Rx: The Quiet Revolution showcases healthcare organizations, in locations as varied as Alaska, Maine, Mississippi and San Francisco , who are finding ways to reshape health care in a way that works for patients. The future of medicine, however, ultimately rests with the schools that are training the next generation of doctors.
One of those schools, the Hofstra North Shore-LIJ School of Medicine on Long Island, is helping to rewrite the rules of medical education. Its entire curriculum is organized around the principle of “putting the patient first.” In the first week of class, students begin the training to become EMTs and are put into live situations with real patients. Dr. Lawrence Smith, the school’s founding dean of medicine, explains why the traditional model of medical education is outdated and how Hofstra is changing things up.
Q: What historically has been the approach to physician training? Why has it become out of date or not as effective as it once was?
Physician training in the United States has had two major periods of development. The first was the revolution that took place from the 1890s to the 1920s when medical schools realized that they had to teach science in a serious way. In an effort to bring teaching, clinical care and investigation under one umbrella, scientific and clinical communities were established in academically-oriented hospitals. Medical schools built individual science departments designed to teach all of the science known at the time to medical students and to have them memorize all that science. Science was taught by discipline: anatomy, physiology, pharmacology, etc. The feeling was that there was some magical moment, which occurred at the end of the second year of medical school, where the medical student would have memorized every known scientific fact about how the human body works.
That approach doesn’t work well anymore for a number reasons. First of all, the sheer volume of knowledge today is well beyond anyone’s capacity for memorization. Secondly, when students learn in scientific silos, it is difficult for them to figure out how to apply that science to an actual patient. There is a significant disconnect between doing well in a medical school subject and the effective care of an actual patient. Clinical medicine is always contextualized in caring for real patients and so students would often leave the science behind.
Not only do we now know way too much about the human body for anybody to effectively memorize all that they need to know, but there is questionable value in memorizing millions of disconnected facts now that it has become so easy to look facts up. If you have access to a computer or even an iPhone, there isn’t a fact about the human body you couldn’t find within seconds. That’s why the way in which we teach science to medical students is clearly out of step.
As the model of U.S. medical education evolved, again in the early 1900s, it was clear that the most effective place for students to learn was the hospital. This put them where the patient was, where the thinking about the patient was, and where they could watch the evolution of virtually every disease. Clearly that’s not the case anymore. Virtually 70 to 75 percent of all diseases no longer require hospitalization. Even 50 to 60 percent of surgeries are done on an outpatient basis. The idea that students stationed on the ward of a hospital would see everything they need to know to become a doctor was fine in the 1940s and 50s and even through the 60s and 70s, but soon thereafter became an anachronism. Today, while there are certainly many diseases that are treated, and therefore learned well in the hospital setting, there are many more diseases that never appear in the hospital. We had to rethink the model and have the student, patient, and thinking about the patient come together to where the patient was actually being treated. And that’s in the ambulatory setting.
Q: And do those types of “out patient” diseases tend to be chronic diseases?
It’s all types of diseases. We’ve gotten significantly better at keeping people alive, which means that we have many more patients with chronic disease living much longer lives. And on the diagnostic front, we are now able to perform an ever-increasing number of accurate and sophisticated testing on an outpatient basis—testing that previously would have required hospitalization.
Q: How is Hofstra’s approach to medical education unique? How did you restructure medical education at Hofstra?
Part of the obligation of a medical school is to take students who could be as young as 22 years old and in four years’ time provide them with the tools necessary to redefine themselves as physicians. This requires a maturation and fundamental change in their personal identity. That will only happen if during that time students are truly responsible for patients.
However, during the past 20 years, patient safety, malpractice cases and regulatory requirements took center stage, and students became marginalized in the care process. They became observers but not active participants in the required test, procedure or examination. But the fact is, you can observe for the rest of your life and you’ll never become a physician. You have to learn by doing. And somebody has to be the first patient that you ever do it on. At Hofstra, we have pushed really hard to connect students with the patient and the community from the outset in a real role. The difference, compared to the old days, is that it’s always supervised. The role is real. The responsibility is real. The contact between the student physician and the patient is real. It took a lot of hard work to implement, but we fundamentally believe that if we don’t get back to that, we’re failing to properly train competent, capable physicians.
Q: One of Hofstra’s core values is “putting the patient first.” Is this the medicine of the future?
If you asked any doctor from any era if they were practicing patient-centered medicine my guess is that every doctor would say yes. But the fact of the matter is, they were part of a system that prioritized making the doctor as efficient and effective as possible. And even though doctors always, hopefully, were listening to their patients and working to relieve their patients’ suffering, the premise was that the doctor is the key caregiver, and if you can’t maximize the utility of that person’s time, you’ve designed a wasteful system. Now, contrast that with the idea of designing the entire system around the needs of the patient at any given moment and figuring out who are the right people to satisfy that patient’s needs–maybe it’s not just the doctor. Out of that idea came care models designed around patients and the clustering of teams of caregivers: doctors, doctors of specialty, generalists, nurse practitioners, physician assistants, dietitians and on and on. You assemble teams around the patient to address his or her medical issues in the most effective way. And suddenly the word ‘coordination’ crops up into the design. Coordination implies orchestrating all the bits and pieces of care that are done by disparate people, sometimes in disparate places in a way that is easily understandable and not terribly burdensome to the patient to manage and maneuver.
Q: That seems like a very different role for a doctor than just dispensing prescriptions.
Absolutely. So now you’re thinking the doctor is part of a team. Sometimes the doctor is the chief of the team and sometimes he or she is just a member of the team. Sometimes the doctor comes in for a cameo appearance for one specific piece of a complex care plan and sometimes they’re the person responsible for the whole care plan, with everybody doing little bits and pieces answering to him or her.
Q: What skills and qualities do doctors need to practice patient-centered care?
One of the most important skills is listening. Patients are readily able to tell you what’s wrong with them if you just take a deep breath, pause and actually listen to what they have to say. In addition, it’s crucial for the physician to feel an obligation to relieve the patient’s suffering. In an era where we have endless super-specialized physicians you’ll often see a patient sent to multiple physicians where each one tells the patient that they “don’t have a disease in my specialty.” These physicians often feel no obligation to tell the patient what they have or to relieve their suffering. That’s an ultra-siloed way of looking at a patient. Doctors need to step back and say, “This patient didn’t come to me to tell them what they don’t have. This patient came to me to feel better. And what can I do to capitalize on that activity? And who is the captain of this ship anyway?”
We need to move away from this siloed approach and think about how we deliver care. That is where the management of chronic disease comes in, because with complex chronic diseases (and often many people have more than one chronic disease) the patient needs to have a doctor who is his or her doctor, i.e., a primary care physician or someone who is the dominant caregiver–not an array of specialist for every organ. A patient’s primary care physician may need the opinions and advice of other specialized physicians but somebody has to be your doctor who takes care of you, the whole patient–not just your liver or your heart or your kidney. We’ve drifted a long way from that in the last 20 or 30 years as we became infatuated with specialization.
If a person has four or five problems but the main problem is heart disease, you could see the primary doctor being a cardiologist. Or if the main problem is cancer, it could be an oncologist. But somebody has to step up and say, “I’m taking care of the whole patient, not just one problem.” In the complexity of modern medicine, where patients have that doctor, their care goes unbelievably smoothly toward goals. And the patients who don’t have that doctor get bounced from person to person, place to place and their care reads like chaos. By the way, the patients are often complicit in that mess. The patient who wants to brag about having the best specialist for every single thing that’s wrong with them doesn’t realize that unless they have a doctor who is actually managing all of those specialists, they’re probably not getting the most effective care.
Q: Is leadership a prime skill or quality that needs to be developed?
If we define leadership as inspiring people to do the right thing when you don’t necessarily have authority over them–which I think is the mark of true leadership–certainly we would want all physicians to be good at that. Whether it’s motivating the patient or a family member to do the right thing or motivating the team to go the extra mile, or its simply showing by example that you can be a great member of the team.
Q: There is a growing deficit of primary care physicians and economic incentives push medical students into specialized, procedurally-oriented fields like cardiology, radiology and dermatology. Do you see this as a problem and how might we change things?
I think it is a problem. And I’m one of those people who believe that most people go to medical school wanting to be a primary care physician. I don’t think most students come in thinking “I want to be a neuroradiologist.” Then three things happen. One, they realize that primary care physicians are often at the lower end of income scale and work very, very hard. The second is primary care physicians are often at the lower end of peer prestige despite working very, very hard. Lastly, there’s a period with all young doctors where there’s an infatuation with the technology. Many times it’s a passing infatuation, and then they come back to the core values of just wanting to take care of patients. Also, in the modern medical center where patients are sent for highly-specialized care, young doctors often work with specialists more than generalists. As a result, their role models and heroes when they’re young and impressionable are those specialists at academic medical centers. For all of those reasons, we have failed to attract the best and brightest young physicians into the field that should be the most rewarding, which is being a primary care physician, i.e., being someone’s main doctor.