How would you describe your own medical education?
I studied medicine in the late ’70s to the early ’80s and received the typical American mainstream medical education of the time. Knowledge was handed down from the most senior practitioners and department chairs through a strict hierarchy: senior faculty, junior faculty, fellows, residents and then medical students.
The goal was for the more junior practitioners to learn from the experiences of their elders. An unfortunate side effect of this system is that medical education stays mostly the same with each new generation of doctors. Doctors train the next generation the same way they were trained. New evidence-based practices are viewed skeptically and are slow to take root. This is called “eminence-based medicine” rather than “evidence-based medicine.”
In addition, medical professionals – nurses, doctors, pharmacists, physician assistants, etc. – were all trained separately. And they still are, in many places. They don’t learn to operate as equal members of a team because the doctor is the source of orders and others carry them out. Thus, delivery of care is also hierarchical, with any questions or deviations coming back to the doctor for adjustment. The care of various team members is not integrated – orders are simply executed. Full team input is difficult under such a system.
Today, however, the health needs of our country require a more evidence-based and integrative approach.
What does medical education need to do to produce competent integrative health practitioners that use evidence for delivery of health care?
Medical education needs to train all providers in how to critically appraise the research literature and learn how to make evidence-based decisions with patients. It also needs to train providers together in a way that all are full members of the team with important, respected and distinct roles. This needs to be done from day one in medical education all the way through residency and fellowships.
While there are now residencies and fellowships in integrative medicine in many medical schools, there still needs to be a more universal and early stage approach to producing competent integrative health practitioners.
I have identified four areas of improvement that should be included in the curricula of medical schools:
- Problem-driven, evidence-based decision-making skills
- True team-based care that includes the patient
- Expanding the use of self-care and complementary medicine modalities
- Providing training in listening, empathy and compassion
What is problem-driven, evidence-based decision-making?
As a medical student and early practitioner, I found it difficult to bring up questions that were outside of the senior doctor’s orders and experience. For example, when acupuncture was introduced in the U.S. I wanted to learn how to do it. The response of my chief of medicine was, “Why do you want to study ‘quackupuncture’?” His mind was closed and he did not even look at the evidence.
Now, of course, the literature abounds with randomized, controlled trials that demonstrate the effectiveness of acupuncture for pain and other health problems.[1] Students should routinely learn to find and make use of such evidence-based data – not only about acupuncture, but also about all complementary and conventional treatments – as the basis for clinical decisions.
The best decisions are informed by the results of clinical research and meta-analyses, as well as big data focused on patient-centered outcomes and patient satisfaction. Medical education and practice have gradually begun to move to this type of evidence-based system. We need to teach it earlier and to all providers.
What are some of the most respected sources for such data and how should clinicians make use of them?
Good places to start are the Cochrane Collaboration,[2] BMJ Clinical Evidence Summaries,[3] and the Agency for Health Care Research and Quality,[4] which are all excellent and trustworthy sources. But medical schools can go further than simply pointing students in the direction of such sources. They can train them to incorporate this evidence and use critical analysis skills seamlessly in practice.
Clinicians benefit when they learn continuously from their own practices. They can do this by comparing clinical data from their own patients with big data drawn from other clinicians and clinical trials. The goal is to immediately and continuously improve the quality of the care they are delivering.
We also need to educate clinicians in methods of problem-based healing: This is where you start at square one with the patient and apply scientific data to help heal the problems that the patient is having. One example of such methods would be to use a category of evidence (behavioral biochemistry) to complement the treatment of such problems as kidney stones (vitamin B6, magnesium, hydration), viruses (vitamin C, steam and not antibiotics), or osteoarthritis (niacinamide, exercise).
Tell me more about the team-based care in your second suggestion.
I remember one of my first weeks as a new intern on a patient ward. I wrote a medication order and it didn’t get carried out. When I questioned the very experienced nurse on the floor, she said, “Listen, son, you may be the doctor, but here we work as a team. If you had consulted with us, you would have learned that this patient is severely allergic to the medication you prescribed.” This nurse was right. She knew how a team was supposed to work. But this model of team-based care was neither taught in medical school nor universally applied when I was a student.
Physicians do their best work as equal members of a non-hierarchical clinical team that includes health coaches, nurses, behaviorists, pharmacologists, allied health professionals and complementary practitioners. The team meets as a group to discuss the behavioral, physical and mental health needs of each patient. This cooperation and collaboration need to be taught from day one.
I recently visited a medical practice that demonstrates the benefits of interdisciplinary team-based care: An asthma patient stopped showing up at the clinic for his regular medicine and checkups. The health coach team member, who was in touch with the patient’s family and explored his disappearance further, discovered that he had had a crack cocaine relapse. The coach found out where he was, went there, and encouraged him to come back to the clinic for treatment of both his asthma and his addiction. Under the old system, this man may well have either died on the street or been brought into an emergency room. Instead, the health coach reached out to proactively engage and help the patient, thus preventing costly and poorly integrated care.
How can expanding the use of healing tools such as patient self-care and complementary care improve medicine?
Most medical schools today still do not teach motivational interviewing, for example, or other methods to encourage patient self-care through tools such as good nutrition and physical activity. And since the personal spaces of home, community and environment influence health outcomes, such self-care becomes a crucial component of overall health. We also do not teach physicians how to access evidence-based complementary care for their patients.
For example, in addition to acupuncture, there is good evidence demonstrating the effectiveness of several non-pharmacological approaches to chronic pain, including therapeutic yoga, massage, nutrition, relaxation techniques, physical therapy, and bodywork.[5] Expanding the study of such methods and approaches in all medical school curricula would give clinicians the evidence to knowledgeably manage their patients safely.
Lastly, you mentioned training in listening, empathy and compassion as an essential skill for patient-centered care. Tell me more.
It is well documented that medical students lose empathy as they go through training. We must stop this decline in such an essential skill. In addition, nearly half of all primary care physicians are facing burnout – and so have further difficulties with listening and empathy. We need to teach providers how to heal the healer from day one in their training.
Medicine is hard. Resilience is needed.
In the example of the patient with asthma and crack addiction above, the health coach used the tools of empathy, listening and attending to the needs of the patient to help him come back in for treatment. Otherwise, it was likely he would have refused help and ended up using large amounts of resources going in and out of emergency rooms and hospitals. Instead of getting patient-centered care, he would have gotten acute and rescue care – like what I was trained to deliver in my medical education.
How will the newly announced gift to the University of California, Irvine help to transform medical education in the U.S.?
Last month’s announcement at UCI is a huge step in the right direction for training practitioners in evidence-based, integrative care. The Susan and Henry Samueli College of Health Sciences will be the first university-based health sciences system in the U.S. to incorporate integrative health research, teaching and patient care across all its schools and programs. With this – the largest gift in the history of the university – UCI will create the Susan Samueli Integrative Health Institute, which will focus on improving medical care by supporting multidisciplinary research, education, clinical services and community programs.
Faculty and students in computer science, engineering, social sciences, business and other areas will also collaborate with the institute to study the future of integrative health and healing. The college will be able to address the areas of medical education I described earlier:
- Interdisciplinary team-based health science education from day one. The institute will provide collaborative integrative health education among the schools of medicine, nursing, pharmacology and population (public) health.
- Address the social determinants of disease (including education, poverty and the environment) through community programs and education. The institute will also support research on non-invasive devices – created with the disciplines of health engineering and technology – that will both assess health and encourage healthy behaviors through immediate feedback on exercise, nutrition and diet.
- Foster self-care at the undergraduate and community level. The institute will provide integrative health education even for people outside the health care system. Courses on self-care will help students and community members manage problems like depression, obesity and burnout.
How would this approach have changed your medical school experience?
It would have been a game-changer. I’ll tell you one last story about how lack of access to this knowledge held me back as a provider and a patient. When I was in college, I was interested in nutrition and physical fitness.
Since there was no course on applied nutrition in my college, I decided to try a strict raw food diet on my own – to learn what it did. As you can imagine, I made myself pretty sick.
Instead of ignoring the latest science on lifestyle, the new college will help students and community members learn how to monitor their own health parameters and modify their lifestyles SAFELY.
By creating an entire educational institution framed around health and healing, the college will foster cross-fertilization among the “STEM” disciplines – Science, Technology, Engineering and Math – and all types of providers. This inclusive, universal approach to health and healing has the potential to transform health care education in this country and globally.
[1] https://nccih.nih.gov/health/acupuncture/introduction
[2] http://www.cochrane.org An international research consortium with the mission of promoting evidence-informed health decision-making by producing high-quality, relevant, accessible systematic reviews and other synthesized research evidence.
[3] http://www.bmj.com/specialties/bmj-clinical-evidence-summaries
[5] https://www.ncbi.nlm.nih.gov/pubmed/25970869