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 ITOctober 7, 2013From the October 2013 print issue
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."
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."
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."
More than just academic
Indiana University School of Medicine is one of the schools selected for the AMA program, and its plan is to use its million dollars to develop a teaching EHR to ensure students are well versed in system, team and population-based care. It will be a "clone" of an actual clinical EHR, officials say, populated with panels of virtual patients for students to manage using information gathered from de-identified data from actual patients.
With a focus on IT-enabled quality improvement and patient safety, the project will run sequentially over each year of medical school across all phases of the curriculum, says Maryellen Gusic, MD, executive associate dean for educational affairs at IU.
"We are in the midst of redesigning our curriculum," she says. "So what our grant focuses on is the creation of a tool for use in our virtual health system."
Students will "be able to see patient records and make entries in them. They'll be able to devise a plan of care but at the same time, as they think about ordering tests, there will be the ability to have resources built into this teaching EMR to help them learn about the costs of different tests."
Moreover, there will be "resources to help them know about the effectiveness of those tests in helping to discriminate two diseases, and help them understand why one test might be better than the other for that," says Gusic.
The EHR will be built with help from IU's colleagues at the renowned Regenstrief Institute, which specializes in health informatics research and first started developing the pioneering Regenstrief Medical Records System back in the 1970s. And while students traditionally are introduced to EHRs in their clinically focused third year, she says, in this case they'll get to use the teaching EHR "right after matriculation."
Even when students have been exposed to EHRs, says Gusic, "they have not, at many medical schools, had the opportunity to think about how to use informatics to look at population health issues, to use big data to help them make decisions about their patients and the populations of patients they take care of. In the future, we want them to think not only about individual care, but the care of the whole community they're a part of."
This initiative, she adds, is recognition of a critical but perhaps still unappreciated fact: "Knowing how to access information and use information is one of the vital skills a future physician needs."
Out with the old
At New York University School of Medicine, meanwhile, faculty are already hard at work using their $1 million AMA gift to recast a curriculum meant be flexible and far more technology-enabled, developing a virtual patient panel with de-identified data from NYU Langone Medical Center physician network patients.
Students will also make "e-portfolio" with a dashboard to help track development of their competencies, officials say; after graduation the virtual patient panel can also be used to "support a lifelong learning framework in which physicians can input their own patient data."
Marc Triola, MD, associate dean for educational informatics at NYU School of Medicine, says the initiative is to get med school up to speed with "the changes that are happening on the clinical delivery network with the new care delivery models that the federal government is putting forth, the new ecosystem of data and the new way patients are interacting with the healthcare system."
And it's about time, he says.
"A lot of the structure and some of the content of medical education is more than 100 years old." The famous Flexner Report, developed by educator Abraham Flexner way back in 1910, has largely informed the model followed by med schools ever since.
"It defined what med school should be," says Triola. "It's four year long - two years of classroom-based instruction and two years of clinical. It should be based on the scientific method and scientific reasoning. That's kept medical school programs very similar for a very long time."
But in case it's escaped your notice, in the past decade or two, "there's been huge changes in healthcare," he says. "Not only in the way we deliver care, and where we deliver care, but also in the use of a team, for example, that is more about the continuity of how we interact with a patient."
Not for nothing, there have also been enormous advances in technology, and in the amount of data that's available, and in the ways data is used in making care decisions about individual patients and patient populations, and in how the business of medicine affects how physicians approach the way they practice.
"It's clear that, because of all those changes, we need a similar change in medical education," says Triola.
Recently, NYU launched a "curriculum for the 21st century," switching to a schedule that sees students spending 18 months of classroom, followed by two-and-a-half years of clinical experience, he says. "We've also moved toward a more integrated approach of teaching the basic sciences, integrated with clinical and patient-based medicine and care topics. That's opened the door to have a lot more agility in how we teach and how we adapt to this changing care environment."
Offering students the chance to chart their own path through school is essential for - and emblematic of - this new era in care, says Triola. "As the healthcare environment becomes more complex, it's not our job to produce a one-size-fits-all physician."
At NYU, he says, the bywords are "different opportunities for different students to become different kinds of physicians to meet the diverse needs of the healthcare environment."
The three-year long, care coordination and analytics curriculum, for example, "allows us to take de-identified clinical data from our practice network and from our EMR (and) be able to use those data to teach our students, from day one, about how to take care of panels of patients and populations of patients - data from the actual practicing physicians that these students will become.
"That type of authenticity will bring a level of relevance and practicality to teaching this topic that we simply never had before," he adds. "It's a huge leap forward, for us and for the students who are going to be graduating as much more sophisticated practitioners."
Aliye Runyan, MD, is an education and research fellow at the American Medical Student Association. She's also a 2012 graduate of University of Miami-Miller School of Medicine.
But none of that came until the "beginning of third year," says Runyan, "right before we were going into the hospitals full-time." At that point in their schooling, students get a "pretty basic training in EMR, and then they kind of learn it as they go."
At the time, she says, "I just thought, 'Oh, this is just how it works. I'll just shadow for the first two years and then I'll get to be more on my own.'"
But with some perspective, now that she has her sheepskin and is planning to start practicing soon, Runyan thinks differently.
"Now that I think about it, in retrospect, it would make more sense if I knew how to document (earlier), if I had those skills," she says. "The transition to third year would be much smoother. That's a big part, that learning curve of how to document. Everything is documentation. That would have been really helpful."
As a first- and second-year student, when she was "shadowing," Runyan had to sign a confidentiality agreement. "I got to look at a paper chart," she says. "I should be able to look at an electronic record. Or at least get to know the system. That way I'm learning more, I'm a more intricate part of the team."
When the American Medical Student Association gathers for its Empowering Future Physicians conferences in Philadelphia and Atlanta, Oct. 11-13 and Oct. 18-20, respectively, it's fair to wonder how many first- and second-year docs-in-training will be thinking the same thing.
"We've seen a significant increase in efforts to integrate learning using the electronic health record in the last couple years," says Carol Aschenbrener, MD, chief medical education officer at the Association of American Medical Colleges. (AAMC is the other sponsor, alongside AMA, of the Liaison Committee on Medical Education.)
There may well be good reasons for certain schools' slowness to adopt and adapt, she says. "Some students, we hear, are not using EHRs but it's not the fault necessarily of the educational program. Some systems, as they're implemented, make it very difficult for the student to interact directly."
Despite the forward strides, there's plenty of room for improvement still, she says. How to get there? There are plenty of ways to push for wider use.
"Medical educators (should) advocate with the companies that make electronic health records about the importance of accessibility to the learner," says Aschenbrener. Educational use has not been a priority, to date."
A lot of attention has been paid to encouraging hospital and physician uptake and meaningful use, these past few years - and rightfully so - but, "We need to think about criteria for systems, functionality for systems, that facilitate the education and training of young physicians," she says.
Speaking of meaningful use, there may be certain policy levers that could be pulled, too, says AMA's Skochelak.
The government has "been doing great work at the federal level" spurring adoption, she says. Might the feds also be willing to encourage "innovation in education that relates to what's coming in the Affordable Care Act?"
Granted, bodies such as the ONC have "so much to focus on to just get things off the ground that thinking about the special needs of trainees - at the moment, at least - hasn't been high on their list."
But with EHRs increasingly "woven into the way we practice," it may be worth thinking about whether schools ought to be incentivized the way providers have been, to emulate the way things are these days in practice.
After all, "We don't want (them) to teach, 'Here's how you use an EHR,' she says. "We want (them) to bring the real world of practice into where the students are."
Barring deeper federal involvement, "We need to make a strong case that if we want the physicians of tomorrow to be highly skilled in the use of these electronic medical records, we need to make it easier for them to interact with the record while they're in medical school and in residency," says Aschenbrener.
After all, she says, "Young people really want to use it."