A Brave New World: The Case for Curriculum Reform at Mayo Medical School

A Brave New World

The Case for Curriculum Reform at Mayo Medical School

While the practice of medicine has changed tremendously over the past hundred years, medical education has remained remarkably static. Most medical schools still rely heavily on lectures and give tests that require the memorization of facts, even though the body of medical knowledge far outweighs what any one mind can contain. And while the successful practice of medicine is now more than ever before a team effort, not a solo endeavor, most medical schools remain competitive environments that fail to encourage the team-based approach to care that students will encounter in practice.

In failing to adjust to the advancing medical landscape, medical education — and medical care — have suffered. As a result, many national groups, including the Institute of Medicine, the Commonwealth Fund and the Association of American Medical Colleges, have begun sounding a call for curriculum reform.

"Since the Institute of Medicine released "Crossing the Quality Chasm" in 2001, there’s been an increasing amount of discussion about the quality of health care in this country," says Keith Lindor, M.D., dean, Mayo Medical School. "The consensus is that we can’t fix our quality problem without addressing our education problem."

The groups mentioned above have begun to define that problem in a number of reports, including Health Professions Education: A Bridge to Quality; Training Tomorrow’s Doctors: The Medical Education Mission of Academic Health Centers; and Educating Doctors to Provide High Quality Care: A Vision for Medical Education in the United States. The final document, written by a committee comprised of the deans of 10 leading U.S. medical schools (including Anthony Windebank, M.D., former dean of Mayo Medical School), helped guide Mayo staff as they revised the Mayo Medical School curriculum.

"The curriculum changes we’ve implemented are designed to prepare students for the future of health care," says Dr. Lindor. "We want to provide them with the tools they’ll need to serve a diverse patient population living with complex chronic conditions; to work as part of a team; and to keep up with an ever-growing body of medical knowledge."

Dr. Lindor and a team of faculty and students worked together for nearly a year to design the new curriculum. They began by establishing a set of objectives, determining that graduates of Mayo Medical School should be:

Outstanding scholarly clinicians, scientists and educators who place the needs of the patient first
Compassionate physicians who value diversity and work toward social responsibility
Effective leaders and members of interdisciplinary teams who improve the processes and outcomes of health care
Promoters of wellness in themselves, their patients and communities
Creative thinkers who translate discovery into practice and advance medicine through innovation and education

The group’s work resulted in a revised curriculum that emphasizes integration throughout the four years of training and between courses and clerkships; limits the time students spend in lecture; and provides ample opportunity for self-directed career exploration, service learning, research and volunteer work.

"The changes we’ve made are very logical," says Dr. Lindor. "And I believe they’ll prove to do a much better job of teaching these students how to be doctors."

Developing life-long learners

There was a time when four years of lecture-based instruction provided new physicians with the knowledge base they would need for a lifetime of practice. But as the body of medical knowledge has continued to expand, it has become increasingly difficult to provide learners with all of the information required to adequately care for patients.

Take, for example, diabetes care. Not so long ago, receiving a diagnosis of type 1 diabetes was a death sentence. But with the discovery of insulin in 1921, the outlook changed. As physicians learned about insulin’s ability to balance blood sugar levels, and communicated this information to their patients, deaths from diabetes plummeted.

Today, many more options exist for helping people manage diabetes and reduce its complications. Yet only half of the 20 million Americans living with diabetes receive the appropriate course of care for the disease. The rest have physicians who are either unaware of, or fail to recommend, such care standards as regular testing of blood sugar levels. Many of today’s diabetes patients are nearly as vulnerable to complications as they would have been several decades ago — simply because their providers aren’t up-to-date on the newest improvements in care.

This is due, in part, to traditional physician education.

"We’ve been educating physicians to practice as they would have in 1950," says Patricia Barrier, M.D., associate dean for student affairs at Mayo Medical School. "Half a century ago, it was possible to be a solo practitioner and adequately keep up with the advances in medical care that would benefit your patients. Today, that’s virtually impossible."

To address this, Mayo looked for ways to foster independent, life-long learning among its students. Students now spend a third less time in lectures, and instead use the time to review literature or meet with colleagues for discussion.

"The new curriculum is setting us up to be adult learners," says Jeremy Gregory, a first-year student at Mayo Medical School. "We’ll be better able to serve our patients because we’ll know how to access information on our own, rather than relying on what’s been fed to us."

Making the clinical connection

Reading and lectures provide students with essential information on diseases and conditions. But seeing the impact those diseases or conditions have on patients is often what provides context and makes the information take up permanent residence in a student’s mind. Students at Mayo Medical School now experience both concurrently, spending afternoons in clinical areas related to what they are studying in the mornings.

"We now have students in rooms with patients on their third day of medical school, which thrills them," says Dr. Lindor. "One of our students told me that for the first time in her very successful academic career, she was truly excited to learn."

In addition to its inspirational qualities, hands-on clinical education has practical benefits.

"Study after study shows that when you see a patient with a condition you’re learning about, you’re much more likely to retain information about that condition," says Joseph Grande, M.D., associate dean for academic affairs at Mayo Medical School. "Because of our small class size and broad clinical resources, we’re in a unique position at Mayo to be able to provide this valuable integration to our students."

Teaching the art of medicine

Anyone who has been a patient knows that there is more to being a good doctor than being able to make an accurate diagnosis or design an effective treatment plan.

"Doctors need to know so much more than what they read in their textbooks," says Dr. Grande. "They need to develop the interpersonal skills and personal qualities that make a remarkable difference in patient care outcomes."

The March 2006 Mayo Clinic Proceedings included an article outlining the top seven attributes identified by patients as ideal physician characteristics. Researchers found that patients wanted their physician to be confident, empathetic, humane, personal, forthright, respectful and thorough. Earlier studies have demonstrated the impact such physician attributes have on patient compliance and recovery.

Mayo’s revised curriculum addresses the need to develop these attributes in part through its five overarching themes: basic science foundations, clinical experiences, leadership, physician and society, and principles of pharmacology and therapeutics. Three of these — clinical experiences, leadership, and physician and society — provide students opportunities to develop the interpersonal skills that are crucial to excellent patient care.

In addition, 20 weeks of selectives built into the curriculum provide further opportunities for students to develop these skills. Students are given periodic two- and four-week blocks of time during which they are able to gain experience in areas such as palliative medicine, global health, rural medicine and service learning.

Though the students choose how to spend most of their selective time, all first-year medical students are required to spend their initial selective period shadowing various members of the health care team, including nurses, admitting clerks and radiography technicians.

"I think the time we spend shadowing will help us realize the influence other staff members have on patient care," says Gregory. "It will help us better understand the patient’s total experience within the health care system."

Gregory says he is excited about the selectives and believes they will help him — and his fellow students — develop the qualities patients value in a physician.

"The selectives focus on the more humanistic side of medicine, and reinforce the idea that there is more to being a doctor than science."

Just the beginning

Though excited by the initial positive response to the curriculum changes, Dr. Grande stresses that the revised curriculum is a work in progress.

"We do not consider the curriculum to be a finished product, and continue to have committees closely examining all components," he says. "We’ll also be looking at student outcomes to find out if the changes we’ve made will prove as effective as we anticipate." Initially met with some skepticism from both faculty and students, both groups have since embraced the curriculum.

"We’re blessed with a faculty that’s very interested in being involved in our medical school, and they’ve responded well to our changing curricular needs," says Dr. Lindor. "When I put out a call for mentors for our 43 students, 140 faculty members volunteered for the job. That’s the type of involvement that has helped make our program successful in the past, and will continue to be important in the future." Students are equally enthusiastic.

"The students I’ve spoken with are discovering how nice it is to learn on their own," says Dr. Barrier. "Instead of sitting in a lecture hall all day, they’re pouring over information on their own or working in small groups with their classmates or faculty members to better understand a subject. It’s just amazing to see them respond in this way."