Readying for a Revolution
From its integration of value-based care concepts to its approach to teaching the Krebs cycle, see how Austin’s new medical school is preparing students to tackle the challenges of the modern health care system.
The last great revolution in American medical education predates the digital age. It came before Reaganomics. Watergate. The moon landing. World War II. The Great Depression. The sinking of the Titanic.
Just two years after Henry Ford’s first Model T rolled off the line, in 1910, Abraham Flexner published a book-length study of medical education in the United States and Canada. The Flexner Report called for more stringent admission and graduation requirements and set standards for curricular adherence to mainstream science.
More than a century later, we find ourselves in the age of the internet, artificial intelligence and smartphones. A time of electronic health records, 3D ultrasounds and outpatient laparoscopic procedures. When doctors can video-chat with an expert a continent away — while working with a surgical robot.
It’s well past time to rethink medical education.
Opportunity in Austin
In 2012, Travis County residents voted to invest in a medical school in Austin, Texas — the last push needed to make the long-awaited addition to the campus of city’s Tier 1 research university a reality. As leaders for the new Dell Medical School at The University of Texas at Austin came together, they recognized an opportunity for a shift in the way doctors are trained — one that would arm medical students with the knowledge, skills and confidence needed to transform the modern health care system.
Sue Cox, M.D., an early architect of the school’s curriculum, says the ability to “start from scratch” was key.
“We were free from the preconceived notions and other restraints that are sometimes present at established schools,” says Cox, who would eventually be named Dell Med’s executive vice dean of academics and chair of medical education. “Our curriculum designers were able to identify the ideas and methods that are ‘the best of the best’ and then adapt them to our model.”
Sue Cox, M.D.
Executive Vice Dean of Academics
Beth Nelson, M.D., associate dean for undergraduate medical education, says the Dell Med model centers on student development — as future physicians and future leaders.
“From day one, our students are working in teams to solve patient problems — whether in the classroom through case studies or in the hospital during clerkships,” says Nelson. “Our curriculum instills in students the value of communication, collaboration and effective leadership, all with the goal of transforming health and health care to benefit patients and communities.”
The curriculum is anchored by a heavy emphasis on value-based care — the idea that better care at lower cost can be achieved by tying payment incentives to outcomes, not treatments — and health systems science, which examines the changing role of the physician and teaches students to think about patients in the context of social determinants of their health and the needs of the community.
A New Approach to the Fundamentals
Medical data changes fast. Technological advancements and clinical research breakthroughs cause diagnostic procedures and treatments to become outdated after only a few years. That’s why Dell Medical School developed a curriculum centered on active learning and problem solving — one that trains lifelong learners.
Traditionally, students spend the first two years of medical school in the classroom learning everything there is to know about the human body — how it works and how to fix it — through lectures and detailed examinations that rely heavily on memorization.
Dell Med has condensed the pre-clinical basic science curriculum to 12 months and is pioneering a new approach. In “PILLARS” (Professionalism, Inquiry, Learning and Leadership through Active Reasoning and Synthesis), students work together on clinically based case studies, applying knowledge learned outside the classroom through individual, self-paced study. Teams rotate and roles change, ensuring students get the most well-rounded experience possible. Both teams and individuals receive feedback at the end of every session.
“Increasingly, a determinant of what makes a great doctor will be a combination of reasoning skills and communication skills,” says Andrew Bergemann, Ph.D., director for the Cells to Populations course. “Getting used to working in teams and learning how to explain things to fellow students helps prepare students for the real thing.”
Bergemann believes this structure better engages students and helps them retain information. For example, students learn the Krebs cycle as it applies to a theoretical patient’s case rather than simply memorizing it.
“We’re not teaching biochemists; these students want to become clinicians,” he says. “If the content doesn’t seem relevant, they’ll struggle to have an emotional connection and to retain the information. They need to understand why they’re learning what they’re learning.”
Accelerating & Expanding Clinical Opportunities
For students in Dell Med’s first class, clerkships are in full swing. In hospitals and clinics across Austin, these future doctors are working directly with patients and learning from world-class physicians.
Dell Med’s condensed pre-clerkship coursework allows students to begin clerkships during the second year instead of the third, as is more traditional. The Dell Med year is broken up into six clerkships: Internal Medicine, Psychology/Neurology, Pediatrics, Women’s Health, Surgery and Emergency Medicine. Most rotations last eight weeks, with each week focusing on a particular sub-specialty and a week of examinations at the end. Clerkship evaluations and testing align with Dell Med’s commitment to value-based care and patient safety.
“For instance, students are required to reflect on and document value-based decisions in the care of their patients,” says Sherine Salib, M.D., Internal Medicine clerkship director and chair of the school’s subcommittee on Health Care Delivery. “They also highlight safety-related issues to optimize patient care.”
In between each clerkship, students come back to the classroom for eight hours of intersessions. These focus on health systems science, interprofessional care and value-based care.
“It’s an opportunity for students to analyze and learn from the systems they’re working in,” Nelson, the associate dean, says. “We want them to go out and be part of a better health care system. We’re preparing them to understand the challenges within the current system so they can begin envisioning what the future should be — and how they can make it happen.”
Family medicine is typically included as a standard clerkship service, lasting anywhere from 4 to 8 weeks at most medical schools. At Dell Med, students participate in an ongoing, two-year Primary Care, Family and Community Medicine Clerkship one afternoon a week throughout their second and third years. Students are paired with primary care physicians around Austin, including 18 at CommUnity Care Health Centers, federally qualified health clinics serving women and children with low income.
Salib says the Primary Care clerkship allows students to develop long-term relationships with patients, just as they would in an actual primary care setting.
“The longitudinal approach offers students an opportunity to truly appreciate, delve into and understand community-based health care challenges, not only for the individual patient but for health care systems,” says Salib. “And it’s a chance for them to start exploring innovative approaches to implementing improvements.”
Adds Nelson: “During the clerkships, students learn the core medical knowledge that a physician of any specialty needs as a foundation. At Dell Med, we hope students also learn to apply that knowledge in the context of providing value to a patient, advocating for underserved populations and affecting change in the larger health care system. Then, in their third year, they can leverage what they’ve learned to make a difference through community-centered projects, research or health care redesign.”
During Year 3, or the “Innovation, Leadership and Discovery Year,” students have an opportunity to leverage their knowledge and experience to benefit the community and undertake individualized experiences tailored to their long goals. Students choose between conducting an independent project in one of three areas of distinction — Health Care Innovation and Design, Population Health or Clinical /Translational Research — or pursuing a dual degree. Students also continue their Primary Care clerkship throughout the third year to make sure they remain clinically grounded.
Shaping Leaders, Team Players & Caring Clinicians
Quality patient care comes down to relationships — relationships between patient and physician; physician and care teams; and physician and the community. To train students in the art of positive relationship building, three courses run parallel to the core basic science and clinical coursework throughout all four years of the Dell Med curriculum.
Through Developing Outstanding Clinical Skills (DOCS), the school’s unique approach to a doctoring course, teams of five students are paired with a faculty mentor. Students remain on the same DOCS team throughout their education.
DOCS groups meet once a week during Year 1 and focus on variety of topics, from how to work with patients to the business of medicine to large-scale advocacy and public policy issues. In the following years, groups meet once a month and serve as safe havens, where students can process challenging experiences in clerkships or research projects and receive guidance from their teams.
“DOCS prepares our students to not only interact with patients, but to connect with patients on a human level and advocate for their best interests,” Nelson says. “Our faculty mentors are outstanding physicians, and the four-year-long experience allows them to coach their students and see progress over time.”
When students begin clerkships, they already have ample experience working with other care professionals thanks to Dell Med’s integrated interprofessional education course, which spans all four years. In Year 1, Dell Med students work through real-world communication challenges with University of Texas at Austin students studying nursing, pharmacy and social work.
John Luk, M.D., assistant dean of interprofessional integration, believes teamwork is crucial to making a significant impact on the health care system.
“Some schools offer one-time events or an educational series about other care professions, but that’s not enough,” says Luk. “To improve the patient experience — and improve the value of care — professionals across disciplines must work together seamlessly. At Dell Med, we’re committed to integration.”
A leadership curriculum also spans all four years, including 20 dedicated hours in the first year. Students learn skills and methodologies crafted by the school’s physician leaders that they then apply in their courses and clinical experiences.
Cox sees this as one of the core differentiators of the Dell Med educational experience.
“At most medical schools, patient care and medical education are the top two educational priorities. We put leadership first — above everything else,” says Cox. “When students graduate from the Dell Medical School, they will be as comfortable taking on systemic health care challenges as they are caring for individual patients.”
John Luk, M.D.
Assistant Dean of Interprofessional Integration, Department of Medical Education
Lessons Learned & the Path Forward
Now that Dell Med’s first class of students has put the curriculum to the test, school leaders — and even students themselves — are looking at ways to improve the experience for future classes.
Nelson says most of the change centers on the leadership curriculum. Initially spread throughout the first year, students in the Class of 2021 now participate in immersive modules at the beginning of each semester. Additionally, teams of five students are now paired with a leadership coach who follows them through all four years, similar to the DOCs model.
“The restructuring allows for students to have time to really process the leadership material, which is essential to their development and success in their PILLARS courses,” she says.
School leaders also decided to move the epidemiology course to the beginning of the year in order to make sure the curriculum’s focus on population health and community needs are front and center.
Though only a few months into Year 2 clerkships, Nelson says she has already seen successes, as well as areas for improvement in the program.
“Our second-year students have identified hospital processes and procedures that could be optimized, and Seton leadership has been incredibly receptive and interested in their insights,” she says. “That happened faster than any of us thought.”
But as students move away from the Year 1 classroom experience to the patient-centered Year 2 clerkships, faculty have noticed that some are struggling with the transition.
“Moving forward, we want to do a better job of preparing students for that leap,” Nelson says. “There is a lot of flexibility and time in Year 1 that disappears in the second year, when students spend most of their time in a clinical setting.”
Anish Patel, a member of Dell Med’s first class, is part of an undergraduate medical education subcommittee focused on designing and analyzing feedback surveys to inform future improvements. He’s also conducting research to uncover the educational outcomes that Dell Med students value, the effects of a real-time feedback tool on their clinical performance and how clerkship grading criteria affects how students spend time studying and seeing patients.
“Our research is analyzing Dell Med students’ goals — who they want to become and what they want to be able to do — and then, in turn, analyzing how the school’s curriculum shapes our outcomes as physician leaders,” Patel says. “As a brand-new school with ambitious and noble goals, curriculum obstacles are inevitable. But the faculty and staff are incredibly receptive to our perceptions and concerns as a class. They’re consistently striving to make the educational experience better.”
Crystal Zuzek contributed to this report.