Regenesis

Regenesis - Renewing medical education at Emory

To the ancients, the serpent entwined around the staff of Aesculapius represented the renewal of youth and health, because of the way a snake periodically sheds its skin and emerges a freshly transformed creature. It is an apt metaphor - this sloughing away of dead scales and this rejuvenation - for the nine-month-long process Emory University School of Medicine underwent last year as it re-evaluated and re-imagined the entire corpus of its medical education programs.

Not that there was anything all that wrong with the old skin. But if the creators of Emory's Strategic Plan for Teaching and Education got it right, the new will wear better and respond more elastically to the challenges facing medical education in the new century. It is a skin designed to accommodate the school and give it direction as it grows from the ranks of the very, very good to the ranks of the preeminent.

Destination: preeminence?

The competition

Emory compared itself to these benchmark medical schools:
  • Cornell University
  • Duke University
  • Harvard University
  • Johns Hopkins University
  • UA - Birmingham
  • UNC - Chapel Hill
  • University of Pennsylvania
  • University of Washington - Seattle
  • Vanderbilt University
  • Washington University

It's a bold goal, preeminence, even for an institution as strong as Emory University School of Medicine.

Admission to the school is exceedingly selective. Each year, Emory captures about 15% of all applications to US medical schools. Administrators and staff sift through more than 7,500 applications, interviewing about 800 candidates for a class of 112. As students, these overachievers consistently pull in outstanding scores on their board exams. As graduates they're hot tickets in the nation's residency programs. Program directors around the country report that their Emory-educated physicians are among the best prepared and are often candidates for chief resident.

The school boasts a large and distinguished faculty, excellent clinical facilities (particularly its "jewel," Grady Memorial Hospital), and close ties with world-renowned organizations such as the CDC and The Carter Center. Emory's track record is the envy of many schools and has made it the predominant medical school in Atlanta and a leader in the Southeast.

So why in the face of such glaring success did Dean Thomas Lawley, his associate deans, and 180 faculty, students, and staff from every department in the medical school spend the better part of 1998 looking for things to change?

Shedding our skin

Are our graduates good communicators and empathetic practitioners? We need to ensure that great test-takers and overachievers become great doctors.

The temptation can be strong to rest on one's laurels, especially when things are clearly going so well," says Jack Shulman, Emory's executive associate dean for medical education and student affairs and coordinator of the steering committee that guided creation of the teaching strategic plan.

"Believe me, all large, successful institutions are prone to inertia. But in our hearts, we know we can't afford to sit still at Emory. It would be a disservice to our students and patients and a great danger in an environment that evolves as rapidly as health care and education."

Furthermore, there is clear room for improvement.

For all its strengths, the School of Medicine can do more in terms of teaching things like medical economics and information technology and in addressing topics like alternative medicine, death and dying, legal issues, and domestic violence.

"We admit students who do exceptionally well on standardized exams," says Shulman. "The real issue for our faculty though is to take these great test-takers and overachievers and ensure that they become great doctors. I submit we have a great track record doing both. But as medicine changes and requires new skills, we can do even better - and we can devise better ways to prove we are succeeding."

Joel Felner, associate dean for clinical education, co-chair of the strategic planning steering committee, and coordinator of the curriculum subcommittee, agrees.

"Is the School of Medicine doing enough to instill in its graduates exemplary ethical skills as well as clinical skills?" he asks. "Is it doing enough to ensure that they are good communicators, empathetic practitioners, in possession of good business and computer skills? Will they be able to think outside the box and be leaders in medical discovery? These are things you can't test for on multiple choice quizzes, but they're essential for practicing responsible medicine in today's environment."

Other areas also deserve attention. Significant upgrades are due for the school's facilities, which lag behind the reputation and caliber of its students and faculty. Strategic planners acknowledge that more scholarship support for medical students also is a high priority. Each year, Emory loses several top prospects to schools with more money to offer, and many students who do come here graduate into a life of immediate, heavy debt.


The man with the plan: Emory medical
school Dean Thomas Lawley has led
the school through two years of mapping
out the future of its teaching mission.

And in a situation not unique to Emory, teachers at academic health sciences centers increasingly find themselves between a research rock and a clinical hard place. Financial constrictions brought on by managed care have led institutions across the nation to beef up revenues by bringing in more research grants and seeing more patients. With little external funding available, clinical dollars have traditionally subsidized teaching, but those revenues are now under pressure. Dwindling insurance reimbursements have cut into those internal sources. While faculty are personally and professionally committed to the teaching, research, and clinical care missions, they are concerned that teaching not be maimed by the financial crunch.

So even though the medical school continues to admit and matriculate the best students, it does so under complex conditions. Still, the dean and his staff and faculty are ready to strive to do even better.

Establishing a strategy for redressing our weaknesses, making the most of our strengths, and identifying potential threats can be thought of as a form of preventive medicine for the school, says Juha Kokko, who was chair of medicine for more than a decade before becoming associate dean for clinical research.

"Many external forces threaten or may soon threaten the success of our teaching mission," says Kokko, who served on the steering committee and was co-chair of the finance subcommittee. The strategic plan, he says, will be a valuable tool for vigilant defense of education. "Much of the work of the planners centered on devising ways to track threats and ultimately defuse them."

Dean Lawley received the completed document - including reports from the 10 subcommittees - shortly before Christmas 1998. After some fine-tuning, approvals were tendered by Lawley, Executive Vice President for Health Affairs Michael Johns, and University Provost Rebecca Chopp. (The schools of nursing and public health also crafted teaching plans.)

The many specific recommendations contained in the medical school plan can be boiled down to three major areas of concern - facilities, students, and faculty - all of which overlap to some extent. Linking all the recommendations is the issue of finance: Who pays to implement the recommendations, and where will the money come from?

Facilities: Space to spread



The medical school's three missions - patient care, research, and education - are often described as an equilateral triangle. If pushed to choose a first among these equals, however, one could argue that as the core activity of the school, teaching is the springboard for the other two missions. Our educational mission put a medical school here in the first place. But Emory University cannot have medical students without patients, and teaching impels questions that lead to research.

However, there is sometimes a disconnect between such commonly held assumptions and the reality of academic medicine at the end of the century - a disparity in the way these core missions are recognized and supported. Success is more easily measured and often more richly rewarded in the arenas of research and patient care, a fact sometimes disheartening to dedicated teachers and frustrating to students and junior faculty. "It's difficult for young physicians to go into teaching when other options offer more recognition, prestige, and income," notes Atlanta internist Arnie Mellits, a 1993 graduate who deferred his dream of teaching full time in an academic medical center in favor of private practice. Mellits now gets his teaching fix as a volunteer instructor in the medical problem-solving course.

A significant part of the strategic planning process for the Woodruff Health Sciences Center has been to ensure that the teaching mission at Emory gets an equal shake with research and patient care. A plan for research was completed in early 1997 for the schools of medicine, nursing, and public health, as well as for the Yerkes Primate Center and for the health sciences center as a whole. That same year, Emory Healthcare, including The Emory Clinic and Emory Hospitals, developed a plan for clinical services. Both plans are currently in the implementation stage.

With regard to teaching, it appears this time to be a case of last but not least.

"Although teaching is central to everything," Shulman says, "some elements in the clinical and research plans were better dealt with first, as they may facilitate and enhance the teaching plan."

For example, some desired improvements in the medical school are contingent on space. Lack of it gets in the way of curriculum development. While the school may want to incorporate more problem-based learning seminars or technology-based instruction, that's impossible without classroom space and without sufficient staff time to develop and evaluate the courses.

"In that respect, the research and clinical plans are helping free up more space in which we can solve our teaching problems," says Shulman.

The biggest chunk of space available for teaching will become available with the decision to construct, over the next two years, a new 325,000-square-foot biomedical research facility to connect with the Rollins Research Center. Researchers now housed in the Anatomy and Physiology Building will move into the new Whitehead Research Building in 2001, thereby freeing up A/P real estate for the School of Medicine. The teaching strategic plan recommends up to $25 million in renovations and additions to the A/P space. An Emory University matching grant program will cover about $5 million, with the balance to be raised by health sciences center development staff.






The renovation will begin in late 2001. When the work is completed early in 2003, the revamped A/P structures will function as the central medical school complex Emory has lacked. A predesign study gives an early idea of what the new space will look like. Preliminary plans call for an Office of Information Technology (IT), as well as a sizable IT lab and multimedia center. Additionally, students will have two study areas, one enhanced with 50 computer workstations, and their own copy center. Greatly expanded classrooms - of various sizes to accommodate small-group seminars as well as full-class lectures - are planned as well.

Medical school faculty and administration will get room to spread their roots. The Office of Medical Education and Student Affairs, in particular, has been straining to do its work with a staff of only 14 (by comparison, in 1998, one benchmark school, UNC at Chapel Hill, had over 50) squeezed into a 1,500-square-foot corner of the Woodruff Health Sciences Center Administration Building (WHSCAB). More space in the new building will mean the ability to hire needed personnel so the office can begin to offer or expand ancillary services, such as student counseling, facilities for students to take their boards via computer, and computerized development and tracking of innovative curricula.

Past reviews by the Liaison Committee for Medical Education (LCME), the national accrediting body for medical schools, have noted the need for more space for medical education at Emory. Over the past two years, the school has alleviated that concern somewhat by investing $500,000 in WHSCAB improvements, including a computer lab, classrooms, and more student study and social space. Significant remaining deficiencies will be addressed as the new plan is implemented.

Students will welcome more elbow room and a place to call home. "I feel it's a huge step forward for the medical school," says recent graduate Josh Klopper of the plans to transform A/P into a centralized medical education complex.

"Until the past couple of years, Emory medical students didn't have amenities comparable to, say, law students, who have an entire complex complete with their library on-site," he says. Or, for that matter, compared to business students, who have a brand-new building and state-of-the-art multimedia facilities. Med students have felt dispossessed, wandering like nomads from building to building in search of a class, a place to study or grab a nap. "We need a place of our own to come to, to feel at home," Klopper says.

Although current facilities have gotten the basic job done, folklore nevertheless passes from student to student: wistful tales of medical schools where students are assigned private cubicles for an entire academic year and never have to scramble for study space or a place to stash their belongings. Of places where students are provided with laptops and tech support. Of places where parties are not held in parking lots.

"But you can always find stuff to complain about," says Klopper, who began an internal medicine residency at the University of Colorado this summer. "Honestly, the teachers here are wonderful. They're knowledgeable, dedicated, and totally available. And in the clinical years, in terms of resources and educational opportunities, I would be shocked if there was a place that had teaching hospitals any better or more diverse than Emory's. You couldn't ask for more opportunities for education."

Just for more state-of-the-art facilities in which to take advantage of those opportunities.

Like Klopper, ob/gyn resident Ashim Kumar feels a centralized medical school that offers more support services will better serve Emory students. Kumar completed his first two years of medical school at the University of AlabamaÐBirmingham (UAB) then transferred to Emory for his third and fourth years. He particularly appreciated the extensive computer access provided at UAB's clinical sites, finding it helpful to be able to observe a patient at bedside then immediately log onto the hospital's website to research information on more than 500 pediatric diseases linked to their database.

Kumar echoes Klopper's opinion of Emory's teaching hospitals, particularly Grady. "It is one of the treasures of Emory," he says. "Unlike some medical schools, Emory-affiliated hospitals stress that medical interns and residents have a responsibility to help teach medical students," says Kumar. "Dr. [Ken] Walker and Dr. Kokko really drive that point home. It makes medicine a phenomenal rotation at Emory."

Students: The fruit of our labors


Wish list

The Strategic Plan for Teaching and Education includes these recommendations:
  • Increase space, personnel,
    and finances for the Office
    of Medical Education and
    Student Affairs.
  • Enhance the role of and
    respect for education in the
    academic health center.
  • Enhance facilities for
    teaching, especially
    problem-based and
    small-group teaching
    approaches.
  • Create study and lounge
    areas.
  • Develop financial and other
    teaching rewards.
  • Enhance training in
    informatics and increase
    the use of computers
    for learning and curriculum
    evaluation.
  • Develop faculty teaching
    workshops.
  • Develop better ways to
    train and evaluate students
    in communication and
    physical exam skills.
  • Develop new programs in
    cultural diversity,
    socioeconomics of medicine,
    jurisprudence, domestic
    violence, substance abuse,
    and others.
  • Support the use of education
    specialists.
  • Increase outpatient
    experiences in the various
    clinical clerkships and
    electives.
  • Expand international
    research opportunities.
  • Incorporate Allied Health
    programs more fully within
    the medical school.
  • Increase the amount of
    basic science taught in the
    third and fourth years.

The ongoing interplay between medical students, medical residents, and fellows is something Joel Felner refers to as the "coffeepot curriculum."

This casual interaction - late-night caffeine in the hospital lounge, a quick consultation in a hallway, banter at a water fountain - reinforces what is taught in the classroom. It models the kind of professional collaboration students ultimately will need to practice successfully as physicians. The coffeepot curriculum occurs far from the classroom yet imparts lifelong skills in teamwork and problem-solving.

The coffeepot curriculum enriches both students and faculty on other levels as well, Shulman says. "Here at Emory, there is a very special chemistry that permeates the medical school, and it has to do with the closeness, the trust, the collegiality that our faculty and students share. No matter what else we do or change in our strategic planning, we are determined to retain and strengthen that chemistry. It's vital to the success of our programs."

When it comes to teaching and developing such clinical skills, Willis Hurst has been there, done that, and written books about it. The 48-year veteran of the Emory faculty and former chair of medicine has won his share of local and national teaching awards and authored three books on medical education. The preface to his most recent work includes a quote from Herbert Gerjuoy that was included in Alvin Toffler's 1971 bestseller Future Shock. "Tomorrow's illiterate," it reads in part, "will not be the man who can't read; he will be the man who has not learned how to learn."

An ability to teach students and house officers how to think and learn is the mark of what Hurst calls a "true teacher." In today's world of information overload, that ability is essential.

"There's simply no way medical students can learn everything they need to know in just four years," Hurst says, "and the information will just keep changing. Merely dispensing information is not teaching, and memorizing is not the goal."

Not only do nascent doctors need to learn how to learn, he says, nascent teachers of medicine need to be taught how to teach. To do this requires funded teaching and faculty development programs, Hurst says. "Otherwise, the economic survival of our true teachers is threatened."

The curriculum subcommittee agreed on the need for such funded programs and also noted some important trends in medical practice the school should address in its planning: a continuing shift toward outpatient care, an emphasis on population-based health care, an increased demand for generalist clinicians over specialists, and the enhanced use of other health care professionals in the workplace. The report suggests the medical school increase its use of problem-based learning seminars, informatics, and ambulatory care training. It asks the school to reduce lecture time, especially in the first two years, by about 10%, to a level more in keeping with benchmark schools. And it advocates developing admittedly resource-intensive tools, such as objective standardized clinical examinations. These evaluate students' clinical skills with the assistance of simulated patients (like the "Harvey" mannequin used to teach cardiology) and actors hired and trained to work as "standardized patients."

To continue to compete for the best and brightest, the medical school needs to make its scholarships and other forms of financial aid more available and more generous. Roughly three-quarters of Emory's medical students need financial aid, yet on average the school offers fewer scholarship dollars per student than do benchmark institutions ($5,500 compared with $9,250). The average Emory School of Medicine graduate walks out the front gates owing $88,000. By the time students finish postgraduate and specialty training, they can easily be in their mid-30s before they can begin repaying their medical school debt.

Points out Lawley, "We want to be sure that an Emory medical education is available to any deserving student, regardless of his or her bank account."

Faculty: Cultivating their growth

It's not just student finances that are at issue. Faculty, especially junior faculty, need the School of Medicine to proactively protect them from the escalating pressures associated with managed care. It's unreasonable, says Lawley, to ask faculty to see more patients, conduct more funded research, and teach more small classes - and to do it all in the same 40 to 60 hours per week.

"Managed care has been hard on the classroom," the dean says. "The reductions in reimbursement that keep private practice physicians working longer hours and seeing more patients have had the same impact on Emory clinician-teachers, pulling them out of classrooms and labs."

The last thing Emory wants to see is competition between its teaching, patient care, and research missions. "We certainly don't want to penalize our faculty for teaching," Lawley says. "At the same time, we realize our clinical care activities can no longer cross-subsidize teaching and research to the degree that they have in the past."

One solution proposed in the teaching strategic plan is to sharply escalate the number of financial awards available to teachers by establishing an endowed professorship fund. Awards would be for one year, might be renewed, and would provide significant financial boosts up to $10,000. The exact number of these awards hasn't been determined - and the money to pay for them has to be raised. Nonetheless, the dean says the first of these new awards will be presented this coming academic year to faculty who are heavily involved in undergraduate teaching programs.

Currently, the School of Medicine hands out only one cash-bearing teaching award each year, the Evangeline Papageorge Teaching Award, and that has been given only since 1993. The Papageorge Award, named for the longtime associate dean of students, is voted on and largely funded by alumni. This year it carried a cash stipend of $12,000.

The list of past winners of the Papageorge Award reads like a "who's who" of Emory medicine: Jack Shulman in 1993, followed by Whit Sewell, Willis Hurst, Ken Walker, Richard Amerson, Kyle Petersen, and, this year, Joel Felner. This list points out yet another reason for the universally acknowledged need for more such awards and other teaching support. As the only game in town, the Papageorge goes to senior faculty, those who need it least in terms of income and career advancement. It serves as a capstone to a distinguished professional life, not as an incentive to pursue one.

The honor is no less, says 1999 winner Felner, who has won a fistful of nonÐcash-bearing awards in his 28 years at Emory. "It is gratifying - and important - to hear from my students and alumni that I've gotten it right. It impels me to do better.


Tomorrow's illiterate will not be one who can't read, but one who has not learned how to learn.

"But we must do more to honor our faculty at all levels who are excellent teachers. I'm not suggesting that we give awards to everyone who teaches, mind you, but certainly we should reward those who shoulder big blocks of teaching and those who demonstrate exceptional skill. And we need to put some teeth in these awards in the form of money. Serious money."

The issue of salary and other financial incentives tied to faculty teaching is decidedly front-burner. The dean has given teaching awards top priority for implementation - even before the new building. But such talk is not cheap: fully funding the proposal could cost over $8 million.

Nevertheless, beginning to establish these awards is one visible step the school can take in giving value to teaching.

"We must demonstrate, concretely, the value of teaching," adds Kokko. "We assign a value to our clinical enterprise and to our research, a value which is easily measured by number of patients seen or dollars generated."

If pay and promotion are determined by one's value to the institution, and if that value is determined by how much money a person brings in, there will be a problem if teaching can't prove its value. "Compared to research and patient care, unvalued teaching will just increasingly get lip service," he says.

Medical schools around the country are struggling with similar problems. The next generation of medical educators and administrators will increasingly peer over each other's shoulders to see which approaches work best to address these challenges.

Money: The root of the matter

Like plaque to an arterial wall, questions of finance have adhered to each element of the teaching strategic plan. The thousands of hours spent producing the plan - spotting the trends, identifying the threats, making the recommendations - still boil down to one nagging question: Yeah, but how are we going to pay for it?

The tough reality is that small-group seminars and problem-based learning cost a lot of money. Adding computers, renovating classrooms, establishing teaching awards - these all require more of the same green commodity steadily being depleted by managed care cutbacks.

The total cost to implement the strategic plan as it now stands hovers at $40 million. Besides the university's $5-million pledge for the new facility, most of the rest will have to be earned the old-fashioned way - through fundraising with alumni, corporations, and foundations. Tuition income is simply not large enough to cover medical education programs.

The Office of Medical Development is staffing up to meet these fundraising challenges. Following a year-long search, John Blohm was hired late last year as senior associate vice president for health sciences development. In the past several months, he has hired two professionals - a senior director of development and a director of development for clinical programs - to raise money specifically for the medical school. He has also added a health sciences center development writer and filled development positions for planned giving and corporate and foundation relations.

Bringing it to fruition

With its nine-month gestation period, the teaching strategic plan lends itself easily to talk of birth...or maybe rebirth. Like the shedding serpent, the school appears poised to emerge a renewed creature.

"It was a labor of love," said one junior faculty, explaining how she met the arduous schedule expected of committee members - long meetings held either first thing in the morning or at the end of the work day. "It was painful, but ultimately worth every minute."

In this Issue


From the Director  /  Letters

Regenesis: Renewing Medical
Education at Emory

What makes Joel Felner so good?

Virtual Doc

A New Voice for Nursing

Moving Forward  /  Noteworthy

Youth, Firearms, and Violence

Finding the Papa of the Mummies

 

Lawley concurs. "The value of such planning - of having our faculty and students intellectually engaged in the life of the school - is immense. It is a tribute to their interest and enthusiasm that these extremely busy people made this a priority."

Even more remarkable was the scope of participation: roughly 12% of the entire faculty, with representation at all levels of seniority, served on at least one subcommittee. This allowed for a broadly inclusive plan that a sizable cross-section of the faculty have a vested interest in seeing succeed.

In the past, medical school planning for significant new education facilities lacked the support necessary to bring them to fruition. In 1978, for instance, a long-range planning committee for the School of Medicine identified the need for a medical education building. The group strongly recommended immediate construction of such a facility but other university and medical school building projects took precedence.

The medical school's most recent foray into strategic planning will be implemented, says Lawley. "It was an integral part of the overall WHSC strategic planning process, and both the school and the WHSC as a whole are committed and ready to implement needed changes."

And, as important as the process was, "the implementation of the right plan clearly is more important than the history of its creation," he says.

The plan will really begin to have a palpable impact this fall, when the first new teaching awards are handed out. The plan's larger rejuvenating effects will be felt increasingly through the next five years as the medical school builds its new home - and enhances its curriculum.

"This is a good plan," Lawley says. "I know that, and the faculty who created it know that. We are creating our future - a better future - and the proof is right around the corner."


Darryl Gossett is senior managing editor in the office of health sciences publications at Emory.

 


Copyright © Emory University, 1999. All Rights Reserved.
Send comments to the Editors.
Web version by Jaime Henriquez.