It is time to rethink how we educate physicians

This week on the KGI Podcast, I sat down with KGI School of Medicine Founding Dean Dr. J. Mario Molina. You can listen to the entire interview here!

What are your thoughts about what needs to happen or change in medical education?

Dr. J. Mario Molina: I've been interested in medical education for a long time. I was on the faculty for a short time at the University of Southern California, now known as the Keck School of Medicine. And I've been on the board at Johns Hopkins for a number of years. I've just been very interested in medical education and what's going to happen in the future and how things have changed. Not only has medicine changed but I think so have the students.

There are really opportunities for us to prepare students for the 21st century in new ways. The paradigm we have of medical education came out of Johns Hopkins with the Flexner Report in 1910. That was really based on the founder's experiences in Germany where they had large universities that funded medical education and research and had dedicated faculties, something that really was unusual at that time in the United States.

So the Flexner Report came out in 1910 and he basically said that medical schools needed to be affiliated with the university, they needed to emphasize research, and they needed to be four-year schools. Not all of them were at that time. He also emphasized the preparation. At Hopkins, they expected their students to have a bachelor's degree and a reading knowledge of at least French and German, which was really novel. The third thing that was really different about Hopkins was that they admitted women on an equal basis with men.

This became the gold standard that all the medical schools had to follow. Within about two years, half the medical schools in the United States had closed. Everyone else began to retool, trying to match what Hopkins was doing. That model has been in place for 100 years but now we're in the 21st century and medicine has changed radically.

The new sciences of things like genetics are very important. I think doctors don't get enough education in things like nutrition, for example, and the other thing is that medicine is changing so rapidly.

What we teach the students today will be out of date in 10 or 15 years.

That means that what we really need to do is give students the fundamental tools to continue learning and applying this new knowledge to their practices as they're going along.

As you mentioned we have a great opportunity here at KGI because we're starting with a blank slate. There are no traditions that have to be undone and that was the same thing at Hopkins. When Hopkins started, it was a brand new school with no traditions, so they could do what they wanted and try new things. I think we have that opportunity here too. We want our students to become lifelong learners. But when I talk to people about "What is it you want from your doctor?" I get different answers depending on who I'm talking to.

When we talk to people that run residency programs or hospitals, who are in a sense our customers, they want well-trained clinicians who know the basics, can examine a patient, develop a plan for that patient. They need someone that can read an x-ray, an EKG, a CT scan, and write a note that people can understand. Those are sort of the basics. They'll teach them the practice of medicine through their residency program.

When I talk to lay people, they want someone that they can relate to, someone who will be interested in them, someone who can understand where they're coming from, and someone who can communicate effectively with them. That's another thing that I think is really important.

We hear a lot about "The job of being a physician is not nearly as rewarding as it used to be." What do you tell young people when they raise these kind of questions, "Why would I be a doctor? They have to work so hard." What do you say?

Well I think medicine is a great career and I think most people are going into medicine today for the same reasons that I went into medicine and that my classmates went into medicine. That is they enjoy science and they want to help people. That's still true today. Things have gotten more difficult as medicine has gotten more complex and more bureaucratic.

But the same basic concept of one-on-one contact with a patient, being a detective trying to figure out what's wrong with this patient, and then working with them to formulate a plan to restore their health. Those fundamentals haven't changed. I think one of the things that has changed however is we have a better appreciation now about the impacts of social and cultural factors on health.

The old medical model was really focused on disease and if you were sick, we would do something for you. I think more and more doctors are being called upon to help patients be healthy, not just "not sick" but to be healthy and what are all the things that are involved with that. For example, we know now from research that sometimes your zip code might be more important to your health than your genetic code. We need to understand both.

Is there an opportunity to design a medical school curriculum that would be able to incorporate all of those new kinds of concerns? Is there that flexibility?

Well, the Liaison Committee on Medical Education (LCME) is the body that accredits medical schools. We have to follow their rules and their guidelines. But there is tremendous latitude within that. And I think that there is a place for a school that is different and that experiments with education. The things that I would like to see this medical school do are:

• Become known for excellent teaching
• Preparing good clinicians
• Do research in things like medical education, medical economics, and healthcare policy

Those are things that most medical schools don't put a lot of emphasis on.

Most medical schools are interested in biomedical research and I'm not sure we need another school that's going to be a big program in biomedical research.

But there are sort of neglected areas like teaching and healthcare policy and economics that have been ignored. I think the students need to understand a little bit about the economics of healthcare. Doctors have the ability to drive care in a way that no one else does and drive up costs. At the same time, I think if they understood the implications of their decisions, they could make decisions that might actually lower the cost of care.

We used to think that people had insurance and so the cost of care didn't matter. But what we're finding especially now as more and more of the cost of healthcare is being shifted to the patients through co-pays and deductibles, that the decisions we make can hit patients in their wallets. We not only have to think about what is the best medicine, but also what is the most effective way of delivering that. That's one of the things I learned from my years in the insurance industry.

How do you envision selecting a medical school class that sort of fits with the ethos that you're talking about?

In business when you interview people for a job, you're looking for certain skills. I think the same applies with medical students. There are a tremendous number of students out there applying to medical school and typically what we select are the top students by grades in science and their MCAT scores. But we need look at some of the softer skills. How do you relate to patients? What kind of leadership skills do you have? How do you work in a team?

There was a study that I saw recently that showed that the best predictor of how a medical student was going to perform in a residency was not their grades, not their board scores, but whether or not they participated in team sports. Medicine is a team sport. It's no longer a doctor hanging out a shingle going into solo practice. Seventy percent of doctors join a group and medicine is delivered by teams of healthcare professionals. One of the things we need to look at is how do we make sure that our graduates have the ability to function well as a member of a team.

Yes, as an institution obviously we take that value very, very, very seriously. What excites you about this opportunity?

Well aside from some of the things we've talked about already, The Claremont Colleges have a great reputation. KGI is located in a great place geographically. We sit kind of in the middle of Los Angeles, Riverside, and San Bernardino counties. It's the second largest metropolitan area in the country, just behind New York. I wouldn't be surprised if in a few years this area is actually has a population larger than that of the New York metropolitan area. So there are lots of opportunities, lots of hospitals, lots of patients.

We have The Claremont Colleges to draw on. You have KGI, which has excellent programs in science and in healthcare, like the pharmacy school. You've got the Claremont Graduate University, which brings in things like economics, healthcare policy, public health, a school of business.

And last but not least, we have the Harvey Mudd College, which is one of the best programs for engineering in the country. Many schools have to spend years and years and years building up a program in engineering to go along with a medical school. We don't have that problem. We already have a master's in Public Health. We can tap into people in economics and public policy.

We have world-class science here. It's all right here. It's just waiting for that final piece of the puzzle, which is a medical school.

We don't have to spend years and years and years building it. It's already right here. And finally, we've got a nice campus here. We have a physical location and room to grow.

Have you given thought to how you want to articulate the mission and vision of the school? What are the major foci that you're going to have?

Our mission is to advance the knowledge of medicine and improve the health of our communities while preparing our clinicians who will redefine quality and compassionate care. That's what we want to do. Our vision is to create a new paradigm of medical education preparing clinicians for the 21st century. So we want to redefine the way we teach and at the same time prepare people that are going to be competent clinicians that are really going to redefine how we look at quality and compassionate care.

This is something that keeps coming up over and over and over again. People want their doctors to care about them and they want them to know about them. Osler said many years ago that sometimes it's more important to know what kind of patient you're treating than what the disease is. I think sometimes that's true, especially in an era of chronic diseases. Now we have people that have diabetes who will have diabetes the rest of their lives. We have people that have autoimmune disorders and they're going to suffer with these things for years and years. It's less about "Are we going to cure someone?" as about, "How are we going to help them deal with their conditions?"

That requires compassion.

To learn more about the KGI School of Medicine, visit kgi.edu.