Pioneers in Physician Training

I

t was while her grandmother was being treated in the spinal clinic at UM/Jackson Memorial Hospital that Orly Morgan decided she wanted to become a doctor. The depth and quality of care her grandmother received for what was a complicated diagnosis, and the respect she was shown as a retired nurse, helped draw Morgan to the University of Miami Miller School of Medicine.

“The extent to which it felt like a community coming together to treat my grandmother really inspired me,” she said.

She is only a first-year student, but thanks to the Miller School’s new NextGenMD curriculum, Morgan and her classmates already have a lot of experience considering and solving patient cases like her grandmother’s — even in the midst of a global pandemic.

“We have a lecture in the morning and then immediately hop into a small group with a clinical vignette based on that lecture,” she said. “We apply it right now. I feel like it gives you the opportunity to get things wrong, which is really important.”

Latha Chandran, M.D., M.P.H., executive dean and founding chair of the Department of Medical Education, says that is an essential part of the Miller School’s new symptom-based approach.

“Patients come to us as an integrated whole,” she said. “How do you think in an integrated manner with the patient in front of you? What are the different conditions you have to think about? I think it allows the students to have a big-picture holistic understanding of the human condition.”

As the medical education team gears up for the launch of Phase 2 of the new curriculum, sending the students into an expanded network of clinical sites throughout the community, they are also busy tweaking Phase 1 based on extensive feedback from students and the lessons learned throughout this challenging academic year. There is widespread agreement that the early emphasis on clinical skills is already benefiting the future doctors — and will definitely benefit their fortunate future patients.

“The approach of NextGen is going to be really helpful as far as our preparation for clinical careers,” said Haley Barefoot, a member of the Class of 2024. “We have interactive sessions over Zoom that are very case-based, not just learning in theory what is happening. If the patient has these symptoms, what might be going on? What labs would you order next to confirm or rule out your current diagnosis?

“It’s getting us ready to get to the hospital.”

Students and faculty are calling this approach “University of Miami Collaborative Learning” (UMCL). “They get together and discuss a specific case,” Dr. Chandran said. “It’s good because they don’t have the answers — it’s struggling with the question and having peer discussions safely that facilitates learning.” Students challenge themselves in the small groups, and content experts come back and help them close the loop.

Barefoot and her classmate Sarah Jacobs serve as curriculum representatives, meeting with the faculty and giving feedback on how things are going. That communication is much more frequent than in the past, and has allowed constant improvements, which the students greatly appreciate.

“You feel really heard — the faculty really want your feedback,” Morgan said. “There are lots of focus groups, small groups to give feedback. For example, we said the test schedule was really stressful, so they changed it. We can now take our test on each week’s case from Friday to Monday.”

“I feel validated — my school heard me, and they cared.”

The constant communication is more critical than ever since a great deal of in-person learning had to be redesigned because of the COVID-19 pandemic. “It would be hard to conceive of a more trying time to launch this new curriculum,” said Amar R. Deshpande, M.D., associate dean for medical education and administration. “It was based on principles that involve working closely together in small groups — and all of a sudden we had to figure out how to do it virtually.

“It was a big challenge in a short time frame under difficult conditions, but our team was committed to making it work.”

Dr. Chandran agrees. “Have we succeeded? I think we are on our way,” she said. “I am very proud of the team, which has done a remarkable job. The resilience of this team has been incredible.

“The other piece that I have emphasized is the continuous learning. The students are partners in this journey. The things that work, we keep doing more, and the things that didn’t work we are changing.”

The curriculum representatives say the commitment to taking action based on student feedback is welcomed throughout the first NextGenMD class, and they know it will make a difference for the classes to come. “We’re leaving it better for the next generation,” Jacobs said.

Feedback is an early and constant theme for the hands-on patient experience as well, said Gauri Agarwal, M.D., associate dean for curriculum. Using objective structured clinical examinations, or OSCEs, students conduct a history or perform a procedure with a standardized patient or simulator and receive feedback on strengths and weaknesses. Several OSCEs have been established within the clinical clerkships.

“Our Gordon Center and our standardized patient program have gone into hyper drive to expand this,” Dr. Agarwal said. “At the time of graduation, what are the tasks we want to make sure every student is capable of doing, regardless of specialty choice? Our faculty have made those determinations using national guidelines. We need to ensure all students are capable of performing these skills, and at the expected level.”

A one-week transition to clerkship course will be conducted in June for the legacy third-year students, who will also be participating in Phase 2 of the new curriculum. Current first-year students will take the course in September, with an emphasis on practical skills for moving from the classroom to a clinical environment.

“Faculty will talk to the students about making sure they understand the expectations of the team, how to navigate different situations, how to handle tough questions from the attending physician, and what ethical situations might arise,” Dr. Agarwal said. “How do they maintain their resilience and empathy as they go through their training?”

Integrating foundational science clerkships with clinical science has also been a top priority. “For example, how can anatomy fit best with surgery? Or genetics with pediatrics?” Dr. Agarwal asked. “It’s exciting to me because that’s how students learn best — while they’re taking care of patients.”

Morgan has loved the Medicine as a Profession class, which has involved, among other things, learning clinical skills with standardized patients and talking to patients on Zoom about their experience. In the Zoom sessions, some patients with sickle cell anemia expressed concerns about receiving adequate pain management, which prompted Morgan to make a promise to herself that she would never undervalue a patient’s pain.

Direct observation of students’ clinical skills will be a central element of Phase 2. The Miller School has long conducted residency preparation boot camps with fourth-year students who are about to graduate, but the new curriculum will have more boot camps, and they will begin earlier. “Running our prior boot camps was a great way of evaluating the curriculum,” Dr. Agarwal said. “You can see the gaps; you can see where in the curriculum you need to emphasize different skills in order to have students prepared for residency training.”

New software has also helped enhance student skills. Full Code software by Minerva presents specific emergency cases and immediately involves students in stabilizing the patient, taking a patient history, and initiating management of the case. “We have received a lot of great feedback about Full Code from students in emergency medicine,” Dr. Agarwal said.

Scholar Rx, another software tool, is “a way to keep students’ minds on all the foundational science content,” she said. Shortening Phase 1 to begin clinical experiences earlier has presented a challenge to the curriculum, and Scholar Rx helps students continue to focus on science in the clerkship phase.

In NextGenMD every student has a second degree or a scholarly concentration; the M.D./M.P.H. program is especially popular and has an exceptional reputation. “Having a foundation in public health makes you better understand the barriers that certain populations are facing,” Barefoot said. “I want to have a community focus — social determinants of health have such an impact on our health outcomes.”

Morgan is an admissions ambassador for the M.D./M.P.H. program because she too is passionate about public health. “I’m very thankful that this program exists and excited and happy that I’m doing it,” she said.

The community focus will expand as the students’ clinical experience moves to several different places next year, including federally qualified health centers and hospital districts throughout South Florida.

Students and faculty alike are enthusiastic about the value of the increased emphasis on mentoring throughout the NextGenMD curriculum. Longitudinal clinical educators meet regularly with a group of eight students, forming a relationship and helping each student navigate issues that may come up. These longitudinal educators will continue to work with students across all phases of their education.

“You can talk about any topic with this valuable resource who has been through it,” Morgan said. Each student is also working with a capstone adviser to develop a research project.

The mentorship is an essential piece of NextGenMD, Dr. Chandran said.

“In the end the students figure out how to learn, how to problem solve, how to work with other members of the team and how to reflect on their own growth because learning, we believe, is a lifelong process.”

UNIVERSITY OF MIAMI MEDICINE

SPRING 2021