Branches from the same tree
David J. Skorton, MD, is president and CEO of the Association of American Medical Colleges (AAMC), a not-for-profit institution that represents the 154 accredited medical schools in the United States (and 17 in Canada), as well as nearly 400 teaching hospitals and health systems, and more than 80 academic societies. He joined the AAMC in July 2019 after a long and distinguished career after serving as president of two universities—Cornell University (2006 to 2015) and the University of Iowa (2003 to 2006)—and, most recently, serving as the 13th secretary of the Smithsonian Institution.
Dr. Skorton visited the UND School of Medicine & Health Sciences (SMHS) in August 2019 to speak at the School’s MD White Coat Ceremony—his first visit to a member institution since becoming AAMC President—at the request of UND’s interim president and SMHS dean, Dr. Joshua Wynne. Among the busy schedule of events Dr. Skorton kept during his two days in Grand Forks was a sit-down with Dr. Wynne to discuss medical education in the U.S., distance learning, and the added value the arts and humanities bring to the sciences.
The following is a transcript of the two physicians’ conversation, edited for clarity and space.
Joshua Wynne: Something that is very important to me, as I know it is with you, is combining the arts with the sciences. I wanted to start by asking you to talk about that a little bit. When we look at the jobs you’ve had—some at the very big research universities, but also at the Smithsonian—I’m wondering what you think the importance is of the liberal arts to the sciences, especially as it relates to the health care field.
David Skorton: It’s not a mistake or totally surprising that those bridges can be built. There was a study by Root-Bernstein that showed that scientists who reached the top level of scientific accomplishment—Nobel Laureates—are much more likely to have an avocation in poetry, the arts, something like that. So, I think there’s good evidence that the arts are important to many of us in the sciences. But most importantly, these [biomedical] problems just aren’t so easy to categorize. In the medical sphere, places like UND have brought the humanities into the mainstream of medical education, which is fabulous. Not only by introducing concepts like empathy and communication, but beyond that, there was a study by Harvard Medical School that took some students learning how to do physical exams to the Museum of Fine Arts in Boston and taught them how to look closely at works of art. And it turns out that this increased students’ ability to observe things in patients, because they’d learned how to see things more closely. And you guys—I mean this sincerely—are at the forefront of this. To answer your question, I’ve had a nonlinear career path, which I’m happy about. There’s a recent book I’d been reading [by David Epstein] called Range on the notion that specialization in one’s life early on—which used to be a mantra—is maybe not the only or best way to reach excellence. I didn’t do it on purpose, but I bounced around a lot. I wanted to be a musician—that’s how I started. Obviously, I was a flop at that, since you’re not streaming my music or paying to hear me play now. But I never lost my interest in the performing arts. Much later, when I was a medical student, and later doing research, it came to me from reading thought leaders over the generations that problems and challenges in the world don’t come in neat categories. Even medical problems—patients don’t walk in and say “I have a problem with this particular part of my biochemical pathway.” They come in with a whole bunch of things. Problems, fears, the need to communicate and be heard. You know Einstein has this quote from the thirties in an essay where he says—and I’m paraphrasing—that all science, religion, and arts are branches from the same tree. And I really believe that’s the case.
JW: [My spouse] Susan and I hosted a reception for the incoming medical student class recently at the North Dakota Museum of Art, and what was interesting to me was that without us encouraging the students, some of them—who’d never been there before, even if they did their undergrad work at UND—were wandering through and looking at the art and talking about it. We heard more than a few students say “I went to UND but had no idea this place existed. Thank you for opening it up to me and letting me experience this.”
DS: That’s really a gift to give those young people. So, I was at the Smithsonian until just recently, and the newest museum there—the National Museum of African American History and Culture—where the founding director there, who’s now the Secretary of the Smithsonian, Dr. Lonnie Bunch, estimated to me once that about a quarter of the people who’ve gone to that museum have never been to any museum before. So opening up that world is amazing. When patients come to us, or when we think about the general population, about 10-20 percent of our health can be related to health care. About 80 percent is related to other factors, including the social determinants of health, who your grandparents were and your zip code. That puts you right in the junction of science, the social sciences, the humanities, and to some extent the arts.
JW: In the realm of medical education, and education generally, there are important trends underway that will continue and maybe accelerate in the future. We’ve seen that many current students like to study and interact on their timeframe in their locale. This is different from the way you and I experienced medical school in the large lecture hall where the professor gets in front of the class and does a data dump from their brain to the student’s brain. Increasingly we’re seeing students who want to engage in active learning, not necessarily all together or at the same time—that is to say, asynchronously—and not necessarily physically in a lecture hall. What do you see as some trends for the future? Is it possible, for example, to use virtual reality to train people in “teammanship”—which we think is vitally important in the future of American medicine?
DS: All kinds of trends are happening. This thing you described, which some for the last decade or so have called the “flipped” classroom [small group, student-directed learning facilitated by instructors], is interesting. We’re interested in having them get that information in whatever way they want, in whatever method is used, as a place to test out this so-called active learning. You’re doing it at UND, and as I understand it you’re working toward an intensification of that process in a new curriculum. I think there are a couple trends overall that will be interesting over the years for us to be in close touch with. One—the push toward competency-based education. Isn’t it possible that student A versus student B would have a different time to get to a point where she or he is competent at doing something? There’s already a discussion around the country about shortening medical school. Might we get to a point where it’s really individualized through technology as you suggest and through a flexible curriculum, as you have and are developing? To have the education customized for each student, to a certain extent. Or for categories or cohorts of students. All those things will happen, and I think that day will come when we’ll ask if someone really needs a bachelor’s degree to go to medical school or law school. Could you pass some competency threshold and then proceed to professional education? Now, I’m old school. In fact, I’m old period. No other qualifier. So, I think there’s enormous benefit to having the breadth of a baccalaureate experience, but also the socialization that occurs on campus.
JW: Let me follow up on your competency-based education idea, which I agree with completely. If we apply this especially to medical education, one of the issues or stumbling blocks is post-degree training, that is, residency training. If students finish at different times based on their attainment of certain competencies, how does that feed into a residency program that uses a computerized system on a given day to admit everyone? Would that have to evolve as well? How would that work after medical school?
DS: That is a great question, and before I answer that let me just say that one of the challenges that you and I both have is the problem of our success in increasing the number of med schools in the country and the number of students per class. And now, just recently, the medical schools in the United States have caught up with the goals set up by the AAMC to increase the number of doctors being educated by 30 percent. We’ve gone just over that. Now we have another problem, which you brought up one aspect of, which is: are there going to be enough slots in graduate medical education, and will the federal government have the wisdom to understand that we need to put some more funds into creating more [residency] slots so that we can increase the overall supply of doctors in the country and avoid a serious physician shortage? This is the overriding issue. In terms of how we would work competency-based education in terms of currently fixed deadlines for moving to the next phase, that’s a problem to be faced. Another thing I find exciting at UND is the fact that you have communities for the groupings that you put people in where you combine other health care workers.
JW: Our learning communities. These are both physical and virtual. We put the students of different disciplines together physically, but we also do some educational activities with them together as a group, such as our Interprofessional Health Care course.
DS: What a great idea. Think of all the people who contribute to health care in the country. The physicians, the nurses, the physician assistants, the pharmacists, the medical librarians, occupational therapists, physical therapists, and others. And you’re bringing them together.
JW: Going back to your comment about the numbers and distribution, but also the team approach, one of the things that we were thinking about as far as the prediction of how many practitioners one needs is using a pretty simple business formula. The output (that is, the number of practitioners needed to provide outstanding healthcare) is a function of the number of people you have and what you invest in systems, often called capital, and some efficiency factor when you bring them all together. The usual prediction of the number of physicians we need assumes that the efficiency factor doesn’t change. What we say is, yes, there is a real need for more physicians and other providers, which is one of the reasons we expanded class size. But we said that’s necessary but not sufficient. The way we can get a better output—that is, better and cheaper patient care—is not just simply increasing the number of physicians, not simply doing capital things like a new building, but actually improving the efficiency by which those ingredients are brought together.
DS: This sounds exactly right. And by the way, a tip of the hat for the breadth of education that’s going on here, and an extra tip of the hat to our nursing colleagues.
DS: Nurses are helping us get around the bases in so many ways. The clinic I was co-director of at the University of Iowa for over 20 years, which was devoted to the care of the adolescent and adult with congenital heart disease, was run expertly by an advanced practice nurse who had her own practice within it and also kept us moving in a more efficient direction. But your definition of efficiency in this setting is one I’ve never heard before. It’s very, very interesting. You ought to jot that down for somebody to read. I want to ask you a quick question. Do you think what you’ve been discussing about efficiency in education, putting on your presidential hat for a moment for the University of North Dakota writ large, does that go for the other kinds of education?
JW: I’m smiling because this reminds me of the conversation we had last night. I was discussing accepting the interim presidency with a former fellow dean of a medical school, who now has a very senior position where he oversees both the medical campus as well as the non-medical campus. He urged me to accept this interim position for the following reason: He said, based on his experience at this other major public institution, that the most attractive part of [a presidency role] was being able to find partnerships between what was going on at the medical campus as well as the non-medical campus, which was largely but not completely undergraduate. They have a lot of other graduate programs, but not medically focused. And he thought that the articulations that they found between the two institutions were extremely productive in building this idea of maximizing productivity by bringing together different members of the educational team. But you brought up nursing. There has been a not always a smooth relationship, shall we say, between physicians and nursing. Assuming this is correct, what further can we do to try to foster, encourage, and welcome a more balanced and appropriate relationship so there isn’t an arm wrestle, but an arm-in-arm relationship, working together for patient care?
DS: The answer is a long, multidimensional answer. I’m thinking about this, starting where my office is, my building on K Street in Washington. My predecessor, our colleague, and friend, Dr. Darrell Kirch, is a wonderful leader, a very visionary man. When he was putting together that building, not only is the AAMC headquartered there, but [he brought in] organizations that are devoted to education of other health professions. Two floors of the building are actually devoted to that, so that’s somewhat a symbolic thing, but also allows us to run into each other at the water cooler, so to speak, as we would say in the old days. Then there’s legislative piece, which includes identifying the scope of practice that’s permitted. In general those are developed on a state-by-state basis. Those are things that have to be thought about very, very carefully. And then there’s the issue of how you fund all of this. I want to say, having been in public higher education for most of my career at University of Iowa, and having a chance to recognize the success that you’ve had in public higher education here at UND, it’s obvious that the Legislature of the State of North Dakota and this university have found common ground. We’re sitting in a building that’s magnificent, a great investment for the future. Looks like it was a sizable investment to my eye, but obviously a great investment for the future, and I congratulate you and the Legislature.
JW: Just as a point of information, this is not going to be the answer in all states, obviously. But as you may know, we actually have gotten the State Legislature as a partner in GME slots, and the state is now funding 35 GME slots in North Dakota. This is provided through state appropriations. Those are tax dollars, and when this bill came up, in a state well known for being careful with its financial resources, almost 80 percent of the Legislature voted for the bill. Nearly 80 percent is a landslide in any state, and these are careful legislators who spend public money very carefully. They realized the importance of this issue.
DS: There’s so much denigration of elected officials these days everywhere. What a great thing to see, a partnership, an example. You can be sure that [Dr. Skorton’s Chief of Staff] Jennifer [Schlener] and I are going to go back and talk about this example with our government relations people because it’s a fabulous, fabulous example. But you brought up public universities. I just want to say one more thing. Having been in both the public and private sector, the public higher education system is the bulwark of American higher education. And Jennifer and I have both been in public higher education for years and years, as you are. And of course the private sector is also extremely important. But the public higher education system is what people are depending on in every corner of this country. It’s not a mistake that the first visit I’m making as president of the AAMC is here. Part is because it’s you, somebody I admire so much. But part of it is also that I wanted to visit a public university in a community-based setting, and it’s very, very impressive. The only thing I’m impatient about is, as great as it is to see you, I can’t wait to meet the students this evening. All 77 of them.
JW: You’ll enjoy it.
DS: Yes. I hope they stay awake throughout my speech. For the record, let me just first say that I’m thrilled to be here. I’ve been a fan of Dr. Wynne for a very long time. You’re very lucky to have him leading the whole University of North Dakota, not only the School of Medicine & Health Sciences. Dr. Wynne has two attributes that are made for the moment. Not only is he a distinguished academic who’s got chops in research, patient care, teaching, and more recently, health care policy. He’s the genuine article. Two—he’s never satisfied. He always wants to push the envelope a little bit and make things better. Those two things are fabulous attributes and it’s wonderful to be here and to celebrate all you’re doing.