Future of Medical Education: “Back to Basics in a New World”

1. Future of Medical Education:“Back to Basics in a New World” Lawrence Smith, MD Dean and EVP Clinical Affairs Hofstra North Shore-LIJ School of Medicine

2. “It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change.” Charles Darwin

3. Historic Periods in American Medical School Development • Pre 1800 (4) • Pre Civil War (31) • Post Civil War (35) • Post Flexner Report (9) • Post World War II to 1978 (45) • Plateau phase 1978 – 2003 (1) • Millennial growth and development (15+)

4. What has been happening in the Plateau Phase? • Demographic issue • Patient factors • External environment • Medical student factors • Curricular issues • Hospital factors • Model of care changes • Residency changes • Clerkship changes • Data explosion/value driven health care

5. The “deconstructive” educational model The Competencies!

6. The Competencies: organizer or fragmenter of medical education? • Professionalism • Patient care • Medical knowledge • Practiced based learning and improvement • System based practice • Interpersonal and communication skills

7. Is the whole equal to the sum of the parts? Has the competency based education movement been good or bad for Medicine?

8. Deconstructed Model • Competencies as discreet entities • Observable events • Process measures • Artificial constructs and metrics • Assumes many parallel developmental paths as if each area is independent • Milestone achievement • Is it on the test • Gaming very effective • “Passing the Test” defines excellence

9. Integrative Whole Model • Complex, critical thinking • Integration, hypothetical-deductive reasoning • Being effective, instead of right • Focuses on who is the “complete physician” • Emphasize ownership of patient • Effective team performance • Judged by action in context and achieving outcomes • Encourages learning in action, not preplanned • Evokes self-responsibility for excellence

10. Deconstructive Model • Focuses on discreet tasks • Can you do it not did you do it! • Enumerates reasons for failure • Blames for mistakes • Attempts to deconstruct complexity into rules • Obsessed with eliminating uncertainty • Reduces everything to what can be measured • End product is completed “check list” • Content expert is always deferred to

11. Integrative Whole Model • Focuses on the whole and not the tasks • Are you effective? • Did the patient do well? • Makes things happen in context • Understands failure and improves next time • Embraces complexity • Functions well under uncertainty • Recognizes and reflects on things that don’t make sense • End product is a functional whole – i.e. The Internist • Key faculty are the master clinicians

12. Physical Exam • Discreet Competency: Can she do the cardiac exam correctly? • Integrative: Does she do a cardiac exam when indicated in a real clinical situation, detect the abnormal findings and trust her exam so that she can initiate action based on it?

13. What is Missing? • The “whole doctor” • Personal ownership of the patient • Professional growth • Embracing the culture of medicine • Effectiveness in action • Clear end-product of training

14. Master Clinician • Great listener/history taker • Great communicator • Empathetic • Makes the complex and confusing – clear and simple • Can explain clinical reasoning and illness to patient, family, student, and resident

15. Master Clinician • Learns from practice • Collegial • “Cares” about the patient as a person • Makes every patients’ suffering a little less • Confident and decisive • Loves being a doctor and exudes that joy

16. Master Clinician • Feels total responsibility for their patients • Sophisticated clinical reasoning and intuition • Always learning – remains flexible in thinking • Says “I don’t know”

17. Master Clinician • See the patients’ illness in context of their entire life • Cool under pressure • Inspires patient trust • Unyielding integrity • Reflective

18. Master Clinician • Advocates for the patient, challenges the system • Humble and selfless • Never cuts corners • Only satisfied with excellence

19. Master Clinician • Does the right thing • Does it at the right time • Does it right • Does only the right thing • Can prove it was done right • Does it right in novel situations • Does it better next time Adaptive Expertise

20. How do we encourage the development of future master clinicians?

21. Professional Growth The development and internalization of the attributes, applied knowledge, judgement and behaviors of the good physician into ones concept of self

22. Professionalism(alternate perspective) • The personal development of a new “professional” self identity • Creation of a new understanding of self and the world • Occurs in stages • Results from meaningful professional experiences, dialogue and reflection

23. Stage 1: Early Entry • Reflex responses derive from previous non-professional life • Rules of the profession not clearly understood • Immature learner-”I am smart and can beat anyone at the game” • Surprise and angst at adverse reactions to “usual behaviors”

24. Stage2:Reward/Punishment • It’s all about ME • Figuring out the “rules of the game” • What’s on the test ? • Cram and forget, get high grades • Motivation is the “system’s reward/punishment” • Satisfaction comes from the external rewards

25. Stage 3:Team Membership • Can hold multiple points of view • Relationships are critical • Begin to integrate and apply knowledge • The “Profession” is a relationship • Motivation is the “Medicine team does it this way” • Satisfaction is from successful team and individual relationships

26. Stage 4: Physician Self • Integrated the Profession(values, thinking,etc.) into a new self identity • Professional behaviors become habitual • Can break away from the rules and the team when appropriate • Leads the team • Knowledge is put into effective action • Can be flexible and self-critical • Motivation “I know the right thing to do” • Satisfaction is internally derived (integrity)

27. Stage 5: Mentor • It’s all about others • Holds a “big picture” perspective • Teaches the “rules” of doctoring • Guides the team • Art and Science of Medicine are one • Nurtures the transformation to Physician • Motivation is to see others succeed • Satisfaction derives from the accomplishments of others

28. What prevents this from happening?

29. Poor learning experiences -The problem of the “Preliminary Residency” -Off-target assessment methods -The “safe” hospital -Unclear Medical School “goals”

30. Loss of the Culture of “doctors” • Learner issues – no time to reflect • Hospital staff issues • Practice issues • Generational issues • Loss of the “Presence of role models”

31. Where do we need to take our students? Where the patients and master clinicians are!

32. The reconstruction of the whole doctor Competency guided education that helps organize our thinking, not fragment our learners.

33. Back To Basics • Critical thinking skills • Knowledge in action • Ownership of the patient • Acceptance of the role, privileges and obligation of physicianhood • Rejecting mediocrity • Developing leadership

34. Back to Basics • Integrated, conceptual learning • Trust the students-tell them what you want them to learn • The patient is the text • Assess and reward what really matters

35. Values • Community • Scholarship • Innovation • Learning • Humanism • Diversity • Professionalism • Patient Centered • Reflection • Vision

36. Guiding Principles of our Curriculum Design True to our mission, values, and drivers Fully integrated, developmental, four-year science and clinical curriculum Integration of health, disease (normal and abnormal), and intervention An “adult learner” environment that values independent study and self-directed learning Built upon experiential and active small group case-based learning Early, real clinical skills

37. Guiding Principles of our Curriculum Design Conceptual knowledge in action, not memorizing facts Early meaningful patient interactions with emphasis on both individual and population health Emphasis on scholarship, critical thinking, and lifelong learning Focused on learning rather than teaching  Meaningful Assessment that drives learning Emphasis on reflection, and transformation

38. Put the right people and opportunities in front of the students • Great Teachers • Sponsors of our young physicians • Powerful role models • Personal mentors • Time to reflect and socialize

39. Positive Role Models • Happy • Good communicators • Empathetic • Clear, rigorous thinkers • Efficient • Effective • Confident • Excited • Courageous

40. Role Models NOT : • The academic dilatants • The arrogant or narcissistic • Throughput mechanic • Coerced unhappy physicians • Whiners

41. Maybe Visionaries

42. Now when they saw him afar off, even before he came near them, they conspired against him to kill him. Then they said to one another, “Look, this dreamer is coming! Come therefore, let us now kill him and cast him into some pit; and we shall say, ‘Some wild beast has devoured him.’ We shall see what will become of his dreams!” • Genesis 37:18-20

43. But how shall we educate men of goodness, to a sense of one another, to a love of truth? And more urgently, how shall we do this in a bad time? Daniel Berrigan