In Conversation With… Susan E. Skochelak, MD, PhD
Approach to Improving Safety
Editor's note: Dr. Skochelak is the Group Vice President for Medical Education at the American Medical Association (AMA). She leads the AMA's Accelerating Change in Medical Education initiative, which aims to promote innovation to align physician training with the changing needs of our health care system. She has pioneered new models for community-based interdisciplinary medical education and initiated new programs in rural, urban, global, and public health. We spoke with her about her experience in medical education.
Dr. Robert M. Wachter: Tell us a little bit about your background and what got you interested in medical education.
Dr. Susan E. Skochelak: I worked in faculty roles all of my career, mostly at the University of Wisconsin as the Senior Associate Dean for Academic Affairs before I came to the AMA. A big part of what motivated me was the opportunity to shape medical education in the way that I had hoped I would have been trained during my time as a student and a resident. I was very frustrated in medical education early on. For the first 2 years in medical school, we really didn't see patients and that wasn't what I came to medical school for. So when I was in faculty roles, I worked to change that and bring new methods to teaching our future physicians.
I joined the AMA about 10 years ago to lead the medical education group. The AMA's founding had to do with medical education and forming standards for medical education and standards for ethics for the profession. This association has always been involved in medical education but hadn't been overly visible or active in recent decades until we partnered with medical schools to make some changes.
RW: As you thought about the evolution of medical education, let's say from your vantage point as a junior medical educator, it sounds like early clinical exposure was one concern. What was your broader view of what we were good at and what we could do better?
SS: I trained at the University of Michigan, and it was wonderful in terms of a strong background in science and understanding about the human body, but it was very focused on the tertiary care center in which we trained in Ann Arbor. Between my first and second year as a student, I had a formative experience working in a rural community, and it left an imprint on me that ended up being my career choice. In medical school, we never talked about important concepts like the difference between Medicare and Medicaid. Yet that is so important to patients—understanding their context, their resources, the communities—those kinds of things were missing. I am excited that we're finally starting to address those in medical education.
RW: How important has the quality, safety, and value movement been in driving changes in medical education?
SS: It has been driven in part from that movement, but it's also coming from the disappointment that many of us have about the overall indicators of health in this country. It's not just how we're doing in patient safety and quality, but what's missing that's not helping us help our patients and help communities be as healthy as they can be. Another driver has been health systems folks saying we're not preparing young physicians for practice in the ways that we really need to. They don't understand the ambulatory setting. They don't understand systems. They don't understand quality and safety and how to work in teams. That's the environment we're practicing in. We need education to rise up and become a part of that environment.
RW: That's an ambitious agenda, and if your medical school was anything like mine, I don't remember having a lot of free time. Now you are being charged with helping to catalyze a movement where a medical student will have earlier clinical exposure; more exposure to patients outside the tertiary and quaternary system; and more education in social determinants, system leadership, and system transformation. Where does the space come from for these new curricular elements?
SS: It has to come from two places. The first has to do with redundancy in the curriculum. One of our partner schools, the University of Michigan, had their students write out for their curriculum committee where they were getting repeat areas. For example, they might have multiple lectures on low back pain across the 4 years. Because only the students experience this, they are in the perfect place to say we have about 25% redundancy in the curriculum. Some of that should be planned, but some of that can be eliminated. Things do have to be removed in order to put new material in. You cannot find this in electives or evenings or Saturdays. Most schools have reevaluated, especially core fundamental science. We don't have histology courses anymore, typically. We're integrating the way we teach anatomy into much more around an organ system approach. We're letting go of some core courses. If you've already passed the MCATs with flying colors, do you really need another biochemistry course in medical school? Schools have been bold in saying we're not eliminating fundamental or basic science; we're repurposing it. We're integrating it more effectively, and by doing so we're making room for new curricular content.
RW: I can only imagine the pushback from teachers of those courses, who believed that they were doing crucial work and that students needed it—if some of them were going to grow up to be physician–investigators who cure cancer, this was foundational to their education. How did you work through those issues?
SS: People had to reach across the discipline divide, make partners, and understand and listen. Now most of these courses in medical schools are not owned by departments. When I was in the Dean's office, I had five department chairs that were heads of their courses. Getting them to change within the political system was fairly challenging. Now, there is a more centralized approach in part from the way we accredit medical schools to say we want the curriculum to be holistic and integrated. We want our colleagues in fundamental and basic science to be teachers. But they don't have to do it by owning a course or owning a discipline. There was important work (acrimonious at times) at all of these schools, but by returning to the content in important ways—for example, UCSF does a brilliant job of coming back to the various basic science disciplines in the third and fourth year so that the content is seriously revisited and not just given lip service.
RW: Students are in some ways the most important constituency here. As you talked to student audiences early on in thinking about this transformation, were they a proponent of moving in this direction?
SS: Generally, students have been more positive than anxious about these changes. A lot of it has to do with understanding where they will be in the future with their practices. I don't think it's fair to say that all students welcome change. Anxiety has crept into medical education for them about residency, the match, and future career choice. But one thing that's different in many of the schools we've partnered with is they've opened up the curriculum box. It's not lockstep for every student now. Most students have a core of maybe 18 months that they have to complete, and then a lot of freedom in terms of developing tracks or areas of special expertise. That goes a long way in having the student community be your allies and recognizing their interests, such as wanting to focus on a Medical Scientist Training Program (MSTP) track or on social and community health. It allows the learner to take more charge of this stage of their education.
RW: How has the drive to rethink the content of the curriculum (what learners needed to learn) synced with new ways of thinking about how to best deliver and absorb education?
SS: In the last decade, the approach to training our physicians in medical school has deeply changed to focus on outcomes that relate to defining what you want them to be able to do by the time they leave medical school and enter residency. This formative process now says that in order to get there they need a lot of opportunity for feedback and correction. Moving away from the old lecture style (absorb only medical knowledge and then regurgitate it on a test) to multifactorial ways of doing assessments of students that include knowledge assessment but also peer review, faculty review, and demonstration through simulation. The cutting-edge schools now have learning portfolios for their students, where the learners can see with dashboards how they are progressing in areas that relate anywhere from the medical knowledge side of what they need to accomplish to performance of key competencies that have been defined.
RW: Students still operate in a real world of needing to apply to a residency when all this is done, and the residency will look at how the school has judged how good the student is. What are the role of grades and all of those traditional metrics?
SS: Right now there is a disconnect between how students are assessed for residency programs and the adult learning principles that we've been moving toward in undergraduate education, specifically because many schools have gone to pass/fail, especially in the first 2 years. The numeric marker that many residency program directors use is their scores on the USMLE [United States Medical Licensing Examination] Step 1 exam. This exam is for licensure purposes and for some feedback for programs, etc. It was never designed to be a ranking for whether you get an interview in residency programs or not. But that is currently how it's being used. And that's causing some real anxiety, not just for the students but for the medical educators on both sides of the aisle (UME [Undergraduate Medical Education] and GME [Graduate Medical Education]) to say this aberration is not serving anybody in the best way possible and to ask whether we might look for other solutions for ranking our students for residency.
RW: So in some ways, an unintended consequence was that test became disproportionately important because there were no other objective measures of performance?
RW: Is the lesion that we need a better test or that, in an environment where we are dealing with adults, the residency still has a legitimate need to be able to rank people and we need to figure out a new way of doing that?
SS: The latter. The test is designed well for what it's meant to do. But it doesn't answer the question as a residency program director: How do I find the best pool of folks to interview and then ultimately find the right candidates for my residency program? One interesting thing about the health system science–approach with these schools is that the students at their interview process have been telling us they have great rapport with being able to talk to the program directors, the faculty, the residents about some of the work that they've been doing as medical students, especially in the quality improvement/patient safety project area. If they write about it in their personal essay or if they talk about their project, people get very excited to hear that they've been involved and have a deep knowledge on how to work on system improvement. They feel that is giving them a very positive view by the residency program directors.
RW: If you were the czar of all this, how would you square this circle of creating an environment in the first couple of years that is more experiential, less judgmental, less about facts, more about teamwork and team behaviors, and then the residency director needing to figure out: Do I choose student A or B?
SS: I would be misrepresenting if I told you there was an answer right now. We've had this wonderful 5-year project with medical schools, next we'll be announcing a new RFP [request for proposal] for the next 5-year initiative to work on that transition from UME to GME, and a selected group of institutional partners that want to experiment with and try new ways to understand that handoff in the modern way that we've been moving in adult education.
RW: How about clinical rotations? We've been talking mostly about the first couple of years and early clinical exposure, teamwork, and system science. What about the experience is in the third and fourth year? What have you been seeing in terms of innovation?
SS: Many exciting things are happening on the clinical rotation side. Some themes have included moving those rotations earlier, so it's not unusual for students to be entering actual clerkships after 12 to 18 months. Some schools are having students delay taking their Step 1 USMLE exam until after they do the bulk of their clinical clerkships, and that has been an interesting phenomenon as well. More integration and longitudinal experiences and ambulatory experiences in the clerkships. More focus on core learning not on esoteric learning. Trying to make sure that students get maybe the top 10 diagnoses of what you might pick from for that rotation rather than just plopping you on a ward team to see whatever comes in through the door. A lot of opportunity in the fourth year to individualize the work that you're doing and go deep into projects. Using the fourth year rather than just as a place to gather a bunch of different electives as a place to round out your learning around a theme, and that theme might be leadership, health systems improvement, medical education, or community practice.
RW: Our main academic hospital becomes more tertiary and quaternary every day, and we're partnering with other organizations where more of our primary and secondary care is going to occur. How does the funding model and organizational changes in health care delivery systems sync up with the goals and the desires for education?
SS: Those become very important. A piece of what is critical for the education change to occur is the partnership with the educational system and the health care system around bringing these concepts front and center into the way in which students learn. We've thought a lot about ways that education, beyond even students, can bring better value to the health care system rather than just be a drain on it. There's a great story that came from one of our partner institutions at East Carolina University, where they said our faculty don't even know how to teach the content of patient safety and the health care systems. They partnered with their system to form a teaching academy to train 35 of their partners, their faculty, using the Institute for Healthcare Improvement Open School and other resources to get them up to speed on the content before they even brought this material in to the medical student. They spent the first year working on faculty development. The system ended up with 35 amazingly exciting quality improvement projects that each one of these faculty had planned from their own viewpoint. That really brings value back to the health care system.
RW: Talk about the consortium that you created. What was the rationale and how did it work out?
SS: It was very clear when we started this project at the AMA 5 years ago that people had a great deal of agreement about what needed to change in medical education, but it wasn't changing. We understood the impediment in part to be resource, good intentions but really no opportunity to make those changes. We began with a grant program where we awarded $1 million to each of 11 medical schools based on a very competitive proposal process, looking for schools that wanted to focus more on the principles that we've just articulated: more on adult learning, more on bringing health systems into the process of education, more on health system science content. We structured it in a way that said we're not just giving out grants—go out and do good work. We want to learn from you, we want to evaluate together, and we want to rapidly disseminate best practices. We formed a consortium of schools, first with the original 11 that received the large grants from the AMA. Then, 2 years later we opened up this consortium with smaller awards to another 21 schools. We have more than 30 schools now that have been working together for a number of years on these improvements. We're reaching 19,000 students total, almost one-fifth of the entire MD/DO education population. Together, they will deliver more than 33 million patient visits every year with this new training that they've been undergoing.
RW: All of the things we've talked about would have been true and necessary and challenging if the health care system stayed on paper, just different. But in the last 10 years, we've also seen a shift in the way we store and move information around to now almost completely digital. How does that all influence this work?
SS: We've worked in two important areas that relate to digitization. The first is the concern about electronic health records (EHRs) and the knowledge that almost half the students in the country don't work in the electronic setting, even though this is the number one tool for all health care providers in our day-to-day lives. We would never let a student graduate not knowing how to use a stethoscope, but we're letting them enter residency practice having to practice right away—day one in residency—without having them. I don't mean train on a particular vendor's tool, but how to understand and own this tool—saying this should be making my life better not worse. Some elements of these tools weren't designed perhaps optimally for the work that we do as physicians. At the same time, we've been working with physician, nursing, and pharmacy schools in developing new curricula on the EHR and how to help people understand that this is a tool that you can conquer, master, and use to make your job better rather than make it be a time sink. So that has been one project that we've had fun supporting and working on.
The second is understanding populations and the use of data and how big data can be helpful in improving quality outcomes. Our lead school there has been NYU School of Medicine. They've developed a wonderful course online called "Health Care by the Numbers." They've developed a web interface for a number of publicly available datasets that you can query and examine in terms of what are the top diagnoses in your area, in the state of New York, what are the average charges for different kinds of procedures or hospitalizations. They've been a leader in helping students ask clinically relevant questions and then answer them with big data in a way that we hope spurs their ongoing interest to say, "I can manage my patients, my population, and understand the community better if I have a handle on this important topic."
RW: The curriculum here is so vastly different than it was 5 or 10 years ago. But another thing is quite different: In my class many years ago, probably 90% of us were right out of college, and I think it's probably close to that percentage here that are not. They all have a lot of experience doing other things.
SS: The changing face of medical students is a part of why this individualized learning plan is very important. We have people coming back from other health care jobs. If you're a person who has worked as a physical therapist for a couple of years, you probably don't need 4 years of medical school. We don't know exactly how many you need, but if we were more flexible we would get you out in 2 and a half, and you could move on and be a productive person in the health care system.
RW: The AMA is a brand, and as you said probably a lot of people didn't even know what it did in medical education. Have there been challenges associated with that and what have been some of the advantages?
SS: The biggest challenge early on was skepticism: People wondered why the AMA was involved in medical education because they didn't know AMA's history of work or our accreditation in partnership with the LCME for medical schools. Part of it was proving that a piece of the reason we were doing this had to do with mission and the interest in improving physician training. The benefit is we aren't front and center in the political arena of medical education. Being a little bit to the outside, we can call more things into question. We can push a little harder, and we have the wonderful fortune of being able to bring resources to the schools. It was amazing when we started this program in 2013, 85% of the medical schools applied for the grant. That means the community is ready for change. They need some resources. They need some of this learning process that we've set up with the consortium to really make the changes that they wish for.
RW: Anything I didn't ask about that you'd like to talk about?
SS: We've done a lot of great work at the medical student level. Our biggest concern now is what happens then to all these great people that have been inspired to make change, be leaders, and be systems oriented when they get to residency programs, where that is not a part of the landscape and may not be valued. We're worried they might feel like why did I learn all of that or why did I get invested in all of that if there isn't any support in my training program? So we're very excited to look for partnerships in the GME arena over the next phase of this project, because that's a harder one. There are many more training programs—thousands of residency programs rather than hundreds of medical schools. And we don't know what all of the pain points are, much less what some of the solutions will be.
RW: Interesting that you say it's harder. I can see that the space is much bigger and more diffuse. On the other hand, the residents feel more directly inserted in and involved in the care delivery environment. Maybe I'm naïve sitting here, but it feels like most places are in the business now of having to transform their care delivery around some of the principles you're trying to teach.
SS: I think you're right. So that gives us hope that there are going to be simpatico people out there with good ideas, and if we can bring them together and form a cohesive unit of people that are all working on the same problem, we'll get some quick wins and some good solutions.
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