S. Claiborne “Clay” Johnston, M.D., Ph.D., attended his ﬁrst medical conference more than 20 years ago, when he was a neurology resident at the University of California, San Francisco. It was organized by the American Neurological Association, and what Johnston most remembers is “the awkward feeling of everybody else knowing each other,” he said in a recent interview, “and me not knowing anyone and sitting in gigantic auditoriums trying to absorb the basic science of what was shown on the gels and all that.”
Today, Johnston thinks there are more innovative, engaging ways to deliver medical education. He’s putting many of them into practice at the University of Texas at Austin, where he serves as the inaugural dean and vice president for medical affairs at the new Dell Medical School — the ﬁrst built-from-scratch medical school to open at a ﬁrst-tier research university in the United States in 50 years. Johnston is using the opportunity to rethink everything about how physicians are trained. And not just in medical school.
During a Medical Events HQ session at PCMA Convening Leaders 2017 in Austin this past January, Johnston traced a clear line from better undergraduate medical education, to better medical conferences, to better health-care delivery. All of that starts, he said, with recognizing that the U.S. health-care system is “broken”: ﬁrst in spending in the world but 34th in out-comes, focused on acute care instead of prevention, technologically out-of-date, and built for the convenience of medical professionals rather than patients. Dell Medical School is trying to ﬁx that with a curriculum that emphasizes team-based problem-solving, creativity, and leadership.
Medicine Man Clay Johnston
thinks that health care in the
United States has ‘gone off
the rails’ — and that fixing it
means changing the medical-
But what happens once Dell’s students become physicians and begin relying on conferences for further edu-cation and training? “For this to work, it’s not just about bringing all the neurologists together or even bringing all the physicians together,” Johnston said at Convening Leaders. “It’s thinking differently about the teams that are going to have to come together to solve these problems.… Somehow we’ve got to bring more of that into all of our meetings.”
And that’s just the beginning. Convene talked to Johnston about what else the medical conferences of tomorrow will need to do, from getting rid of lectures, to making use of design thinking, to putting the patient at the center of the program. We also asked some medical-meeting professionals if and how they see their programs evolving to meet the needs of tomorrow’s physicians. The prognosis? Read what follows to ﬁnd out.
What made you want to take a job at an entirely new medical school?
I wanted to take the job because I felt like health care in general in medical education had gone off the rails and that we needed to think about how it could be done better. This was a great opportunity in starting from scratch to take a look at health care, ask questions about what would make it better, and then think about what that translated into in terms of the physicians of the future. What that translated into in terms of a curriculum for medical school.
How long ago did you come onboard before the school actually opened to its first students?
I’ve been in this job now three years. We’ve just had students for about eight months now. We started recruiting about a year and a half after I started.
What was important to you in terms of changing the model of medical education?
One thing was to de-emphasize memorization and the sort of facts-oriented approach. Eliminate lectures, or at least reduce them dramatically. Then, focus on problem-solving in teams. Our curriculum is largely based on that. We’re not the ﬁrst to make that change, although it’s a little more dramatic here than in almost any other place. Reduce the amount of time that we spend teaching basic sciences. Then we could change the content of what people were learning as well.
For us, we’re really interested in training leaders. The health-care system is not what we’d want, and physicians need to rise up and be leaders in making those changes, not resisting change. Also, in how to work in teams and communication skills and human-centered design, starting with the person and designing the care around their needs, not around our needs as providers. Systems engineer-ing amongst a host of other things that are really focused on, how do we ﬁx this system of health care? Not just, how do we perform in a one-on-one encounter that occurs in a clinic or the hospital?
Can you talk a little more about your team-based approach?
I’ll give you an example. We don’t have a lecture hall. Instead, we have a room where it’s tiered and there are tables on each tier and there are chairs that swivel. The students can face the front and get instructions from a teacher, but those instructions are often, “Okay, here’s the problem.” It’s often a case: “Patient shows up unable to speak and can’t move the right hand. What’s going on?” The students can break into groups and try to work on that case. Then the instructor can move from table to table to guide them, or go back to the front of the room to provide additional instruction.
The reason I think this is relevant for [medical conferences] is, the reason we teach this way is it’s much more effective in teaching adults than lecturing. It’s very interactive, but also encourages people to work in teams and recognize that in a team people can bring different expertise and knowledge. That’s important in getting the right answer. It teaches a lot of things. It’s also just much more engaging for adults. It’s much more fun than sitting and listening, where attention really wanes quickly in a lecture hall. I do think that there are ways to do this in conferences. It can make them much more engaging.
The traditional approach at conferences is just “Here are some new facts for you.” That’s even reinforced by continuing medical education requirements, that you’ll give people the facts to answer some speciﬁc questions. Telling people facts, especially as adults, doesn’t work particularly well. There is a ton of literature that shows that whereas if they’re forced to use facts in solving a task, then they are much more likely to take it in. If you’re doing a conference on, I don’t know, new therapies for multiple sclerosis, then actually working through some cases with somebody who’s very knowledgeable on that subject — it could be a large room, but small groups working on a case — can be a much more effective and engaging way to teach that material.
Do you think that medical conferences today are out of step when it comes to delivering education?
I think it’s an antiquated model. Lectures can be very entertaining, but they can also be horrendously bad. All of us stop paying attention after 20 minutes. With rare exceptions, it’s very hard for people to maintain attention for longer than that. We’re setting them up for failure, whereas if we could make things much more interactive they could be much more effective.
How are your students responding to your teaching model?
The students love learning this way. For them, it’s much more fun to be in school than the way they learned organic chemistry or took their pre-med courses. They see the utility of it. That’s the other thing: When you teach away from cases, away from what the students are seeing as most relevant, then they’re asking questions. They’re hoping to get back into an environment in which they are doing what doctors do. This way, we give them the feeling that they’re right there in the clinic or hospital as they work through these cases.
Traditionally in medical school, you spend your first two years in the class-room and the second two years on the wards, doing hands-on clinical work. Does your school introduce that hands-on education sooner?
We do. We introduce the notion of thinking about patients right away — day one of the curriculum. We actually don’t do two years of basic science; we just do a year before they hit the wards. We’ve shrunk that down quite a bit to give us more time to do other things, to get them where they want to be, learn-ing from patient care.
How important do you see that type of work being to future medical conferences?
I think it should be important. There’s audience-response systems to make things more interactive, but that’s still about feeding back speciﬁc facts. It’s not concepts. It’s not working together. It’s not problem solving, really. I’ll give you another place where we’ve used this highly effectively, and plan to do so even more. When I was [associate vice chancellor for research at the University of California, San Francisco], we started to do work with the design ﬁrm IDEO — a human-centered design ﬁrm. Now we’ve hired the guy who ran their health-care practice [as executive director of the University of Texas at Austin’s Design Institute for Health]; a guy named Stacey Chang.
They have a certain way of approaching problems. It involves collecting ideas, getting people stimulated to provide ideas, and then going through a process of sharing and proving those ideas to come up with a best idea or a best few ideas.
That’s a really useful exercise, even in conferences, where collectively you’re coming together to synthesize information that can come up with new solutions, new approaches. We use that [process] all the time as a general method of pulling people together to gain consensus and move the organization forward.
How does that work in practice?
How this would be adapted to a medical conference would be interesting. Let’s say you’ve got a group of oncologists coming together and the focus is on clinical trials. This process could be great at trying to ﬁnd solutions to improving the quality and pace of clinical trials. You’d give them some background information beforehand. You’d seed subgroups with some expertise that they’d be apt to have coming [to the conference]. You use it as a vehicle for having them teach each other, and escalate the best ideas up to the larger group.
Do medical conferences generally tend to overlook the expertise and experience of their attendees?
That’s deﬁnitely true. I think they tend to select a handful of people from the audience and put them up on the podium, when others in the audience may be just as informed, but certainly could contribute in an important way to the topic. Then they just rely on the Q&A to bring out that additional expertise.
Is some of your new education model simply a function of the fact that it’s 2017 and the students who are now coming through medical school are used to a different way of learning?
Deﬁnitely there are differences in this generation [compared to] ours. We were forced to sit in a chair and listen to a lecture and take notes and then digest those notes to reproduce in a test. That’s the model that we followed in our educational events and conferences. For our students, they watch a YouTube video, and then they go pull down a document on Google, and then they write a few words, and then they go back. It’s a really scattered way of approaching a topic, but overall more effective both in terms of learning and ultimately in terms of accessing knowledge than the method that we have relied on — relying on memory as a vehicle.
I do think that some of this is just what [today’s students] bring to it, but I’ve got to say, I think it’s introducible to adults. I think one of the things you discover as a physician, you come back to these conferences — you discover how little you learn from a lecture. You’re not getting tested on it, right? It’s just whatever you absorb. Ask people two weeks later what they learned, and they’re probably not going to be able to tell you that much. But you do remember from a new case: “Oh, I just saw this case of X. I’d never seen one before, and this is what it taught me.” The way adults learn is experientially far more than through memorization-based work.
In addition to what you’ve already discussed, how else might you introduce that type of learning into a medical conference?
I’m a stroke neurologist. I’m about to head off to the International Stroke Conference tomorrow. They’re mixing it up a little bit. I’m actually participating in a part of the conference that’s meant to mimic TED, where we have 18 minutes to give a presentation. We have a max of six slides, I think. They’re on more cutting-edge or controversial top-ics. Most of that will be short presentations of scientiﬁc data, and most of it will be pretty dull. Some of it will be bad science. It just always is.
It would be great if we could think differently about this. For example, the topic that I’m talking about is clinical trials — how poorly we do them, how long it takes to complete clinical trials, from the idea to being able to change practice. It’s a long journey, 15 years or more. Why does it need to be this way? What are the things that we could do that could make it better? That could be a really effective 45-minute session, where we brought together people and gave them some basic data that they would have to review in advance of the session. They’d come together to work in teams to suggest solutions to this, and then share those together, and then have those discussed by some experts.
That would be a really effective and interesting way to get across that mate-rial. I only have 18 minutes, and what I described is probably 90 minutes. Nonetheless, it would be really engaging. My guess is that people who participated would come away energized and with brand-new ideas about what they could do together and also individually. That’s the kind of thing that I think could work in conferences. It takes more organization, more moderation, but I think the return would be tremendous.