Strategy Implemented, Inc. supports North American medical institutions and healthcare providers in developing sustainable relationships and community-based programs that address local, regional, and global health concerns. Dr. Robert K. Crone, President and CEO, paves the way for domestic medical institutions to extend their expertise to both the local and global needs of the community. He also serves as Senior Advisor to the Dean on Academic Affairs and Professor of Clinical Pediatrics at Weill Cornell Medical College in Qatar. We had the distinct pleasure to speak with Dr. Crone about his experiences in healthcare consulting and his thoughts on medical education.
In the consulting that your company does for medical schools, what are the most common problems that you are asked to address? How do these affect medical education?
Our vision is “One World One Medicine” – every citizen of the world should have access to quality healthcare at a consistently high standard. As we are often asked to look at various aspects of the healthcare system, I think it is important to emphasize the impact of the healthcare workforce education continuum from the secondary school student to a fully trained and globally competitive member of the healthcare team. It is important to include nurses and allied healthcare professionals, technologists, healthcare informaticians, and managers.
Globally, as populations age and acquire more chronic diseases as well as become more affluent and well informed, we will all have the same pursuit: access to a cost-effective, high quality healthcare system benchmarked to an international standard. As most healthcare systems remain physician-centric today, this puts considerable pressure on the physician labor force and behooves us to find ways to produce well-trained physicians in the shortest possible period of time to meet demand. However, we should also identify ways to include the whole healthcare team and take advantage of technological innovation in the solutions we provide.
In my travels, particularly to the emerging economies of the Middle East, Asia and Latin America, I see very sizeable investments being made in the development of new healthcare facilities from primary care centers to multi-specialty tertiary and quarternary care hospitals. This has been accompanied by only a very recent awareness that these facilities will remain empty unless we can develop clear strategies how to prepare local populations to become the next generation of healthcare providers. A new hospital can be ready in a matter of months to a couple of years, whereas preparation of globally competitive healthcare providers takes a decade or more. Hence our consulting practice has evolved into one that looks comprehensively at developing greater local capacity for medical and health professions education and training.
In the meantime, a shorter-term solution employed by many clinical organizations to address shortages is to import healthcare professionals from other locales. This can be an expensive and cumbersome process: How do health systems ensure the quality of an imported healthcare workforce? Are there international standards that allow diverse healthcare systems to recruit/import international medical or other healthcare graduates from disparate places around the world? As workforce shortages drive global recruitment strategies, schools and healthcare systems are looking for ways to benchmark graduates to be competitive in a global market. There are currently about 1.5 million medical students in 2,372 medical schools scattered across the globe. How does a health system in Kuwait or Sweden know that a medical graduate from Argentina or the UK has the requisite knowledge, skills, attitudes, language facility and aptitude to practice effectively and to continue to learn in their environment unless there are global standards for medical education and post-graduate training?
This is where the almost 100 years of experience with objective and organized assessment processes from the US “House of Medicine” can and does play an increasingly important role in developing international standards. The systems that evolved in the US were designed to unify systems across all 50 states – not so dissimilar from trying to find a way to interpret systems used by different nations. Nearly all components of the US assessment, accreditation and certification community now have international programs of one sort or another. The National Board of Medical Examiners (NBME), the Association of American Medical Colleges (AAMC), the Liaison Committee for Medical Education (LCME), the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Medical Specialties (ABMS), the Federation of State Medical Boards (FSMB) and the Educational Commission for Foreign Medical Graduates (ECFMG) as well as entities from Canada, United Kingdom, Australia and New Zealand are engaged in the development of standards beyond their national borders. Medical communities around the world are pursuing objective, evidence-based methods of assessing the quality of medical education and training programs before allowing the graduates of those programs to work in their jurisdiction. Just as national licensing and certification requirements have shaped medical education and training, so too will international licensing and certification requirements as medicine “globalizes” more formally.
To your mind, what are two of the most interesting trends in medical education?
There are many interesting trends! Here at home in the US, we face similar workforce challenges – we are aging, acquiring our chronic diseases, gaining greater access through the Affordable Care act, our needs are growing and changing faster than supply. We have moved from being in-patient centric to a need for high quality community-based care. Thus, although the external drivers may be different in other parts of the world, the net result is similar. We all need to find ways to educate and train our workforce in smarter, faster and cheaper ways to keep pace with changes in demand for different types of services. To deliver affordable care we need to have affordable education. US medical schools also have to ensure that graduates are globally competitive, so the pursuit of “smarter, faster, cheaper” is probably an important trend to watch. Many organizations will pursue just one or two of those components and believe they are competitive but those that get all three components lined up will ultimately become dominant players.
The projected shortage of physicians in the US has led to an expansion of the number of medical schools with at least 17 new schools either open or under development, leading to a projected increase in graduates of US medical schools from about 16,000 per year to 20,000 per year (a bigger percentage are being trained for a community care setting). The immediate challenge is that despite this increase in undergraduate slots, residency training (GME) has been capped at approximately 24,000 slots with no immediate plan by the Federal Government to increase funding to expand GME. This year, for the first time in history, more than a handful of graduates of US medical schools did not match to a residency training slot. There does not seem to be any policy logic for increasing undergraduate medical training without a commensurate increase in GME, if the expansion is to address a growing physician workforce shortage. In theory the new schools should be well-placed to take advantage of new technologies and new approaches in academic medicine to enable “smarter, faster, cheaper” education for their students but there will be pressure to find creative solutions for expanding GME to keep up with demand.
Smarter, faster, cheaper is really only being made possible through the utilization of creative technologies to support teaching and learning – globally available resources that can be shared and developed across multi-cultural communities housing diverse patient conditions and needs, and with differing volumes of patients to manage. An orthopedic surgeon from Duke Medical Center recently recorded an operation using Google Glass and plans to broadcast the operation to colleagues in India. For a device that costs $1,500, imagine the educational implications for training students and healthcare professionals anywhere in the world. It feels as though we are in the early stages of a revolution where enterprising individuals and institutions are coming up with a plethora of learning methodologies and simulation-based education that optimize memory, assess and build knowledge and skills of the learner as he or she practices what they have learned. We can anticipate with time, the consolidation of some of these initiatives into comprehensive integrated systems where a clinical environment for the patient (which could be in a hospital setting, at home in a different state or in a foreign country) is also one of continuous experiential learning and assessment for the healthcare professional team.
The combination of adaptive learning and measurement of competency applied to medical education will enable medical students to move through education and training programs at a pace that optimizes their ability to deliver safe, high quality patient care. First promoted by Sal Khan of the Khan Academy for students in K through 12, this approach may well be preparing students for the type of lifelong learning and assessment required of healthcare professionals. When this in turn is combined with the ability of healthcare professionals to share outcomes and approach within global communities, it is easy to see the potential for a transformative impact on patient management around the world.
Right now, medical school is still a time-based process whereby students are expected to achieve certain educational and competency milestones as a group, based upon the time when those subjects are placed within the curriculum. Students’ achievements are then assessed, usually as a cohort by the school’s faculty with the support of an educational assessment team. All, or at the very least, all but a few are expected to achieve the minimum standards to progress on to the next subject or the next year’s program. The few who “fail” are typically provided remedial time and work with the expectation that they will “get it “ the next time around. Those that don’t are counseled to seek other professional pursuits.
As educational tools in medicine become more robust, with asynchronous learning and competency-based assessment tools, each student will be building their own portfolio of achievement, independent of the rest of the class. One could argue that the student could avail themselves of the curricula and subject areas of different schools around the world that have globally recognized experts in different specialties. In the medium term one could envisage that a license to practice could be based on the student completing a comprehensive list of subjects that either one school or the national assessment body in medicine, such as the National Board of Medical Examiners or USMLE determines are sufficient for the student’s performance and achievements to warrant their being awarded an MD degree or medical licensure. This trend de-emphasizes the importance of the “name” of the school a student might attend, but emphasizes the individual pathway to achievement. Smarter, faster, cheaper?
If you took over a medical school tomorrow, what are three changes you would make.
First, I would revise the selection process to ensure that candidates had demonstrated their aptitude and experience to excel in interpersonal communication skills, teamwork, empathy, and a desire to contribute positively to society through previous work or life experience in addition to their academic achievements. There should be room for individuals in mid-career to enter US medical schools.
In today’s world, team-based practice is critically important, yet our health professional schools continue to educate our students in silos. The second change, would be find ways to create interdisciplinary educational programs and incorporating a team-based approach to prepare our students to work collaboratively and respectfully with our non-physician colleagues to optimize patient-centered health outcomes, prevent medical errors and improve chronic disease management. As much of primary care evolves to a protocol-driven, technology-supported, distributive model provided primarily by non-physicians, our educational system must adapt to prepare our future physicians for a different, but critically important role as head of a health care delivery team.
My third area of focus would be based on my belief that all students should have the opportunity to work in regions of the world outside of their societal, political, professional and/or geographical “comfort zone”. That will mean different things to different people, however I believe it is critically important that the next generation of leaders and practitioners in medicine gain a first-hand understanding of other perspectives, problems and possible solutions for communities around this increasingly small and flattening planet.