric patient versus such a patient close to death, or a rural farmworker suffering from exposure to herbicides. These kinds of patients do not visit the academic medical center. Ironically, the knowledge and skills required to treat these kinds of common medical problems are specialized, yet this knowledge is not the focus of medical education in the late 20th century.
In an article from the New England Journal of Medicine titled “The Ecology of Medical Care,” written by a group of researchers in the departments of Preventative Medicine, Medicine and Biostatistics at the University of North Carolina, the following is reported:
The focus of medical textbooks is that 1 case (in the metaphorical sense) that makes it to the university medical center. The year the article was written was 1961 (NEJM, 1961, 265:885). The focus of medical education in academic medical centers today is largely the same.
In his book The Innovator’s Dilemma (1998, Harvard University Press), Clayton Christensen describes the forces against change in established corporate structures. Using examples from corporate America, he illustrates how innovation almost always comes from outside a corporate structure, from what he calls disruptive technology. The values, the culture, the way decisions are made within the established corporate institution producing the sustaining technology in a field make it impossible for that institution to change quickly enough to meet the demand of customers for change.
The ability of academic medical centers to meet the need for educational reform can be examined using this paradigm. Their product, medical care, is ever more technically driven, and the performance of their product is needed by an ever smaller group of patients (those with the rarest diseases not treatable anywhere else). Meanwhile the mainstream customers (patients) have needs that are very different from this rarefied set of the most demanding customers. The resulting situation we find today sets up beautifully a platform for launching the development of a disruptive technology, a new approach to medical education and health care delivery. This disruptive technology would embody different values, build a new culture and succeed where the sustaining technology fails because the disruptive technology is unencumbered by the culture of the sustaining technology, which values only the research contributions to the health of the sickest, the most exotic patients under medical care today. By canvassing the consumers of medical care, and by taking aim at meeting the health care needs of the majority of patients, the disruptive approach to medical education can be launched, with high likelihood of success.
In response to the changing environment in which doctors practice today, medical leaders have recognized the need for addressing present-day shortcomings in medical education. The American Association of Medical Colleges (AAMC) has sounded the call for deep reforms in the way physicians are trained in AAMC-accredited medical schools. In 1995, a strategic plan was adopted by the AAMC to meet the challenges facing medical schools and teaching hospitals (“Taking Charge of the Future: A Strategic Plan for the Association of American Medical Colleges”). The president of the AAMC, Jordan Cohen, M.D., in an article in Academic Medicine (1998; 73:132-137), called for leadership in improving the education of doctors. He stated that change is not happening fast enough, that there is no time to waste even while recognizing there are many obstacles to change. And perhaps the biggest obstacle to the necessary changes is the culture and the value system found within America’s medical schools.
Our goal is to broadly train the physicians of tomorrow, giving them learning opportunities that will make them lifelong learners – to equip them so that they can teach themselves what they need to know to practice medicine in an era of genetic intervention, the application of stem cell technology, massive choices of pharmacological applications, the use of a broad array of new diagnostic and therapeutic technologies in their own offices. The basic science component of this training program will occur in a university setting, integrated into the culture and value system of a liberal arts university, The Florida State University. The clinical training component will occur almost completely on the front lines of the health care delivery system, in the North Florida region as well as sites across the state of Florida – ambulatory care settings including physicians’ clinics, HMOs and chronic-care facilities in rural, urban and suburban settings. The curriculum will be comprehensive, preparing students to enter residency training in any specialty. However, it will emphasize the college’s mission of providing primary care to Florida’s elderly, rural and other medically underserved populations. Finally, the training program will focus on creating a culture that places value on the doctor-patient relationship, generalist ambulatory medical care and working as part of the health care delivery team.
The dynamic curriculum will incorporate the competencies mandated by the customers – patient groups including the elderly, chronic disease foundations, patients of HMOs, patients from rural and inner-city areas, gender groups, etc., the patient populations found in Florida and across the United States. This new curriculum will undoubtedly create new research opportunities: In the academic medical center, research drives the curriculum; in our disruptive-technology model, the curriculum will drive new research initiatives. The Internet will play an integral role in the educational program – it will be used to link clinical training at diverse ambulatory sites, facilitate small-group interactions of students, faculty, community physicians or patients at proximal or distant geographic sites across North Florida, the state, the country or the world. It can be used to facilitate learning activities for all of the above groups and to assure comparability of educational experiences at multiple training sites.
Much of the basic science curriculum will be delivered in a case-based, small-group approach utilizing teams of instructors that may include basic science faculty, clinical faculty, other health care delivery team members (nurse practitioners, physician assistants, pharmacists, etc.), other students, social workers, therapists and patients. The McMasters (Canada), Harvard Medical School New Pathway, and University of New Mexico models for the case-based approach are mature and tested and have been shown to work in schools accredited by the LCME of the AAMC; a multitude of published cases are available for use in this curriculum should they be desirable. Clinical training will occur primarily in ambulatory settings. As will be described under clinical curriculum below, we will use well-tested clinical training programs in AAMC-accredited medical schools that focus on ambulatory training sites as models in the development of our clinical curriculum.
An integrated curriculum will be developed containing a core curriculum – the fundamental and unchanging concepts of how humans work at the macroscopic, microscopic and molecular levels (physiology, anatomy, biochemistry, cellular and molecular biology, and human behavior) – which will be defined and incorporated. Preparation for the practice of medicine in the next 5-15 years will necessitate additional curricular components of molecular biology such as genomics, molecular embryology, molecular pharmacology, etc. Other components of the curriculum that will be continuous throughout the four years may include:
1) Treatment of specific patient populations – the elderly, patients with chronic diseases, rural populations, inner-city populations, gender groups, children, etc.
3) Human behavior and the impact of behavior on compliance with treatment regimens.
4) Biomedical ethics.
5) Preventative health care (nutrition and fitness; environment and health; etc.) – focus on the well patient versus the sick patient.
6) Alternative medicine.
7) The practice of medicine – practice management, HMOs, etc.
8) The basic clinical skills – ability to take a patient history and perform a physical examination, communication skills and skills in developing interpersonal relationships. The use of standardized patients (pediatric, adult, geriatric) will play an important role in the training of medical students in these skills.
As stated above, the curriculum will be integrated, so the boundaries between basic science and clinical curriculum will to some degree disappear. Training in the care of patients will be a continuum throughout all four years of medical training. The required clinical clerkships that traditionally occur in the third year of medical education will occur almost entirely in ambulatory settings – three months or less of specialized clinical training in hospital settings will be part of this curriculum. The University of Minnesota School of Medicine Rural Physician Associate Program (RPAP) has such a clinical training program as a pathway within the School of Medicine and has a long history that demonstrates that this approach to medical training works. The University of Washington School of Medicine WWAMI program also utilizes ambulatory sites in five states for clinical training of physicians in Family Medicine. Michigan State’s College of Human Medicine uses six Michigan communities for clinical training of future physicians and also focuses heavily on training with local physicians in the communities. These are mature programs with long histories of meeting AAMC standards for accreditation. In the Minnesota RPAP program, students spend only three months of the two clinical years in teaching hospital settings in Minneapolis, and spend the rest of their clinical training in physicians’ offices in rural areas of Minnesota. In the University of Washington WWAMI program, students spend Year 1 and Year 3 in rural settings in Wyoming, Alaska, Montana and Idaho. Michigan State’s Upper Peninsula clinical training program is focused entirely in rural community settings. These schools have tried-and-true mechanisms in place to assess students, physician preceptors and training sites to assure comparability for the LCME of the AAMC. These programs will be used as models for the development of the clinical curriculum.
The FSU clinical faculty will be composed of some full-time physician educators but will draw heavily on the pool of local and regional community physicians who will be compensated for the training of students in their practices. Minnesota, Washington and Michigan State provide models for the credentialing process for such community clinical faculty. Because of the unique curriculum and structure, Florida State University will not own a teaching hospital nor a physician practice plan for clinical teaching faculty. All clinical teaching faculty will have ongoing faculty development/training as part of their compensation package.
The historical size of the PIMS class was 30 members. Great value has been placed on the PIMS culture and values by the PIMS students, alumni and faculty, as well as the administrations of the UF College of Medicine and FSU. A major challenge for the FSU medical program is to retain this culture and set of values in the face of change. This is possible if the PIMS recruiting and admission philosophies are retained, and if the curriculum and facilities are designed to foster small-group interactions, both in delivering the curriculum and in providing dedicated study environments such as the current PIMS class has in the PIMS resource center, a dedicated study facility available to the students 24 hours a day. Upon completion of the new medical school facility, the class size would reach full maturity at 100-120. The inaugural class of 30 students will graduate in the year 2005, and will be the first class to earn their M.D. at The Florida State University. The second year is being offered for the first time in 2002, and in 2003 the first regional medical school campuses will be operational.
Today, such diverse groups as HMO administrators and the leadership of the AAMC, medical educators and medical students and, most important, patients of all kinds agree on the following: Our nation’s medical schools are producing the finest medical specialists on the planet, and their faculties are producing research astounding in both breadth and depth. Yet, many patients are not getting the medical care they want or need. Recently, a large survey of people representative of all population groups within an entire population identified the roles the ideal physician should be competent to perform (CanMEDS 2000, The Royal College of Physicians and Surgeons of Canada, 1996). These roles are: Medical Expert (clinical decision-maker), Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional. These same competencies were recently endorsed by several American medical specialty societies. The time is right to launch a new approach to equipping physicians with the skills to play these roles in the lives of their patients. That approach will be launched at The Florida State University.