Thursday, September 30, 2010
The UCSD School of Medicine has rewritten its curriculum for incoming medical students this fall. We discuss how the program has changed, and what motivated the school to change its approach.
Maureen Cavanaugh: The traditional curriculum that's been used in medical school for about 100 years is being given a makeover starting this semester at the UCSD School of Medicine.
It's an effort to get students more engaged in the clinical application of medical science and interacting with patients at a much earlier point in their undergraduate education.
Dr. Jess Mandel, associate dean for Undergraduate Medical Education at the UCSD School of Medicine. And, Dr. Mandel, welcome.
DR. JESS MANDEL (Dean, Undergraduate Medical Education, UCSD School of Medicine): Thank you, Maureen.
CAVANAUGH: What motivated this change in curriculum?
DR. MANDEL: Well, this change really started about three and a half years ago when the faculty came together and reviewed the current curriculum and really recognized that there’ve been enormous changes in the way in which research is performed. There’s enormous changes in the way in which medicine is practiced but at most schools of medicine the way doctors have been taught really has not changed as much as those other two parts of what we do. That really led to a major effort that involved scores of faculty, scores of students, assistance from peer institutions, from national organizations in putting together our new curriculum.
CAVANAUGH: So tell – Let’s go and talk a little bit about the traditional curriculum for a moment. What have medical students, undergrad med students, been – how have they been taught for 100 years at medical schools around the country?
DR. MANDEL: So, Maureen, the 100 year figure is actually an exact one because in 1910 something called the Flexner Report came out. It was commissioned by the Carnegie Foundation. And Abraham Flexner went and visited all the medical schools in the country to try to assess the job that they were doing. And he was horrified. What he found was that the majority of medical schools were run for profit, they had very mixed curriculum, they had minimal requirements. And the recommendations that he made really set the tone for the next 100 years. Classically, it involves two years of what’s called basic science preparation. This is where students take courses in biochemistry, anatomy, physiology, for the first two years and then they’re considered ready to see patients in the second two years when they…
CAVANAUGH: I see. So the idea was to bone up on the books and then you might be ready to start actually trying to use the knowledge that you’ve gained from that in some sort of a clinical application.
DR. MANDEL: That’s exactly right. And it really came from the sort of industrial models of 1910 of sort of early assembly line theory. And I think now we look at adult learning much differently. To use an example, which I guess involves childhood learning but is similar, when a child starts to acquire knowledge, the parents do not say go to your room, learn 10,000 words, learn all the rules of grammar, and then you’re ready to have a conversation.
DR. MANDEL: People understand that acquisition of complex skills is a more gradual and iterative process. The same thing is true with learning to be a doctor. We don’t want to prevent them from seeing patients until enough facts have been packed in, we really – we want them to start very early in their career building those skills under supervision with appropriate increases in autonomy and change in role as they learn more.
CAVANAUGH: So what exactly is going to change? How is this going to be implemented, introducing medical students, undergrads, into a clinical setting a little bit earlier.
DR. MANDEL: So there’s a number of changes that we’ve undertaken, one of which is teaching these basic sciences not as individual disciplines with three months for biochemistry, three months for anatomy, but as an integrated organ and system based approach, meaning that when one is studying the heart, for example, we’re studying the anatomy of the heart, we’re looking at it under the microscope, we are learning how the heart works at a molecular level to pump blood. We’re also learning how to take a cardiac history from patients, how to do physical examination involving the heart, having them seeing actual patients with heart disease. So it’s a much more immersive experience rather than saying here’s the anatomy, hold that thought for six months, we’ll come back then and tell you how it actually pumps.
CAVANAUGH: I see. And so how will this actually work? Will students be interacting with patients really early on?
DR. MANDEL: Absolutely. Starting in the first quarter in medical school, they will have an ambulatory experience where they’re spending a half day every other week in a physician’s office. They’ll also be interacting with standardized, simulated patients. These are highly trained actors with whom they can practice taking a history. Some things, like taking a sexual history, can be very awkward for students when they begin, and being able to practice with people who are highly trained patient simulators is very, very useful for them.
CAVANAUGH: I’m speaking with Dr. Jess Mandel. He’s associate dean for Undergraduate Medical Education at UCSD School of Medicine. And we’re talking about a big change that’s being – taking place in the curriculum for undergraduate medical students at UC med school. And I’m wondering, you just talked about some conversations with patients being a little bit awkward for doctors, is one of the goals in this to really address communication skills right off the bat between doctor and patient?
DR. MANDEL: Absolutely, Maureen. And I think one of the early conversations we had as a faculty was really the recognition that there’s two major axes upon which physicians operate on, really sort of a continuum. The first is the continuum of discovery where on one hand you have sort of pure science, you have hypothesis, you have observation, and then those discoveries need to be translated to humans. What works in mice doesn’t always work in people. And understanding safety and efficacy and relative place for a new breakthrough relative to other treatments, and then really applying that to patients, which is not so straightforward. We know that there’s enormous health disparities in this country, differences in access, differences in application and physicians, depending on the path they take, they’re going to end up on one piece of that continuum but they need to understand the whole thing. They need to understand the whole pipeline, not just their little piece of it for that pipeline to work effectively. That’s the first thing. The other thing is that physicians need to be able to operate on vastly different scales of analysis, meaning they need to understand molecules and genes. They need to understand cells and organs. They need to understand the individual, which is the main scale on which we operate, and that’s where communication is so important. But we also need to understand the culture and society in which patients live. You know, we heard about poverty statistics earlier and that obviously has an enormous impact on the health of individuals and populations. So at the heart of it is communication. A physician is there to serve an individual patient and to do so effectively requires more than just the enormous technical skill and knowledge that we expect them to have. To be able to apply that appropriately relies on the communication to really understand the problem, understand the patient, understand the range of treatment options that are available and hook the right patient up with the right treatment.
CAVANAUGH: And, as you talk about changes in curriculum and also changing populations, are those changes influencing any of the programs’ focus in terms of maybe increasing the number of people who might want to go into primary care, or perhaps geriatrics, considering the aging of our population.
DR. MANDEL: Sure, so I think one of the criticisms that’s been leveled at the medical profession is that there’s been a sort of head in the sand approach in terms of dealing with the patient in front of us but not dealing with the larger issues that society faces. And I think over the last 10 or 15 years, there’s been a recognition that we – paramount is always the patient in front of us but that we also have an important role in terms of the stewardship of resources for society in terms of matching the output of our medical school with the health needs of California and the nation as well. It’s clear that the aging of the population has increased demands for certain types of skills among our physicians. The increased diversity of the population in California and that’s very much influenced the curriculum that we give to our students.
CAVANAUGH: In your description of the traditional curriculum that’s been taught for 100 years, its emphasis on really memorizing and book learning seems almost old fashioned looking at the technology we have today where doctors can do almost immediate research through technology, through computers, to help their diagnostic abilities. They don’t necessarily have to all carry it around in their head anymore or should know where to look for it in a particular medical book. Does that also influence this change in the way that medical schools are going to operate?
DR. MANDEL: Sure. And we’ve actually created a specific emphasis on medical informatics, and this has occurred at the same time in which the Department of Medicine at UC San Diego has added a division of Medical Informatics, recognizing that this really does change everything. Not only doctors but patients can look up anything on their cell phone and have a answer 10 seconds later. So, again, it’s not all about the facts but recognizing the facts that one needs to know and how to go out and get them. I think many more errors are made not because people look up the wrong facts but because they don’t know they need to look up something and they’re not asking the right question or not viewing a case in a way in which there’s an understanding of what the key information note is to really influence the way things evolve further. So it’s easier than ever, I think, to answer factual questions. Physicians in training need to be trained to ask the right questions that then can be answered in a variety of ways.
CAVANAUGH: Dr. Mandel, I wonder, have you gotten any criticism from the old guard, so to speak, from people who have been trained in the traditional way about making these changes? What have – what kind of reaction have you heard and how have you worked that into this new curriculum to maybe avoid whatever pitfalls they might – that criticism might have brought to light?
DR. MANDEL: Well, I think, you know, many doctors, myself included, have wonderful things that they remember about their training at various stages along the way. And I think, appropriately, express concerns that the best in that system should be preserved and brought forward. I think what’s interesting is when I talk to anyone, both in medicine and outside about powerful learning experiences, they almost always name a person. They don’t name a course, they don’t name a system, they name people. And it was clear and one of our tasks is really to hook up our learners with the best teachers as people, as purveyors of information but also as role models and as exemplars. It’s particularly important in medicine where professionalism is so important in defining our success. We know, and all of us are patients as well as doctors and teachers, and we know when we go to our doctors, we have enormous expectations about their technical knowledge and their technical skills but they need to be professionals with all that implies in terms of putting the patient’s interests first, respect for privacy, respect for the individual, etcetera. So I think, you know, one of the things I’m most proud of is how we’ve really programmed into this new curriculum a lot of very long term experiences, you know, one-on-one or two-on-one between learners and these great teachers. And I think that has answered some of the concerns in that that is one of the best things about medical education when it’s worked under any system, is really that tight connection between learner – between teacher and student.
CAVANAUGH: I’ve known some people who’ve taken – who’ve gone through med school and who basically found out somewhere along the way when they were introduced to actually treating patients that they really sort of wanted to go into research…
DR. MANDEL: Umm-hmm.
CAVANAUGH: …rather than having that kind of an interaction with patients. And I’m wondering, is there any chance that there might be some med undergrads who say, you know, medicine is just not for me because I just really don’t like to interact with patients. I would just really like to pursue the pure science of it.
DR. MANDEL: Right. So not only do we expect that, we want that.
DR. MANDEL: We want to train physician scientists and that’s a key part of our mission. I think we heard earlier about UCSD being recognized for the quality of its scientific graduate programs and that’s an enormous resource that the medical school is a part of and leverages and one that we’re enormously proud of. Simply put, we want all of our graduates to be scientists, whether they’re perform – either they’ll be performing science or being informed by science. But that connection between science and medicine needs to be a very tight one and, again, wherever they end up on that spectrum of discovery, all the way to implementation, is a place where we need outstanding people. And our job is to help them identify their passion for where they want to be on that and help them be great and successful at it.
CAVANAUGH: I’m wondering, is this earlier introduction into patients and the clinical aspect of medicine, is that – Do you hope that that might also encourage more communication or better communication between doctors and nurses?
DR. MANDEL: Very much so. It’s clear that medicine is practiced as a team sport in this day and age and will continue to be so perhaps at a greater level as things move forward. And that’s actually a cultural shift for the students when we get them. For the most part, as college students, they are individuals. They take their courses, they pass their tests, if they do well they come to medical school. And now we tell them, we know you’re smart, we know you can function as an individual but now your challenge is to function as a team. And one of the key parts in the new curriculum is a huge emphasis on small group activities versus lecture halls. Part of that is that the retention of information is much higher when people are active and actively engaged in it, but a lot of it is to start to mimic the team dynamics that doctors need to work effectively with, with other doctors, with nurses, respiratory therapists, a variety of allied health professionals, and teams that include the patient and the patient’s family as well.
CAVANAUGH: I know this is really sort of very early on but have you gotten any feedback. I know that the semester has just basically started. And how early in the semester are people – are med students going to come out of the classroom and into the clinic, so to speak?
DR. MANDEL: Well, they’ve already begun.
CAVANAUGH: Really? Already begun?
DR. MANDEL: We’re in the fourth week and already their time is divided between more sort of classical basic science pursuits and more clinical pursuits related to really doctoring skills, more of medical interviewing at this point. They’re poised to start heading out into their physician offices as well in the next couple of weeks, so a lot of excitement around that.
CAVANAUGH: I – That’s what I was going to say. I was going to end with. Just by your talking about this and hearing this really rather large change in the way that med students are taught at UCSD, this is a very exciting experiment for you.
DR. MANDEL: It is, and in addition to the sort of change in the software of education, we have a change in the hardware. We have a brand new state of the art education building that’s under construction and will be ready for occupancy in the fall. So I think all institutions always have their sort of internal biorhythms around various things and it’s clear that education at the medical school right now is a source of enormous excitement and enormous pride.
CAVANAUGH: Well, congratulations and continued good luck.
DR. MANDEL: Thank you very much, Maureen.
CAVANAUGH: I’ve been speaking with Dr. Jess Mandel. He’s associate dean for Undergraduate Medical Education at UCSD School of Medicine. If you’d like to comment, please go online, KPBS.org/thesedays. Coming up, we welcome Ambassador Robert Blake, Assistant Secretary of State for South and Central Asia. That’s as These Days continues here on KPBS.