If humans are interdependent, why is medical training modular?
Since the mid-1800s, the clinical component of medical education has been focused on the hospital setting. As a result, we have grounded how we teach—and what people learn—around a state of life most people wish to avoid: illness.
Unfortunately, the focus of the teaching and thus the learning isn’t around how to prevent that illness. The focus is on how to fix the problem once it arises.
We are in essence teaching our health care providers to be reactive as opposed to proactive. Reactively fixing problems is desirable only if you can’t avoid them in the first place.
Compounding the problems of reactivity, our national health care system’s approach to care is not effective at fixing health problems for the long-term. It does not create better health outcomes nor better quality of life. Although the United States spends more on health care than any other developed country, it doesn’t seem that our dollars are providing a good ROI.
Bringing this issue to the forefront, recent research from the Commonwealth Fund highlighted how among developed nations, the United States performed second in terms of health care process measures, but last in terms of outcomes. Our efforts to fix the problems of illness are certainly well-meaning but don’t create the outcomes people – that is the provider, individual, or payer – desire.
This is not to say that we do not need reactive problem solving as a component of our medical education and resulting health care system. We do. But we also need something else. We need our medical education and health system to be grounded in a whole-health approach where we look at the human body—and how we teach providers to care for it—through a proactive, integrated, interdependent lens.
Reactive care is focused on the body-system currently screaming the loudest
As the adage goes, if you listen to your body when it whispers, you won’t have to hear it scream. In the United States, patients tend to end up in hospitals when their body “screams.” There is generally an acute, exacerbated issue that requires immediate medical attention by highly trained physicians to address the problem and get the individual back on the path to health.
But what if more people could avoid the hospital in the first place?
There are pathways to do this, most of which people have found on their own, not because the health system directed them to those solutions. There is a $4 trillion dollar wellness industry for a reason. People have a desire to feel healthy and well because they believe it will improve their lives – based on their own definition of “improve.”
Imagine how many more improved, and even optimized, lives we would have if there was a greater focus on proactive care when our bodies whisper. We’d hear less screaming, and we’d live better lives. The $4 trillion wellness industry can’t achieve this outcome alone. Our health-care system is a critical component to bring this vision to life. To get there, we need the “yes, and…” approach the improv community has made famous.
Yes, we need the reactive model we have in place – although that piece of the pie needs to become smaller. And we need to grow the proactive approaches – and supporting business models – that prevent illness in the first place.
Our modular approach to education results in subpar health
In addition to being mostly reactive, our medical education system creates doctors who specialize in one area – usually one body system like the heart, lungs, brain, nervous system, and so forth. The exception to this rule is internal medicine doctors, primary care physicians, and pediatricians.
The problem with this set-up is it trains people to think modularly – to address problems by only focusing on one body system. That may work in many manufacturing industries where the pieces and parts of the product such as a smartphone are modular or when you have an acute condition that is contained to one part of the body such as a broken bone, but for the most part, that’s not how the human body works. We are interdependent beings. A modular approach simply won’t work when we’re focused on optimizing wellness as opposed to just treating sickness.
A theory from our research helps explain why the modular framing falls short.
The theory, called the theory of interdependence and modularity, states that when there is a performance gap—the functionality or reliability of something is falling short—and the system’s components are unpredictably interdependent—that is, the way one part is designed and functions depends on the way another part is designed and functions and vice versa—then the only way forward is for an organization to wrap its hands around the entire problem and address every critical component in the system so that it will function adequately. The reason is this: treating any given problem in a modular fashion by just improving a specific component of the system will have unpredictable spillover effects into other parts of the system. By preventing individuals from addressing the whole system, a modular approach hamstrings their ability to address these unpredictable interdependencies by taking away too many degrees of freedom from their approach and the whole set of tools they need to succeed.
An example from outside medicine serves to illustrate the implications. Think of the Microsoft Windows Operating System or Apple’s iOS. Both are intricately interdependent. Changing just 10 lines of code would necessitate rewriting millions of others because those 10 lines interact with the rest of the code in ways that are often unforeseeable in advance, given the complicated nature of the operating systems. Having one team dedicated to simply customizing one component of the code without considering the impact on the rest of the code won’t work.
So, too, with health care. Although we can treat a particular symptom or acute condition with a modular approach, those solutions almost always have spillover effects to the rest of the body. These aren’t a big deal when we’re just focused on curing sickness. But when we shift to thinking about optimizing wellness and to preventing many diseases from occurring in the first place, not only do those spillover effects become a bigger deal, but they also show the inadequacy of our current approach that doesn’t allow professionals to address the whole system of the human– from their nutrition to their sleep and lifestyle choices.
With that in mind, what if we took an interdependent approach to medical education? Let’s look at how might we achieve that.
Integrating training around proactive, whole-health care will lead to more life in years
If we took a “yes, and…” approach to medical training, we would grow the pie of what medical education entails. This would include more of a focus on preventive, proactive, predictive care that embodies a whole-health approach.
Provider training around health behaviors would expand, as we know up to 50% of our health outcomes are driven by our health behaviors. In the U.S. today, health behavior training is almost non-existent. For example, fewer than 20% of medical schools require students to take a nutrition course, and most medical schools teach less than 25 hours of nutrition over the student’s four years. This is abominably insufficient given our knowledge around the impact of nutrition on health and disease prevention.
Integrating education around a proactive, whole-health approach would shift the focus to a more balanced framework with reactive, sick care being less of a focus. Training providers in the whole-health, proactive approach would not be another specialty providers could elect. This would not be a “bolt-on” to the current system. Instead, it would be a fundamental shift in educator and trainee mindsets. It would be a reframing, reorganizing, and re-resourcing of our national approach to medical education, the providers that system creates, and the resulting way we deliver health care. It would be how all providers are trained.
Our current, modularized, medical education system is incomplete without this proactive, whole-health approach. To have a holistic system that addresses our whole selves and enables us to live more optimized lives, we need to train providers to take a whole-health perspective, and then enable them to do it in practice. If we do, we’ll have more life in our years, not just more years in our lives.
Ingrained business models – in both education and health care – must shift for this to be our reality
We need to shift the predominant business models within two deeply ingrained industries to make this vision reality: medical education universities and the country’s health care system.
Today’s medical education system is deeply ingrained in a modular structure of departments. For example, a large university medical school has departments that include anesthesiology; dermatology; neurology; obstetrics, gynecology, and reproductive services; urology; and so on. Within each of these, there are more divisions. For example, internal medicine might be divided into cardiovascular medicine, digestive diseases, endocrinology, hematology, pulmonology, and so on. These departments are designed to mirror the departments inside of hospitals, given that medical schools are affiliated with teaching hospitals in which medical students complete the “practicum” portion of their training. A practicum is a supervised clinical experience in which students apply what they’ve learned in their courses in a real setting with real patients. Other departments more academic in nature are designed to facilitate the faculty’s ability to interact with others who share common interests and expertise, and to help them publish in specialized academic journals so that they can influence the field and achieve tenure.
As faculty work together to define the academic curriculum for students, they do so through their departmental structures to codify the scientific knowledge that students should be taught. Faculty in any given department inevitably see the basics of what they research as core knowledge all future doctors should have and work to build that into the curriculum. As they design the curriculum, there is a constant trade off on what gets taught and what gets cut. Any topic that has no natural department or doesn’t fall neatly into the modular structure of how faculty are organized has little chance to get taught.
Similarly, a student’s clinical rotations mirror the structure of the hospitals in which they work. Medical schools thus enjoy a dependent relationship with teaching hospitals. Any fundamental change in a hospital would necessitate a change in the medical school experience. Similarly, any change in a medical school that would disrupt the operations of a teaching hospital renders it a non-starter.
Exchanging this modular structure for one that is interdisciplinary, interdependent, and more holistic of the full set of drivers of health is no simple matter given the dependence on the hospital setting that has been built around curing illness, not cultivating wellness.
The interdependent path forward
Our medical education model is deeply interconnected with our established health care (sick care) business model. This creates a chicken and egg problem. Do we change the health care business model or the medical education model first? Alternatively, do we try to change them both at the same time?
Our prevailing, ingrained health care business models are designed around fee-for-service payments. Providers and provider organizations are paid based on the number of services – visits, surgeries, and so forth – that they deliver. As a result of this revenue driver, the business models of health care systems, hospitals, and provider clinics are organized to maximize this type of revenue. The value propositions, resources, processes, and even priorities and measures of success of the provider’s business model are tailored to fuel the fee-for-service engine. As our national health care system slowly shifts to an outcomes-based payment model – one in which providers are paid for the health they create, not just the sick care they deliver – the health care business model, including its value propositions, resources, processes, and priorities, must be redesigned. Our medical education models will require redesign as well, given the interdependency between the two entities.
How might we create this new future? The easiest path forward would be for an existing, accredited university to create a new medical school – or, better yet, it could be called a “health school.” This could be a similar process to what UT-Austin did with the Dell Medical School just a few years ago. While still a lengthy process, starting a medical school from an already accredited institution speeds up the timeline between first thought and opening. In this net-new health school, faculty would be built around what practice looks like in the health and wellness world versus how it is organized today around the sick care system. The school would be built around the resources, processes, and priorities of health instead of those of a hospital. Additionally, student practicums would take place in the context of wellness institutions as opposed to the rotation-based hospital practicums we have today.
Taking a new approach to medical training and paying providers for the health they enable will improve the ecosystem for us all. Individuals will live enhanced lives, our experience of health and care will be improved, and care providers may enjoy both their training and their jobs quite a bit more.
After all, most went to school to help people improve their lives, not just to fix them once they were broken. Treating humans—and medical education—as interdependent will allow us to begin to explore that path forward.
Ann Somers Hogg is a senior research fellow at the Christensen Institute. She focuses on business model innovation and disruption in health care, including how to transform a sick care system to one that values and incentivizes total health.