Episode 29: Interview with Dr. Jordan Cohen

Mary and a fellow 4th-year student, Charlotte Rolle, interviewed Dr. Jordan Cohen, President Emeritus of the Association of American Colleges (AAMC), Professor of Medicine and Health Policy at George Washington University, and former Professor and Associate Chairman of Medicine at the University of Chicago, during his recent visit to the University of Chicago Pritzker School of Medicine as keynote speaker and visiting professor for the Alpha Omega Alpha honor society induction banquet. They discussed various aspects of medical education and recent developments in its evolution.

If you have questions for us, please send them to pritzkerquestions@gmail.com. Or, call (773) 336-2POD and leave us a message.

[Music: “The Area” used with permission from Eliot Lipp. “Shiggidy” used with permission from Greg Spero and GMG.]

Episode 29 Transcript

Mary Bister: Hello and welcome to a special edition of the Pritzker Podcast from the University of Chicago Pritzker School of Medicine. My name is Mary Bister and I’m joined today by guest co-host, Charlotte Rolle. Charlotte is a fourth-year student here at Pritzker and is currently applying in internal medicine. We’re here to interview Dr. Jordan Cohen. Dr. Cohen is President Emeritus of the AAMC and the current Chairman of the Arnold P. Gold Foundation, which promotes humanism in medicine. Throughout his career, he has been a passionate advocate of education, research, and patient care. He has been Dean of the medical school and Professor of Medicine at the State University of New York at Stony Brook and he was formerly Professor and Associate Chairman of Medicine here at the University of Chicago. He’s also held faculty positions at Harvard, Brown, and Tufts. He is currently Professor of Medicine and Public Health at George Washington University.

Thank you so much for joining us at the podcast, Dr. Cohen.

Jordan Cohen: Well, thank you for inviting me. It’s a pleasure to be here.

MB: So Charlotte and I here have prepared some questions for you sort of addressed to your areas of expertise: medical education, health care reform, items of that nature. So I thought we’d just start out sort of broad and general by asking you what you think are the important trends in medical education at the current moment and how current applicants to medical school might be affected by those trends.

JC: Right. Well, there is several that I think are worth taking note of. Let me start with the application process itself. I think there’s been a recognition over the last several years really that we need to be much more comprehensive in the way we evaluate students for medical school, that there’s been a tendency to over emphasize certain criteria which are terribly important but nevertheless I think need to be put in the broader context. By that I mean the grade point average and the MCAT scores have been used to a degree that tend to communicate a disproportionate interest in those aspects of the applicants’ credentials as opposed or in addition to the other characteristics that we would very much like to see in future physicians and hence in medical school applicants. So there is a lot of work being done presently to try to expand the criteria and to have much better methods for evaluating the students from a variety of different perspectives. And I think that’s the important trend that will continue.

In terms of the education itself, I think one of the trends that’s been visible for several years now, which is becoming I think more prominent, is a learning of the classic Flexnerian distinction, if you will, between the basic science years and the clinical years. It had been the case several decades ago there was a virtually complete separation of the education between the first two years, which were entirely basic science without any contact with clinical work or with patients, as opposed to this latter two years which were entirely clinic-based and hospital-based and very little if any in the way of basic science material. Now I think there’s a recognition that one needs to blend the medical education in a much more realistic way involving contacts with patients very early, in fact, from the very beginning in many schools. And I think that’s a very healthy trend because not only is it important to illustrate many of the basic science concepts with real clinical examples, but it also is a very important way to keep students’ motivation alive because those medical students come to medical school wanting to be doctors and they have an opportunity to see patients even in a very limited way in the early part of their education, I think, is an extremely important aspect of keeping their motivation and their interest alive.

In addition to integrating the curriculum, if you will, vertically, having clinical work done early in medical school and conversely having basic science concepts reintroduced or introduced in a more salient way in the latter years of the medical education, I think there’s also a tendency to horizontally integrate the curriculum by rather than having strict disciplinary courses in anatomy, in physiology, in biochemistry and the like, I think most medical schools now appreciate the advantages of integrating those subjects into more continuous kinds of learning experiences that integrate the basic sciences along a more rational thematic means. Similarly in the clinical years, I think there’s recognition that there’s advantages to having more integrated clinical clerkships as well where, rather than rotating in a very specific and clarified way between the various disciplines in medicine, surgery, pediatrics, obstetrics, et cetera, having opportunities for students to cross those disciplinary lines in the temporal way and experience a more realistic way in which medicine is actually seen in the real world.

So those are the two important trends, I think, in medical education that I would point to. And I guess, finally, I would say that the emphasis now on the clinical education area, not only in medical school but from the post-graduate training, is one that is receiving a good deal more attention, as I think it should, because I think a lot of the preparation for future practice really needs to incorporate many more ideas and topics that relate to the cross-cutting issues of professionalism, of end-of-life care, of cultural competency, communication skills, a whole variety of things that are not discipline-specific but really do command attention by all the specialties and subspecialties in medicine, and I think having ways of keeping focus on those cross-cutting topics during the clinical years of education is an important element in the change that’s occurring.

MB: Definitely. Just to follow up briefly on one of the topics that you mentioned about more holistic ways to evaluate medical school applicants–and obviously that sort of continues down the road when you’re applying to residency and beyond. My understanding is that Step 2 Clinical Skills was an effort to incorporate a little bit more of that into evaluating medical students for residency. Do you think that test has been successful in that objective?

JC: I think it certainly has been a very positive addition to the licensing sequence. I think it’s also encouraged medical schools to place more appropriate emphasis on development of clinical skills among the students. So I think it’s had a very positive impact both in terms of ensuring to the public that the graduates of medical schools have the requisite basic clinical skills to really carry out their responsibilities appropriately, but also it has stimulated medical schools to look for ways to improve their teaching of clinical skills in the course of the education. So I think it has been a very positive movement.

CR: Dr. Cohen, you mentioned sort of other facets of medical education that aren’t traditionally appreciated as being a foundation that you need in medical school: health care disparities, end-of-life care. Mary and I were having a discussion because recently we have to do our financially exit interviews, and that prompted some research and I saw that there was this statement that came up at the AAMC a while ago. They had surveyed graduates of medical school: 90% felt very competent in the foundation of their medical training but only 20-60% reported knowing about the financial aspects of medicine. What sort of changes can medical schools and pretty much residency programs make to ensure that their graduates come out being very aware of insurance, Medicaid versus Medicare, really sort of having a good ground and knowing the financial responsibilities of the health care field and how we need to know this so we can better inform our patients?

JC: Well, first of all, this is not a new plate on the part of the medical students. I think it’s always been difficult for medical schools to communicate effectively some of the financial business aspects of medicine. Largely it’s been taught in terms of preparing students for setting up their practices and sort of being medicine small business people or having knowledge about some of the economic and regulatory, other elements of practice that are obviously important but really go beyond the issues of clinical knowledge and clinical skills and patient care, per se. But in addition to that, I think as you point out in your question, there is a now a recognition that medicine is increasingly involved in much larger issues of insurance, of Medicare, of policies that influence medical practice in a very real way for which students would like to be, and I think deserve to be, better prepared to deal with those issues and understand them in a more comprehensive and clearer way.

And I think there are efforts to try to address that issue. How successful they are, I can’t say because I think many of those are still quite new, but I think efforts to try to include in the medical school curriculum and recently in graduate education curriculum opportunities to learn about health policy and some of the issues related to financing medical care and some of the areas of health care reform needs to address some of these issues, I think, they’re recently on students’ minds as I think it should be. But I think educators are beginning to take note of that, trying to find ways to deal with it. Not an easy thing to do but first of all, these are not as stable, if you will, areas of knowledge that some of the other aspects of medical education tend to be. Although we’re always dealing with change, the fact is that the issues we’re talking about here I think may be changing even faster than the science is changing so it’s hard to keep up with some of the issues in terms of what students need the most.

So in any event, I guess the last thing I’d say about this is that to the extent that the concerns that students have about the inadequacy or the desire to have more in the way of education in some of these areas I think I would suggest that this is the motivation or the reason behind it. But I think there is a–there needs to be a recognition that being a physician means being a life-long learner. The expectation that one should learn everything before one starts practice, I think, is obviously not realistic, first of all. Secondly, it’s not wise because the changes that are occurring in medicine, both scientifically and otherwise, I think really require that all of us keep an attitude of wanting to be a learner as we go through our careers and any of these things need to be learned as we go along, as they’re changing.

MB: Sort of going along the financial line but in a little bit more personal way, medical student indebtedness has reached pretty much astronomical levels over the last several years, and when you combine that with an increasing need for primary care practitioners to sort of buttress any sort of health care reform that might happen is going to depend a lot on having more practitioners available to care for patients who are newly insured or now have access to care that they may not have access to before. How does one reconcile the levels of indebtedness with trying to encourage more students to go into primary care fields?

JC: Well you’ve raised two seemingly important issues. The relationship between the two, I think, isn’t quite as cause-and-effect as you may be implying. I think, first of all, there’s no question about the fact that we need more primary care physicians and other primary care providers in the system even now, let alone what we should ideally have in a reformed system that should be much more fundamentally based on a primary care foundation than it is today. So we do need more primary care providers, physicians, and others to make health care reform really function the way it ultimately needs to. Secondly, we have an enormous problem with the medical school debt. The relationship between the magnitude of debt and students’ career choices isn’t quite as clear as your question implies. When one looks at the magnitude of student debt in relationship to career choice, there is not a very strong if any correlation to the debt level on the student’s choice which I think reflects several things. First of all, it reflects the fact that students really choose what they want to do largely because of what interests them and what they find stimulating and gratifying and intellectually challenging and all the rest, and I think to a lesser degree, it’s driven by economic considerations, although I wouldn’t downplay the importance of that, I mean, in many circumstances. It’s just I don’t think overriding consideration for most students.

The issue of student debt though, I think, has to be taken very seriously and it is taken very seriously. It’s a matter of just of in principle, it’s just unconscionable that we’ve saddled physicians with so much educational debt that it certainly hampers many of the things that they would otherwise choose to do for themselves and their families. So we need to address that issue and finding a solution to it, I think, is not going to be easy. The cost of medical education is high. It is very costly to educate students the way we do, and I think the way we educate students has a lot of rationale and credibility associated with it, so I’m not suggesting that there’s a cheap way to do it, although I do think we ought to continue to look for ways to make education more efficient, more cost-effective. I think some of the new technologies that are becoming available quickly–information technology, distance learning, and computer-based education–does have the potential to reduce the need for as many faculty and some of the other costs of medical education. But I think in the final analysis the medical education shouldn’t be done on the cheap because it is obviously very sophisticated, difficult area for students to learn about the need to kind of education resources that are available presently to make sure that that is appropriate.

So the question is where is the money going to come from to make that happen and I think we need seriously to reconsider how we are funding medical education. At the moment, it is heavily based on the income that medical schools receive, not so much from tuition but from other aspects of their activity–the clinical peer research aspects–but in the final analysis the students bear a huge burden relative to their own resources that we have to find a way to alleviate. My own personal view quite frankly is that this is the profession’s responsibility. I think the more we try to look to outside sources like government to provide the resources to offset this expensive education, I think it’s not going to be very successful strategy. I think we need to look to ourselves. By that I mean schools need much more from their alumni to contribute to the scholarship funds and the other funds that are available to support medical education and I think in the long run it is a professional obligation to ensure that those coming behind us are benefitted by advantages that we’ve had for most of our professional lives. So I would encourage medical schools to redouble their efforts to try to develop resources from their own alumni, those who are supporting the schools generally rather than to look at outside sources like the government doing this for us.

CR: Dr. Cohen, you mentioned that obviously with health care reform, there’s an enormous need to increase the amount of primary care physicians and I think we all agree with that wholeheartedly. My question to you has to do with the fact that many large academic institutions either do not have a family medicine program or are actually downsizing their family medicine programs. What sort of incentives, if any, can health care reform provide to ensure that we either maintain these programs, improve the programs, or provide new programs for incoming physicians?

JC: Well that’s a very good question and it’s multifaceted. I think, first of all, let me say that it’s not just family medicine, of course, that is responsible for developing future workforce in the primary care area–internal medicine, pediatrics, obstetrics/gynecology and, again, non-physician health care workers as well. But the role of the government in health care reform in trying to encourage the continued presence and the further development of family medicine programs or other training programs that are devoted to primary care practice, I think, has been aspects to it. But first of all, again, the reimbursement of primary care services in the marketplace of medicine I think has been woefully undervalued. So I think we need to continue to encourage the policy makers to recognize the value of primary care services and to see that the financial rewards that are present in this system like that. But as I’m sure you know, it’s not just a question of financial rewards that are a problem for primary care practitioners; the way in which primary care practice is organized presently has been in most instances–certainly many instances in the country–is very discouraging to those who are in primary care practice. It’s a burden of paper work, very heavy patient loads that interfere with their established long term relationships with their patients.

The variety of things that are generally summarized being “hassle factors” in the practice of medicine that discourage a lot of people from even thinking about primary care careers in the first place but also discourage those who have chose primary care to continue the primary care practice because of the discouragement and the frustrations that they experience in the course of their careers. I think there’s a lot we need to do in health care reform to make primary care more enjoyable, more gratifying both to practitioners and to their patients, quite frankly, as well as addressing the issue of income disparity.

MB: Just to get a little bit more deeply into the health care reform issues, one of the strategies for empowering patients, getting things done in health care has been increased reporting, grading, report cards, those sorts of efforts in order to allow patients to find out a little bit more about the quality of the care that’s going on in any given institution or from any given practitioner. And then there are things like US News & World Report rankings, the Hospital Honor Roll, things like that. If cost control, reform, and things like that depend on having a more informed and educated patient base, do you think that these programs are effective–Leapfrog for example, and things like that–in educating the patients and consumers at health care, and if not, what do you suggest could be done in their place?

JC: Again you raised a very complex and broad area that’s very important. Let me say that I think the way I would frame these issues in the context in which they ought to be considered, I think, is in the context of accountability. I think there’s no question about the fact that the profession as a whole and individual practitioners of medicine need to not only accept the need for accountability but I think they need to embrace it as something that is absolutely integral to their function as professionals. One of the bedrock concepts of professionalism is that we are involved in an implicit social contract where we as professionals and as a profession in general are obligated to serve the public’s interest, in return for which we get a number of privileges from the public that constitute the other side of that social contract: the ability to self-regulate, to establish our own standards for medical education, for research agenda, for a whole host of issues that the profession is responsible for setting for itself are all, if you will, deeded from society in return for the expectation that we are going to be working in the public’s interest using our knowledge and our skills at the benefit of the public. That’s the fundamental concept of professionalism.

And in that context, I think there is the expectation, the obligation that we need to be accountable to the public for what we do. We can’t simply hide behind a veil of secrecy and say, “Just trust us because we’re doing God’s work and leave us alone.” Quite the contrary, I think we have an obligation to be transparent and to embrace the need for measuring what we do, for evaluating what we do, for communicating the results of those evaluations to the public so that they can in fact have the documentation that’s required for them to acknowledge that what we are doing in fact is in their interest. I think it’s only with that kind of a set of relationships that we can maintain public trust. The whole system depends ultimately on public trusting the profession and individual physicians trusting their doctors to, in fact, be working primarily on their behalf, the kind of analysis to be–dutiful to every obligation that we are working in the public’s interest. So in that sense I think these efforts to try to measure performance, to communicate those measurements back to the public so they can make intelligent judgments about individual practitioners and about individual hospitals and the professional in general is doing should be applauded and should be encouraged.

Having said that, I think we’re still very much in the early stages of the metrics, the actual measurements that can capture the true value of the things that we’re trying to do. So I think we have a lot of work that we need to do to make those measurements more accurate, more reliable in terms of communicating actual issues that we’d like to see documented. In that context, I think some of the measures that are currently in vogue I think fall far short of that standard and I would use the US News & World Report as a prime example of that kind of a metric that has a great deal of popular appeal but really has very limited if any credibility in terms of differentiating schools or hospitals or whatever. It’s largely a reputational measure that doesn’t have much in the way of credible, solid data.

MB: I think we time for one more question if you want to go ahead, Char.

CR: Just a point, I think our student population is going to love this question. So speaking of popular metrics —

JC: I may not!

CR: Speaking of popular metrics, USMLE Step 1. Throughout the past years, we’ve seen actually a gradual increase in Step 1 score and consequently some may–and this is an implied cause and effect–but consequently we’ve actually seen a gradual increase in the amount of young physicians choosing subspecialty practices that often require higher Step 1 scores. Do you think that this is an area of concern for us in terms of how much physicians we are putting into primary care specialties, and if so, what sort of other evaluation tools can we utilize to offset this effect?

JC: Again you asked a very, very important question and I think several things. Let me say first of all, I think the degree to which the licensing examinations, which after all is what Step 1 is–it’s the first step in the licensing sequence to become a licensed physician–the fact that we have gotten in the habit or the system has gotten in the habit of using results of a licensing examination as a important factor in determining who moves on to various types of some specialty training programs, I think is quite regrettable.

First of all, in my view, the licensing exam ought to be a pass-fail examination. If you’re evaluating someone for their ability to be a licensed physician, it should be whether they’ve met the minimum criteria, period. It’s not how far above the minimum criterion have they been able to score on the test that should determine whether or not they get a license. So I’ve been a strong advocate for a pass-fail system for all of the steps in the licensing sequence because I think that’s all that really is justifiable in terms of the licensing examination.

Secondly, my understanding is that Step 1 is–that there is consideration from the NBME to consolidate Step 1 and Step 2 into a single summative evaluation at the end of medical school, which I think makes a lot of sense, particularly I think as we talked about before the fact that medical education, the curriculum now is no longer so clearly defined as basic science in the first two years and clinical science in the last two years, so that the test that was originally organized to reflect that way in which medical education was bifurcated, I think, is no longer a justification for two steps in that examination. It makes a lot more sense, it seems to me, to have one examination at the end of medical school that is a pass-fail examination that determines whether or not the student has met the minimum criteria with that kind of test can actually measure.

Now, you asked whether there are alternatives. Absolutely. And I think the movement towards a medical school performance evaluation–the so-called MSPE, which is an attempt to try to standardize the way in which medical schools evaluate students and pass that evaluation onto residency program directors as they make their judgments about choosing their applicants to residency programs–that effort is intended to be a much more holistic, comprehensive evaluation than the Step 1 or Step 2 examination. My hope is that that is becoming more useful for program directors as not only an alternative but a much superior way of evaluating students than simply the NBME test scores. The problem with the evaluations that residency programs have available to them is that medical schools have not, up to recently, consistently provided systematic, credible information to program directors that allow them to make those judgments. So they’ve had almost by default to depend upon board scores, the NBME or USMLE scores, because they didn’t have any other way to really evaluate students, recognizing again that many programs just like many medical schools have many, many, many more applicants and physicians, that they have to have some way to screen their applicants so that they can practically deal with the process of evaluation.

So anyway, I think there is hope on the horizon, if not already being implemented, to put us into a better position.

MB: All right. Thank you so much, Charlotte. Thank you Dr. Cohen for joining us today on the Pritzker Podcast. We’ll see you next time.