In the Jan. 9 issue of the Journal of the American Medical Association, Rochester physicians reconsider the very definition of what makes a good doctor. The authors propose sweeping changes to ensure physician competence in typically overlooked areas such as teamwork, interpersonal skills, clinical reasoning, and managing ambiguous clinical situations – a necessary real-world skill that traditional schooling doesn’t teach.
“For patients, it’s not enough to know that their doctor scored well on a multiple-choice test,” says principal author Ronald M. Epstein, M.D., a practicing physician in the Department of Family Medicine, who has spent his career researching and teaching about the patient-physician relationship. In the JAMA article, Epstein points out that sometimes, student doctors who perform especially well on standardized tests are especially lacking in such traits as empathy, responsibility, and tolerance.
Many of the ideas are already embodied in Rochester’s new curriculum and are rooted in Epstein’s search for ways to train better doctors. As a family physician, he took a broad view of what constitutes competent medical practice. After examining the ways that medical students are being taught and assessed, Epstein found that not all the right questions were being asked.
“There were lots of studies of the reliability of assessment instruments, but very little on whether what we assess is really what matters in medical care,” says Epstein. “More troubling was that few people had even identified a problem.”
So, Epstein and Edward M. Hundert, M.D., dean of the School of Medicine and Dentistry, set out to redefine the very meaning of what makes a good doctor, beyond technical skill and knowledge. Epstein studied the philosophy of medicine, from the earliest writings from Greece and India to modern discussions of ethics and professionalism. He also drew on his original training in music, which emphasizes the use of all mental faculties – including thinking, reasoning, judgment and emotions – along with a technical skill.
His ideas are part of a wider reform spearheaded by Hundert, who is the architect of Rochester’s innovative medical school curriculum, which embodies many of the ideas discussed in the JAMA article. At Rochester, in a program known as the double-helix curriculum, students work with patients starting in their first year, not in their second or third year, which is the traditional approach. Basic science and clinical work are intertwined throughout training like the strands of a double helix. At the end of their second and third years, students have a professional-competency assessment that lasts two full weeks and embodies all of the elements of competence laid out in Epstein and Hundert’s article.
Last year, educators who visited Rochester as part of an accreditation inspection by the Liaison Committee on Medical Education said they found “no areas of concern—an unprecedented finding in American medical education.” The team gave the curriculum a perfect score and praised the university’s reforms as “innovative, bold, and highly successful.”
Those reforms include rigorous assessments of a student’s performance in actual clinical sessions. Computerized, video-ready learning rooms – with a functioning doctor’s office built into them – help students and faculty rate their work, using a system that examines 700 aspects of patient-physician interaction.
“We frame every question in terms of a patient, not just as an abstract multiple-choice question,” says Epstein.
The new curriculum has attracted national attention. Also published in the Jan. 9 issue of JAMA is an endorsing editorial written by the executive director of the Accreditation Council for Graduate Medical Education. The endorsement makes it likely that Rochester’s new definition of competence will be widely discussed at federal agencies, medical schools, and licensing boards interested in reducing medical errors and improving the quality of care.
Another endorsement of the program came from the Department of Education's Foundation for the Improvement of Post-Secondary Education (FIPSE). FIPSE rarely awards grants to medical schools, but it decided to support development of a new comprehensive-assessment methodology within the double helix curriculum with a half-million dollar grant. It reasoned that the Rochester approach could become a national model – for medical schools across the country, but also for other professional schools such as law or architecture.
At its heart, the work of Epstein and Hundert is an attempt to remind the healthcare industry that medicine is more than knowing the facts and demonstrating skill. “Medicine, no matter how technological it is, is always a human enterprise,” says Epstein.
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