Are med schools failing future docs?

As the most-wired generation works toward their degrees – and gears up to practice in a whole new healthcare world – some are rethinking how much IT

It's a safe bet that this fall's crop of new medical students is the most tech-savvy cohort yet. These are young adults, after all, who've been tapping on smartphones since they were 16, surfing the Web pretty much since they could read.
But how much information technology are they actually getting their hands on in school?
Physicians nationwide are being carroted and sticked into making meaningful use of electronic health records and other health IT, but what about the physicians of tomorrow? Many medical students have never even had the chance to make a note in an EHR, even though the technology will be inextricable from the way they'll practice from now on.
That's to say nothing of more advanced analytics training, say, or a primer in the newfangled terminology - quality measures, care teams, bundled payments - that will be the common language of the post-reform era.
A study published last year by the Alliance for Clinical Education, which comprises education leaders from an array of medical specialties united to work toward better instruction of medical students, was not encouraging.
It found that just 64 percent of med school programs allowed future docs any use of electronic records; of those that do, only two-thirds allowed students to actually write notes with in the EHR.
"Schools have a responsibility to graduate students with the expertise and sense of duty in the basics of practice," said Lynn Cleary, MD, president of the Alliance for Clinical Education, upon that study's publication. "The EHR is now part of that skill set."
Maya M. Hammoud, the study's lead author and associate professor of obstetrics and gynecology at the University of Michigan Medical School, says most schools "realize it's important," to give students a solid grounding in EHRs, but "it's difficult to implement; it's a different way of doing things."
There are hurdles both practical and philosophical when it comes to actual patient care, says Hammoud.
For one, "How do we meet billing requirements and, at the same time, be able to write notes in the charts. If a student writes a note, and the note is not accurate, and then there's an issue with the patient and there's a legal issue, what happens? That's one reason it's been difficult to integrate: People want students to write their notes, but don't want it to be part of the chart."
But more generally, EHRs in the student setting represent a fundamental change from just five or 10 years ago, she says: "How do we get the faculty to adjust to it? And then how do we integrate it with the students?"
Having published the Alliance for Clinical Education study in 2012, Hammoud says she hopes those adoption numbers "would be a lot higher now."
Still, she says, "The main issue is that the students feel kind of marginalized. Even when there is an electronic health record, and there is a spot for student note, when it's classified as a student note it's not counted as part of the chart, it's like, 'I'm not really part of providing patient care, so what's the point of me writing the note there?'"
That's doing a disservice to students who "are a lot smarter these days than we used to be when we were in medical school," she says. "They're very savvy in technology, and they're very idealistic and want to do the right thing."

Eyes on the prize
This past June, the American Medical Association awarded $11 million, to be split among 11 medical schools, in a bid to push the envelope on the way the physicians of the future are taught. Its Accelerating Change in Medical Education initiative is one way to help "close gaps in readiness for practice," says Susan Skochelak, MD, group vice president of medical education at AMA.
Schools such as Mayo Medical School, University of California, Davis School of Medicine and The Warren Alpert Medical School of Brown University were each granted $1 million over five years to pursue new paradigms of education, from completely immersing students in the healthcare system from the first day of classes and to the deployment of virtual patients. Even better, the 11 schools will establish a learning consortium to share and learn from each other's smart ideas.
If it's tempting to be dismayed by the fact that perhaps one-third or more of medical school students aren't given even basic access to EHRs, it should be encouraging, at least, that the response to AMA's call for proposals for IT-enabled teaching was widespread and robust. Of 141 eligible schools, 119 of them, or more than 80 percent, submitted proposals, officials say.
"We were really surprised at how many schools responded - and gratified," says Skochelak. "It speaks to the readiness for change that's out there." Most schools "know they want to change," she says, "but they're having trouble breaking out of the constraints that they're in."
AMA, as one of the two co-sponsors of the Liaison Committee on Medical Education, the accreditation body for medical schools, has a special interest in the topic, says Skochelak - who agrees that there's some serious work to do in integrating technology in education.
Observers "have been saying for some time that our graduates are not really ready for the real world of practice," she says. Without some pretty big changes, "We were a little pessimistic that there would be enough change for what's needed right now."
AMA isn't the only one who thinks so, says Skochelak. "When you talk to people who are hiring in the major health systems or you talk to graduates, what they'll say is they really are not prepared. They don't know how to manage panels of patients; they don't fully even necessarily know what to do with an EHR."

Next-generation tools
None of this is meant to cast aspersions on medical schools in general, of course. Merely to point out that some have been quicker to adopt and embrace health IT than others.
In fact, says Skochelak, "Some of our schools are really going into that next-generation of what we need to do to teach."
But other schools, just like myriad physician practices and a goodly number of hospitals, have been slow to adopt. There are several reasons for that, she says.
"One of the problems we have is that we don't really know how to use a teaching EHR, and the vendor products out there are not designed for teaching. Right now, yes, students can get in the EHR, they can read, but they cannot write a note, because they are not a legal provider. They cannot manipulate the system the way a physician would want to get quality data - that's incredibly important and will become more so."
That's why it's all the more important that new students are introduced to the interface "early on," she says. "It allows the students to learn the data in an EHR so you find out, for example, 'How am I doing on my hemoglobin A1c for my diabetic panel of patients?' Physicians should be able to get that information now; it's important in reporting and outcomes. It immediately helps them understand the reality and usefulness of it."
There's a tendency for schools to have students mostly be "observers," says Skochelak. But it's important to offer "authentic and hands-on" experience. "Standing in front of EHR can be pretty tedious. Students really want to have experiences they know will help them when they get out."

New world
The healthcare landscape when they get out, of course, is going to look a lot different than it did for physicians doing their residencies even a decade ago. Docs in the world after the Affordable Care Act are going to have to understand and be fluent in a whole host of approaches to accountable care that were never part of the equation before.
"That was one of the areas we identified as probably one of the weakest in terms of medical education," said Skochelak. Even though most schools are starting to "come along in terms of IT," their ability to offer students a grounding in the reality of post-reform care delivery is still lacking.
"Shepherding resources effectively, making sure the best quality is provided, and how do you measure it? What's the science of quality improvement if you identify a gap? These are topics that are also being brought into this new initiative and are front and center. We're hoping to develop new programs that other schools can rapidly take up."
Because there's one key message for med students, she says, whether they're first-years or residents: "It's your job, for the rest of your life, to pay attention to this stuff"
The good news is that they're up for the task. Hammoud, from University of Michigan, makes points out that students usually "learn a lot faster than the rest of the staff." Indeed, "sometimes they're helping them learn."
Skochelak, in her past role as dean for academic affairs at University of Wisconsin School of Medicine and Public Health, remembers seeing young residents who had already "set-up templates and decision rules" in the EHR. "It was a natural for them. In some ways we just have to get out of their way and then take the best ideas they come up with."
And good ideas are the driving force behind AMA's Accelerating Change in Medical Education project: Find the best of them, from the most forward thinking medical schools, and then support them - and the other 10 schools in the consortium - for five years.
"We're looking for rapid dissemination around the schools, which will hopefully give confidence to other medical schools," says Skochelak. "If one school does it, fine. But if 11 schools implement something and it's been highly evaluated then it will give other schools more confidence in picking up these ideas."

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