Carving New Milestones in Physician Training

Medical students
Students in the Hofstra North Shore-LIJ School of Medicine start their studies with EMT certification.

Larry Smith, MD, founding dean of the Hofstra North Shore-LIJ School of Medicine, recently spoke about the challenges of build and launch a new kind of medical school. In this new installment of our Health Care Leadership series, Dr. Smith discusses the program’s innovative curriculum that prepares students for the demands of a dynamic and ever-changing health-care field. Find video highlights at the conclusion of today’s post.

Question from interviewer: The medical school is one of the first new MD degree granting institutions in New York State in close to 40 years. As founding Dean, tell me a little bit about your philosophy and the philosophy of the school. How is it different and why?

Dr. Smith: We had a 30-year pause in the United States in building any new medical schools. Our goal was to look at what had changed in that period of time that made the way the other schools operated, a little bit out of step with the way science and the way clinical medicine had progressed.

We need physicians who are very rigorously trained. Science is moving very, very quickly. We understand the mechanisms of disease better than ever before. There is no way to have physicians in the 2020s who don’t really understand the molecular science basis of medicine. We’ve had to really work on how to teach that in a way that a physician can use it at the bedside. And that’s been a big challenge.

Q: How do you do that?

Dr. Smith: We made a decision to teach all of the basic science of medicine in the context of real clinical problems. We guided the students to learn what was traditionally classroom science in the context of trying to understand and solve a patient’s real medical issues.

We looked at the issue of how medicine will be practiced in the future. Team care is critical. All of the physicians of the future will be working within the disciplinary teams and that’s the way we begin to train our students right from the very beginning.

For instance, the first clinical experience that our students have is on an ambulance with a paramedic and an EMT as part of the team. And throughout their medical school training they work with other professionals and train together with groups of people that they’ll ultimately work with together.

Critcal Thinking, Not Memorization

Q: You require students to become certified EMTs in the first nine weeks of medical school. That’s not done in other medical schools. How is that helpful?

Dr. Smith: This is important. This is not just about providing students an experience on an ambulance. They go through the full curriculum and actually take the licensing exam in the state. It provides the students enormous credibility early on.

We’re having the students meet patients and solve real patient problems with the science we’re teaching them. So it’s a positive attribute for the students to be seen by the physicians they’re working with as a licensed medical professional with a real skill set.

Q: How are the students, and the faculty responding to some of these unique approaches?

Dr. Smith: Students chose our medical school. Students understand our curriculum and want to be here. I think they’re excited by it. And the word has spread that the active learning, the engagement as adult learners, the problem solving and critical reasoning that we emphasize as opposed to memorization, is a much more exciting curriculum.

The faculty on the other hand, needed to be convinced early on. But I think we now have almost an entire faculty that believes that this is a better way to teach students.

Q: The school just received full accreditation by the Liaison Committee on Medical Education. What does it mean to the school and to the students?

Dr. Smith: The process of becoming an accredited medical school for an allopathic medical school is fairly complicated. It requires three steps; preliminary, provisional, and full accreditation. We had passed the preliminary just before we started operating. The provisional allowed us to move students through the third and fourth year of medical school. And the full accreditation occurred during the final year of the first class. We’ve met all of the requirements and are now fully accredited.

Q: How many students do you have in your first graduating class? And how many students would you project in the next five or ten years?

Dr. Smith: The first class started as a class of 40 and we’ll be graduating about 30 in the first graduation year, which is this year. We will ultimately be graduating 100 a year. Our class of first year medical students this year is a class of 100. That’s the class size we intend to continue.

Q: Tell me a little bit about the makeup of the class and where you see that happening over the next couple of years.

Dr. Smith: The geographic dominance is the tri-state area representing about 40% of the class. And the rest of the class comes literally from all over the country.

We establish policies on our admissions, where we outlined what we are looking for. We asked the question, “What kinds of things do we want to consider as diversity?” Beyond geography we look at diversity in types of educational and work experiences; ethnic diversity, income diversity of family members, first generation immigrants, first people to go to medical school in a family. We included lots of elements of diversity to try to get the student body to reflect the amazing diversity of the population of patients we serve.

Q: Now with this new accreditation, how will you be competing for students for the medical school?

Dr. Smith: We’ve been very successful in competing for students, but the full accreditation will provide everybody confidence.

We are a private medical school, so we’re not bound to take only students from New York State. We can look at the entire national pool of applicants. We’ve done remarkably well at attracting students. I think we’ll only improve as our reputation continues to be known nationwide.

Q: Talk a little bit about the interview process; the process you employ to select those 100 out of 6,000 applicants.

Dr. Smith: The first step is screening the approximately 6,000 applications. And there’s where we apply those diversity criteria, so that we’re interviewing people with all of those different attributes. Then we do what’s called a behavioral interview.

In a behavioral interview, the assumption is that someone’s already screened your academic performance. You’re sitting in an interview where the interviewer assumes you’re smart enough to go to medical school. So it isn’t a question of asking “Why did you get a B plus instead of an A in organic chemistry?” -- that’s all done by the screeners. The job here is to find out what kind of a person they are. Will they fit into the class? Will they learn in a collaborative nature of our case-based learning?

There’s a structured and semi-scripted way of asking questions, probing the candidates to express themselves in ways that tell you a little bit about how they learn, how they function, how they deal with adversity. We ask about the types of things that we think make them better citizens of this mosaic of a class that we put together.

Q: You have a different curriculum with some very unique ideas and a ground level approach to teaching. Are you attracting a different kind of student because of that approach?

Dr. Smith: I think that very few students come to our medical school having ever learned the way we expect them to learn here -- solving problems and learning the factual basis of the solutions to problems on their own. The faculty is really there to coach them in the critical thinking and the use of the information.

This is different from how they teach in undergraduate school. We were concerned that people would get here and not be able to learn that way, but that has not proven to be the issue. In fact, within a very short time, almost everybody gets very good at this.

Q: Are you creating attention from other medical schools? Are they coming here to look at some of your unique approaches?

Dr. Smith: A fair number of schools have come here and have spent anywhere from one to four days looking at our curriculum and trying to understand what we’re doing. Some of them have liked it and some of them have not. All of them are envious that we had a blank slate to build this curriculum on. We’ve made a lot of friends that way.

Keeping Pace with New Discoveries

Q: You mentioned before how medicine and science are changing. And you’re taking some very unique approaches to how you’re training your students. What are some of the differences that you expect these students to have in their medical career versus some of the experiences you’ve had in your medical career?

Dr. Smith: When I was trained, people really believed that you could learn everything you needed to know in medicine at a point in time and most of that would last you a lifetime. I think we realize now that the pace of new discovery is so fast that you have to be flexible.

You have to be willing to discard things that you learned that turned out not to be true. You need to be able to teach yourself, because you couldn’t possibly stay static and ever think you’re going to be up-to-date in the future. And so, we’re really emphasizing people who can be self-learners.

Q: Tell me about the interaction between students and some of the research that goes on throughout the health group.

Dr. Smith: This is really a scientifically rigorous curriculum that we put the students through. We encourage all the students at some point in medical school to participate in real scientific research. Most of them do it the first summer.

We link students with scientific labs both at Feinstein, as well as in our clinical departments. It’s been very positive. We expect them to produce posters and presentations of their research. Some of them have already published their research.

Q: The importance of patient interaction today has become important across the board. Not only where our culture has gone, but also in terms of payments, back to the hospitals for some of the government programs. What are you doing differently to train these students in terms of patient interaction?

Dr. Smith: When it comes to doctor/patient communication, empathy skills, and patient education skills we use a simulation center. We start the first week of medical school training students in these skills. We have them look at themselves videotaped, having professional patience and give them feedback. We do this through all four years of medical school.

Q: Recently we saw the results of the Ebola virus spreading and now measles, which at least we have a vaccine for. Are you going to alter your training or your curriculum at all to look at some of these pandemic issues that seem to be coming up more often?

Dr. Smith: Our curriculum is a little bit different than the traditional curriculum. For instance, in a course we call Interacting with the Environment where we deal with things like immunizations we’ve already had cases built into the curriculum with issues around refusing immunizations for your children. And that inclusion was long before the current measles crisis. We included those types of medical ethics issues in our curriculum.

Q: Are students getting involved in trips to help governments or people around the world with some of these problems?

Dr. Smith: About a quarter to a third of the students have had international experiences. And usually, they look for third world experiences where these types of very core, public health type issues still plague less developed countries. The students like getting involved in that. It reminds you of the roots of where medicine could make major gains with just relatively small investments. And that’s been good.

Attracting Medical Residents

Q: Let’s talk a little bit about your 1,600-plus residents across the North Shore-LIJ Health System. Are you training them differently than other residents in other hospitals? And how is it making a difference day-to-day in the hospital system?

Dr. Smith: From the medical school standpoint, all those places where residents are learning are the prime places for clinical education of medical students. The residency programs in many ways form the cultural base of where we send the students for their clinical education.

Those residents also become our own physicians and the physicians in this region. We believe that we’re really training the future workforce for this region.

We are just beginning to export the creativity of the medical school curriculum into the residency programs. We hope this rubs off and gives people permission to really be daring and try new ways to train physicians at every level, not just at the medical school level.

Q: How are you attracting and retaining these residents from around the country?

Dr. Smith: Attracting is pretty easy. Our residency programs have been around for many years, long before the medical school, and are well-known and very competitive. Keeping them is another story. We try to make it attractive for them to stay. We try to give them opportunities that look competitive with anybody else’s opportunities, and we try to recruit them early, before they get approached by forces that would draw them outside of the region.

Q: How is that interfacing with some of the issues and some of the patients that you have in the hospitals?

Dr. Smith: The residents taking care of patients and being their doctor is pretty traditional; that’s the core business of training a practicing doctor. But we also get residents involved in patient safety issues, in quality projects, in looking at population data. The residents are seeing a much broader perspective than just the bedside skills of their future specialty.

Q: You seem very excited about the school and medicine. And with many years of wisdom and experience, you seem very happy and excited about what you are doing today. Tell me a little bit about how you feel about this experience.

Dr. Smith: The privilege of being the founding dean of a new medical school was a special gift. This has been one of the most exciting endeavors I’ve ever done in my career, and every day I remind myself what a privilege it is. There aren’t a lot of people who get to start a medical school from scratch. Myself and the faculty that we’ve had, have done that. We all recognize how special that has been.

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