Four Big Ideas from the Carnegie Study on Medical Education



this program is brought to you by Stanford University please visit us at stanford.edu I've begin by saying I'm delighted to be here and I'm looking forward to the conversation with each of you and it's nice to see a number of colleagues and friends who I've known through the years this is an opportunity to sort of lay out for you the four big ideas that we've sort of coalesced around in our Carnegie study about the future of medical education so that's why I'm excited about the opportunity to engage in dialogue about this I have to say that in my now almost four decades of work in medical education that I've never seen a time like this in the sense that every single organization in the house of medicine is saying can't we do this better it doesn't make any difference whether it's the AMC the AMA the nbme our RCS you name the alphabet soup but they're all saying we've got to think this again and we've got to do it better probably thinking it through in a new way that allows us to be more efficient in terms of the learning approach to this given the fact that we're more and more compressed on the time end of things so with that is background this is what I'm going to do it's where is it we got the right side what they did I didn't I got it okay so the first thing I want to do is describe a bit about where we come from it's striking to me that the framework within which we work in medical education was set at least a hundred years ago and so I want to describe a little bit about the flexion report after all Abraham Flexner was one of the first people to do the kind of national survey work that we're doing again and it is in a sense in his honor that we are doing it so at the foundation we genuflect before his picture each time we go by so i want to share with you just a snap shot of that and then to suggest that obviously things have changed dramatically in the past hundred years and talk about a few of those sort of tidal wave things so that will bring us to the current study and where we are today the majority of the time though I want to talk about our four big ideas in medical education so this is good old Abe you of course was not a physician his brother was at Hopkins but he was a schoolmaster and he was hired in part at the request of the Council on medical education by the AMA who recognized they had a huge problem with the quality of medical education at the time but as is true today were incapable of addressing it internally because of all the conflicting self-interest that were at work there so what flexner said was in looking around and he actually had a wonderful template in hopkins and a few other major medical schools at that point was that to be a quality physician required a university education and what you may not know is that i believe it was hopkins there was the first university to require first medical school to require graduating from college not high school but college appreciated harbored preceded most of the other schools and they in fact weren't sure they were going to make it when they did that after all why would you want to go through college when you could get right into medical school out of high school so he was saying that the important thing is here that you need to be immersed in a culture of inquiry and discovery that if you want physicians to be the kind and quality that we expect you've got to do that so he like many others at the time recommended 2+2 curriculum two years of basic science immersion in the laboratory and the experience of the sciences essential to medicine and then two years of clinical experience after being trained to think like a scientist to apply that at the bedside and to do so with faculty who were going from the laboratory to the bedside and back again sounds very much like clinical translational research so the other thing to keep in mind is there were no residences there were no fellowships there was no certification there was no accreditation there was nothing so you could be a mom-and-pop operation which of course was part of the problem and he also was very much in the sort of progressive educational movement in terms of recommending laboratory and clinical experience namely active learning processes so in many respects you can see that's a pretty close template to what we have today medical schools are all in universities they all most of them have teaching hospitals and the curriculum is pretty much two plus two now we're morphing then obviously but the basic outline remains the same so what's happened in the past hundred years and in particular what is sort of swept over us in the past ten to twenty years and the first thing of course is just the incredible explosion of biomedical knowledge and as a result of that you have to know more and more and therefore have to know it in a less and less environment and so you end up going deep and the analog of that explosion is the sub specialization within every discipline I think somebody was saying about 20 years ago there were 20 specialties of medicine now there are over 200 if you can't all the fellowships and every year it continues to expand in fact that somebody said when you get two guys together they say oh let's have a fellowship and a new one is born on left-handed whatever it is the concomitant to that sort of narrowing focus is the requirement to actually think broader and thus developing interdisciplinary approaches to research it's very unusual these days to have one discipline engaged in a serious research effort it really takes multiple specialties the second thing is that teaching hospitals have really been transformed when inflection ursday people were in there forever well not quite but for long periods of time there was no great rush people spent a lot of time learning on a few number of patients very relaxed environment that is of course totally changed and the rapid pace the rapid throughput the requirement to be cost-competitive means that for the most part education has been squeezed out of most of the teaching hospitals in fact I'm shocked at my own Hospital at how bad it's gotten just in the past five years or so and as a result from a learning perspective you don't see the common and you certainly don't see chronic illness in the context of inpatient services and hospitals so what am i doing you're running out of gas okay just read it through the internet alright so what's happening there is that the teaching hospital environment is no longer a good learning environment for medical students and actually not for interns either it's fabulous for fellows it's really good for high-end residence but the basic function of a teaching hospital is kind of going by the boards at the most basic level the next thing that has happened is this incredible expansion in curriculum as the knowledge expands the requirement to cover more in less time is there as we talked about the expansion of residences the expansion of fellowships all of which is reflective of this knowledge expansion and finally one of the things I have been a strong national advocate for is changing USMLE and one of the reasons for that is that it really reflects the old flexneri and model not the contemporary reality so think about it if you have a 2+2 curriculum you need to test at the end of the each of those two periods well Stanford's curriculum you CSFs curriculum everybody has gone interdisciplinary and increased the amount of clinical experience in the first two years it doesn't reflect those exams anymore so get rid of step one that's what they're going to do keep step two because you need something to certify licensure for supervised practice you really don't need step 3 because in the old model up until probably 20 years ago you could be a GP if you just had one year of internship and that's why you have that exam unsupervised practice nobody does that anymore so why not leave it to the certifying exams so I one on the first one I lost on the second one to the state licensing boards but this gives us a huge opportunity to rethink the way in which do undergraduate medical education now my faculty tell me that they will retire or quit if I try to do my next dream change and Neil you would have the same problem after the heavy lifting we both done in terms of changing our curriculums in recent years but I think it's time to rethink once again and I'll show you what that looks is going to look like so that brings us to our Carnegie study Lee Schulman had a sort of a dream of saying couldn't we redo all of those fabulous studies of preparation for the professions the flexor and others did in the first years of the Carnegie Foundation it was founded in 1906 so the first study that they really did was flex nurse in 1908 that came out in 1910 the first wave of these cross comparison studies were done for the clergy lawyers and engineers the second wave is nursing and medicine the clergy book is out all of these will result in books they're all published by jossey-bass the clergy's out the law is out engineers and press and nursing in medicine we reach still writing we were supposed to be done a year ago I'll be lucky if I get this thing drafted this year but we anticipate it will be published in 09 as part of our study in medicine we cite visited 14 medical schools in fact we asked Neil if we could come look at Stanford as our pilot to test out our stuff and you were engaged in that pesky LCM II thing at the time and said this would not be a good time and I knew exactly so we did it at UCSF but we looked at a variety of medical schools around the country and to academic medical centers as well before each of them we did about a dozen interviews while we were there for three days we did 100 for focus groups and over 100 observations the focus of our study was not on the basic science instruction because there's been a huge amount of investment and energy put into that it really is the clinical and one of the issues was should we look just at ume or should we look at you and me and Jimmy and we said well you can't understand you owe me and the clinical if you don't understand GME so we took on those and after we did that then what we did was we kind of have immersed ourselves in the learning sciences and have been trying to read everything we could not only in medical education but in education and learning and cognitive research generally so on the basis of that we have begun writing Molly cook and Bridget O'Brien are my two colleagues in this and so to start with I think it's important just to keep in mind the obvious which is that our mission is to produce knowledgeable skillful compassionate physicians who are committed body and soul in mind to the relentless pursuit of excellence in medicine to continuously advancing the field but we don't want is people who get out of here and look 20 years out into practice exactly like they looked when they graduated and the more we looked at surgery in particular that would be really bad for one's future careers since surgery doesn't look anything like it did when most people graduated or OBGYN I might and I want to tell you a little story that illustrates part of the process of how learning occurs and it comes from some interviews I did a couple of weeks ago with some chief residents in radiology the reason for the radiology is that I was giving this address to the Association of University of radiologists last week and I thought be nice to know what radiologists do so I was take round and did some observations and interviewed some chief residents and one of them when I asked to tell me a powerful learning experience reflected back to her first year as a radiology resident what you need to understand is that in about the first first of all they have their preliminary internship and then they come into radiology and in the first six months they rotate through a whole bunch of sub specialty rotations so that after six months they can take call independently so she was describing her first experience at san francisco general hospital or county hospital and she was really really hoping given the fact that she was alone that it would be a relatively light night but of course that was never would never the right Veronica could never be the case of SF gah okay so all of a sudden in comes this as she says nasty auto accident victim who is really in bad shape and so they go through and they do the images and she's sitting there with her packs image reviewers they're waiting for these images to come up on this patient and as they're slowly coming up and she's beginning to do the reading in walks the whole team the whole trauma team all ten of them and she's particularly upset about this because the trauma surgeon who's really big and can be perceived as really gruff although he's a teddy bear inside had a reputation of being a surgeon if you know what I mean and so she was worried about this with him sitting over her shoulder with nine other people on this little place waiting for her to read the images that were coming off these slides and so she did what she was trained to do she sat down and she said okay let's look at the spleen and so she pulls it up and sort of is very interesting how they scroll back and forth and look up and down those MRIs and begins to stage it and interpret it and much to her surprise the trauma surgeon who happens to be Andre Campbell sat down next to her and began to talk about how her staging of the spleen or the kidney or whatever the organ was that they were looking at would influence what he and the trauma team would do in surgery so all of a sudden the lights went on oh I get it now I see how I'm connected and what I bring to this impacts the patient and the team that's working on that so reflecting back on that four years later that incident comes to mind for her in terms of a very powerful source of learning it also influenced her identity as a radiologist in terms of seeing what her role was and the fact that she really needed to be committed heart and soul to doing the very best job because it had immediate ramifications on the patient powerful identity formation process so that's sort of a background story to what we're going to hear what we want to be able to think about and how we want to frame our study is to think about the fact that we're about formation and we take that actually from the clergy study in terms of creating habits of mind and habits of heart the aspirations and commitments as well as the knowledge that is required for it we want habits of knowledge which allow the learner to integrate knowledge and experience the two critical things that have to go together in order to diagnose and treat it also means that they need to be able to integrate the many different roles and responsibilities that physicians perform from clinician to advocate to policy analyst to quality improvement the varying rules that are responsible for the physician to perform and that each person who comes through training develops a specialized form of knowledge no one of us is the same and we want to encourage that kind of specialization of focus energy and commitment those are the habits of the mind and we want them as habits because we want them to be automatic in the sense of no matter what's happening that's the typical way that we approach the patient but we also want more than that we want to form habits of the heart namely we want them to pursue sort of been a hardwired in fashion excellence in improving health and health care and we want that to shape the net result of this their identity as a physician committed to excellence so that's the context in which we're imagining our study so now what are those four big ideas that we're sort of clustering our thinking around and what I'm going to do is I'm going to share with you each of these individually tell you what's the sort of learning Sciences background for this what's the rationale why do we think this is an important thing and then give you some illustrative examples of some of the strategies the people are already adopting to try to deal with each of these ideas because we believe that what the future is calling us to is actually resident in a lot of the innovation that's going on nationally so it's sort of understanding that tapping into it and then enlarging it in meaningful ways so the first one in fact this should be no surprise in terms of all of our work on integrated curriculum is integration that is the ability to connect multiple forms of knowledge and reasoning as well as roles and to be able to use that in service to our patients the second is individualization it is the recognition that each person is unique and distinctive and that they can develop their core area of unique form of expertise and that they ought to have a somewhat unique pathway through the learning experience that acknowledges their differing speed at which they achieve expertise the third if you haven't guessed already is insistence upon excellence it is a commitment to pursue excellence and to advance the fields and your areas of scholarship is absolutely on the mark with this this area and the final piece is sort of the result of this which is identity formation it is shaping the identity of the physician so that they embody these capacities and these commitments so let's take a look at each of these first one is integration and one of the exciting pieces that comes out of the cognitive research related to physician knowledge and reasoning and is more broadly applicable or consistent with i should say reasoning of expertise generally is that it it is not enough to learn formal knowledge and it is not enough to just have clinical experience and lots and lots of cases the key is connecting the two and we know from some preliminary research that how you frame something influences the way you see it but also the number of cases you see develops pattern recognition that helps you to connect with the basics so we need both formal codified knowledge and we need a stronger emphasis early on experiential contextual practical knowledge the second piece of it is that we need to acknowledge and recognize that it's not just analytical knowledge that we're after it's not what are the 39 causes of a heart failure rather it is the combination of that in relationship to the automatic pattern recognition so the people have estimated that probably seventy eighty percent of most of the things that physician see if they've had lots of experience is here it's automatic pattern recognition it is not rational analytic problem solving except as you go back and say hmm is that right what else could be there and if it's complex and difficult then there's a lot of this that goes on one of the things that we never talk about is this which is creative imaginative adaptive thinking and reasoning and if you think about a quality improvement thing there's no right way to do this and usually there's not any really rational reason for why we currently do it but it's the creative idea sort of putting something strange together with something else that allows you to think through a new way of doing things and it's that creative imaginative work that is so critical to advancing any field of inquiry and endeavor and finally not only are we interested in the ability to integrate and move back and forth between these cognitive functions but also physicians play as we may as I mentioned already multiple roles and each of those needs to be part of the repertoire of experiences and capabilities that we expect of our physicians healer listener innovator discoverer leader we need all of them alright so let's talk about courses and clerkships on the ume side and I want to just briefly mention three things here and then I'm going to illustrate each of those in more depth the first is that almost all medical schools in the US now have done what are two schools have done which is we've changed from a disciplinary based curriculum to an integrated one in the first two years and we've also brought more clinical experience into the first two years most of us have failed bringing the basic sciences through to the third and fourth years but nonetheless we begun to think about that what we are recommending is that there be a better balance and that we think across four years not two plus two do we blow that up we throw it out we've been moving that direction now let's radically move it to next phase this is the one where my faculty are going to retire on me let's think outside the box let's use that creative thinking juices again and imagine what it might be like to have a four year curriculum where you start people in clinical immersion and then you run in a parallel track throughout those four years both the formal knowledge and the clinical experience would look very different and I'm going to show you how that might look the second piece is that just as we had to take the curriculum away from the departments and integrate them centrally we need to do the same thing with the clerkships in fact the problems even worse in the clinical environment because it is totally captive to the surface demands of the particular discipline and whatever happens to be there is whatever that curriculum is there are some very exciting programs going on that have a totally different model and the get out of the predominantly in patient oriented discipline-specific endless rotation flight pattern and create a year-long integrated patient-centered panel of patients for those students and preceptors to take that third year so i'm going to show you what that looks like since most people can't even imagine I couldn't imagine when I first heard about it and the third thing which I'm not going to deal with but I wanted to mention in passing is that we need to think a new thought about assessment as well that we cannot just focus on the knowledge because that is not enough we need portfolios we need other mechanisms for documenting the range of competencies skills and abilities that we expect and we've got to do that in a much better fashion that includes mentoring and other capacities that help and not just you me this needs to be um e and g m-e together there ought to be continued you ought to take it with you when you go it builds continuously but i don't have time to talk about that so just put that as a placeholder to think about let me talk first about the clerkship and then come back to the curriculum because i've been thinking about how you could actually connect these the oldest one of these as far as i can tell is at the university of south dakota where they have sent you students there to yankton community multi-specialty practice and the it's not a clerkship in the classic sense they are immersed in that multi specialty practice it is patient centered and they go where the patients go the one that's gotten the biggest press for this is Cambridge hospital at Harvard and it's interesting that most of these tend to be rural or community-based because you can never get the mass general or Brigham and Women's or parnassus UCSF or Stanford Medical Center to do it at the home ship the most resistant now think about that one as a statement of where we are in terms of what an academic Medical Center ought to be about but having said that no Cambridge Massachusetts yeah it's a Harvard rotation no it's their core integrated third year they spend the entire third year in that hospital now what they've done is the other ones as General Brigham 21 mm Deaconess be I have adopted the one year period so one of the ways you stop the discontinuity problem is you at least keep them in the same facility for one year that actually helps immensely but this is radical and in fact when I gave my talk to the radiologist and friday first somebody from cambridge got up and said thank you for highlighting our program this is wonderful right after it gets up I'm for Mass General and I want you to know this is not Harvard's program I said yes I knew that it is Harvard's program but it is not what the other hospitals are doing yes I know that they have a classic format with some longitudinal things to run through it which we're playing with it at both be a and San Francisco General as well but what this looks like is that you take the teaching away from the house tap and bring it back to the faculty for the seven core disciplines that you would expect the rotations to go through on the inpatient services at in the third year clerkships you put them into the clinics in those specialties for a half day each and then you rotate by week in terms of which ones are there and so there and the fact that they have rotations in the emergency department and in the urgent care centers they pick up a panel of patients which ranges someplace between 50 and 100 patients each and they then follow them wherever they go and so we had to modify the pager system in fact our students who are in this program now have pagers that is the envy actually the house staff and the faculty who don't have it which is that when any time their panel of patients enters the system and in any clinic ed inpatient they're automatically paged so these empty slots are the times when they can follow that patient through to a clinic experience and you wouldn't believe how much students learn in that process nor the positive impact this thing has on the patients so just I shouldn't digress this far but I can't help myself I got an unsolicited phone call from a surgeon at Mount Zion who had just seen one of the students patients who had been referred from the internal medicine clinic where he had multiple problems but he also had diminished cognitive capacities and so it wasn't a real good historian couldn't really communicate that well his issues but they wanted a referral to a surgeon to see if some of the swelling could be surgically excised or dealt with in some surgical manner and the surgeon looked at him and said nope sorry can't do it but the patient came along I mean the student came with the patient and so the student was able to be a little bit better than the patient was that communicating what was needed likewise when the bad news came back that certain can do anything the patient became very agitated really couldn't understand what was going on and it was the student who was able to do the translation for the patient and therefore help them figure out what the next step would be and how to carry that through so I got this call from the surgeon who was just amazed at how different the patient interaction was with that particular patient because that student was there understood the history of the patient and could follow through so if that patient had also actually gone into surgery then the student would go to surgery rounds on that particular patient and hear what the team was doing if it was an internal medicine gone in patient again the same thing would be true it's a great way to learn all the different specialties that interact with patient because they often go with the patient through it they have what they call their school which is their tutorial it is student generated and it comes right out of the cases that they're seeing so it beautifully the integration of specialties in care of the patient itself now what if we said that's a great model for the third year how would that influence how we might design a four-year curriculum so let me show you my idea my suggestion would be that we start with a physical exam boot camp so that one month into it they could at least operate like a medical assistant or an EMT or some basic level of performance and then they get linked up with that small team of people who are working in that longitudinal clinic experience they get assigned to one of those teams and so they begin to do what they can do which is not much but that's fine they can interview they can take a history they can do initial physical exams they can go look things up they're going to be the educators in the group and the learning experience goes back and forth between formally structured learning and that panel of patients so the team would consist of first year second year third year student may be an intern we've got a pilot that we're going to start at the BA which is going to take our our third year longitudinal experience there and connect it with what's going on in internal medicine residency program so they will have blocks of inpatient outpatient and the students will go with them so begin thinking about teams but thinking about it in very different ways all of which are centered in a panel of patients so now instead of having to read about paper cases you have real cases instead of having to bring in standardized patients to practice on you have the real thing and you spend a fair amount of your time each week in doing that so we're very excited about that the other piece of this is the inquiry discovery innovation piece that if you want to inculcate and kind of hardwired innovation thinking into people then it has to be part of the curriculum so many schools are doing pathways the same thing you're doing that's really good very important to do and it ought to be actually part of everything else that's there as well it's thinking about how do we make things better how do we think a new thought and everybody can participate in that alright if we bump that up to the next level to residency education one of the things we need to do is we need to encourage continuously the integration of knowledge as part of the learning process and i must say that when I was observing those radiology residents it was striking to me to see how that learning happened and reflected this process that they would sit down with an attending they read the slides and first look at sort of the anatomical features of what they were doing bringing that base of knowledge together and it was also interesting that for the sort of first-year residents that a lot of it was just sort of naming what is this how do you describe this how do we write this up and later it was sort of fine fine points in looking at that but it means connecting all of that formal knowledge with pattern recognition and then the analytic checking with feedback one of the things that's happening nationally is the integration of residences and fellowships I think it's appalling if you think about it that I believe I got the figures right that an MD ph.d the average age of an MD PhD who gets there are 0 1 grant-funded is what do you guess how old are they now it's up to 44 now you're halfway to retirement before you can actually get what you're trying to do it's absurd it's it's it's unbelievable so one of the responses to that along with the sort of explosion of knowledge and sub specialization is say you know what we got it we got to think of new thought and we have two core back and think about a smaller core and provide earlier specialization so in medicine you're seeing people advocating for a two plus one so you take 22 years core the third year you could be a general internist if that's what you want our hospital is but you could also go right into fellowship and since 70 plus percent do you just shaved a year off of that Bravo the same is true in radiology they're thinking about a three and two combination surgery is thinking about a three and two most specialties are saying we've got to cut the time down and they're beginning to think about ways to connect ume and Jimmy so one of our emphasis is what we're calling our pathways to Discovery Program which can start with year one can move on through into faculty positions and you can flexibly enter this program at any level and you can get a masters degree as part of that process if you choose and by virtue of having experience and succeeding at that at the ume level it shaves time off and guarantees the slot in a GME program so we've got to think about across the barriers in new ways that speed things up and finally we need to focus on the capacities and the abilities to do leadership discovery advocacy and quality improvement okay second theme the rest of these going to go much faster get carried away with this one but we'll move faster on it so one of the key things that we know about ourselves about our children about our grandchildren if you're my age is that everybody is different every single person is different now the cognitive processes of learning are the same but what you bring to it how you traverse through it how you get to the other side is always unique and we need to do a better job of acknowledging and recognizing those differences in our learners that come to us with amazing backgrounds amazing expertise in fact it reminds me that every year when i asked the the first day of orientation I usually have hands go up how many of you have a PhD how many of you have a master's degree how many of you are health professionals it's amazing how many people have done wonderful things and yet we treat them all the same we need multiple paths to recognize that people take different routes to learning and reasoning and what's clear from the evidence too is that people attend two different things they ignore different things and they engage with different intensity in different ways that's all individually determined and driven and obviously they achieve mastery at different rates and in different areas the other interesting piece is that part of what happens when you are part of a learning community or any community for that matter is that how you engage with it is again individually determined and so what you get out of it is totally different reminded of a luncheon I give luncheons for students routinely so I can sort of hear their stories and in last summer I had one with first years not with third years end of 3rd year no was beginning of third years and as we went around and asked them where they had done their first set of rotations two of them have been down at Fresno and the first one said all is fantastic experience that got to do all this stuff and the second one said it was a terrible experience I had to do all this stuff saying the same thing and that's just so classic of how people respond in different ways to the same experience in a community of practice so one of the things that has been really transformative to us as we search team is a whole new body of research that I was actually not aware of at all called workplace learning and it's quite different than adult learning theory which in my book is a cop I love well you know it's that other stuff not empirically driven not helpful and mostly opinion this on the other hand is driven not by a vocational learning but rather by workplace learning and I bill it's book is really exceptional these are two wonderful articles but what they take as acting premise is that one learns in a work environment not by Bullock's but by experience and that the key is the level of participation in the tasks and activities of that community and so you can think about it as starting on very much on the peripheral doing really minor things but observing what's going on till you are at the point where you are actually leading and doing so that curriculum in a sense is the set of cases the tasks the experience of the work community and well of some of it yes except more of a cognitive apprenticeship i would say than the classic one but this is influenced by three things might ask relationships and the structure of the work itself so let's look at that one of the key things about this is that the key task of the teacher or the master is lining out the tasks that the learner will participate in and that means defining the level of responsibility and not just at orientation day it is in relation to this particular task what do I expect you to do it is sequencing those from relatively easy to complex and it is it requires in order to do that continuity and that's the problem with our constant churning that is our current clerkship structure there is total discontinuity on absolutely every level and faculty are the last to observe it i might add but students will tell you about it with great clarity the second piece of learning in this environment is that it's dependent on the nature of the relationships among the people who work and participate in that and some groups have what is termed an invitational quality they welcome learners to it and some people say you're a pain in the butt I'm busy I don't want to deal with you shut up stand in the corner watch if you get something out great but I'm too busy to deal with you okay totally different experiences second is that if you want people to risk and to grow and to work at the highest edge of their capacities then they have to be supported in that and they have to know there's somebody there to catch them if they screw up and that requires appropriate mentorship and apprenticeship and finally their capacity to gain from that is determined in large measure by them it's back to the student who didn't get anything and somebody who did so all of those are true and they all contribute to the relationship in the final piece of this structure that connects with participation is the work practices itself namely how much time pressure is there what's the workload of the group it absolutely determines how much time you've got to teach and work in these environments and how does the work gets structured and what's the hierarchy and who does what all of that has to be understood by the learners in fact we were talking about some funny stories about students showing up and nobody being there and thinking oh well I'll go home wrong they're all in delivering the baby and you should have been there earlier okay so all of this influences how learning occurs and it's all a combination of both the group and the individual so what are some strategies for individualizing things well the first thing is that we have to work better we have to work smarter at sequencing and guiding learning and that's why it has to be longitudinal it really should be longitudinal from day one on through and it auto include individual learning plans and portfolios and reflections on that second thing is we've got to shrink the curriculum you can't just keep stuffing more in which means you have to think bet more about how you integrate and the conceptual integration of that not just as it gazillion sets of facts and information and the way we can do that is by reclaiming time because of the ability to determine when somebody has mastered what we expect them to do the problem with the current system is it's set up as a safety net for the slowest person and since everybody goes through locks deck most people get through but we haven't got a clue as to how many times they actually need to do something when we were at the University of Southern Illinois and looking at surgical education one of their issues was a camera which procedure they were looking at but the question was how many times you need to do the procedure in order to become competent and therefore be able to move on and they concluded it was about 35 times gave you pretty good routine expertise with a little bit of adaptive expertise they were doing 150 of them and thus not getting to the more complex ones which they needed all being driven by service of course rather than learning so we have lots of room in the system if we use it smarter and we need to offer electives areas of specialization where students and residents are able to concentrate on something in depth and develop the scholarly habits of mind for asking the tough questions engaging in inquiry and discovery to advance the field and I don't mean that just in the sense of bench research I mean that in the sense of improving the flow of the practice I mean in communicating with patient I mean every single dimension we can think of how do we date on a daily basis improve the quality of what we do and have that built into us hardwired which of course leads us exactly into this third point which is insistence upon excellence one of the things that we want is we want a sort of ongoing commitment to develop not just routine expertise not knowing what to do when it always comes up the same way but to be able to be adaptive experts to know what happens when it's confusing when it's gray when it's overlapping when it nothing makes sense and that means that we need learners who are in the mode of learning continuously because they have a lifetime of practice and be from Erickson's work on deliberate practice sort of regardless of field the figures it takes about ten i think it's 10,000 hours of practice which explains why when i wanted when i spurred it up in junior high and wanted to play basketball without ever practicing that i was so bad you need lots and lots of practice and the way in which you get better is not just by practice it is by being very deliberate about advancing your knowledge and skills as part of that process and that's what brighter and scarred million surpassing ourselves right about in terms of the fact that there's a difference between experts and experienced non-experts or between grand master chess players and you and me and it is in part the fact that they continuously work on improving the quality of what they do relentlessly and that the best place to do that is in the context of a community that works continuously on knowledge building thus the University but I have to say it's not just the University there are lots and lots of practices that are devoted to quality improvement and in fact are doing much better than we are at being able to do that so it's being immersed in a community of practice that values of firms and as part of their everyday practice it's always asking a question how can we do this better how can we think a new thought about was that we're doing so what are we doing you might met might remember some of these characters the first thing we need to do is we need to reframe how we think about what is a physician it is not just a clinician it is also an innovator a pathfinder field builder and as part of that process well we know from medical education but also from education generally is that if you want people to do that then you have to immerse them in the messiness of the issues of the practice where are the contested areas where do people disagree violently disagree oftentimes and that's exactly the point you want to get them engaged and you want to immerse them in a discovery process so that they take ownership they begin to sense the importance of wrestling with those things and they understand what scholarship is all about and on the GME and obviously the practice based learning and systems based practice are two of the ACGME competencies which are aimed directly at this particular issue which is how do i improve what I'm doing how do I reflect what I'm doing how do I evaluate it and therefore how do I make it better and finally the fourth one is identity formation that we are about shaping the lives of future physicians we want them to take on the professional identity behaviors and aspirations and the moral commitments to do what is right on behalf of patients and to serve their knees to their best of their ability so we do that through learning in practice communities we do it and they learn it by observing role models and team interactions there's a lot of stuff written about the hidden curriculum right Clarence hidden curriculum and how it actually corrupts and so if you look at the empathy factors and other things that we preach about and want people to adopt they actually go the other way the more experienced the have in it the more distant they become so we need to find ways to address that and to work at creating more positive models and taking seriously that it really is the practice environment that shapes that most powerfully and therefore we need to work on that yes it is yep and teaching directly to it coaching and assessment is all part of that so how are we seeing people working on this formal instruction is certainly one way people have their ethics courses they have their professionalism courses and certainly that's important I would say it's the least important of all of these but it is important to hold up so that it reflects the values of the community in the formal instruction that's their honor codes are in pledges are typical of what we see as well as white coat ceremonies two things to illustrations here one is that probably the place that's done more on this than any place to transform the culture of the institution is at the University of Texas Medical Branch in Galveston jaxxed elbows worked down there for I think about a dozen years professionalism was his prime reason for being in every employee every trainee every faculty member in there has to sign the pledge which says something the fact on my honor as a member of the utmb community I solemnly pledge to treat everyone with respect compassion and integrity as part of my academic and professional activities every single person to there and he's cut down the turnover rate on the nursing staff he's made that institution the the highest rated in terms of the place we'd like to work at the best to work out although I have to say as he would say and did say to us I haven't cracked the faculty and the residence yet but we're working on that another interesting approach and the place where culture really shines is mayo how many of you ever been to mail it is something unto itself up there in the prairies but the reason we chose to go there was because it's it's not embedded in your University it's one of the few medical schools that is not it's embedded in a healthcare system and the number one value is treat the patient comes first every time and so we thought well how can that be any good for education where is education all this well as it turns out it's a great place for education and we saw illustration after illustration of how that played out in terms of when they found people violating that somebody not wanting to have a patient turf to them and well was that the best thing for the patient well okay and lots of stories about the heroes the old male brothers still live on right into the sunset it's all part of that symbolism storytelling dimension of the culture which focuses on the patient first buildings are amazing well clearly especially in the winter time I have to tell you I don't know how they did now what's really funny though is up for those of you who haven't been to mail they don't wear white coats because that's sort of dirty I suppose I don't know they wear suits everybody wear suits and men's wearhouse has a special Mayo section of acceptable men's suits very different culture we saw one guy who was protesting because he was wearing a turtleneck he thought that was really cool okay anyway strong culture for better or for real second thing is enacting the values within the practice community and I want to share two different examples here one is the approach to appreciative inquiry which of course David would love which focuses on identifying telling stories sharing stories about the best of who we are and Indiana University is doing that better than anybody else around the flip side of it is to say you know what almost everybody does a great job ninety percent of our faculty residents are have integrity our compassionate respectful each other it's the two percent that caused all the problems so UCSF we took the bottom feeder approach we said the problem is how do you deal with the outliers who constantly screw up the education for our students and our residents and so we just added two items on the student and resident rating forms of teachers and the items were treats me with respect treats others respect if somebody gets a rating of a 1 2 or 3 on a five-point scale then that gets automatically sent to Maxine papadakis who is our associate dean for student affairs and if they begin to pile up so it's a clear pattern as is typically the case then she does an administrative intervention first trying to work with the faculty member if that doesn't work as usually doesn't then you go to the department chair and the department chair chews on them and it took us about three years to turn around a whole division actually I'm sure you would know where that was but do not tell and they now have great ratings they really do so you can take either the top or the bottom but the hardest thing is to get administrative will to do anything period so that's critical all right finally assessment reflection feedback are important both formal and informal and I'm going to skip on for that one so well we're are four big ideas first was integration the importance of integrating different forms of knowledge different forms of reasoning different roles in the profession of medicine and then to think about individualization adding a particular capacity a particular focus particularly way through the environment that adds to what they are able to do that that's overlaid with an absolute hardwired commitment to excellence and that that results in an identity that forms the physician of the future that we expect so what would Flexner think let's go back to where we started he said let's think like a scientist that's actually not a bad adage it's just inadequate learn actively and deeply we certainly would concur with that and be immersed in a learning community namely a university and a teaching hospital which i think is a bit more challenging today than it was then and we're saying again integration is critical individualization insistence on excellence to think like a physician scientist actually combination of both of those and to enact and live out the values of the profession so personally I think Flexner would think this is great and since he's not here to disagree with me I I can claim anything I want on that so in conclusion what I would say is that the future that we are trying to create and which we want to see the formation of physicians to become is that we want to integrate and balance formal knowledge and clinical experience to offer individual pathways through the learning process and into practice that we want to engage the learners in the pursuit of excellence and that as a result of all that we want to shape the hearts the minds and the souls of our future practitioners thank you right now so feel free just has to be with any questions you have in mind find a couple myself but Thursday yeah thanks summary of the work you've been doing it's with analyst inspiring to think about when you were talking about individualization individualization I thought you were going to talk about some of the interest in a competency-based approach in some schools that have basically said we don't care how you get there here are the competencies number this column yep Minnesota go a little bit more on that yes and in fact if I had more time to illustrate it I would would have picked Minnesota it's an example of that which basically says you pay for four years you can get out of here and three if you want just have to meet benchmarks in the performance or you can stay longer if you want I think that's exactly the right way to go and that was what I was hitting at with a surgery example which is let's try and figure the best we can what is essential to learn and then let's hone in on it make sure people get it and then let them specialize in other areas some thank you if you take societal perspective which says that we're turning out too many specialists in email journalists that part's don't work with one another there will be an economic gain and sub optimization the whole be bizarre out of us I don't fear in the examples of integration somebody beyond the medicine box and in fact if we really take the challenge society is giving us we need to be degraded even on a broader scale you're absolutely right the challenge of specialization is that atomized approach to the world no question about it you can think about that from our perspective from a couple of different points one is the integration theme and i'll actually flag that as a point to think about the other place is in terms of specialization in the opposite sense in which you would imagine it because you can specialized in being a generalist it's sort of like the quantitative sciences are beginning to be used in epidemiology much more because you need that sort of scope or span and certainly in areas of concentration one of those at least at UCSF is in public policy and advocacy and health disparities in a variety of other areas that are actually aimed at exactly those issues for which we need system changes absolutely clinically more right good to see you again so a lot of this work which is wonderful and appears to be happening as I would imagine it would for the medical student level and some of it sort of filtering into the residency level I wonder if you could comment them bit more because in my cohort of training colleagues residency to send a group comes a black hole for many of these things you go you sort of disappear into the work of the hospital or the clinic and in some ways rightly so the emergent process needs to happen but I particularly liked your notion of time-saving by figuring out achievement of competency and in particular to me and having more time to do some of these one longitudinal multi-domain working processes that begin in medical school and seem to abruptly come to a halt when when you hit residency yeah the fox on that Oh totally couldn't agree more absolutely agree in fact it was striking to us when we went around the country that with the if you look historically at medical education um II has innovated way WAY longer invested way more money in part because it's a different ownership model the curriculum is owned by the dean's office its own centrally and well it has sort of given up much of its responsibility when it was departmentally run still the resources are there and the focus is there and therefore the likelihood of having more critical masses there then each individual department has as part of its old-fashioned apprenticeship which is throw them in hope they make it at the end will say go to it and if they pass their fine repeatedly we heard residents say exactly what you said which is I had all this great experience I wanted to continue working on some things and it's just a black hole it's just back really black terribly terribly no light on in the place and the part of that is driven by the RR CS and which is really again driven mostly by the bottom and so if you say we need a minimal threshold for a program to run and since faculty trillion community programs are amazingly resistant to doing anything then we will tell you exactly how many hours you have to be here and how many hours you have to be there and as a result and that result of it is it's totally constrained totally constrained and then you add the perturbations of the particular healthcare system you're in and it's it's a disaster so the good news is that I think nationally people are beginning to recognize that and so the educational innovation projects that internal medicine is started are now beginning to get picked up in other specialties and there's beginning to be more willingness to say okay if you meet bottom threshold then let's give you more autonomy to think creatively about how to do that but I really think GME is still the wasteland well it's an interesting issue and if I could sort of back out to a larger view I have a chapter in the book on financing of medical education I happen to be of the belief and I may be wrong but I think there's reasonable evidence but actually there's plenty of money in the system for medical education for you and me and Jimmy both of them the problem is it doesn't get used for that okay so the feds sent it to the hospital and the hospital says oh great we need a new MRI that's where it goes do residency program director time get bought out the way it's posted no not in many systems and funding for you and me exactly the same situation I i get from student fees eight million a year theoretically comes through i get to of that the rest of the ghost of other institution missions okay so bottom line is is there money yeah there's lots of money is it used appropriately no it is not there are a number of places that have done some very very creative work in that capacity in partnering between the educational focus and the departments and school on one hand and medical centers on the other so michigan would be an example pan is another example florida's another example and at michigan they got i don't know why they got it but they got a huge huge multi-million dollar bolus gift that goes into an Innovation Fund and so you know it's like our academy of medical educators faculty can apply for these grants and buys out time and they can actually innovate and do things and I think that's what is required in order to do that but let's say no good yeah thank you very the forward-looking plan that you have is time constrained and stopping money constraints too I didn't I expected you to mention the use of the experiential technologies like virtual patients to gain experience as an intermediate and this model comes from the workplace Delta Air Line which is a major component which quite different scenarios of the point is that there are technologies in fact the double AMC now has with the men and portal virtual patients for students to gain the experience that we want them to get to the clinic and they have it under their belt so so before they get there one of the problems with having isn't it that patients are resisting coming with medical students your mental schools to be practiced on my students with a fair it's a competition and so it seems to me that one way to counter balance that fear on the one hand and give experience for students to be prepared is the registration absolutely part I went an hour and ten on this thing so I trimmed all sorts of stuff out and that's one of them but simulations virtual reality and virtual patients we have to essentially offload a lot of what we would normally have developed expertise around in the context of practice into these other environments so simulation centers virtual patients are certainly the technology that is there and will be needed yes I just wanted to take a little bit of a step back interested in your thoughts and curious about how some of these ideas that you're talking about chicken in terms of longitudinal learning self-directed learning how that might affect our admissions process what the requirements would be to get into medical school what our selection process would be that that would be any different in your mind and what the current model is can I had when you stay after school both up when we stay in medical so what you're seeing oh yeah okay first of all I would say that we did not look at the admissions process if you think of our study for the most part we started the clerkships we also looked at the foundations of patient care of the doctoring courses in the first two years but that was it so we didn't get back at the front end of this we may in as before we wind up put something in on admissions certainly if we're wanting people who are creative adaptive then we need to select for those issues and is chemistry required for that probably not but you do need some scientific basis and certainly need statistics which isn't required but should be required so yeah there are some tweaking kind of things and there's a very interesting work mostly coming out of McMaster University of different models of how to do emissions selection processes that look more like an objective structured clinical exam in a short period of time with a core of people who do those interviews so there are some very interesting models out there that are beginning to be adapted and used regarding staying in school or throwing out my personal bias is that if you do a reasonably good job of the selection process then we ought to do as much as we can to help people succeed whether they're the average dropout rate and medical school is probably about two to three percent in my experience you know it's probably on average we probably dismiss one student a year at UCSF and I'd say we're an outlier on that score that most schools won't do it it just won't go to that problem and the real problem is that for people who can't make it they invest six seven years before you finally say we've had enough and you've had enough go do something else and now they've got two hundred thousand dollars in debt it's not fair of them so I would be a fairly strong component back to competency assessment but also providing as much support services as you can yeah I really enjoyed the presentation and the four points that big ideas but of the four three of them are ones i don't think this would be tremendous controversy about the striving for excellence and individualization and the identity formation those those are great the one where I think there is controversy is the part about integration best ways to get there and I think if you are you mentioned this in your discussion that your faculty would be enough for I think the resistance comes in part because of the enormous energy that it would take to get there and then the concern that how do you know at the end of the day that what you're doing is better and going forward I think there were data from Harvard or somewhere else that said she would compare and we did this critically and we now have evidence which everyone's looking for that doing Anna sonje toodle integrated model is better I think there would be more buying from faculty that so my question to you is you really think so but it might be but how do you assess the outcome given how complex the the challenges how do you assess the outcome of a Cambridge program or other programs to try to drive with evidence faculty to look at this as a better or a different model worth exploring well we are in an evidence based environment which is a good thing on the whole what we've seen from curriculum reform nationally if you look at the first two years so let me start there and then we'll go to cambridge our experience at ucsf I'm sure it was the same as yours and every other school I talked to before we went through it was if you look at step one of the boards there's very little movement there's a little bit uptick which was true for us but not a huge difference so then you say well what's the I got all this work well because there are other important things that we want to see one of which is due faculty and students find this a better learning environment in which to live and what we know from the prior one was it was a hellacious one is terrible and back to the issue of should I stay in or not a lot of people said if this is what it's about i don't even want to be here so i do think that there is a lot to the process that one goes through on that the second thing is that if you want people to be able to retain it and use it then you have to learn it in the context of later use and you have to use it multiple times in adaptive ways in different capacities and there's beginning to be some reasonable research to suggest that in fact is true now related to the reason I was smirking on the Cambridge is that there is some very nice data and it follows basically what we just found which is a if you look at step two results they're better but they aren't hugely better but if you look at the learning that they're doing if you look at the integration they're doing if you look at the mentoring that they're getting if you look at satisfaction both with them and what with their patients it's immensely better it's doing exactly what the program asked for now does that convince anybody didn't convince colleagues at Harvard and we essentially decided to do it even though we didn't have any day so you go back to the third point about innovation and excellence the reason you do research is because you don't know if one's better than the other to begin with you can't it's impossible and that's the challenge in convincing our colleagues to go along with this humongous investment in planning and change and effort on it because what's the evidence well you can know the evidence in advance and that's that's the challenge they're all over the map as they would expect to be so I think they've done it for about three or four years now and in fact we've got quite a few of them at UCSF and raisin see programs and I've talked to a number of them the intent was never to produce to shift one direction or another the intent was to create better doctors and to create even more importantly a better learning experience for them and all of their data is from my perspective looks really good and in a different talk I would have shown you the data but too short a couple minutes less little close I want to get your reflections on how you would evaluate whether the ideas about providing both particular aspect and of course the students in this regard with something in the back of your mind which is that that weight just has something I want to look at it from I probably cluster it according to Big Ideas go for the end in mind and and then try to do as multiple ways of looking at it as possible but in line with the rationale which is why are we doing this so what's the learning theory telus should be going on should guide us in terms of trying to think about how to do an inquiry related to it it's a great question I've count on you to help us out now what the thing is we're running out of time to thank everybody for coming appreciate the preceding program is copyrighted by Stanford University please visit us at stanford.edu

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