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Creating the Medical Schools of the Future

Skochelak, Susan E. MD, MPH; Stack, Steven J. MD

doi: 10.1097/ACM.0000000000001160
Invited Commentaries
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Despite wide consensus on needed changes in medical education, experts agree that the gap continues to widen between how physicians are trained and the future needs of our health care system. A new model for medical education is needed to create the medical school of the future. The American Medical Association (AMA) is working to support innovative models through partnerships with medical schools, educators, professional organizations, and accreditors. In 2013, the AMA designed an initiative to support rapid innovation among medical schools and disseminate the ideas being tested to additional medical schools. Awards of $1 million were made to 11 medical schools to redesign curricula for flexible, individualized learning pathways, measure achievement of competencies, develop new assessment tools to test readiness for residency, and implement new models for clinical experiences within health care systems. The medical schools have partnered with the AMA to create the AMA Accelerating Change in Medical Education Consortium, working together to share prototypes and participate in a national evaluation plan. Most of the schools have embarked on major curriculum revisions, replacing as much as 25% of the curriculum with new content in health care delivery and health system science in all four years of training. Schools are developing new certification in quality and patient safety and population management. In 2015, the AMA invited 21 additional schools to join the 11 founding schools in testing and disseminating innovation through the consortium and beyond.

S.E. Skochelak is group vice president, Medical Education, American Medical Association, Chicago, Illinois.

S.J. Stack is an emergency physician residing in Lexington, Kentucky, and president, American Medical Association, Chicago, Illinois.

Funding/Support: The AMA Accelerating Change in Medical Education Consortium is funded by the AMA.

Other disclosures: S.E. Skochelak is an employee of the AMA. S.J. Stack serves as the 2016 AMA president.

Ethical approval: Reported as not applicable.

Disclaimers: This Commentary represents the views of the authors and does not necessarily represent the views of the AMA.

Correspondence should be addressed to Susan E. Skochelak, American Medical Association, 330 N. Wabash Ave., Chicago, IL 60611-5885; e-mail: susan.skochelak@ama-assn.org.

The U.S. health care system is experiencing unprecedented change. Increasing emphasis on stewardship of resources, patient outcomes, chronic disease management, and changing delivery and payment models is having a profound impact on physicians’ day-to-day practice. Recent federal legislation, including the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), established new payment mechanisms and incentives to change practice models. Now is a time when the newest physicians entering medicine should be leading the way to improved delivery systems and healthier populations. Yet national professional organizations, employers, foundations, and advocacy groups widely agree that a gap exists and continues to widen between how physicians are trained and the future needs of our health care system.

It is time for a new model and approach to medical education in the United States—one that will facilitate the improvements in care delivery and stewardship of resources that our nation requires while more directly meeting the needs of medical students, physicians, health professionals, and patients in the 21st century. For that to happen, we need to create the medical schools of the future. This exciting environment would advance the best elements of today’s health care by

  • Training physicians on the science of health care delivery and their role within the system;
  • Addressing health care finances and how to be responsible stewards of health care costs;
  • Preparing physicians to effectively lead teams of health care professionals; and
  • Supporting flexible pathways for physician training and assessing competencies students acquire before and during medical school as well as readiness for residency training.

Wide consensus on the need for deep restructuring and breakthrough innovation has existed within the medical education community for more than a decade.1 The defined changes, however, have not been implemented. If initiating the change were easy, radical redesign would already be well under way. It is clear that significant barriers to innovation are prohibiting medical schools from evolving in needed directions. These barriers include lack of available resources for innovation, real or perceived accreditation and regulatory restrictions, institutional rigidity, underdeveloped technology support within and across institutions, and historical divides between health care system and academic system leaders.

New ideas, new models, and new partnerships are needed to catalyze change in medical education. The American Medical Association (AMA) is providing strategic leadership to accelerate the rapid cycle development and broad implementation of such changes through partnerships with medical schools, health care delivery systems, professional associations, and other national leaders.

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Accelerating Change in Medical Education

To facilitate the process of creating the medical school of the future, the AMA launched an $11 million competitive grant opportunity in 2013 to promote the alignment of medical education and training with the changing needs of our health care system. The AMA outlined the following goals for the initiative: (1) develop new methods for measuring and assessing key competencies for physicians at all training levels to create more flexible, individualized learning plans; (2) promote exemplary methods to achieve patient safety, performance improvement, and patient-centered team care; (3) improve understanding of the health care system and health care financing in medical training; and (4) optimize the learning environment. Eligible applicants included the 141 U.S. medical schools accredited by the Liaison Committee on Medical Education (LCME) at the time the initiative was announced, and requirements included an identified principal investigator serving as an institutional academic leader and an identified health system partner providing new training opportunities.

More than 80% of U.S. medical schools submitted proposals; 30 applicants were selected via a competitive review process and invited to submit detailed proposals. In June 2013, the AMA announced the final funding awards and partnered with 11 leading medical schools, awarding $1 million to each over a five-year period to plan and implement their innovative ideas to create prototypes for the medical school of the future.2

We designed the initiative to support rapid innovation among the schools and to disseminate the ideas being tested to additional medical schools. In addition to individual grant awards for each school, a critical component of the initiative is the establishment of the AMA Accelerating Change in Medical Education Consortium. This learning collaborative, formed in partnership with the AMA and the selected schools, provides a platform for creating common projects and a national evaluation plan so that evidence-based best practices can be developed, evaluated, shared, and implemented among all medical schools. The consortium, originally comprising approximately 75 people, includes 5 or 6 team members from each of the schools, senior AMA leadership, and members of the national advisory panel. Five consortium meetings have occurred, hosted at various medical school campuses. The meetings have been regularly attended by leaders from the Association of American Medical Colleges (AAMC), the National Board of Medical Examiners, the Accreditation Council for Graduate Medical Education (ACGME), the National Center for Interprofessional Practice and Education, and the LCME.

The consortium schools are working together to align recent national recommendations on medical school graduation competencies to better define assessment strategies. As a group, they have mapped the six ACGME competency domains with the ACGME residency milestones3 and the AAMC Core Entrustable Professional Activities (EPAs) for Entering Residency,4 and they are developing new assessment tools to test readiness for residency. Many consortium schools are working on flexible and individualized progression through the curriculum, with the goal of enabling students to enter residency when they demonstrate their entry-level abilities instead of after a specific amount of time.

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Innovations for the Medical Schools of the Future

Consortium schools have proposed ideas for innovations in medical education, which have been described and are being tested in a number of venues.5 The medical schools of the future require full implementation of competency-based curriculum redesign to standardize learning outcomes and individualize learning processes, establishment of habits of inquiry to produce master lifelong learners, integration of health care delivery science into the curriculum, and development of new immersion experiences within the health care delivery system to ensure that our future physicians are fully prepared to lead the system innovations that are required for continuous improvement of health care. New technology and tools for managing the learning environment and new methods of assessment for measuring achievement of competencies must be developed to implement the changes above. Students must be prepared for the health care delivery environments that are the result of structures incentivized by the Affordable Care Act and MACRA, so that they can make informed choices about career and practice options.

The medical schools in the AMA Accelerating Change in Medical Education Consortium are innovating in all these areas. Competency-based curriculum redesign and implementation is under way at the University of Michigan Medical School, Oregon Health and Sciences University, Vanderbilt University School of Medicine, and the University of California San Francisco School of Medicine. Schools are designing pathways for progression through education and training based on predetermined milestones or EPAs, using portfolios to provide continuous self-assessment guided by faculty coaches and using student performance data to set individual learning goals. A core set of material is defined for the first phase of medical education, with multiple branching opportunities for individualized study concentrations following mastery of core materials. Comprehensive electronic portfolio systems linked to learning management systems have been developed, and new roles for faculty coaches are being defined.

Medical schools are developing new experiences for students that immerse them in the health care delivery system to experience health care through patient-centered and team care approaches. At Penn State Hershey College of Medicine, first-year students are trained to be patient navigators, assisting patients and families in optimizing their experiences with the systems of care delivery, both providing a valued service and giving students a unique view of potential areas for improvement in care delivery. The University of California Davis School of Medicine, in partnership with Kaiser Permanente, has developed an accelerated pathway to provide students, working with clinician mentor coaches, with immersive clinical experiences in diverse communities initiated before students enter classes in the fall of the first year.

New comprehensive, integrated curricula for health system science have been developed at Mayo Medical School, the Warren Alpert Medical School of Brown University, Penn State Hershey College of Medicine, and the Brody School of Medicine at East Carolina University. This new content includes health care system organization and financing, patient safety and quality improvement, medical informatics and clinical decision making, population health management, social determinants of health, team-based care, and chronic disease management, among other topics. The schools have developed new masters’ degree and certificate programs to acknowledge students’ achievement of expertise in the science of health care delivery and population management. The Brody School of Medicine has implemented a Teachers of Quality Academy to provide intensive faculty development in these new content areas.

Enhancing learning through new uses of technology is a core theme at many schools. At the New York University School of Medicine, students are answering questions about health care outcomes by analyzing big-data sets from the New York Statewide Planning and Research Cooperative System and the National Health and Nutrition Examination Survey in a new “Health Care by the Numbers” course. The Regenstreif Institute and the Indiana University School of Medicine have developed a fully functional teaching electronic health record populated with more than 10,000 deidentified patient data records to allow students to develop mastery in managing panels of patients and optimizing health outcomes.

In general, the 11 founding consortium schools have followed two pathways in building these new models. Most have embarked on major curriculum revisions, making major additions of new content in the science of health care delivery and removing required material in all four years of training to make room for what they have estimated to be 25% to 30% new material. Or they have developed differentiated tracks for the students selected into new programs emphasizing these new content areas. All schools have introduced new material for all students. For example, all schools have added content and activities in interprofessional education and team-based care. These changes have not occurred without overcoming barriers, including lack of faculty trained in the new competency areas, recruitment of new clinical sites that provide the appropriate experiences for training, and resistance from faculty and staff to removing historic curriculum topics to make way for new material.

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Expanding the Consortium

In 2015, a follow-up survey conducted with medical schools that had applied, but not been selected for, the 2013 AMA innovation grants indicated strong interest in joining the medical school consortium without regard for whether funding was provided for school projects. In the fall of 2015, the AMA sponsored a second request for proposals from all accredited MD- and DO-granting medical schools. Selected schools would be invited to become members of the AMA Accelerating Change in Medical Education Consortium and work to disseminate and implement bold, innovative projects that promote systemic change in medical education to train future physicians to succeed in our rapidly evolving health care system. Schools were asked to identify projects in one or more of six thematic areas: (1) developing flexible, competency-based pathways in medical education; (2) teaching and assessing new content in health system science; (3) working with health care delivery systems in novel ways; (4) making technology work to support learning and assessment; (5) envisioning the master adaptive learner; and (6) shaping tomorrow’s leaders. Selected schools would receive $75,000 in funding over three years to participate in consortium-related activities. Applications were received from 108 schools (64%) of the 170 MD- and DO-granting schools eligible to participate. Twenty-one new medical schools were selected and are joining the 11 founding schools as members of the innovation consortium in 2016.6

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A Vision for the Future

At the end of the five-year award cycle, we expect graduating medical students participating in these transformed education pathways to be prepared for next levels of training and medical practice in the following ways:

  • Master core education in basic, clinical, and health care delivery sciences;
  • Customize and differentiate their learning experience, through learning-based technology, potentially moving to advanced training on the basis of achievement of competencies rather than time in rank;
  • Understand our rapidly changing health care system;
  • Embrace the physician’s new roles in the health care system;
  • Steward health care costs in a responsible manner;
  • Participate effectively as leaders and members of teams in health care delivery; and
  • Provide leadership for ongoing improvements in delivery of health care to optimize health outcomes for patients, families, and communities.

Students will be optimally prepared for their residency training through assessment of achievement of milestones or EPAs and will be highly skilled adaptive learners, a core skill for lifelong learning.

The tremendous response of medical schools interested in competing for the AMA Accelerating Change in Medical Education initiative is a clear signal that medical schools are eager to implement the transformative changes needed to respond to the evolving health care environment. Medical schools across the country are striving to initiate innovations to promote the ultimate goal of improving the health of our patients and communities. The AMA is working on next steps to disseminate these new models to other medical and health professions schools through national and regional conferences, presentations, and publications; by developing a textbook in health system science and a national assessment exam in consultation with the National Board of Medical Examiners; and through webinars, social media, and a resource Web site.7

Early evidence of dissemination across schools within the consortium comes from their first-year grant progress reports. All schools have reported either new or modified grant objectives at the end of the first year, influenced by working with the other consortium schools; an average of three modified objectives was reported, with a range from one to eight per school. The cohort of 21 schools selected to join the consortium in 2016 were chosen, in part, on the basis of their proposals to adopt or enhance innovations that have been implemented at the 11 founding consortium schools.

Students entering medical school in 2015 will not enter practice until after 2020. The nation’s health care system demands physicians who are trained to enter the health system that will be in the 2020s, not the one that exists today. Medical schools of the future will be characterized by systems ready for and adaptable to rapid change—change in technology, in dissemination of information and data, in care delivery—and by providing environments that prepare physicians to be lifelong adaptive learners who use new information, data sources, and technologies effectively as decision-making tools for better, safer, and more cost-effective patient care. Together, we are developing the new models for medical schools that will effectively train our next generations of future physicians and optimally serve our patients and communities.

Acknowledgments: The authors wish to acknowledge the principal investigators and grant teams from the American Medical Association (AMA) Accelerating Change in Medical Education Consortium schools.

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References

1. Skochelak SE. A decade of reports calling for change in medical education: What do they say? Acad Med. 2010;85(9 suppl):S26S33.
2. American Medical Association. Accelerating change in medical education. www.changemeded.org. Accessed January 22, 2016.
3. Accreditation Council for Graduate Medical Education. Milestones. https://www.acgme.org/acgmeweb/tabid/430/ProgramandInstitutionalAccreditation/NextAccreditationSystem/Milestones.aspx. Accessed February 4, 2016.
4. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency: Curriculum Developers’ Guide. May 2014. Washington, DC: Association of American Medical Colleges; https://members.aamc.org/eweb/upload/core%20EPA%20Curriculum%20Dev%20Guide.pdf. Accessed February 4, 2016.
5. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. 2010.Stanford, Calif: Jossey-Bass/Carnegie Foundation for the Advancement of Teaching.
6. American Medical Association. Accelerating change in medical education. Schools. Consortium schools. http://www.ama-assn.org/ama/pub/about-ama/strategic-focus/accelerating-change-in-medical-education/schools.page. Accessed February 4, 2016.
7. American Medical Association. Accelerating change in medical education. Solutions and outcomes. http://www.ama-assn.org/ama/pub/about-ama/strategic-focus/accelerating-change-in-medical-education/solutions-and-outcomes.page. Accessed February 4, 2016.
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