Diagnosing the doctors of tomorrow: Methods for selecting and teaching students stand apart in new medical school
by JESSE TUEL
An archaic Latin phrase that graced the printed page as early as 1535 best describes the unknown future of medicine.
The premise that future physicians should be "thought leaders"--intellectually nimble, research-minded doctors who draw from the latest knowledge to tailor care for each patient--guides Virginia Tech's exploration of the unknown. On the heels of a 20-year span during which no new medical schools were established in the United States, Tech has exercised its innovative awareness to craft a school that utilizes radically different but proven methods of selecting and teaching students.
From a blank slate to fruition, the Virginia Tech Carilion (VTC) School of Medicine and Research Institute in Roanoke, Va., opened its doors Aug. 2, ushering the charter class of 42 students into a progressive, entrepreneurial program of medical education that already stands boldly apart.
The school, a first-of-its-kind public-private partnership between Tech and Carilion Clinic, a regional health care network, selected its charter class through multiple-mini interviews (MMI), a technique only a half-dozen U.S. medical colleges employ, according to the technique's co-creator. Additionally, students are immersing themselves in a curriculum that centers on problem-based learning, a faculty-intensive and demanding approach that just 15 percent of U.S. medical colleges utilize.
VTC administrators said concepts students learn today must be applicable when they begin practicing medicine. After four years of medical school, three to seven years of residency, and one to three years of fellowship, VTC physicians will be equipped to handle whatever the future holds.
"What is the future? This is the challenging part of starting a medical school because we don't know what this future is going to look like," said Cynda Johnson, the school's founding dean. "So that is why our school is based on the mission of developing 'physician thought leaders,' through inquiry, research, and discovery. We're going to be training these students to be able to face--and lead--this unknown world of medicine."
"The neat thing about it is we had a clean slate," said Richard Vari, associate dean for medical education. Planning took on a simple premise, he said: "'What are the best things going on in the country? And let's do that. Or, let's not. Let's do it better.'"
Panning for gold
Three weeks before the start of classes, a media-day tour of the Roanoke facility revealed faculty and staff in the last throes of a meticulous preparatory process that began in January 2007, when Virginia Tech President Charles W. Steger and Carilion Clinic President and CEO Edward G. Murphy announced the new school. A new-carpet smell permeated the pristine building, clad in 207 tons of familiar Hokie Stone. Classroom desks were still being assembled, while the library was still empty of books. Sight lines of mountains and the Roanoke cityscape, visible through large windows on all sides of the building, stood ready to welcome 42 new residents.
Just how the applicant pool was trimmed to 42 is intriguing. About 230 of the 1,650 applicants landed on-site interviews during the 2009-10 academic year, and the 42 spots were filled as August approached.
Many applicants were attracted to VTC for the research emphasis and the entrepreneurial chance to shape a new school and undertake a unique curriculum. Meanwhile, administrators analyzed applicants beyond the traditional MCAT and GPA tallies. They identified applicants who had a heart for serving others through medicine and who adopted an interest--academics, music, athletics, research, and more--and pushed themselves to excel, said Stephen Workman, director of admissions.
"Even if their overall grades or MCAT scores aren't necessarily at the top, if we see evidence of that kind of spark and enthusiasm and performance, those are the people who interest us," Workman said.
On site, the MMIs further refined the applicant pool. In a process similar to speed-dating, students rotated through 10 interview stations. A scenario was posted on the door of each room, and after a brief time for review, the student was ushered in for eight minutes one-on-one with an interviewer. For instance, one of the practice questions posted online for applicants asked them to discuss the ethical implications of a doctor prescribing homeopathic medicine to a patient as a reassuring placebo, even without evidence it would be effective.
Interviewers, many of whom were community leaders specifically trained for the MMIs, would listen to the applicant's rationale and then ask questions regarding the choices made by the applicant, rating candidates based on the interaction. Students also had an 18-minute traditional interview with a member of the admissions committee.
The MMI identifies students who don't "necessarily take the party line at face value," Workman said. "They will be inquiring. They will examine the evidence. They will ask when evidence is in absence. We think that will be reflective of their ability to be a better physician down the road."
"The response that I got from each applicant was different and interesting," said Bill Flattery, vice president of operations for The Physicians Group at Carilion Clinic, who served as a community-based interviewer. "I was surprised that the format could be so effective. The very best were able to emerge."
Grounded in questions of morality and ethics, the MMI weighs a student's ability to comprehend and apply new information for the benefit of the patient. It's also a proven predictor for scores on national licensing exams, which test for clinical decision-making skills while indirectly predicting future success, such as fewer complaints registered and a higher survival rate among patients who have suffered cardiac events, said Harold Reiter, professor and admissions chairman at the Michael G. DeGroote School of Medicine at McMaster University in Ontario, Canada, who co-created the MMI with Kevin Eva, Geoff Norman, and Jack Rosenfeld about 10 years ago.
The use of multiple interviews dilutes the bias of a single stellar or poor performance. "Anyone can perform admirably or horribly in one interview, regardless of their personal or professional skills," said Reiter, who traveled to Roanoke in July 2009 to train VTC leaders on the process.
Raeva Malik, a Potomac, Md., native who courted the idea of medical school from a young age through her bachelor's and master's degrees at Georgetown University, said the interviews were "intense." She was nervous at first, but grew more comfortable as she progressed through the 10 rooms. "Most people, when they're put under a high-pressure situation, will perform better," Malik said. "In the medical field, you always have to think on your feet."
Robert Brown, who earned his biology major and chemistry minor at the University of North Carolina at Chapel Hill, endured a number of one-on-one and panel interviews for various medical schools. He left more than one of those interviews unsure if the interviewers understood him fully. Not so at the end of the MMI.
"I thought it was the best interview process I've ever been to in my life," Brown said. "At the end of it, I really felt they knew me."
For some prospective students, the attention to detail evident in the MMI and interview weekends was a deciding factor.
"We were just blown away--how organized they were, the whole community effort," said Don Vile, a 2000 Harvard University undergraduate who worked in software engineering and management before deciding to enter medical school, ultimately choosing VTC from among the five schools that accepted him. Don and his wife welcomed the birth of their daughter, Nadia, this summer, and his choice of schools encountered another factor--the best place for his family.
Vile credits Harvard with teaching him how to compete at the academic level required in medical school. He worked at Appian Corp., based in Washington, D.C., leading the architectural team in a start-up IT software company that grew from 10 to 200 employees. After six years at Appian, Vile had reached a point in middle management where to advance further he needed to learn new computer languages or go the M.B.A. route. "I was not willing to make that investment unless I really loved what I was doing," Vile said. "I enjoyed software, but it wasn't my passion."
His interests were in his Harvard major, engineering sciences with a speciality in biomedical research. Vile started volunteering at local hospitals and entered a Georgetown post-baccalaureate program for a full academic year of chemistry, physics, organic chemistry, biology, and biochemistry, preparing himself for the rigors of medical school.
Early in his application to VTC, Vile recognized that his start-up experience at Appian neatly mirrored the entrepreneurial nature of a new medical school.
"I thought about it as a great opportunity to be [part of] something new," said Vile, who interviewed on-site in October 2009 and was accepted just before the holidays. "The startup, in and of itself, is a neat environment. Combined with medical school, it'll be all the more interesting."
Malik felt much the same.
"I think it's exciting to be involved in a new medical school," Malik said. "I think first-year students will be offered many opportunities that medical students don't typically have. The students are going to be a part of building the medical school [along] with faculty. We're going to have critical input."
Students, in fact, will evaluate the medical school and faculty after the first year of matriculation as part of the push toward provisional accreditation. The school received preliminary accreditation from the Liaison Committee for Medical Education in mid-2009. After the first class graduates, VTC will be eligible for full accreditation.
It's a rare chance indeed. Not a single new medical school was opened in the United States from 1982 until 2002, when the Florida State University College of Medicine broke the dry spell. Ten schools have launched since 2002, according to the Association of American Medical Colleges.
The solution is the problem
On any given Monday, each of the six teams, seven students per team, will be given an actual patient case--the chief complaint, medical history, and physical exam for a patient with cardiovascular disease, for instance. Students then work through the case together, guided by a faculty facilitator, researching specific topics to present to the team at the next session on Wednesday. One student might describe the anatomy of the heart's chambers; another might diagram electrical activity as currents move through the heart tissue. They'll apply this knowledge to the case and receive new information about the patient, leading to additional research and presentations on Friday. The week culminates with a private session for students to interact with the physician and the actual patient, allowing for meaningful learning in real time.
This is problem-based learning, focused on patient casework, with fewer traditional lectures, more hands-on learning, and a new case each Monday.
Directing the VTC curriculum is Richard Vari, lured away from the University of North Dakota School of Medicine and Health Sciences, where he led the curricular transition from traditional to problem-based about 15 years ago and earned the school the distinction of being named one of eight models for the future of learning by the Carnegie Foundation for the Advancement of Learning. At North Dakota, like at VTC, the smaller class sizes were suitable for the educational format.
"It focuses on adult-learning theory," Vari said of problem-based learning, adding that it gives students the flexibility to uncover what they need to learn about the human body without sitting in a lecture hall. "This is so much more applicable. They're constantly refreshing their thirst for knowledge."
Vari said the differences were visible right away. Prior to problem-based learning, first-year students were "bored" in lectures, he said. After the switch, "We saw these students really actively engaged and enthused," he said.
Students excelled at teaching their fellow students, displaying the intellectual prowess that got them into medical school in the first place. "That was a huge surprise, an appreciation of how talented they are," Vari said. "They want to learn, and they don't want to waste their time."
All the while, through discovery, research, and teamwork, VTC students will embrace the school's four value domains: basic sciences, clinical sciences, interprofessionalism, and research.
So much planning, so much excitement. Now it's time to deliver, as Johnson put it. "We've put together what I think is an excellent curriculum that will stand the test of time and train students for the future of medicine," Johnson said.
- - - - - - - - -
One part world-class research university, one part dynamic network of health care providers, one part new school of medicine, and one part new biomedical research institute.
This is the Virginia Tech Carilion (VTC) School of Medicine and Research Institute. Launched this fall, the research institute will eventually house hundreds of researchers while giving Virginia Tech and VTC students an outlet for conducting primary research of their own.
As a graduation requirement, medical students must produce a publishable, hypothesis-driven research project, satisfying one of the school's four value domains. The formula means students and faculty members will carve out the time for meaningful involvement in research. "It's not just going to be dabbling," said Michael Friedlander, the institute's founding executive director. "They're going to be fully engaged in research. Just as they learn to work as part of a health care delivery team, the medical students will also learn to work in interdisciplinary research teams--with biomedical faculty members, Ph.D. students, postdoctoral fellows, laboratory technicians, clinical research coordinators, and undergraduate students."
VTC graduates will leave medical school as "thought leaders"--understanding what makes a good experiment, what a good control is and when one can reach a conclusion. "They'll be a tremendously educated advocates for the benefit of the patient," Friedlander said. "We think this research is really going to make a better doctor."
Cynda Johnson, founding dean of the school of medicine, said research is inseparable from primary practice. Johnson--with 35 years in primary practice and academia--called research the "missing element" in general medical education.
Friedlander aims to have the first wave of seven to nine principle investigators (PIs) in place by the end of the 2010-11 academic year, and each of those PIs will bring or hire researchers for his or her team. The goal is 25-30 PIs, with a range of 250-350 people working on site.
The researchers will work across four broad areas: neurosciences, cancer biology, cardiovascular sciences, and immunology and infectious disease. They'll focus on problems that have the potential for the greatest impact on public health.
For the top researchers Friedlander wants, the institute boasts a new opportunity in a unique partnership. "This is a place used to big-time research," Friedlander said. "It's not like we're starting from scratch." Without the presence of Tech and the Carilion reputation, he said, "it would be a much harder sell."
High-impact medical research is just around the bend--one more point of pride for the university and the region.