George C. Mejicano, M.D., senior associate dean for education at Oregon Health and Science University’s School of Medicine, is overseeing a dramatic revision of the school’s curriculum, designed to tailor coursework to the strengths and weaknesses of each student. The new program also emphasizes the acquisition of skills needed to deliver optimal care, including the ability to manage large populations of patients, conduct ongoing assessments of the quality and efficiency of care delivered, and better manage chronic conditions. Quality Matters asked Mejicano about the school’s new model and the challenges of implementing it.
Quality Matters: With your new approach, students will enter and exit the medical school at different times, with graduation contingent on demonstrating competency in areas you’ve prioritized. What was the problem with the old way—that is, enrolling a cohort of students and teaching them foundational science and the skills of clinical practice in lockstep?
Mejicano: There are a number of issues, but the most important is that it assumes that all students are the same. We end up equating someone who has served as a medic in Afghanistan or a person who was a veterinary surgeon with a French major. It's just bad pedagogy. We need to be able to distinguish them—how they learn, what they need, and what their interests and skill sets are. Then we can customize their curricula. I expect that most of the curricula are going to be very similar, but some will be radically different.
Quality Matters: What’s an example of a customized approach that would be considered more radical?
Mejicano: A person who is a practicing physician assistant (PA) decides to apply to medical school. They have been working in a pediatric clinic for two years as a PA. They could conceivably skip much of the basic science content because they took it already when they were earning their PA master’s degree, as well as numerous rotations—including pediatrics since they actually worked as a frontline clinician in a pediatric clinic—such that they could graduate much earlier than a typical medical student.
Quality Matters: You’re also seeking to better integrate basic science education with clinical practice—in part by having scientists and clinicians collaborate on the design of courses. What’s been the problem with handling them discretely?
Mejicano: The separation, which has been going on for more than 100 years in most medical schools across the country, has led to all sorts of bad behavior and outcomes. The classic problem is the binge-and-purge mentality. I learn anatomy and that’s all I’m learning. I take my final exam on Friday, and on Monday I’ve probably forgotten much of what I learned, but it doesn’t matter because I’m on to the next thing. We hope that by showing the immediate application of basic science to clinical practice, more of the material will stick. That’s why we’re bringing biochemists, physiologists, radiologists, surgeons, and internists together to design our six educational blocks on organ systems. Their disciplines have to be intertwined. Clinical medicine demands it. That’s a big theme of our reforms.
Quality Matters: How might that play out in the classroom?
Mejicano: Let’s take the kidney as an example. If I learn the anatomy of the kidney, how it functions, how the kidney clears the body of metabolites and certain drugs, and how chronic kidney disease manifests in real patients, the material will be more effectively bound together. That will hopefully lead to better retention and integration of disparate concepts.
Quality Matters: Will the classroom experience differ in other ways as well?
Mejicano: Yes. I’ll contrast it to when I was a student many years ago. I could sit in the back of the lecture hall and never talk to anybody. Going forward, we have to be able to engage students to see if they really understand the material. Part of that requires being much better at incorporating new teaching modalities including team-based learning, simulations, and case-based learning. We also plan to weave in other things—we call them threads—such as public policy and system-based practice. We’re trying to get across the idea that you can take a high-performing doctor and put him or her in a bad system, and you’re probably going to get bad care. Similarly, you can take someone who is pretty mediocre or subpar and put him or her in a good system, and patients are probably going to get good care because there are checks and balances. We also want to convince students that achieving high-quality care is not only about assessing your skills and improving yourself, but it’s also about improving the care processes where you work to ensure that the system is facilitating the delivery of optimal care.
Quality Matters: You’ve said you’re trying to create doctors that can meet future needs. How did you determine what a high-performing doctor would look like in the future?
Mejicano: We asked many people in a lot of different places what kind of doctor they would want to hire in 2020 or 2030. One person, the CEO of a health system that operates rural and suburban hospitals in Oregon, said he wanted two things: number one, people with emotional intelligence, and number two, people who are competent in predictive analysis, so they can look at populations of patients and predict which ones are going to have problems down the road.
Quality Matters: Why is emotional intelligence so important?
Mejicano: Because you can never take the human element out of health care, and in order to provide patient-centered care, you need to be able to understand what the patient wants out of the experience. You also need to be able to read verbal and nonverbal cues to tell if a patient is too shocked by the diagnosis to absorb information or how to ask for an organ donation from a family whose kid was just killed in a motorcycle accident. These decisions and skills are not algorithmic.
Quality Matters: Does this change the criteria you use to select students?
Mejicano: Yes, because there are some things that are teachable and some things that aren’t. I use a basketball analogy—we can teach you how to guard and play defense, but we can’t teach you height. In medical school, we can teach skills like motivational interviewing, but we need to ensure students have communication skills because some of those are fixed. So there’s a lot of filtering that happens in the interview process. And that assessment of ability and skill continues throughout their education. Students get feedback not only from attendings and residents supervising the student, they are also getting feedback from patients and their families. Some are going to say, “You know what? You don’t know how to talk to people." We are also using what we call curricular or portfolio coaches to assess performance—a faculty member who tells you how you are really doing. The analogy I use is a high school or college coach. They are not your friend; they want you to perform really well. Here we don’t hesitate to point out that the person isn’t cut out for the job. In many places there’s an unspoken rule that once you get into medical school, it’s unlikely you won’t graduate. I have no qualms about kicking out students who don’t pass muster: I don’t want them treating my family or yours or anyone else’s.
Quality Matters: How about self-assessment. How do you go about teaching that?
Mejicano: I compare it to assessing or analyzing the quality of a dinner party. There are a variety of things that contribute to a successful party: you need a good recipe—that’s medical knowledge. You need to know what kind of kitchen you are working with—how many burners, how big is the microwave—that’s like assessing the strengths and weaknesses of the system in which you’re operating. There’s the cooking skill. Do you know how to sauté or flip a pancake? That’s patient care and procedure skills. There’s also the communication piece—was the dinner conversation fun and inclusive or was it awkward? Then there’s the professionalism piece—have guests asked about bringing a dish or do they offer to wash the dishes? And finally there’s the review of the dinner party—how did it go, what went wrong? In the past, medical education has emphasized the recipes; that is, the acquisition of knowledge. But all six matter and they matter equally.
Quality Matters: It sounds like there are a lot of moving pieces to your plan, which makes us wonder what sort of resources you’ve had to devote to this.
Mejicano: We’ve benefited from a $1 million grant from the AMA [American Medical Association] Accelerating Change in Medical Education and have submitted other proposals for more external funds. In addition, we have invested about $2.5 million ourselves. But part of it is spending differently. In the past we paid faculty based on the hours they spend teaching, rather than using outcomes as a metric for compensation. We’re testing whether we can pay for outcomes with a select group of faculty who were hired on one-year contracts. It may work, because the primary job for most faculty is not education; they are mainly clinicians or researchers. We’re also devoting resources to teaching faculty about the art and science of teaching. Up until now they have been learning it experientially because one rarely is taught how to teach in higher education.
Quality Matters: As you implement this model, are you seeing interest in it from other medical schools?
Mejicano: Yes. There are 11 schools that were funded by the AMA initiative and we are actively collaborating with each other so that best practices can be vetted and rapidly shared with other schools. The AMA has received numerous inquiries about the initiative, including from many other schools, as well as from a wide variety of stakeholders who are keenly interested in what we all are doing.
Quality Matters: How will you evaluate its success?
Mejicano: We will be using well-known benchmarks to assess traditional knowledge acquisition (e.g., examination scores at the local and national level). In addition, we’ll be using multimodal assessment methods to determine milestone and competency achievement, including patient experience of care surveys, global impressions by clinicians, standardized patient examinations, objective structured clinical examinations, procedural logs, quality improvement data, reflection narratives, standardized shelf examinations, and peer assessment tools. We also will develop new tools to assess proficiency in working in teams, applying quality improvement science, and clinical informatics. We also want to assess whether our graduates are “residency ready” by using surveys of our former students, as well as the residency program directors that have accepted them into their training programs. We hope to use students in the other AMA consortium schools as “controls” for some of the innovations we’ll put into place—and we’ll serve as the other schools’ controls for their interventions.