Tiffany Hanssen: This is All Of It. I'm Tiffany Hanssen in for Alison Stewart today. Well, in our previous segment, we were talking with a doctor about her medical training, and now we're going to turn our attention to a new medical school curriculum from an institution on Long Island that aims to raise the next generation of doctors to be competent, compassionate and collaborative. Dr. David Elkowitz is the Associate Dean for Academic Programs and Educational Culture at the Zucker School of Medicine at Hofstra/Northwell. He's also the Director of the Academy of Medical Educators, and he joins us now to talk about the Zucker School's innovative approaches to medical school. Welcome, doctor.

Dr. David Elkowitz: Hi. How are you?

Tiffany Hanssen: Doing great. Thank you. All right. In that last conversation we talked about see one, do one, teach one. It's a common expression as we learned. I'm wondering how Zucker's curriculum stays true, if it does, to that three-tiered approach.

Dr. David Elkowitz: Oh, 100%. We have very small group classrooms here, a very, very small class size. Our students, right from day 1, not only learn medical education, they are exposed to patients, but they actually go through almost a teaching fellowship. From day 1, they start teaching each other about things they learned the night before, things that happen in the classroom. As we have a discussion over the next few minutes, you'll start seeing how this concept of not only learning but teaching is woven through our entire four-year medical education program.

Tiffany Hanssen: We talk about this as a new approach. I'm curious what was lacking in the older approach, the more "traditional" approach to medical education that you think needed a little bit of tweaking?

Dr. David Elkowitz: First of all, I came through that old medical type of approach, more of a traditional type of approach where you sit in a classroom for eight hours a day and you have a professor or a sage on the stage, so to speak, that's essentially delivering information to learners just passively sitting there in the classroom trying to collect all this information in order for them to learn it or at least be introduced to it.

Here at our school, we're a student-centered curriculum, a very active curriculum where our students essentially develop learning objectives and learn the material in part on their own and then come into the classroom here and apply it with professors, patients, right from day 1. It's a very active approach. Students, when they come here to our school, not only learning and applying medical information in real-time with patients as certified EMTs, right from day 1, but they're also teaching each other as well.

Why this shift? Technology over the years has changed. When I went to medical school, in order for me to stay on the floors during my clinical years and stay with the team, I would absolutely have to know a lot of information, memorize a lot of information, and have it at my disposal in order for me to stay with the team so I wouldn't have to go down to the library and look up information I should know.

These days, all of us are walking around with cell phones and we all have the medical information at our disposal, at our fingertips. Really, when we're on the floors with patients and doctors, we need a different skill set. How do we apply? We can get the facts very quickly, obviously, but first of all, where do we get the facts from? Scrutinizing sources is something that we teach our students right from day 1, how to go about doing that, how to apply that information, those facts that we have at our fingertips, to the patient right in front of us. That's very, very important. Technology has really guided medical education from a passive approach to much more of an active approach.

Tiffany Hanssen: Specifically, when we're talking about technology, what are some pieces of technology that have really made it so that parts of that older style of education are just no longer useful? In fact, is there a specific thing? I know we talked in our previous segment about, we used to see on TV doctors carrying around clipboards. Now everything is a medical record on the computer when you walk in. A concrete example like that of another way maybe, that a patient might see technology changing the way doctors are interacting.

Dr. David Elkowitz: Oh, as you were asking that question, I had a big smile on my face because when I was a resident and fellow and even new attending as a pathologist, I would have my pockets stuffed with notes, cheat sheets, review books, and all sorts of sources just so I have that fact at my fingertips. Patients would absolutely see that, our reliance on that information.

Now in these days, whether it's all the interventions that are obviously electronic and technology forward, but certainly the facts that on our cell phones we have at our fingertips that are evidence-based and the sources are good, we can get that information quicker and much more reliably in front of the patient. Now what do we expect out of our students? Our students have that. We don't have to memorize all this stuff that we had to do 20, 30 years ago. How do we apply those facts to have better patient outcomes in real-time. The patients absolutely see that and their visits are more efficient. Maybe the technology is helping, if used in the right way, for much better outcomes.

Tiffany Hanssen: I'm wondering though, for example, if you are speaking with a physician about a particular ailment and you say, "My ankle hurts when I do this, doctor," how is it for the patient experience when the doctor then just immediately looks at their phone or looks at the computer versus the old days when Dr. Elkowitz would just rattle it off the top of his head?

Dr. David Elkowitz: At the end of the day, the way a patient looks at their physician, it's not just where they're getting the information from, whether it's a phone or whether it's from a review book or maybe they have to excuse themselves and go down to the library. At the end of the day, a patient's confidence is going to be predicated on, first, the rapport that the physician builds with that patient, the communication. Is that patient being listened to? How transparent is that doctor? Is that doctor becoming a partner with that patient to figure out the information that they need to be treated appropriately?

At the end of the day, that's really the secret sauce. Listen, I have a personal experience. Right now, I'm a stage 4 cancer patient being treated. Walked into one of my visits and asked the question of my doctor and she didn't know the answer, but she goes, "You know what, let me grab my computer and let's figure this out together." Just rolled her chair around with me sitting on the table with my robe on, and we figured it out together.

The technology is important and it certainly facilitated change in medical education, but the reality is that a patient is only going to look at their physician with trust if they know that they're being listened to, if the physician built rapport and if the physician is knowledgeable and it's evidence-based.

Tiffany Hanssen: First of all, best of luck with your recovery.

Dr. David Elkowitz: Oh, everything is going well. Thank you.

Tiffany Hanssen: Okay, great. Second, let's talk about this memorization a little bit, just from the perspective of teaching, because I know you say that we've taken some of that off the table for medical students. They are not required to memorize as much or keep as much in their-- rolling around in their pockets on little pieces of paper that they can't keep memorized. If they're not doing that, how are you, as an educator, assessing the their knowledge?

Dr. David Elkowitz: That's a great question because I'm faced with having to give evaluations to medical students all the time. It appears to be a conundrum, but it's really not. Many times we'll actually give the facts on an examination, "Listen, I'm telling you that these are the facts," but we'll ask a question in a way that they would have to take those facts and apply it to solve a problem.

What we're really assessing is critical thinking and problem solving with a set of facts that they already are given. We flip it around and when they take boards, that's essentially what boards are testing now. Back in my day, boards were very fact-based. "Do you know this, or do you not know this?" Today, yes, medical information, they have to know a certain amount of medical information, certainly, but a big part of what they're being tested on is for them to be able to answer a kind of a higher order question, to test their critical thinking and problem solving.

Very, very often we'll give them the facts and we are actually testing not only how they problem-solve, how they're going to critically think, but also their communication skills, how they're going to talk with the patient, how they're going to explain these tough concepts in a way that a patient is going to be able to understand. That's how we go about testing here. To that end, we have a lot of essays, we have oral examinations, which is a very, very unique thing in medical education, especially on the medical school, the UME education.

Tiffany Hanssen: We talked about the technological changes and how that necessitated this change in the way we view medical training in med school, in residency. I'm wondering how much societal changes are also pushing the need for change here because we can imagine a day in the past when the doctor, usually a man, was really-- his advice, his knowledge was taken as gospel. You do what this person says, you believe everything this person says, and he's going to hand it down to you as an edict and you'd better do it, otherwise tough luck.

Obviously that's not the case anymore, and that's not what people expect anymore. That's not what people have become used to or are demanding. How much of what we see in the changes from medical school are precipitated by that change in the culture around physicians, people who are becoming physicians the way we are expecting them to behave?

Dr. David Elkowitz: It's important that physicians certainly have the heart, the spirit, that when they see a patient, that it's a partnership. I think that's first and foremost. Developing a relationship with that patient built on trust and rapport, that's very, very important.

The second thing is that, as you know, half of our class, half of the medical school class, just in general across the country are men and women. That's a seismic change from 40, 50 years ago as well. Again, what makes, I think Hofstra, the Zucker School of Medicine, unique is that these elements that we're talking about are embedded right in the curriculum from day 1. Our students are very, very sensitive to this whole idea that the patient is part of the team. Certainly the patient and the physician have to work together in order to have great outcomes. Trust has to be built.

Even as a pathologist, I read a lot of slides, look at a lot of images. Our students have to understand that behind every slide, behind every blood test, behind every image, there's a human being, there's a patient that's worried, there's a family that's worried. I think that society expects physicians to be able to function with patients and families in that way very, very differently than 40, 50 years ago where essentially, like you described, just going to do what I'm told and that's the way it's going to be.

Tiffany Hanssen: Tough luck.

Dr. David Elkowitz: That's right.

Tiffany Hanssen: Listeners, we're talking with Dr. David Elkowitz, who's the Associate Dean for Academic Programs and Educational Culture at the Zucker School of Medicine at Hofstra/Northwell. He's also the Director of the Academy of Medical Educators. We are talking about new medical school curriculum and what that looks like going forward. Do you have questions about how doctors are trained? Are you curious about how doctors talk about risk or death? Where do you think doctors could use more training? You can call us, you can text us at 212-433-9692. Dr. Elkowitz will continue here with the conversation in just a minute. We're going to take a quick break. This is All Of It. I'm Tiffany Hanssen in for Alison Stewart. Stay with us.

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Tiffany Hanssen: This is All Of It. I'm Tiffany Hanssen in for Alison Stewart. We're talking with Dr. David Elkowitz, the Associate Dean for Academic Programs and Educational Culture at the Zucker School of Medicine at Hofstra/Northwell. Dr. Elkowitz, we're going to just go ahead and dive in here with one of our callers and bring Dr. Sherman into the conversation. Good afternoon.

Dr. Sherman: Hi, good afternoon. Dr. Elkowitz, I'm an 80-year-old retired geriatrician, actually, and about 15 years ago, I wrote an editorial called See One, Do One, Have One, Teach One, as I was experiencing the onset of acute and chronic illnesses late in life. That actually gave me new understanding and new empathy for teaching medical students about the subtleties of procedures, the unspoken issues that occur with some procedures because I actually experienced them myself. You want to comment on that?

Dr. David Elkowitz: I certainly understand where you're coming from. Over the last eight and a half years, I've been experiencing, as I just explained, my cancer diagnosis. Interestingly enough, I teach the pathology of cancer and use a lot of my own slides, a lot of my own images, all my blood work, and my entire medical record I use to demonstrate basic understanding of molecular pathology and cancer.

I will say that this experience that I went through, or I'm going through still, over the last eight and a half years made me much, much more sensitive to essentially the humanistic side of medicine, even pathology. When I used to take a look at a slide as a medical student 30 years ago, it was a slide that I had to memorize, but now our students realize that that slide had to come from tissue from a procedure that came out of the body. Behind that slide, lives a patient with a lot of worries and concerns. Behind that slide, lives a family that's worried, that's wondering what the outcome is going to be.

In a way, it turned out to be a wonderful thing where our students don't look at static images and slides and all sorts of other things just as in isolation. They understand that even a simple blood test had a human being behind it that was probably-- woke up and worried about what those results were going to be. I couldn't agree with you more. This situation certainly made me a little more sensitive to that.

Tiffany Hanssen: Dr. Sherman, thank you so much for your call. Dr. Elkowitz, we have a text here, too, from a Hofstra alum that says, "I was a caregiver for my mother when she had dementia. I think doctors need better training to work with patients who have Alzheimer's." Not necessarily to address the specific training around Alzheimer's but there is training that would be useful when dealing with Alzheimer's patients that can be taught more broadly, I would think, about compassion, about empathy. How are you addressing those kinds of softer skills?

Dr. David Elkowitz: You can't have good patient outcomes without building rapport and trust. How we're developing those skills here is, at first, we are dealing with a very small class, with very small class sizes. In our case-based curriculum, we call it Pearls, our students- certainly, as they're learning about medical education, including Alzheimer's and the pathology, the mechanisms of what's creating Alzheimer's and how to treat it, our students are also learning the skills of teaching each other, communicating with each other. Then at the end they do a group and self assessment on how that session went.

The assessment is a personal assessment on what they know, what they didn't know, and the group assessment on how everybody think it went. Everybody in that room does their own individual, group and self assessment. What makes this unique is that they're actually graded on that. They're graded on the quality of assessments, how transparent, how honest they were. If there was an action plan that was created, are they going to fulfill that in the upcoming weeks?

Alzheimer's or any disease has that secret ingredient of physicians that possess humility, reflection, that possess obviously medical knowledge, but when they know something and when they don't know something and how they're going to look it up and work in a team environment.

Tiffany Hanssen: Let's talk with Jennifer at Harlem Hospital here. Hi, Jennifer.

Jennifer: Thank you so much for taking my call and thank you for this excellent segment. I'm working as an administrator on a prenatal health program at the OB/GYN Clinic at Harlem Hospital Center, and I just wanted to underscore the critical importance which we're increasingly aware of, about the social determinants issue. Majority of our patients are tackling such incredibly serious social and economic issues that when they come in, in many ways, their healthcare needs are so marginalized because they're so oppressed by everything else.

I'm hoping and assuming, Dr. Elkowitz, with the kind of focus that you're putting forth in your program, that that is very much a centerpiece. It certainly was part of my training in psychology, mental health, medical anthro, and public health. I know increasingly it's very much a focus for clinicians, so I'd welcome your feedback on this.

Tiffany Hanssen: Thanks, Jennifer. Dr. Elkowitz?

Dr. David Elkowitz: We wrote papers stemming from this curriculum on leadership. We wrote papers on healthcare costs and introducing those concepts very, very early on with our learners. Listen, at the end of the day, in order for there to be a great outcome, there has to be a right diagnosis. The patient then has to accept the treatment plan, but then someone's going to have to pay for that.

Our students certainly are exposed very early on to insurance issues, to compassionate care issues with the drug companies. Through their cases, they become certified EMTs right from day 1 of their medical training, so they're exposed to a lot of what was just described, seeing patients on the ambulances as first-year med students. Again, what we try to do here is we try to take these types of threads that we're discussing and weave it through a medical education curriculum. I think that that really is a unique part of who we are in order to ultimately achieve great outcomes.

Tiffany Hanssen: Dr. Elkowitz, another doctor here, Sarah in Brooklyn. Hi, doctor.

Sarah: Hey. Going along those same exact lines, in my medical education, I didn't receive any education about insurance companies, prior authorizations, and any really empowerment to change the system. The system that exists is terrible for so many patients, and so many patients either can't afford the care or get these massive bills that they can't afford and end up going bankrupt because of it. I just feel like at medical education you do a better job to empower medical students and physicians to become political, to become lobbyists, to change the system, because the system is just so broken and we see it every single day.

Tiffany Hanssen: Sarah, thanks so much for the comment. Dr. Elkowitz, I feel like that's a whole other segment that you and I could have about the medical system. Any quick thoughts on Sarah's comments there before we [inaudible 00:22:37]

Dr. David Elkowitz: No, I hear what she's saying. One of the challenges we have as a medical school, especially in the first two-- we call it the pre-clinical years, is that we have a mission to make sure that our students are exposed to the medical education material and learn how to critically think. That takes an enormous amount of time.

What we really tried to intentionally do is make our students aware of all the societal issues as they're learning about these cases. We embed them into their cases. They see a lot of these types of societal issues as they rotate with the ambulances as certified EMTs. When they rotate through the hospitals and their physicians offices in the very, very first year of their first day of medical school, they are very, very much exposed to all of these issues that are being described.

We intentionally expose our students with the understanding that medical education is not a two-year or four-year deal. It extends into residencies, our Northwell's residency and fellowship programs, and even as lifelong learners, as new attendings.

Tiffany Hanssen: We have been talking with Dr. David Elkowitz, who is the Associate Dean for Academic Programs and Educational Culture at the Zucker School of Medicine at Hofstra/Northwell. Dr. Elkowitz, also the Director of the Academy of Medical Educators, talking about new approaches to medical school curriculum. Dr. Elkowitz, thank you so much for your time today, and we really appreciate it.

Dr. David Elkowitz: My pleasure.

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