This story is dedicated to Kellie Engle, director of curriculum, and the hundreds of faculty, students and staff throughout the WWAMI region whose hard work, commitment and talent make outstanding education possible.

 

Before she started medical school, Washington native Arita Thatte was working in finance on the East Coast. “It was super-abstract,” she says. “I was typing numbers into a computer.”

First-year student Aera Shin and her preceptor, Lise Alexander, M.D. ’03, examine patient Sheryl Blumberg (center). Alexander, who practices at Pacific Medical Center in Federal Way, Wash., is one of many physicians who volunteer to teach students in the new curriculum.
Photo: Clare McLean

Thatte is finding medical school anything but abstract. She is among the first cohort of students at the UW School of Medicine to experience a new curriculum, begun in fall 2015. Among other innovations, the curriculum brings students into contact with real patients immediately, which helps students connect their classroom learning with real-life experience.

“When you’re studying,” explains Thatte, “you’re thinking about how it’s relevant to your future practice as a clinician.”

Although patients provide valuable insights for medical students, they sometimes provide even more. For instance, Thatte knows she has a lot to learn, and she’s sometimes a little reticent in front of the patients. One of them, a woman in her eighties, noticed.

The patient’s advice? “She told me not to be so timid,” Thatte remembers. “That was really encouraging.”

A little history

For more than 100 years, American medical-school curricula have followed a structure developed by Abraham Flexner, an educator hired by the Carnegie Foundation in the early 1900s to examine the state of medical schools nationwide. He found medical education wanting and issued a series of recommendations. Today’s traditional medical-school format — two years of classroom-based learning, then two years of hands-on training with patients in clinics and hospitals — is an outcome of the Flexner report.

In other words: learn about something before you practice it. But does this teaching method hold up after 100 years of rapid technological and societal change? Not completely.

“If you apply information that you’ve learned to a real problem, you will retain that information better,” says Suzanne Allen, M.D., MPH, the UW School of Medicine’s vice dean for academic, rural and regional affairs.

And that is the core of the new UW School of Medicine curriculum: taking down the fence between the classroom and the clinic; integrating what students learn in the classroom with what they learn, see and do in clinical settings. Instead of waiting until third-year clerkships to interact with patients, as is traditional in many medical schools,* students in the new curriculum see patients their first year. In fact, students see patients their first week.

Learning and doing is a good combination. “I love that we have the opportunity to practice our clinical skills alongside our academic work,” says first-year medical student Aera Shin. Shin is based in Seattle, one of several campus sites. “It provides a way to solidify the material we learn in class through real-life application.”

*See the sidebar on the Colleges, below.

The WWAMI factor

Viewed one way, a major, five-state curriculum renewal — with a goal to update and standardize classes throughout the region — could be an enormous challenge.

“We heard it over and over,” says Michael Ryan, M.D., Res. ’89, Chief Res. ’90, associate dean for curriculum. “People told us we couldn’t do this curriculum in the region.” Ryan and his collaborators, including Suzanne Allen and Marjorie Wenrich, MPH, chief of staff for UW Medicine, disagreed.

“We used WWAMI as the reason to do curriculum renewal,” says Ryan. “It’s why we’re successful — because we have so much talent throughout the five-state region. Why not use everyone’s brainpower and energy to build the world’s best curriculum?”

The seed for curriculum renewal was planted during the School’s last national accreditation — a yearlong process of self-study accompanied by a site visit. The accreditation went well, and the School received the maximum accreditation term. At the same time, many medical schools nationwide were starting to respond to rapid advances in medical knowledge, technology and a new understanding regarding the value of active, integrated, lifelong learning.

“Medicine is changing rapidly, and we need to be prepared to change with it,” says Paul G. Ramsey, M.D., CEO, UW Medicine, and dean of the UW School of Medicine. After the accreditation was completed, he brought key leaders together to consider employing continuous curriculum improvement and assessment, rather than the usual pattern of examining a curriculum every 15 or 20 years.

The idea resonated with Allen, Ryan and other leaders, who initiated a curriculum renewal process focused on continuous improvement. Starting in 2010 — 100 years after the Flexner report — they met with people throughout the region, listening to and speaking with students, teachers and staff about curriculum successes and potential improvements. Paramount throughout their deliberations was the UW School of Medicine’s goal: educating doctors from the region for the region.

“I couldn’t be more pleased with the results,” says Ramsey. “Having the region come together to embrace a new idea so readily — one designed to produce even better, more adaptable doctors — is a new high in our WWAMI collaboration.”

A flip to lifelong learning

Although the fast pace of 21st-century medical research and technology is a wonderful development, it presents some educational challenges. How can medical students learn all there is to know about medicine?

“There’s no way for a modern medical student to know everything,” says Tanya Leinicke, M.D., associate director for the Foundations of Clinical Medicine and College faculty at Alaska WWAMI. “What they really need to learn is how to learn and how to integrate information.”

Marcella Pascualy, M.D., Res. ’88, and R. Lane Brown, Ph.D., participate at a planning meeting for the new curriculum in January 2015.
Photo: Robert Steiner, Ph.D., Res. (obstetrics and gynecology)

In other words: don’t teach students hundreds of facts. Instead, teach them how to learn and reflect, how to be critical, how to prepare. And how to be nimble, thorough and careful.

This concept has led to two primary changes in the WWAMI learning environment. First, students are being ushered into a “flipped” classroom: fewer lectures, more preparatory work outside of class, and considerable in-class, case-based discussions.

“When they come to class, they’re being asked to do what they’re going to do as physicians for the rest of their careers — be on their toes and prepared to analyze,” says Ryan. “And, when needed, to look up information and consult others about things they don’t know.”

The second change is a massive, thoughtful integration of classes and topics. The first two years of medical school used to contain more than 30 basic science classes. Now there are seven, covered in 18 months. The students aren’t learning less; rather, their classes have become broader and more interdisciplinary. (See Invaders and Defenders.)

As Ryan says, “We wanted our curriculum to match what actually happens. Diseases don’t follow a course description, and patients rarely show up with a single problem.”

This different way of teaching surprised some first-year students, like Thatte, located at the UW School of Medicine Spokane site. She had been a little wary of the first two years of medical school; friends and family had compared the educational process of becoming a doctor to memorizing all the bar codes at the supermarket.

“Our experience has been the polar opposite,” she says. “It’s been much more conceptual. They want us to know things in a way that’s useful and not just about memorization.”

 

 

The long view

The new curriculum started in fall 2015 with the entering class, and while its two main tenets — early exposure to patients and flipped, revitalized classes — may sound fairly straightforward, it has involved an enormous amount of work and collaboration. Across five states, under deadline, at in-person retreats, via Zoom and Skype, and through an untold number of emails and weekly phone conferences. At any given point in time, 25 to 30 people from throughout the region would be talking together — debating approaches, discussing how to train new teachers and analyzing what to change.

You could call it messy and complex. The participants called it collaborative and inclusive.

“There’s a difference between a curriculum being handed to you and a curriculum being developed in conjunction with you, your needs, your site and your available resources,” says Janelle Clauser, M.D., director of the Foundations of Clinical Medicine course in Spokane. “It’s been a super-fun challenge to work on curriculum and change things to make them better.”

The challenges — and rewards — continue. Ryan and the large five-state team are about eight months in, approaching the halfway mark in the 18 months of their students’ “foundation” phase. Many classes and upcoming portions of the curriculum still require work and planning. Administrators and teachers are taking feedback from students and faculty and incorporating it into the curriculum in real time. It’s very much a work in progress. In fact, some of the planners compare it to flying an airplane while it’s being built. That sounds just about right to Ryan.

“This project has been a real gift: partners across five states and teams building together,” says Ryan. “And with everyone’s help, our plane is airborne. Sometimes the flight’s a little bumpy, but we’re definitely flying in the right direction.”

The Foundations of Clinical Medicine
Getting Ready for Patient Care

Joined at the hip. That’s how Margaret Isaac, M.D. ’03, and Karen McDonough, M.D., Res. ’96, Chief Res. ’98, co-directors of the Foundations of Clinical Medicine course describe their relationship. “My kids know her ringtone on my phone,” says Isaac.

Margaret Isaac, M.D. ’03, (left), Karen McDonough, M.D., Res. ’96, Chief Res. ’98 (right), and colleagues across WWAMI are creating tools for first-year students and their teachers.
Photo: Clare McLean

Since summer 2014, the two faculty members have worked nonstop to create a 46-week class for new students at the UW School of Medicine. And they’ve been working with dozens of colleagues across the WWAMI region to do so.

Tanya Leinicke, M.D., associate director for the Foundations of Clinical Medicine and College faculty in Alaska, remembers the conference calls, held every Tuesday, and the open communication and dogged determination required by all the participants. “We’d just slowly attack the agenda and discuss ways to teach each topic,” she says.

Then came additional, in-depth work for Isaac and McDonough, which included preparing multi-media modules for at-home student learning, a crucial part of the flipped classroom. This process included pulling in colleagues with specialties such as cross-cultural medicine and sexual health.

“We’ve put a lot of time into creating robust and rich out-of-class resources because of another curriculum theme…to limit lecture time and keep face-to-face time interactive and active,” says Isaac.

They’ve also spent a great deal of time preparing tools for teachers throughout the WWAMI region so classes would be similarly structured, regardless of site. The tools are reassuring. “You feel a lot more secure walking into a small group with an outline of what you should follow,” McDonough says.

What students are learning

The Foundations of Clinical Medicine course is the successor to a previous class, the Introduction to Clinical Medicine; both Isaac and McDonough had taught parts of it. This new class, though, spans the students’ first, 18-month phase and was created to prepare students for patient interaction right from the start.

Learning the science behind medicine is one thing. Learning how to be a doctor is another. In the foundations class, explains Yvette Haeberle, M.D., the clinical curriculum coordinator at Wyoming WWAMI, the students learn how to do a physical exam, how to interview patients, how to interact with patients, and how to be a professional. The overarching goal, she says, is to really see the patient.

“We want them to consider the patient first as a human being, as a person, and not as a disease, a diagnosis or a problem to be tackled,” says Haeberle.

Getting ready for patient care

Students during immersion, a part of the foundations class. Top: Spokane student Chau Nguyen learns how to obtain vitals with Nanette Smith, M.D. ’78, MPH; bottom left: students learn how to deal with field emergencies at a back-country camp in Soldotna, Alaska; bottom right: Meghan Johnston, M.D. ’11 (left), and Michael Spinelli, M.D, FACP (right), pose with Montana students during an immersion social in Bozeman.
Top photo: Clare McLean. Bottom left photo: Tanya Leinicke, M.D. Bottom right photo: Ashley Siemer.

Learning how to treat a patient with dignity and respect is a skill, and it’s one the students start to hone early in the foundations class. First comes immersion, an intensive, multi-week orientation and clinical skills “boot camp.” During immersion, they learn how to interview patients to obtain a medical history and perform a basic physical exam. After that, the Foundations of Clinical Medicine class, the block courses and the flipped classroom come fully into play. Students study and prepare at home, then come to class for lecture and discussion.

Then comes a core part of the foundations class and of the new curriculum: meeting patients much earlier in the training. “Our students are really having an opportunity to practice communications skills, physical exam skills and clinical reasoning skills very early on,” says McDonough. “We are so much more focused on interactive skills practice than when I was in medical school.”

How does the Foundations of Clinical Medicine class immerse students in patient care? Small groups of students are assigned a faculty member for semi-weekly lessons at the bedsides of hospitalized patients (see the sidebar on the Colleges, below). Students also have a primary-care practicum, a hands-on medical experience in which they work with a community physician in a local facility on alternate weeks.

Dustin Worth, D.O., College head at the University of Idaho, is a big proponent of this innovative learning system. In fact, a description of the hospital tutorial helped the University of Idaho recruit him.

“I could see what a huge potential impact on the students that type of experience could have,” says Worth, “if they had it from the very beginning of medical school.”

Just the beginning

The students are giving the class an enthusiastic thumbs up. “I love the early clinical exposure,” says first-year student Ian Isby, located at the Alaska WWAMI site at the University of Alaska-Anchorage.

Their teachers think the Foundations of Clinical Medicine class is going pretty well, too. Mike Spinelli, M.D., FACP, associate director for Montana WWAMI, has hosted students in his clinic for years. This year is different, in part because first-year students are joining his third-year students for hands-on clinical experiences — and in part because this crop of first-year students, thanks to the new curriculum, already have a knowledge base.

Tanya Leinicke describes what she and her colleagues are seeing in this year’s students. “Their comfort level in the clinical setting is so much better than in the past,” says Leinicke. “They’re more confident, the ideas are starting to jell; the neurons are firing.”

First-year, Spokane-based medical student Ariana Kamaliazad has been enjoying her experiences, too — she recalls one encounter where she was so interested in talking with the patient that she barely had time to do a physical exam.

“That interview reminded me that I chose to go to medical school because of the people I would get to meet and help,” says Kamaliazad. “It felt like the beginning of the rest of my life.”

The First Two Weeks: Immersion

“This was a powerful experience.”
Connor Tice, First-year Student, Montana WWAMI, at Montana State University in Bozeman

First-year students Hao Tong, Miranda Timonen and Peiran Zhou, Ph.D., proudly don their new white coats at the immersion graduation ceremony.
Photo: Clare McLean

“I feel like they kind of blew us out of the water,” says Amanda Kost, M.D., Res. ’08. That’s her assessment of how well first-year students did in immersion, an orientation to medical school that provided an entire course’s worth of instruction on history-taking and the physical exam in two or three short weeks.

Immersion was created as part of the Foundations of Clinical Medicine class; its purpose was to provide students with the basic skills they’d need to interact with patients and doctors during the first 18 months of medical school. And it was an experiment for Kost and Margaret Isaac, the co-directors for the program. “Margaret and I had no idea how this would go,” Kost says.

It went enormously well. In addition to teaching basic clinical skills, each site added a special experience to the two-week period, some promoting class camaraderie, others promoting additional learning. Montana students, for instance, participated in a public health weekend, visiting several reservations to learn about health issues faced by Native Americans. Students in Alaska got hands-on practice in high-performance CPR with the help of the local fire department and learned about nonverbal communication skills from a horse-whisperer.

Wyoming students took a wilderness medicine course — actually hiking into the mountains for several days while learning. “It gave them confidence in being able to present patient cases and organize their thoughts in a logical format,” says Yvette Haeberle.

Immersion, like the rest of the Foundations of Clinical Medicine course, is all about the patients. It’s a focus that shines through for the participants.

“Through my training thus far,” wrote one Seattle-based student, “I understand that no matter how inexperienced I am right now, I already have an obligation to the patients I see and to the community.”

First Time’s the Charm

The UW School of Medicine’s new curriculum is innovative — but what’s it like to be a student going through it for the first time? First-year students Natalie Meadows and Pramod Chavali weigh in on a series of questions. A few other members of the cohort share brief stories, too.

Natalie Meadows
Laramie, Wyo.

What first drew you to medicine?
The scientific foundation inspired me first, but my desire for a unique human connection is what truly ignited my ambition to become a medical doctor. I want to provide a service to people they can’t provide for themselves — be it medical advice and treatments or encouragement and compassion. To me, being a doctor is all about providing empathy and hope.

Is the new curriculum helping you fuel that ambition?
From day one in our primary-care preceptorships, we were told to “just go talk” with our patients — get to know them as people first and symptoms second. It’s easy to think of our patients as puzzles, especially when we are constantly trying to integrate piles of information. But the new curriculum places a high value on learning how to communicate with patients as human beings.

I want to address the specific healthcare needs of Latino patients, and I was pleased to see a module on cross-cultural medicine and working with interpreters so early in the program.

Do the clinical experiences complement the classroom experiences?
What really gets me excited are the moments in the clinic when I’ve been able to synthesize even a tiny bit of information from class and apply it to a patient’s case.

Just last week, my primary-care preceptor asked why I thought a patient was still in the hospital, despite showing significant improvement. I looked over the patient’s chart and — reaching into the recesses of my novice mental pharmacology library — noted she had recently started taking an arrhythmia medication. I thought she was probably in the hospital so we could watch for complications. My reasoning wasn’t too far off, and we discussed other aspects of the patient’s care best carried out in a hospital setting.

I didn’t make any medical decisions that day, and I didn’t save any lives, but I felt like I was starting to contribute to the care of an individual patient. Bit by bit, moments like these make me feel like I’m actually becoming a doctor.

What has been your best experience thus far?
During immersion, my class had the opportunity to complete the 10-day Wilderness First Responders course through the National Outdoor Leadership School (NOLS). One of our final scenarios involved a fictitious landslide that injured six people. We had to treat the injured to the best of our abilities and get them to safety.

This was an opportunity to apply our medical skills and test our critical thinking and problem-solving abilities. It helped us realize that, although it seems like there’s an insurmountable amount of material to learn, we can and will continue to apply the knowledge we acquire to save and improve lives. Plus, it was awesome to see how we all worked together to address an enormous problem.

Do you like the emphasis on team-based learning?
My class works very well together. We take turns being students and teachers to one another.

I also feel a responsibility to be as prepared as I can be for each class so I can contribute to our discussions and the problems we work through in groups. It motivates me and encourages me. And I think that providing the best care for patients involves relying on a network of people with a variety of skills and experience. Working with my peers has solidified my desire to foster a collaborative work environment in the future.

What’s your dream job?
I want to cultivate a strong and longitudinal relationship with my patients. I want to be a presence in my community as a political advocate or a vocal promoter of healthy lifestyle choices. And I want to appreciate the incredible opportunity it is to be a physician and connect with humanity on such an intimate level. As far as where I practice and the specialty I choose — those details will work themselves out in time.

Pramod Chavali
Spokane, Wash.

What excites you about the new curriculum?
The careers that interested me fell in two categories: working on problems and working with people. My undergraduate degree in biomedical engineering focused on solving problems, but I wanted more. Which is why I chose medicine. The technical and social faces of medical practice aren’t separate from each other — they’re intimately intertwined.

The curriculum addressed this dichotomy from the start. The first thing I learned about, right on day one of immersion, was the patient interview — both a technical tool for gathering vital information and a powerful social tool for engaging with patients. The curriculum continues this theme throughout our Foundations of Clinical Medicine workshops, which focus on how to apply technical skills within the context of patient interaction.

What’s a day in class like?
We typically spend four hours in the classroom each day, and that’s divided into one- or two-hour blocks. With the flipped classroom model, we study material on a particular topic, like chest pain or a chronic cough, and then come to class to answer problems in small groups and practice simulations with fake patients (often our clinical mentors).

We have “hospital mornings” on Tuesday or Thursday, where we work with a physician mentor to perform a full interview and physical with a patient. And I spend every other Wednesday in a local clinic working one-on-one with a physician mentor.

The best part about the curriculum is the variety we get every day — it keeps things fresh.

Is the flipped classroom model working for you?
I’ll admit that a part of me was a little worried. The material is challenging, and it can be overwhelming to tackle most of the initial learning on our own without a lecture. But the payoff is worth it. The flipped classroom model helps us learn through self-study — which is how we’ll learn for the rest of our lives as professionals.

Combining classroom work with the Foundations of Clinical Medicine helps me internalize concepts more effectively, too.

Could you describe a memorable moment?
The most memorable so far was a workshop on working with patients suffering from drug addictions. We listened to members of the community speak about their experiences struggling with addiction and gained real insight into its effect on individual and public health. Hearing their stories was an incredible opportunity and a precious gift.

The foundation of all our work so far has been the notion that throughout our engagement with patients, we as physicians should be guided by humility and curiosity — two words that affected our class so profoundly that we included them in the oath we took when we entered medical school.

What keeps you motivated each week?
Problem-based learning is ideal for me, and while the actual process of reading and reviewing may not be all that engaging, it’s satisfying to apply my knowledge in clinical scenarios or physiological puzzles. Like in our first block — we had a practice case involving an anemic patient and malaria medication. The case involved some subtle and surprising connections to different metabolic and physiologic concepts, and it was fascinating to struggle and untangle them.

Where do you want to go after medical school?
Since my undergraduate work in bioengineering, I’ve had strong academic interests, and I don’t want to give that up or let my research training go to waste. I like variety and unpredictability, so my ideal job might be a faculty position at the medical sciences department of a large research university — like the UW — working as a hospitalist while also teaching and doing research.

Invaders and Defenders
Mixing Disciplines in the New Curriculum

For more than 20 years, medical students enrolled in the same microbiology and immunology courses at the UW School of Medicine. But all that changed in fall 2015. Enter Invaders and Defenders, one of seven interdisciplinary basic science blocks included in the first phase of the new curriculum.

Meena Ramchandani, M.D. (right), was one of the WWAMI faculty members who helped John Lynch, M.D. ’02, Fel. ’07, MPH (left), put together the
Invaders and Defenders block.
Photo: Clare McLean

“It’s a fundamentally different approach to learning in the medical-school curriculum,” says Invaders and Defenders block co-leader John Lynch, M.D. ’02, Fel. ’07, MPH, UW associate professor of medicine in the Division of Allergy and Infectious Diseases.

Like all of the new blocks, Invaders and Defenders takes an integrative approach, covering traditional microbiology material as well as the immune system, infectious diseases, inflammation and repair, skin and connective tissue, anatomy, histology and pharmacology.

“Threaded throughout are important, complementary topics like ethics, health equity, diversity and global health,” says Lynch. The classroom is also a lot more interactive — flipping traditional notions around teaching and learning.

Creating the classroom conversation

“We know that people don’t do well sitting and listening for very long. They zone out if they don’t see the value of being present,” says Lynch. This is one reason the blocks moved away from traditional lectures toward the flipped classroom, where in-class time focuses on more interactive activities that require higher-level processing.

What does this look like in Invaders and Defenders? “Students might learn about certain rheumatologic diseases based on immunology they’ve studied,” says Lynch. “Then, within two days, they may be in the lab looking at human knees and imaging associated with those same diseases.”

Kristen Hayward, M.D., Res. ’04, Fel. ’09, M.S. ’09, UW assistant professor of pediatrics and director of quality improvement for rheumatology at Seattle Children’s, learned about flipping the classroom through the University of Washington School of Medicine’s Teaching Scholars Program, a one-year professional development program for health educators. “Students learn better when they’re asked to interact with information in some way that’s meaningful and relevant,” says Hayward. She is incorporating rheumatology materials she’s developing into Invaders and Defenders.

And students aren’t the only ones learning. Physicians, clinicians and researchers are teaching in tandem and learning to work together to lead discussions.

“The key thing for instructors is not to just launch into the answer,” says Lynch. “Rather, it’s about facilitating conversations between individual students or student groups so that when one person understands it, they can then teach it to the person next to them.”

WWAMI-wide ownership

This level of systemic change in teaching is taking place throughout the WWAMI region. That’s where Invaders and Defenders teacher Cindy Knall, Ph.D., associate professor of medical education at the University of Alaska Anchorage and UW affiliate associate professor of immunology, comes in.

Knall has been meeting regularly with block leaders from each of the WWAMI sites since January 2015. Together, they’ve been figuring out how to make in-class activities, case studies and out-of-class resources as consistent as possible throughout the five-state region.

“It’s been a pretty intense process for everyone involved,” says Knall. And an inclusive one.

“Dr. Lynch really appreciates that we’re one medical school; we’re equal partners,” says Knall. “We did a good job distributing the workload and the sense of ownership.”

Dynamic teaching for a dynamic curriculum

Knall has also noticed a sense of ownership forming among junior faculty across the region. “Historically, faculty would inherit the old curriculum, which was pretty much set in stone,” she says. “But now, new faculty have the chance to get involved at the development stage.”

It was this chance to shape the future of medical education that attracted Meena Ramchandani, M.D., UW acting instructor of medicine in the Division of Allergy and Infectious Diseases. Specifically, she was drawn to the interactive problem-solving required when applying scientific knowledge to patient cases.

For example, in the HIV module, students learn about the virus, host-pathogen interactions and the mechanisms of disease. Students are then introduced to the diagnosis and management of an HIV patient, including starting anti-retroviral medications, thinking about opportunistic infections and understanding recent advances in the literature.

“Students are learning how to be a physician from the beginning,” Ramchandani says. And, like Michael Ryan, she thinks the fact that the curriculum is a work in progress is a positive thing. “The teaching is dynamic, since medicine changes constantly. That’s one of its advantages,” she says.

Working with the Robert Wood Johnson Foundation

You could argue that the School’s curriculum renewal is a huge and beneficial experiment, one conducted over a five-state region. As it turns out, the Invaders and Defenders block is part of an even larger experiment, the Reimagining Medical Education Initiative.

The initiative is being conducted in five medical schools nationwide by the Robert Wood Johnson Foundation — an organization dedicated to understanding and addressing the biggest health challenges in the U.S. — and the Stanford University School of Medicine. The initiative’s aim is to integrate microbiology and immunology through a flipped-classroom approach.

Working closely with Paul Pottinger, M.D., Fel. ’05, UW associate professor of medicine in the Division of Allergy and Infectious Diseases, Sherilyn Smith, M.D., Fel. ’97, UW professor in the Department of Pediatrics, and Troy Torgerson, M.D., Res. ’01, Ph.D., UW associate professor in the Department of Pediatrics and Seattle Children’s Research Institute investigator, Lynch became involved in the initiative during summer 2014. He helped develop the vision and flipped-classroom materials, including a video series for students to watch outside of class.

“The material developed through this initiative is being implemented, often for the first time, in Invaders and Defenders,” he says. But he’s quick to point out that the UW School of Medicine is venturing even further by transitioning its entire curriculum at once, across five states and six sites.

“It’s a steep learning curve,” he says.

Addressing what’s important

Lynch’s favorite metric for gauging success in the Invaders and Defenders block is the number of students who ask to shadow him and other teachers in clinic. That number is increasing. “Students really liked learning about an infectious disease or immunological concept and immediately putting it into a clinical context,” he says.

Lynch also muses on the fast pace of the classroom, and the way learning and teaching have to keep up with the changes in medicine.

The best way to keep up seems to be addressing what’s important. Teaching students how to work on teams, how to be self-directed and how to think critically. “It’s a lofty goal,” says Lynch — and a worthy one.

More Than a Labor of Love
Reaping the Rewards of Teaching

Why is healthcare so expensive? What makes some people healthier than others? Why do some patients have difficulty accessing care? These questions don’t have simple answers, yet in their complexity lies one of the rewards of teaching. Getting to know the students who ask these questions is another reward.

First-year student Laurie Bazan (left), and her preceptor, Sonja Olson, M.D. ’05, touch base with patient Gail Giles at the Country Doctor Clinic in Seattle.
Photo: Clare McLean

“Interacting with curious students is a big perk,” says Laura Goodell, M.D. ’07, a family physician in Montana and a UW clinical instructor in the Department of Family Medicine. “They ask great questions that require you to think about the standard of care and how to solve problems in new ways.”

In the classroom, Goodell helps students apply basic sciences to clinical medicine, focusing on critical thinking and teamwork. They use these skills in their primary-care practicums: a full day, every other week, spent in a primary-care clinic with a physician-mentor.

Like Goodell, Zach Meyers, M.D., Fel. ’10, primary-care practicum director in Bozeman, Mont., enjoys the excitement of teaching eager students in his clinic — in part because he gets to witness their “lightbulb” moments. For example, when one of Meyers’ patients was hospitalized for tachyarrhythmia, Meyers shared the patient’s EKGs with his practicum student.

“His eyes lit up because he had just learned about arrhythmias and how to read an EKG in class,” says Meyers. “It was fun to be able to interpret the EKGs together and have a real patient to associate with the learning.”

Montana WWAMI faculty member Laura Goodell, M.D. ’07, leads her small group through a clinical case during the Circulatory Systems block.
Photo: Ashley Siemer

In introducing students to patients in clinical settings, the primary-care practicum is enormously beneficial to their development as doctors. However, recruiting faculty is an ongoing challenge. Jeanne Cawse-Lucas, M.D., assistant professor in the Department of Family Medicine and director of the primary-care practicum, must find more than 100 primary-care practicum spots for Seattle-based students alone each year — and leaders at each WWAMI training site must find spots for their students as well. Physicians who sign up are committing to many hours of teaching and mentoring. It’s a significant commitment — some might say a labor of love.

This labor can also provide additional value for physicians. Because of the new Foundations of Clinical Medicine class, students start their primary-care practicums knowing basic skills, such as how to take a history and conduct an interview. They can help with tasks physicians feel they may not have enough time for in the average visit.

“On a busy day, I can send my primary-care practicum student in ahead of me to take a patient’s history, do agenda-setting or even work on motivational interviews for things like smoking cessation,” says Meyers. “It’s nice having someone who can hit the ground running because of immersion and the Foundations of Clinical Medicine.”

The primary-care practicum, however, isn’t the only place where students are meeting patients. They also participate in a part of the Foundations of Clinical Medicine course called College tutorials, where they team up with their College physician-mentor to spend half-days at a hospital.

“In this setting, patients really become the teachers,” says Jeff Seegmiller, Ed.D., Idaho Foundations Phase assistant dean and director of the Idaho WWAMI Medical Education Program. “Patients have the opportunity to open up about things like how difficult it is to be in pain, how they are struggling with medical costs, and how important it is for doctors to offer comfort. This helps them feel like they’re receiving amazing care.”

Such good care, in fact, that one hospital site reported higher rates of patient satisfaction since the College program was introduced. Back in the classroom, teachers like Goodell witness the fruits of these clinical experiences in her students — high morale, empathy and curiosity.

“The students are enthused about the new curriculum, especially the opportunity to put a face to the disease process,” says Goodell.

Setting the Stage
The Colleges

Before the new curriculum, there were the Colleges. Big Sky, Cascade, Columbia River, Denali, Olympic, Palouse, Rainier, Snake River and Wind River. And just as the names evoke a sense of place, the Colleges — founded in 2001 — were intended to give students a sense of place: a cohort of fellow students to interact with, and a mentor. This mentor would take them on hospital rounds during their second year and give them firsthand training on history-taking, physical exams, oral case presentations and write-ups.

The creation of the Colleges, in other words, was a precursor to the new curriculum. Both programs aim to ensure students get clinical exposure early on in medical school. Both programs emphasize treating a patient as a whole person. And both programs focus on professional growth.

“The Colleges have definitely met expectations, and I think most people agree that they’ve exceeded them,” says Erika Goldstein, M.D., Res. ’84, MPH. Goldstein is the associate dean of the Colleges and founding director of the Colleges program. With the new curriculum, however, came new expectations. In the old curriculum, all students came to Seattle for their second year, and the College mentors were based in Seattle. Now, there are College faculty throughout the WWAMI region: one mentor for every five students, a good ratio for mentorship, and a good ratio for giving students in-hospital tutorials every other week.

Now that the Foundations of Clinical Medicine and the Colleges program have combined forces, few schools can claim such extensive clinical preparation, one so well-integrated with the basic science curriculum. Since their integration, students receive a broader set of clinical training experiences, starting day one of medical school and continuing weekly through the first 18 months.

“Students love their clinical skills, and they love their hospital morning experiences because they tie students to the reason they went to medical school,” says Dustin Worth, D.O., College head at the University of Idaho.

Goldstein and her colleagues now have a new challenge: how to maintain a sense of community among College faculty over five states. But there’s no doubt about Goldstein’s positive take on the new curriculum. “There’s a lot more conversation across the region, a lot more uniformity in the curriculum,” she says. “And we benefit from these really excellent educators throughout the region.”

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