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AMA's Susan Skochelak On Reshaping Medical Education

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The field of medical education is experiencing just as much upheaval these days as the field of medicine itself. My next guest is Dr. Susan Skochelak. She is vice president for medical education for the AMA. And she's helping lead a national overhaul for how new physicians are trained. For one thing, she wants them to learn more about teamwork. 

Dr. Skochelak: Healthcare has always been delivered in teams when you think about. Even if you think back to a physician who's in their office in the community. There was someone there that greeted you. That might be the receptionist. There was a nurse or a nursing physician. There was a physician. Often they weren't alone. They were often in a group. This is not a new idea. But nowadays, team care is the norm, and that's because we know that people have areas of expertise in their training that are really important to take advantage of. If you are like me, I love to talk to my pharmacist to say, "I'm not really sure. Do I have to put this medicine in the refrigerator or not"? If you ask me as your physician, I wouldn't know but your pharmacist would know. I mean, I could look it up but my point is that there are lots of people with expertise now that we all rely on for our health. 

Lewis: But is working as a team I guess something that should be taught in medical school. I mean, it kind of seems that it's something that is learned on the job training, if you will? 

Dr. Skochelak: We are not learning it on the job training. We are not learning how to work as teams. That's because we don't understand what makes a team effective. There isn't just one team. It's not like you go and there's a team and you work together for the next 30 years. Think about your experience in health care. The team for you in an outpatient setting is one thing. The team if you have to go get your x-ray procedure done is a different thing. From a physician standpoint, there's a time when my team and I'm leading that team. There are other times, when I'm a member of a team because someone has expertise that is more than mine and I need to be sure I represent what's important about the medical information but they may know much better if they are a physical therapist about how to get the rehabilitation going then I would know. 

Lewis: What are the skills though that you are really teaching them?

Dr. Skochelak: Sure, skills in working with teams are only one aspect of this big initiative. Specifically, in terms of team care it has to do with how you put a team together so that it's functioning effectively and safely; that everybody's voice is valued. People can call time-out if they have a question about something that doesn't seem right. It doesn't matter what level you are at, whether you are a medical student or a supervising physician. It's all about the fact  that the team itself works best when every member is valued and can contribute to their point. Beyond team training, there are so many other elements of health care delivery that are really happening now and into the future that our young phsyican-in-training do not learn about or experience. 

Lewis: Another mission of the project is to teach students to incorporate the costs of the treatment they recommend. How can medical schools teach that? 

Dr. Skochelak: It's important that we understand the health care delivery as it's happening as we are either students training to be physicians or physicians. One of the best stories is that while one of our schools that we are working with at the AMA was putting into place a opportunity for their students to learn about selecting x-rays, in this case MRIs (the more expensive kinds of x-ray that you get if you have a head injury). The faculty physician found out that the patients had to be scheduled 24/7, so his patient may be going at 3 in the morning for an MRI. It made him stop and think to say, "but this is a patient with a family. What are they going to do with their children at 3 in the morning?" That's not to say that the physician is responsible for that, but if you don't know that as a physician, that these are the ways in which your system is working, you don't have an opportunity, A, to help your patient through that. Or more importantly, B,  to maybe change that, if that's more appropriate. 

Lewis: Or also looking at the price of things.. 

Dr. Skochelak: Maybe you have seen articles recently that if you, as a consumer, call around for the same drug to nine different pharmacies in your city you will get nine different prices. If you don't know that the prices varies according to all kinds of different factors, you may just take the word, or as a physician, I might advise you to do certain things without taking cost into account. We can't afford that as individuals these days. And we can't afford that as a society. Seventy percent of the charges that are given for health care come from orders that are given from physicians or providers. 

Lewis: What other skills does the AMA think are important for doctors-in-training to learn these days? 

Dr. Skochelak: The way in which we can maximize outcomes for health is incredibly important and we haven't focused on that. It goes beyond prevention. It goes to understanding different kind of sciences. Like, how do you motivate someone to be more healthy and to get exercise? These are really hard things. If they were easy, we'd have fixed these problems with our pills. We can't. So, understanding how to move prevention into the center and the forefront and another then another area that becomes very important is safety and quality and improved outcomes. 

Lewis: Even medical students only have so many hours in the day. As medical schools incorporate new skills and areas of focus, what are some of the old elements of their education that must be discarded? 

Dr. Skochelak: In some ways, we are repeating things way too many times. Think about if you are a physical therapist and you decide to go to medical school. Or maybe you have a graduate degree in history and you are now deciding to go to medical school. And that's true. About 40 percent of people going into medical school have different career paths. Right now, you go about the same 4-year or maybe even 3-year (because some schools have 3-year curriculum), but you go through exactly the same curriculum. When, as a physical therapist, you could skip a year, maybe a year and half. If you can show me what you can already do, as a faculty I can say, "great, go focus on this and finish in two years." So, there's that level of redundancy that's important to take out of the program. The final point I would make is  memorizing isn't an option anymore. We cannot memorize enough, ever, to stay on top of this knowledge explosion. One of my favorite quotes, and I heard it again two days ago, is: they often will say when you start medical school by the time you leave medical school, half of this information will be out of date. And every medical student's thought bubble is, "then why are you making me learn it if it changes that quickly?" You instead have to understand how do you get the informational at your fingertips when you need it. And in fact, relying too much on memorization, in the world of safety, can be scary, when you want to make sure the information you get is the most up-to-date.

Lewis: Are medical schools addressing the issue of overtreatment these days? 

Dr. Skochelak: Absolutely. That's a part of the value of the safety prospect that we need to... It's a price of prolong suffering of when you have to be in a treatment that you may not be needing; it's that example of "do you really need that x-ray at three in the morning?" It breaks all of our hearts that the United States doesn't have the best health outcomes in the world because we spend the most money on health care. And all of us that work in health care really owe it to ourselves, our citizens and to our country to make sure that we are effective in the way that we deliver health care.