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Med schools offer doses of new reality
Programs adapting to changes in caregiving, health policy

By Sarah Lovenheim
Tuesday, November 10, 2009

When Aaron Laviana started medical school at Georgetown University in 2007, he dissected a cadaver in his first week, in anatomy class. Today, classes such as "Physician-Patient Communication" and "Social and Cultural Issues in Health Care" come first. Dissection doesn't begin until month four at Georgetown -- as part of a unit on limbs -- and anatomy class no longer exists.

At George Washington University's medical school, a third-year class began including a trip to Capitol Hill last November so students could listen to politicians and experts debate the changing health-care system. And Johns Hopkins University, anticipating a growing demand for more personalized medicine, has just launched the most significant revision of its medical school curriculum in 20 years.

Changes such as these are happening across the United States as graduate schools try to catch up with a dramatically changing medical landscape. They need to prepare students for a world where mainstream doctors adopt holistic or alternative techniques, where doctors' offices portray themselves as "medical homes" offering "patient-centered" care, where primary-care physicians are increasingly in demand -- and, of course, where the system of paying for health care is likely to undergo a major upheaval. Catering to these needs, medical experts say, could help future doctors offer preventive care first, reactionary second.

At the Association of American Medical Colleges, which collects curricular information from 130 medical schools, chief lobbyist Atul Grover says that the schools are trying to "move medical education forward at least as fast as medical information and delivery changes," in order to "train people not just for next year, but the next 20 and 30 years."

Laviana, now in his third year of medical school, served on a student-faculty task force that helped overhaul Georgetown's course requirements. For years the curriculum had been organized around traditional subjects such as anatomy, physiology and pathology. Now the school still teaches that material, but organizes it in a style called "systems biology": Faculty members draw from different disciplines as needed to help the students understand the workings of an entire human being. Much of the coursework is based on case studies.

"You learn to manage the patient as the whole, rather than just studying one organ at a time in anatomy class," Laviana said. "The program's preparing people to better manage patients and get a better sense of diagnosis."

The goal of restructuring the medical school was to turn out "the most compassionate, professional" doctors, said executive dean Howard Federoff. "We intended to break down some of the silos that had previously formed the sort of compartmentalized learning in traditional medical educational curriculums." Georgetown launched the revised first-year program in 2008 and began its new second-year program this August. Grover said that, nationwide, about "35 percent of the schools have an organ systems-based approach . . . and more are considering it."

Changes big and small

The trend toward patient-centered medicine was one factor in Johns Hopkins's decision to revise its medical curriculum, according to David Nichols, vice dean for education at the medical school in Baltimore. The other was the expectation, as far back as 2003, that a Democrat would win the White House and push for major health-care reform.

"We came up with a number of drivers that made it clear to us that our curriculum was going to have to change to adapt to future societal developments," Nichols said. "The adoption of systems biology as a way of teaching medicine, and the specific intent to use it in order to teach personalized medicine, gets to the larger societal goal of [achieving] personalized medical care."

Hopkins's new curriculum, called "Genes to Society," aims to teach students to analyze the genetic, environmental and socioeconomic factors that influence an individual patient's condition. One sequence of classes, for example, might be on heart disease. "If we took two different patients," Nichols said, "let's say Mr. Mohammed, who's 29 years old and has a heart attack, and Mrs. Jones, who's 80 years old with a heart attack -- even though they have the same diagnosis, the factors that led to their heart attack could be very different."

Instructors would begin by presenting one of those heart attack cases. Subsequent classes would address the genetics of heart disease, the physiology and functioning of a healthy heart, different kinds of heart medication, the costs and benefits of treating heart disease and the cultural aspect of chronic heart disease -- all discussed in relation to the human being at the center of that case. Other sequences might take the same approach to the endocrine system or liver.

Not all medical schools have made sweeping revisions to their entire curriculum. But smaller changes are evident at many.

Beyond sending students to Capitol Hill, GWU started offering a health policy track, similar to a minor, a few years ago. Although fewer than 10 percent of students choose it, those who enroll learn about legislation and some even write their own proposed laws by graduation. These future doctors will be "better informed about the cost of care and better informed about barriers, such as insurance," said Scott Schroth, senior associate dean for academic affairs.

Howard University's College of Medicine is planning to focus less on lectures and more on small-group sessions to move away from textbook-style learning. "We're putting more emphasis on building communication and interactive skills," said Sheik Hassan, associate dean for academic affairs.

Hassan is also focused on cultural changes, such as trying to attract more medical students from communities where doctors are needed the most. "What I would like to see is to have an increasing number of students from disadvantaged backgrounds, because these are the students who will work by and large in the disadvantaged communities," Hassan said.

The school offers scholarships and loans for such students; what's still missing, said Hassan, are "lower interest rates for those students with loans or perhaps even loan forgiveness."

A surge of specialists

Meanwhile, some educators and students worry that few students are choosing to enter the field that best utilizes the skills taught in the new curricula. That field is primary care -- internal medicine, pediatrics and obstetrics/gynecology. Fifty years ago, half of the nation's physicians practiced primary care; today the proportion is about a third, and only 20 percent of current medical students plan to enter the field. The rest are opting to enter higher-paid specialties, such as orthopedic surgery and dermatology. And few think medical schools can reverse the trend.

"You might learn all about primary-care medicine in school, but I don't know more than one in 10 people looking to practice it," said Aida Taye, a fourth-year medical student at GWU.

A fellow fourth-year student of hers, Arash Nafisi, is that rare case. He's still on a primary-care track: "I feel strongly about the prevention of disease and bringing about sustainable change," he said. But he also notes that by the time he graduates, he will have racked up $300,000 of debt, and it would get paid back a lot faster if he made a specialist's income.

Grover, the spokesman for the medical school association, graduated in 1995 with a specialty in internal medicine. What influenced his choice? "What really made the difference in the mid-1990s was that at the height of managed care, we were all told as med students, 'Hey, you better go into primary care or we can't guarantee you a job.' That was the only time in history in which we had a big uptick in people choosing primary care," he said.

"If the government says, 'If you go into primary care, we'll cover your tuition,' that would change the industry for everyone."

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