A Shot in the Arm for Medical Education

British Medical Journal
November 12, 2013
A Shot in the Arm for Medical Education

A shot in the arm for medical educationBMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6756 (Published 12 November 2013)
Cite this as: BMJ 2013;347:f6756 Undergraduate Article Related content Article metrics Edward Davies, US news and features editor, BMJ
Author Affiliations

1New York, USA
[email protected]
Edward Davies visits a new medical school in Long Island that claims to be doing things both differently and better

The first thing Harvard Medical School tells you about itself on its website is that it was founded in 1782 (http://hms.harvard.edu/about-hms), likewise Johns Hopkins (1889) (http://www.hopkinsmedicine.org/about/), and University of California, Los Angeles (50 years old) (http://healthsciences.ucla.edu/dgsom/pages/about).

But a small medical school on Long Island, New York, is trying to change the emphasis medical schools have on history and make itself relevant to modern healthcare. Hofstra University’s medical school opened its doors to new students on 1 August 2011, and the first thing it tells you on its website is the desire to do things completely differently.

Building a curriculum from scratch
“Hofstra North Shore-LIJ School of Medicine at Hofstra University is ready to be a national leader in Medical Education. We’ve set out not to build a medical school that looks like old ones, but to identify what works and then create a unique medical school on Long Island—one of the most ethnically diverse, immigrant-rich communities in the world—and set a precedent for the future in medical training.”

It’s the first medical school to open in New York for several decades and dean Lawrence Smith was clear from the start that the set-up and curriculum for the school would not be bound by tradition or history, but by the needs of the modern doctor.

“We could do anything we wanted,” says Smith, speaking to the BMJ. “Nobody had ever done anything. There were no traditions that we had to change and push back. We were free to really build the school the way we saw fit.”

“Our decision was that if we were going to make a mark nationally quickly it had to be in how we taught medical students to become doctors. That was the opening gap, so to speak. We could have a good research programme, but we’d never compete with the Harvards and Johns Hopkins of the world. We could have an outstanding health system and clinical training, but so do many medical schools.

“But tackling the issue of what has changed in the way science is conducted, what has changed in the way clinical care has been conducted since the last time that medical curricula were really dramatically changed—and try to figure out what are the gaps now between what was really a 1970s curriculum and the current way medicine and science are practised—that was the driver of how we decided to go radical and really build a curriculum for the 2020s.”

No scientific departments
So how did they do that? Firstly, they got rid of scientific departments.

“It was very clear that the basic science departmental structure, was really a relic of the late 1800s,” says Smith. “Departments were named and siloed by the very earliest phases of biomedical science—names like physiology and pharmacology and microbiology and anatomy.

“Each one of these departments are vestiges of another era of science because amazingly now everybody’s science looks exactly the same no matter what department they’re in. But those departments hung on to their turf with ferocity. So we decided not to have departments. So we have a department of teachers called the department of science education and a department of researchers called the department of molecular medicine. And that’s it.

“That allowed us to ask the question: if we never had departments, what is the right sequence of learning about the human body and health and disease, as opposed to giving biochemistry a course here and anatomy a course here? How would we actually teach this if we didn’t have to worry about the turf of departments?”

These led to their second major innovation—PEARLS. The entire curriculum for the first two years of medical school is based on weekly case studies called patient-centered explorations in active reasoning, learning, and synthesis (PEARLS).

The cases are constructed so that the students identify what it is they need to learn to understand the science behind each case. Everything that happens in the week uses those cases as anchors and the theme of each session in the week unravels directly from that case. Although problem based learning will be nothing new to most people—this curriculum takes it to a whole new level.

Lectures and “fact based sessions” are kept to an absolute minimum and the timetable shows a lot of empty space, with most afternoons free for the students. David Elkowitz, an assistant professor on the faculty at the medical school explains that there is a lot of self-directed study involved.

“Students are expected to learn the information on their own. I’m here as a process conduit, not a content expert. I don’t dispense information.”

It’s a different way of learning and might not be to everybody’s liking—members of the faculty have to go through a careful training process. Although selection is the same as any other medical school, Smith supposes there might be an element of self selection in students applying but Veronica Catanese, vice dean and dean for academic affairs thinks it can work for almost anybody.

“We really haven’t identified a group that we think was not going to be able to learn this way,” she tells the BMJ.

“People are able to learn this way as long as this is the way they want to learn. There’s a little bit of suspension of disbelief that they have to do too because so many people have gotten to where they are in terms of applying and being accepted to medical school by being very good at learning [a different way]. But there are very few phenotypes that haven’t been able to get excited about learning this way.”

An unusual relationship
There is, however, another major difference to this program brought about through its relationship with North Shore-LIJ Health System. Most medical schools will be linked with a major hospital, and some with a larger system of healthcare. But few can claim to have such a close training relationship with a fully integrated system like North Shore-LIJ, which founded the medical school in partnership with Hofstra University.

The North Shore-LIJ Health System is the largest healthcare provider in the region and includes16 hospitals across Long Island and in New York City, 9000 physicians, 10 000 nurses, and most services a patient could need from cradle to grave (box 1).

The relationship not only gives the students early exposure to a broad range of healthcare, but also allows them an unusually hands on start to their education.

The best example of this is that all students join an ambulance team in the first week, an experience only made possible because the crews are employees of the health system so training medical students can become part of their job. Then at the end of the year the students take the state certifying examination and become licensed emergency medicine technicians (EMTs).

“One of our core principles is medical students should encounter patients with ever increasing real responsibility for the patients,” says Smith. “Therefore you have to have some kind of a skill set or else at the beginning all you do is watch. And this EMT curriculum kind of jump-started a real skill set. The other piece is we felt that the students should be part of disaster response for this region. And so the last thing they do in the first course is disaster drills at the New York City fire department training centre.

“In Hurricane Sandy, right next door to us at Nassau Community College, there was a shelter for the medically ill. They put out a call for any EMTs to help staff the shelter and our whole class just literally walked across the swamp that was the flooded area and ran that shelter for almost two weeks because they all were licensed EMTs and totally capable of functioning independently that way.”

Box 1: The North Shore-LIJ health system.
The organisation bills itself as the nation’s second largest, non-profit, secular healthcare system and cares for patients throughout Long Island, Queens, and Staten Island—a service area encompassing more than five million people. It started as just two hospitals, but has now multiplied those many times over, and added 400 ambulatory care centers, long term care facilities, home care, transport systems, childrens hospitals, and close to 40 000 employees. Its president and chief executive Michael Dowling describes it as the “full continuum of care.” “Irrespective of what kind of a service a person needs, I either have it or can easily contract for it. Hospitals are just one piece of the system and they are not the most important piece going forward.” It publishes more than a dozen different publications, from patient information magazines to clinician research, and even has its own television show—Focus on Health (http://www.northshorelij.com/hospitals/news/focus-onhealth)

Does it work?
But as with any new treatment, the key question is simply whether or not it works. Smith points out that the first class have just been through their USMLE (United States Medical Licensing Examination) and done “extraordinarily well” but these students are due to graduate in 2015—the real litmus test, the students tell me, will be as they apply for their first jobs.

Nick Petit, one of four medical students I speak to is positive about his own experience but realistic about what he can say about it so far: “I don’t think we’ve had that litmus test yet to prove that this is a success so should other schools do something similar? Well, we don’t have the proof yet so no.”

And while his three classmates are positive about their experiences of both a new curriculum and new way of working, they are also circumspect about whether it could or should be replicated by other medical schools.

Could this be replicated elsewhere?
Second year student Kevin Smith is unequivocally positive about his experience but believes that the learning style might not work so well in a larger medical school and that replicating the unique relationship with North Shore-LIJ would be hard: “Other schools could certainly take aspects of it, but if you are tied to a smaller health system this would be very difficult to do.”

And classmate Lianne Cagnazzi believes that although academically much of what they do could be used elsewhere, with experiences such as working with an ambulance crew in your first week, the course demands a certain level of maturity that some students, particularly in countries where medicine is an undergraduate degree, may not have.

“All of us took time even between undergrad and medical school and I think your level of maturity and ability to interact with the patient improves with a few more years. If I’d done this at 18 I would have been a mess.”

Observers will have to wait until 2015 to see just how successful this new school and method of teaching is, but so far the omens look positive.

Box 2: A long search for improvement in medical education
The specific subjects up for debate may have changed over the years, but hand wringing over medical education is not a new sport. In 1844, when this publication was still the Provincial Medical and Surgical Journal, the debate over what students should be taught had readers encouraging a variety of changes to the medical curriculum.

“In our schools certain authors should be added to the list commonly in use; some substituted for others,” wrote Henry Dayman to the editor on 16 September 1844. “In Greek, Hippocrates, Aretaeus, Aristotle, with Theophrastus and Dioscorides, fathers in Materia Medica. So, too, Xenophon’s ‘Memorabilia,’ parts of which are semi-medical, might be substituted for his ‘Cyropoedia.’”1

Another correspondent seems to feel that medicine is more about the man (and it was all men) than the education: “The essentials for a medical man are, good health, courage and firmness, a steady hand, common sense and, judgment, acuteness, discernment, discretion, inherent, genius with humility, and some mechanical knowledge,” wrote another correspondent.2

1 Dayman H. Schools of preliminary education for the sons of medical men. Prov Med Surg J 1844;s1-8:482.

2 The Council of Health and Medical Education. Prov Med Surg J 1844;s1-8:595.











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