HARRISBURG, Pa. — The doctors-in-training removed their shoes and padded into Glorian Watson’s tidy first-floor apartment in socks and bare feet. They pulled up chairs at her dining room table, plopped down on her love seat and caught up with the cheerful 52-year-old whose body often rebels against her, with digestive issues so severe that she can find herself hospitalized for days or weeks.
These doctors-to-be don’t know much about her illness, Crohn’s disease. They can’t prescribe her medications, order lab tests or admit her to a hospital. Instead, they’re here to learn something that most medical schools never teach but that matters as much: What’s in her fridge? Does she have a ride to an upcoming appointment? Can she afford her drugs and gluten-free diet?
“We learn a lot about barriers to health care that physicians don’t normally think about,” said Christopher Davis, a second-year medical student at Penn State College of Medicine.
U.S. health care is in a revolution that is starting to shake up one of the most conservative parts of medicine: its antiquated model for training doctors.
Once paid a la carte for the procedures and services they perform, physicians are beginning to be reimbursed for keeping their patients healthy. Doctors trained in the science of medicine, the diagnosis and treatment of the sick person in front of them, are increasingly responsible for helping to keep their patients out of the hospital.
Those changes have been rippling through the health-care system for years in an attempt to address rising costs but were powerfully accelerated by the Affordable Care Act. That has left medical schools scrambling to catch up.
“The irony is that medical education is a bit frozen right now in the tradition that we started almost a century ago,” said Susan Skochelak, group vice president for medical education at the American Medical Association. “It’s just really getting farther and farther behind in helping our young new physicians really know how to work in the current environment.”
That’s changing. Penn State is making its first-year students patient navigators. The University of Texas at Austin is building a medical school from scratch, with an explicit focus on areas beyond the doctor-patient interaction, such as health-care delivery and population health. The AMA is worried enough about the problem that it has been giving out millions of dollars to prod new kinds of teaching, in the hope that doctors’ training can adapt as quickly as the system they will soon join.
The last major upheaval in medical education occurred with the publication of a landmark document called the Flexner Report.
It was 1910.
The document put forth a set of recommendations: Medical students should have two years of basic science and two years of clinical rotations in hospital wards. The basic contour of medical education has been preserved since, even as the amount of information that constitutes medical understanding has exploded exponentially.
Ask doctors and you’ll get different laundry lists of the facts they memorized for tests — the name of each bone in the hand, or all of the biochemical steps of the Krebs cycle involved in metabolism — that they have not used since. Or that they simply look up as needed.
“Our medical education model is based on a very different reality” than the one that exists, said Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School who co-wrote a textbook for medical students on a topic once anathema to medical training: costs. “You can’t memorize everything you need to know to be a good doctor; you can’t memorize the catalogue of prices. What you need to be able to do is know where to access information and have frameworks for how to care for patients.”
In 1974, Victor Fuchs, a health-care economist at Stanford University, wrote a book called “Who Shall Live?” that described the physician as the captain of the medical team. In the preface to the 1982 edition, he demoted the doctor to co-captain. Today, he said, “they’re just a member of the team. They’re becoming a member of the team who knows a lot more about some things than everybody else but a lot less than other people on the team.”
To train doctors for this reality, one nascent medical school is taking a particularly radical approach. Dell Medical School at the University of Texas at Austin is rethinking how medicine is taught, adding a nine-month focus on health-care delivery at the time many medical schools would be sending their doctors on their first clinical rotations.
The school, which will enroll its first students next year, has been seeking out firebrands to lead the way. It announced some of the first hires at the festival South by Southwest: two veterans from the creative design firm IDEO, which is best known for developing the Apple mouse and updating the PalmPilot. The school is bringing on Eddie Erlandson, a well-known executive coach who has worked with Coca-Cola, Dell and the Boston Red Sox, to help teach doctors to work together effectively and to be leaders.
Perhaps more subtle, but just as important, is an effort to set up a financial structure that allows the school to avoid what its dean, Clay Johnston, sees as a major conflict of interest: Medical schools generally receive revenue from the prestigious hospitals they own. That means that schools may be hamstrung by the old way of being reimbursed for each procedure or service they provide.
“The more they do, the more they get paid. The higher prices they can generate, the more they get paid. That isn’t what society should want from health care,” Johnston said. “Only medicine has that, and I think because of that, they’ve become defenders of the status quo. . . . We think that can have a corrupting influence on the innovation goals and on their primary responsibility to society.”
The school is funded in part by a property tax increase that was passed by voter referendum and generated $35 million. It also is pursuing compensation agreements with community doctors and health-care facilities that are tied to meeting specific quality goals, not performing the most procedures. So administrators hope to support the school financially with contracts that pay for overall value.
For example, they are pursuing a partnership to reduce pre-term births, which cause many significant health problems and huge costs. The medical school will be reimbursed based on whether it has been successful at reducing pre-term births, not on the volume of the services it provides.
Kevin Bozic, chairman of surgery at Dell Medical School, is setting up an osteoarthritis center that will teach surgeons to work in teams with many other providers to manage disease, not just fix joints. That will require the embrace of a philosophy unusual in a discipline that has often been governed by the idea that “the chance to cut is a chance to cure.” Bozic wants surgeons to think about preventing surgeries, too, and understand that sometimes the best course is not to operate at all.
“We’re really trying to start from scratch here and design it without a lot of the impediments of the existing system,” Bozic said.
But coming up with new curriculum and new ideas means untrodden ground. Dell’s leaders realize they are engaged in an experiment, which means they could succeed or fail.
“Dell has the biggest opportunity to do something. They’ve got the right people, the right support, the right environment,” Shah said. “Wait and see what they’re able to do.”
A tectonic shift can’t hang on the success of a handful of bold start-ups, and in 2013, the American Medical Association gave $11 million in grants to medical schools making changes that would narrow the gap between how physicians are trained and how medicine is practiced. This year, the AMA decided to extend the program to hand out an additional $1.5 million.
Penn State was one of the grant recipients and last year rolled out the patient navigator program. First-year students pair up and make home visits, where they are faced with problems that can be far more difficult than figuring out which tests to give and what to prescribe. Students learn about the intractable factors that can shape a person’s health — where he lives, what he eats, what social supports he has — essentially, his life.
At Penn State College of Medicine, second-year student Max Hennessy said a patient with severe arthritis complained to him about her reclining chair, which had been broken for a month. She didn’t have the money for a new one and had been getting up at a precarious angle that increased the risk that she would fall and break her hip again. It turned out that the chair wasn’t plugged in, and the students fixed it.
What Hennessy and others said they are learning is that medicine is even more difficult than what they absorb in class. Many chronic medical problems aren’t solved by a prescription or a doctor’s appointment. The best care in the world won’t make a difference unless the patient is invested in a treatment plan.
Brenda Mayberry, a nurse at PinnacleHealth Medical Group who works with the Penn State students, acknowledged that at first she wasn’t sure whether the program would help. But she has changed her mind. For example, Watson, the Crohn’s disease patient, was admitted to the hospital 10 times in the year before the program started. In the year since, she has been admitted only four times.