Once students arrive in medical school, there would still be preclinical studies, but these would be radically altered to what we call an “encounter-based model,” in which the entire curriculum would build from the patient encounter. (A “map” of our proposed curriculum is shown in figure 14.1 at the end of the chapter.) Every patient-doctor interaction begins with the patient’s concerns: What is my diagnosis? How will you treat me? What can I/we do so that I remain well? For each concern, students would learn to differentiate the relevant history from information that is merely distraction. They would learn which physical findings are most diagnostic, which diagnostic tests are most effective to accurately rank the list of possible diagnoses, and which treatments are most effective, based on real, clinical evidence. These early clinical encounters would begin to train students to become the doctors we need and want. Not only would they learn to practice truly evidence-based medicine; they would also learn how to work with all patients and function as part of the team that delivers today’s medical care.
In an encounter-based model, the traditional preclinical courses would be abandoned as students learned how to manage patient encounters from a foundation of empiricism rather than from scientific theory that may or may not explain how or why interventions work. The curriculum would include instruction in clinical reasoning and decision making, techniques to search the medical literature, and critical appraisal of medical studies. Other courses would familiarize students with landmark clinical trials and biostatistical concepts as well as giving instruction in how to make clinical decisions when the existing evidence base is weak. An encounter-based curriculum would immediately put to use textbooks that are presently not used until the clinical years. This would be appropriate because students would be learning the skills of differential diagnosis, evaluation, and treatment—skills essential for a practicing physician—from nearly day one of medical school. Students would begin with the most common complaints diagnosed and managed by generalists and gradually move to the less common diagnoses—those usually managed by specialists. The tempo of these courses would be slow at first, allowing educators both to assure that students’ scientific knowledge base is adequate and to provide a foundation in the language of the science of medicine. Similar to today’s curricula, the preclinical period would culminate with an intensive study of pathophysiology. However, in this revised curriculum, the study of pathophysiology would teach students scientific models not as a justification for how medicine is practiced but as a basis to understand the current theory of disease.
This preliminary course work could be completed in 12 months, allowing for expanded and revised clinical education. The goals of the clinical years are threefold, reflecting our three goals for our graduates. Students would learn to develop effective patient-doctor relationships, to work within a complicated and ever-evolving clinical team, and to master clinical reasoning—the ability to work from a patient’s symptom to an accurate diagnosis, using the tools of the medical history, the physical exam, and appropriately acquired and interpreted diagnostic tests. During the clinical years, students would also master the most evidence-based therapeutics, both medical and surgical.
Presently, the clinical years of medical school are essentially an apprenticeship. Students rotate with senior physicians and are trained by these doctors. The learning in the various specialties (obstetrics and gynecology, surgery, pediatrics, and so forth) is enhanced by didactic curricula meant to fill the holes in the clinical experience. This method has historically been effective—American medical schools produce fine physicians—but inefficient; not all mentors are equally skilled, and students often master topics that are uncommon, thus providing little benefit to their future patients, at the expense of more common, fundamental problems.
The expanded clinical years in a reformed system would carry both greater demands and greater potential. In this proposed curriculum, some of the medical sciences that are currently covered in the “preclinical biennium” would be taught. These topics could now be focused and relevant, being closely linked to clinical cases. In our quest to decrease medical reversal, time would be spent in small groups learning to critically evaluate the evidence behind every decision made during an actual patient encounter. Students would learn to care for today’s patient while mastering the skills needed for lifelong learning. This structure would actually benefit patient care in the training environment. Imagine mentored students in hospitals and medical clinics who work at vetting the diagnostic approach and therapy being offered to patients for the adequacy of its evidence base. With the core clinical experience expanded from 12 to 18 months, there would be ample time to achieve these goals.
In the current model of medical education, the 12 months following the core clinical rotations is the fourth year of medical school, characterized recently by one of our medical students as a very expensive vacation. In our proposed, reformed system, the 18 months that follow the core clinical rotations could be used to enhance the skills and knowledge that students had been acquiring. What would the student have learned? At this point in her training, this “senior student” would possess a relevant and practical knowledge of the scientific foundation of medicine, clinical skills, and an intuitive understanding of the evidence on which practice is based, as well as a pretty good idea of what she wants do to for the rest of her career.
What would we do in these final 18 months? First, to put the encounter-based curriculum in place, we reduced preclinical science training. Now, after the student has been grounded in clinical and evidence-based medicine, is the perfect time to teach the basic sciences. Physiology, cell biology, pharmacology, and other foundational sciences could be revisited at this time. Teaching these sciences to students who already know clinical medicine would be revolutionary. Students at this point would be junior clinicians, rather than recent college graduates, so the instruction could be clinically relevant and case-based. Furthermore, because these students would understand the applicability of the subject matter to clinical medicine, their motivation to learn the material would be enhanced. Because the detailed basic science education would follow experience with trial-based decision making, students would be unlikely to trust mechanistic explanations as the basis for therapy—one common cause of reversals.
Beyond the basic science courses, students could pursue courses and clinical experiences most applicable to their chosen disciplines in medicine. Besides the currently offered clinical rotations, in which students take on more clinical responsibilities and work with subspecialist consultants, there would be a range of seminar, laboratory, clinical simulation, and didactic courses: intensive anatomy for surgeons; advanced diagnostic reasoning for future internists; advanced training in translational research for those hoping to become medical scientists.
OVERCOMING THE CRITICS
As with any curriculum revision, the naysayers will be numerous. Their objections are easy to predict. First, they will say that such restructuring would be hard to adopt. In reality, the only difficult challenge would be having medical schools agree on prerequisites. These discussions are already under way. In addition, if the most competitive medical schools, those that admit a tiny fraction of applicants, begin to publicize their new admission requirements, students will work to satisfy them. It will take some brave medical school and university deans to be the first to adopt such a strategy, but medical schools function in a seller’s market. Many of the nation’s newest medical schools (the Cleveland Clinic Lerner College of Medicine and the University of Central Florida College of Medicine) have adopted progressive curricula with no shortage of applicants.
Others might argue that the requirement of more advanced science classes in the undergraduate years would make it more difficult for non-science majors, who are increasingly attractive to medical schools, to enter medicine. In reality the number of requirements might decrease as the type of courses changes. If more students do end up needing to complete their undergraduate course work a
fter college, medical schools (and patients) will only benefit from applicants who are a little older, a little more mature, and a little more committed to their medical education.
The loudest objection might be that if basic scientific training is decreased, there will be little that differentiates physicians from physician assistants and nurse practitioners. The argument might be that sacrificing training in the scientific foundation of medicine will leave physicians practicing from algorithms. Critics might say that tomorrow’s doctors would be unable to reason from the pathophysiology that underlies the most complicated cases. In fact, we believe the new structure would actually enhance physicians’ scientific knowledge. The more tightly scientific learning and clinical learning are integrated, the more applicable this knowledge will be to the care of patients. In the reformed system, students would learn the foundational sciences from a team of clinicians and basic scientists teaching the most clinically relevant sciences. This differs from the present standard, in which the basic sciences are typically taught by scientists, often gifted in their fields but just as often having little connection to the world of the clinic. These teachers are often likely to teach what they study and enjoy rather than what is critical to the physician in training.
Maybe most convincing in our argument for reform is that some of our finest and most progressive medical schools are already moving in this direction. Many schools no longer require applicants to take college math but suggest biochemistry. Duke University School of Medicine, one of the first to break with Flexnerian dogma, reduced preclinical training to one year. This unified year includes integrated courses in the science of health and disease (rather than the standard curriculum in which students learn about the healthy body in year one and the diseased body in year two). Although Duke made these changes to allow more time for research training, the new program has shown that reduced preclinical training is compatible with training excellent physicians. Many other fine schools, including Yale, Harvard, Case Western Reserve, and Columbia, have either recently reduced, or are planning to reduce, the length of their preclinical curriculum. This curricular change is becoming so common that it seems less and less remarkable. The schools each have their own reasons for making the change, but their willingness to alter their curricula argues that major changes can be made.
Some schools have gone even further. New York University School of Medicine is the first school to offer a medical degree in three years. Selected students are able to complete the preclinical course work in 18 months with a curriculum more focused on their chosen specialty. Texas Tech Health Science Center School of Medicine, Mercer University School of Medicine, and others are also experimenting with three-year programs.
::
The practice of medicine today would be unrecognizable to the medical student and medical educator of the early 20th century, yet the structure of medical school today is unchanged from this bygone era. Diseases that were common 100 years ago have become rare, while new diseases have emerged. Antibiotics were a dream, the stethoscope was advanced technology, and DNA was decades from discovery. The concept that decision making could be based on large clinical trials did not exist, nor did the idea that the universe of medical information could be accessible at the bedside. Although we train excellent physicians, we do so inefficiently, and our training predisposes these doctors to promote and use therapies that will eventually be found wanting. A reformed system, organized around patient encounters and the analysis of investigative trial data, would train the next generation of physicians to practice a more reliable brand of medicine.
14.1 Proposed medical school curriculum.
15 ACADEMIC MEDICINE
THUS FAR, WE HAVE DESCRIBED how medical reversal happens and how its harms affect us. We have been writing about what goes on in regular doctors’ offices—actually not just offices, but in community hospitals, clinics, and operating rooms across the country. This is where most medicine happens. It is where the doctors who are the workhorses of American medicine care for patients. These doctors dictate how medicine is practiced. Their work is incredibly important and reflects so much of what makes the practice of medicine beautiful. Most aspiring physicians hope to break out on their own and practice their craft in the communities they love.
However, most of what is new in medicine does not come from these physicians. Doctors in the community are too busy to dream up new technologies and drugs, test them, and disseminate their results. By and large, the new things in medicine come from someplace else. They come from the academic medical centers, the so-called Ivory Towers. These centers— places like Johns Hopkins, the Mayo Clinic, the University of Chicago, the Harvard hospitals—are institutions committed not just to patient care but also to advancing research and discovery and training future physicians. They are usually closely affiliated with medical schools and universities. In chapter 14, we proposed that medical schools are a good place to address reversal, since all doctors pass through their halls. In this chapter we turn our attention to the academic medical centers, to see how the incentive structures at these institutions might contribute to reversal—and how altering this structure might reduce the prevalence of reversal.
We will do a lot of speculating here, even more than in the previous chapter. There is little research into how the organization of academic centers affects the staying power of the innovations they produce. What follows comes from our observations and those of our colleagues. Academic medical centers are immensely productive places with amazingly smart people turning out mind-bogglingly innovative research. There are, however, things about these centers that may undermine their excellence, or at least keep them from fully realizing their potential.
SUPERSPECIALISTS
Community physicians, including those who have specialized (becoming cardiologists, allergists, hematologists, hand surgeons) care for a wide breadth of patients. A cardiologist might take care of patients with coronaryartery disease, heart failure, and arrhythmias. An endocrinologist will care for people with osteoporosis, diabetes, thyroid disease, and pituitary tumors. Academic physicians often concentrate on a much narrower range of problems. With the exception of the general physicians who fill out the ranks at these centers (family physicians, pediatricians, and internists), much of the faculty at academic medical centers is made up of superspecialists. They are particularly skilled in very small pieces of the health-care puzzle. You might find a cardiologist who focuses solely on cardiac valves—not the coronary arteries, not the muscle of the heart, not the electrical conduction—just those wonderful, paper-thin flaps of durable tissue that open and close each time your heart beats.
This degree of specialization has been both inevitable and advantageous. Because we know so much more than we did a century ago, and the growth in our knowledge has been so rapid, no single person could ever master all the information even within a single specialty; for the most part, only someone deeply specialized will possess the foundational knowledge necessary to truly innovate. Medical advances depend on superspecialists.
There is, however, a price for this degree of specialization. Doctors who focus on just one problem risk losing perspective, coming to see patients—and even the whole of medicine—through the narrow lens of their specialty. By definition, these specialists know everything about their field—not just all the randomized trials ever conducted, but most of the observational studies and the basic science insights as well. Because of their narrow focus, and their knowledge of every study (including those of suspect methodology), these doctors can become overly committed to a therapy. They insist that some drug or intervention should be given to a patient, citing the rare report of improved surrogate end points (not exactly robust evidence). It is often a challenge for these superspecialists to collaborate clinically. It calls for quite a degree of thoughtfulness and humility to entertain the valid input of their (not quite) peers, who may sometimes point out that there is no good evidence supporting the treatment they endorse. The sol
ution to the problem created by superspecialists is to include doctors trained in the big picture, and in assessing evidence-based medicine, when it comes to making decisions for patients.
THOUGHT LEADERS
A subset of superspecialists become thought leaders in their fields. These leaders are the people we all—specialists, generalists, the media—rely on to make the biggest discoveries and to explain how the newest innovations affect patient care. When a new study about cholesterol therapy is published, one of a dozen or so thought leaders write the editorials in top journals, give nearly all of the interviews in the media, and guide most of the discussion. If a new study comes out on cancer of the kidney, everyone wants one New York City doctor’s opinion. When it comes to the care of the elderly, a certain Harvard faculty member is sure to be widely quoted.
How might thought leaders have an impact on medical reversal? At times, thought leaders charge money to meet with and advise pharmaceutical companies. Sometimes these funds are called honoraria and are presented as a gift for giving a talk or sitting through a meeting. The size of honoraria can be significant. An important thought leader can make tens of thousands of dollars (or more) by consulting with drugmakers, insurance companies, and device manufacturers. The relationship between thought leaders and the companies that develop treatments is complicated. Not only does the thought leader provide his advice and opinion to industry. Industry also gets to describe its vision and argue the merits of its intervention. The relationship is a two-way street.
Ending Medical Reversal Page 19
