JAMA Article Furthers Rochester as National Medical School Model

Pioneering Approach Will Create More Competent, Caring Doctors

January 08, 2002

How do you know your doctor is fully competent? The short answer, under traditional medical-school models, is you don't. But a truly innovative approach at the University of Rochester School of Medicine and Dentistry is establishing new ways of training physicians and assessing their competence, to instill in physicians the kinds of qualities patients want: trustworthiness, good judgment, good communication, and the ability to keep up-to-date with changes in the field.

Affirmation of the Rochester approach comes on Jan. 9, when the Journal of the American Medical Association publishes "Defining and Assessing Professional Competence," with an endorsing editorial written by the executive director of the Accreditation Council for Graduate Medical Education. The paper reconsiders the very definition of what makes a good doctor. It proposes 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).

The ACGME's endorsement means that Rochester's new definition of competence is likely to be widely discussed at federal agencies, medical schools, and licensing boards interested in reducing medical errors and improving the quality of care.

The principal author, Ronald M. Epstein, M.D., a practicing physician in the Department of Family Medicine, has spent his career researching and teaching about the patient-physician relationship. Co-author Edward M. Hundert, M.D., dean of the School of Medicine and Dentistry, is the architect of Rochester's innovative Double-Helix curriculum, which uses the approach endorsed in the JAMA article. In other words, these ideas are not just theoretical but already in place at the University of Rochester.

At Rochester, 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.

Another endorsement came from the Department of Education's Foundation for the Improvement of Post-Secondary Education (FIPSE). FIPSE rarely gives 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.

In 2001, when the Liaison Committee on Medical Education came to Rochester for its accreditation inspection, the leading educators who made up the team said they found "no areas of concern-an unprecedented finding in American medical education." The team 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. "After all, for patients, it's not enough to know that their doctor scored well on a multiple-choice test." And as the JAMA article highlights, standardized test scores can be inversely correlated with empathy, responsibility, and tolerance in physicians.

The new approaches at Rochester, which are discussed in the JAMA paper, started with 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 Hundert 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.

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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