COMMITMENT COMPASSION LEADERSHIP AND CARE EDUCATION AND TRAINING
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e designed the Dell Medical School experience to engage motivated students who thrive in a collegial environment filled with challenge and discovery. Our faculty help students build on their life experience, passion for service to their fellow human beings, and commitment to their communities, guiding them through a rich and rigorous curriculum as they grow into our health care system’s next generation of clinician leaders. Perhaps most importantly, we instill in our students a focused appreciation for health system science, clinical problem solving and continuous, lifelong learning that will well serve them, and their patients, far into the future.” Susan “Sue” Cox, M.D. Executive Vice Dean of Academics Chair, Department of Medical Education The Dell Medical School at The University of Texas at Austin
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www.dellmed.utexas.edu
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Pride, Optimism, and the Meaningful Work Ahead Preparing medicine’s next generation of clinician leaders for a lifetime of collaborative service and endless learning.
The faculty and staff of the Dell Medical School at The University of Texas at Austin are proud of how our first class of students to complete the United States Medical Licensing Examination (USMLE) Step 1 performed. Often regarded as one of the most challenging tests a student will ever encounter, the USMLE is designed to measure a future physician’s ability to apply medical concepts and principles to address various health-related scenarios in a safe, patient-centered way. And while the test requires students to demonstrate a solid foundational understanding of areas ranging from anatomy, pathology and biochemistry to immunology, nutrition and cell biology, underlying the entirety of the exercise is the ethical application of basic scientific principles as an expression of a student’s composure and problem-solving acumen. In 2018, the mean national average for medical students taking the USMLE was 230. In that same round of testing, Dell Medical School students scored a mean average of 244, which places their results among those of the “top 10” medical schools in the country. Perhaps most impressively, there were no “gaps” across the test’s subject domains, with Dell Med students exceeding the national mean in every subject area tested, and 100 percent of the students who took the test passing on their first attempt. But just as the results of any test are actually the measure of specific, and often discreet aspects of a subject’s overall knowledge, skills and capabilities, there is a great deal more to know about our students and the kind of medical education they experience here at Dell Med. As our nation’s newest accredited medical school, our experienced faculty embraced the opportunity to thoughtfully construct a curriculum designed to utilize the latest and most promising of contemporary learning techniques. By minimizing lecture and “teacher” time, our students function, from the first day of their course work, in interdisciplinary teams that encourage the kind of collaborative discussions that allow participants to construct a deep understanding of even the most complex of concepts—while emphasizing the benefits of learning itself in a way that we believe will last a lifetime.
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We have accelerated the basic science portions of the curriculum specifically to get our students into a clinical environment as quickly as possible so that they may observe, interact and experience the crucial intersection between knowledge and application that is that actual delivery of care. We have built time into the process for students to complete a supplemental advanced degree in a complimentary discipline of their own choosing, emphasizing value and innovation as part of a broader exposure to the tenants of health system science. And, all along the way, we mentor, encourage, guide and develop the leadership skills that we believe will distinguish our clinicians as uniquely effective members of any health care team or organization. In the following review, we not only offer a brief—and simplified—overview of the Dell Med approach, but more importantly we introduce several of our students who relate their own personal experiences, and discuss how the opportunities they discovered in our organization are shaping their understanding of medicine, and their potential place as part of the larger medical provider community.
Beth Nelson, M.D. Associate Dean of Undergraduate Medical Education, Department of Medical Education Associate Professor, Department of Medical Education
www.dellmed.utexas.edu
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The Dell Medical School at The University of Texas at Austin: A history-making addition to a tradition of making history. In 2012, three generous investments* came together to catalyze the creation of the first medical school to be built as part of a top-tier American research university in nearly 50 years. Four years later, on June 5, 2016, the first class of 50 students, carefully selected from over 4,500 applicants, embarked on what would be, for them, a life-changing journey through what was, for the hundreds of UT Austin faculty members, local physicians, and medical educators who created the new school’s curriculum, the culmination of years of intense and thoughtful work. “At the University of Texas, we say that ‘what starts here changes the world,’” says Sue Cox, M.D., Dell Med’s Executive Vice Dean of Academics. “And on the day our students first began their studies, you could really feel it. Our inaugural class ranged in age from 20 to 39, and they were diverse in so many ways. Some had degrees in biology or engineering, while others had degrees in art or philosophy. They had outstanding grade point averages, of course, and excellent test scores; but they also had a wealth of life experiences, and they shared a passion for service and collaboration that distinguished them as leaders and innovators with a tremendous amount of promise. I remember that all of us, the entire faculty and staff, felt an overwhelming sense of responsibility to do everything we could to help them become the kind of clinicians they all clearly wanted to be.” Perhaps more than any other word, “responsibility” captures the essence of how the Dell Med faculty approached their work. Because the school would be new, they felt that it was critically important that they delivered an educational experience that would prepare their students to meet the unique challenges of a rapidly (even profoundly) changing medical practice environment. So for each of the three major categories of opportunity they identified as being particularly significant to the future of American medicine, our educators designed a corresponding component in what, when taken together, is an educational approach custom designed to help the clinicians we train make a positive difference in everything they do.
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Stated simply, the Dell Medical School experience addresses the following “opportunities” in the following ways: Opportunity 1:
Enhance the organizational practicalities of care delivery to be more effective in today’s rapidly-paced, high-information/high-volume clinical environment.
Approach:
Encourage an interdisciplinary team approach to care delivery by training clinicians to organize, work within, and ultimately lead highly functioning teams of care providers with integrated skills, perspectives and knowledge.
Opportunity 2:
Embrace a health system science philosophy that encompasses every human, technical, and physical resource available in a coordinated, efficient fashion.
Approach:
Emphasize and promote structured clinical practice exposure so that our medical students accumulate a rich data set of experiences upon which they may build their own uniquely personal style of clinical thinking, analysis and judgement.
Opportunity 3:
Maximize outcomes that deliver value to every patient, every payor and, as far as possible, the entire, evolving health care system.
Approach:
Focus on value in health care as defined by some of the premier thought leaders in the field so that, as our students progress, they learn to measure, as accurately as possible, the objective and subjective value they actually deliver through their work.
“Obviously,” says Dr. Cox, “we set our sights high at the Dell Medical School. But as the newest addition to The University of Texas at Austin, a respected institution founded over 130 years ago, we could do no less. We proudly committed ourselves to reaching motivated students, building on their passion and energy, and teaching them the value of a highly functioning team of medical professionals. We are working, every day, to help them understand how they can effectively utilize, participate in, and even positively impact the health care system as a whole. And we are all, together, learning to better embody the highest possible standards of integrity in everything we do.” The challenges facing health care in this country, and around the world, are many. Costs are unsustainable, and increasingly disassociated from both the processes of care and the experiences of patients. Changes come fast. Accepted knowledge is increasingly transitory. There is just so much work to do. But for Dr. Cox and her fellow educators, the opportunity is real, and obvious. “It is our honor to contribute to the education and training of those who will be called upon to do this important work going forward,” she concludes. “And, as the students in our inaugural class prepare to embark on the next stage of their education, serving their residencies at provider organizations around the country, we are confident that they will comport themselves with distinction, taking what started here, at the Dell Medical School at The University of Texas at Austin and, in their own way, working to change the world.”
*$65 million from the University of Texas Board of Regents; $35 million annually provided by a Travis County voter-approved proposition to raise property taxes for ongoing school operations; and a $50 million naming gift from the Michael and Susan Dell Foundation.
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Our students: We would like to introduce the following unique individuals who each, in their own way, represent the commitment of every Dell Medical School student to personally make a positive impact on the health of the communities they serve.
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Year One: The Essentials Competence, Context and Collaboration 9
In their first year at the Dell Medical School, students learn the facts and science of medicine in a way that emphasizes practical application, critical and clinical thinking, and working as part of an interdisciplinary team of clinicians. In PILLARS (Professionalism, Inquiry, Learning and Leadership through Active Reasoning and Synthesis), they work through problems as a group to understand the system that is the anatomy and physiology of the human body, as well as the broader system structures of group dynamics and the health system as a whole—all with an eye toward leadership and leading. Leadership topics include: leadership assessment (self and others), fundamentals, philosophy, skills, practices and behaviors.
www.dellmed.utexas.edu
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Sharmila Paul Look out World. (and we do mean ALL of it) For first year student Sharmila Paul, studying at the Dell Medical School is the next logical step in her personal path of compassion and service. Sharmila Paul, a first-year student at the Dell Medical School, is a young woman with a global vision that may—at least partially—be rooted in her “citizen of the world” personal story. She was born in Melbourne, Australia; raised in Indiana; did her undergraduate work at Rice University in Houston; and now lives in Austin, Texas. She is also very involved with issues related to her Indian heritage, including her first foray into the non-profit social advocacy space, Living Hope, a group she cofounded while she was still in high school. Focused on addressing female infanticide in India (a country she visits as often as she can), she says that, “The purpose of Living Hope was to help address some problematic aspects of Indian culture that go back centuries. Among other positive approaches, we concentrated our efforts on sponsoring cradle drop programs that allowed families to drop off young girls so they could be placed in loving, nurturing homes. We also worked to overcome gender-based violence through female empowerment and vocational training programs because I am personally very impassioned about equity.” With an engineer father, a mother who was a career basic science researcher, and a fascination with science and math, it may come as no great surprise that Sharmila ultimately settled on medicine as her personal calling. But with her non-profit group evaluating programs that would help establish schools and health centers specifically focused on fulfilling the needs of young girls in rural Indian villages, she admits that it was not immediately obvious to her how she could align what she perceived as “traditional, one-on-one patient care” with the kind of broad-based difference she hopes to make in the world. “Then I encountered the Dell Medical School and its culture of service,” she says. “And that’s when I began seeing my two dreams, of being a physician who cares for people, and my desire to make a real difference on larger issues of equity and human dignity, actually coming together. I realized that I could pursue my passions in a way that uses medicine as not just a tool for good, but also as an instrument of healthy change.” One of the first things that struck Sharmila about Dell Med was the emphasis on collaboration that is so much a part of its culture. The pre-admission interview period was intense, she recalls. But once she formally began her studies, she understood why.
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Sharmila Paul “The practice of medicine today is really dynamic,” she says. “Even something that might sound simple, like a basic laboratory test or a health screening, can require a lot of coordination when they are done in the context of a patient’s ongoing health activities. There is so much information, with new knowledge being added to the literature at an unprecedented pace that will only increase with time. While what you know is obviously an incredibly important part of being a physician, knowing how to work efficiently with other knowledgeable professionals, how to integrate data, ask insightful questions, and organize and coordinate all the different resources available through an increasingly complex system, those are the skills that will help define medical practice in the modern era. Dell Med’s faculty understand that to succeed, clinicians need to work within, and ultimately lead highly functional teams. That dynamic constitutes the connective tissue of the entire Dell Med experience; and it started in those initial interviews.”
www.dellmed.utexas.edu
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Sharmila Paul
Dell Med’s focused selection process, which emphasizes an appreciation for collaboration as a core competency to assemble classes filled with students who are ready to conduct intense, mutually supportive work in a pass/fail course structure, resulted in something that, for Sharmila, feels nothing short of “magical.” “I’ve only been here a few months,” she says, “and I already feel deeply connected to the people around me. There’s this sense that, for any one of us to succeed, we all have to succeed. So we really work together. We look out for each other. We meet and talk and bounce ideas around so that when we have the chance to assume different roles on the team, we have an appreciation for what the other members of the team are thinking, experiencing, and trying to accomplish. And because our teams include students from the school of pharmacy, the school of nursing, and the school of social work, we quickly developed a respect and appreciation for the power of a team approach. I’m sure that we will all carry that sense of interdisciplinary collaboration with us wherever we go. Which is how change starts. Real change begins when we start expanding our own expectations about how things can be done, and about what is truly possible if we all come together to work toward a goal.” Which brings us back to the path Sharmila sees for herself and her career. Like every Dell Medical School student, Sharmila participates in the DOCS (Developing Outstanding Clinical Skills) initiative, which matches groups of five students with a dedicated faculty mentor who all remain together as a team for their entire four years. Each time these teams meet, students have an opportunity to discuss everything from matters of professional conduct to the emotions and pressures every medical student experiences over time. For Sharmila, the quality and candor of these conversations have already made an impression.
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“Even though we are only first year students,” she says, “we have access to mentors who are these amazing, premier members of their fields. And while we talk about everything and anything, in my group so far there has been a lot of focus on population health. Under the supervision of several attending physicians, Dell Med students run a clinic for the homeless population here in Austin called the C.D. Doyle Clinic. I am on the list of students who signed up to serve a rotation at the clinic. My friends who have already gone can’t stop talking about how fulfilling the experience was for them. For someone like me, who wants to focus on global health, who wants to work on equity in our own country, and around the world, who wants to work with Doctors Without Borders and things like that, being exposed to a population health perspective by clinician experts who encourage us to rethink established norms is really beautiful.” Thinking about where she is in her career, and the potential directions she might pursue, Sharmila’s expression softens a bit, and she smiles. “I have several years ahead of me here at Dell Med,” she concludes, “including my third year, when I might choose to pursue a Master’s Degree in Healthcare Transformation with a distinction in Population Health. I would like to develop a population health project that involves community engagement in a global health setting because I’m beginning to get a sense of how large systems can be understood, and potentially impacted by targeted interventions. With the input and guidance of my mentors and colleagues at the Dell Medical School, I’m sure my ideas will mature as I develop my skills over time. Overall, I have to admit, I’m just incredibly excited to see where this experience will take me.”
www.dellmed.utexas.edu
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“In their first year at the Dell Medical School, students learn about themselves as leaders while working with other people in teams. The second year focuses on health system science, and how a potential leader functions inside a complex system. In the third year dual degree and distinctions programs, students create and lead projects that require them to use the leadership skills they are developing to begin solving real problems. As a microcosm of the rest of their lives, bringing academics into practice at every step in their education helps to enhance and expand each student’s understanding of what they can potentially achieve.”
Sue Cox, M.D.
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www.dellmed.utexas.edu
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Year Two: Delivery Clerkship, Coordination and Care 17
Students apply what they learned in the first year of medical school to provide care during clinical clerkships in year two. Rotating through six core clerkships in different clinical specialties over the course of a year, physicians-in-training build upon their scientific understanding and clinical skills while working through real cases with real people. The range of experiences during clerkships—from training under respected clinicians to connecting with patients—reinforces foundational skills while shedding light on areas of growth. Between years two and three, Dell Med students take the United States Medical Licensing Examination Step 1. Research suggests that students score higher on the exam if they have significant clinical experiences, one of the benefits of Dell Med’s accelerated curriculum. Leadership focus: enriching the foundation of leadership through personal experience and a multifaceted health systems science curriculum. www.dellmed.utexas.edu
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William Squiers “I decided to go into medicine because I love teaching.”
One second-year student’s passion for sharing knowledge promises to enhance the lives of people he has yet to meet—his future patients. www.dellmed.utexas.edu
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William Squiers is in his second year at the Dell Medical School. Having grown up in Dallas, he is a Texan through and through. Which may be why he describes the undergraduate work he did at Princeton University as having happened, “up north.” At Princeton, he majored in English; after graduation, he spent a year teaching seventh grade math, and coaching three different sports. But medicine, he believes, is in his DNA since so many members of his family pursued medicine as a career, including a grandfather who is a cardiologist, and several siblings who are presently finishing their own medical education and residencies. All that medical schooling means that education is a common topic of conversation pretty much everywhere he goes, resulting in William making a direct association in his own mind between health, medicine, intellectual curiosity and the activity of imparting knowledge and understanding to others. So when he thinks about the attributes of an effective clinician, being an educator, to him, is an important part of the role. “Doctors are always teaching,” he says, adjusting the identification badge clipped to his white coat, which has “Dell Medical School” stitched over the left breast pocket. Since he is in his second year, William is well into his “clerkships,” which are student rotations through various specialty practices. At seven o’clock, he will start his first night in the Emergency Department in the Dell Seton Medical Center at the University of Texas at Austin—the brand new teaching hospital located directly across the street from the medical school. “Clinicians are always learning,” he continues, “and always teaching…students, other clinicians, and patients. Effectively teaching patients about their condition, their options, their situation, and how they can better influence their own health by making informed decisions, those are all really important ways that clinicians can make a positive impact in a person’s life. In a way, I think that every medical intervention starts with a moment of education. So being a physician who excels as a teacher is, to me, the gold standard. And it’s my personal ambition and goal.” With William’s inherent interest in the process of education, the Dell Medical School experience itself is inevitably a subject that he and his family members who have been to medical school, and who are still completing their own medical education talk about a lot. Given that the Dell Med curriculum places a great deal of emphasis on team-based learning and getting students into a clinical environment as quickly as is practically possible, the subjects of interpersonal dynamics, class composition, size and structure receive particular attention. “Class size,” William says, “is an ongoing debate in all areas of education. Is it better to be in a smaller class in which you can really get to know your teachers, and they can get to know you? Or is it more advantageous to go to a very large school where you will probably sacrifice some of the closeness that can develop between a student and a mentor in exchange for a wider range of potential learning and networking opportunities? The dichotomy between those two points of view is certainly not new. What is new, at least to me, is how the Dell Medical School overcomes the issue.”
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William Squiers
Usually packed into questions of “class size” are a range of concerns that include things like teacher experience, classroom-related variables such as personal discussion and information assimilation preferences, curriculum quality, and medical school-specific issues regarding rotations and research opportunities. While smaller classes can make it significantly easier for students to connect with clinician leaders, larger classes tend to be associated with institutions that provide access to a variety of different care settings, exposing students to a range of real-life practice situations from which to learn. Schools with a variety of campuses can include inner-city practices as well as care environments that are more rural in composition and atmosphere. But, significantly, smaller classes often increase each student’s opportunity for hands-on learning, with all the real-time practical feedback that comes with this type of closely supervised experience. “What’s great about the faculty at Dell Med,” William says, rising to go—in 30 minutes he will be on the clock for his first ED rotation, and even though he only has to walk across the street, he is anxious to get started—“is that they found a way to deliver the best of both types of school. “Because there are only 50 students in each class, you can’t help but get close to these impressive professionals who came here from all over the country specifically to teach in an environment that allows them to spend quality time with their students. Every one of our teachers is a recognized authority in their area of expertise, and they know you. They don’t know your file, or your student profile; they actually know you, as a person; they know who you are. Because leadership is a critical part of the curriculum, as a student you have access to a leadership coach who stays with you through the entirety of your experience. My leadership coach is Dr. Beth Nelson, the Associate Dean of Undergraduate Medical Education—she is literally my leadership coach! I’ve met with her multiple times, and I feel very comfortable approaching her. When I have questions I can just straight up walk down to her office. She always tries to make time for me; she's always so accessible. I think that's true of pretty much everyone here on campus.”
www.dellmed.utexas.edu
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William Squiers
“I think that every medical intervention starts with a moment of education. So being a physician who excels as a teacher is, to me, the gold standard.” But what about the issue of care settings and the opportunities a small school might struggle to provide when compared to a school of greater size? “That’s the really interesting part,” William says. “What you might even call a teaching moment: Dell Medical School, the University of Texas at Austin, and Austin itself—scale and diversity are not an issue with any of them.” William’s “teaching moment” is worth discussing. The city of Austin is the capital of Texas, and it is the eleventh largest city in the United States. The University of Texas, as a system, is made up of 14 educational institutions throughout the state, including eight universities and six health institutions— one of which is MD Anderson, the number one cancer care organization in the country, if not the world. Maybe because of its reputation for great weather, live music, and the enormous university presence, people with less experience of the region often think of Austin as being a small, college town kind of a place. But the population is just under one million; over two million when the five-county metropolitan area is included. The annual population growth rate is around three percent, which makes Austin one of the fastest growing cities in the country. And it is very diverse. Like big cities everywhere, Austin has many very positive things to recommend it, but there are also some long-standing issues of income disparity and access to services, including a range of underserved populations and demographics. “Because of all the things that make Austin the unique and dynamic place it is,” William explains, “there is a wide variety of practice environments and rapidly growing populations to serve here. And with both our hospital-based training, and the opportunity to work in the UT Health Austin clinical space, the Dell Medical School takes structured exposure to a variety of practice experiences to a very high level.” UT Health Austin is the clinical group practice designed and managed by the faculty and staff of the Dell Medical School; its primary practice location, the Health Transformation Building, is located adjacent to the Dell Seton Medical Center hospital. Predominantly designed around an innovative Integrated Practice Unit model, UT Health Austin clinics presently include the Musculoskeletal and Women’s Health Institutes, the WorkLife walk-in and occupational health and injury clinic, the Mulva Clinics for the Neurosciences, and a growing number of other specialty and general medicine practices. Focusing on an interdisciplinary, whole-patient approach delivered by dedicated teams of caregivers that include medical and surgical specialists, physical therapists, dietitians, social workers, pharmacists and other medical professionals, the UT Health Austin clinical model of care allows students to participate in a practical, on-site application of the multidisciplinary team structure to which they were first introduced in year-one of their training. “Small class sizes,” William concludes, “great collegial relationships between students, and between students and their teachers; the opportunity to work in sophisticated, interdisciplinary teams; amazing mentors and leadership coaches; and access to this incredible range of practice environments and structures—Dell Medical School is, in my opinion, the perfect blend of the best of what a medical education can be. And I intend to take the same respect for the value of a well thought through educational experience that I am learning here and apply it in everything I do as a physician. But first,” he concludes, adjusting his white coat, “I have an ED rotation to do. And there’s no way I’m going to keep my team waiting.” 23
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“At the Dell Medical School, our mission is to train medical professionals who are deeply ingrained with a passion for continuous, never-ending learning, and who are armed with the tools necessary to apply their knowledge effectively in every situation. By their very presence in the medical practice environment, we believe that our students will, themselves, one day impact the way in which practices are designed, structured, and how they will function in the future.”
Amy Young, M.D. Vice Dean of Professional Practice; Chair and Professor, Department of Women’s Health, Dell Medical School Chief Clinical Officer, UT Health Austin
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www.dellmed.utexas.edu
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Year Three: Growth Innovation, Leadership and Discovery 27
Through individualized experiences in their third year, students make progress toward long-term goals and collaborate to improve health locally. A nine-month “Innovation, Leadership and Discovery” block affords students the opportunity to complete a large, independent distinction project or dual degree. Students also continue clinical practice in primary care, family and community medicine with the option for other electives. Distinctions Experience: •Design and Innovation in Health Care •Population Health •Student Entrepreneur in Residence •Research: Basic, Clinical or Translational
Dual Degree Options: •Master of Business Administration •Master of Education •Master of Public Health •Master of Science in Biomedical Engineering •Master of Science in Health Care Transformation
Leadership focus: long-term growth and advanced collaboration. www.dellmed.utexas.edu
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Brooke Wagen “How Can I Help?” One third-year student’s remarkably simple approach to making the world better, one neighbor, one patient, one life at a time. Brooke Wagen is an adult student in her third year at the Dell Medical School. While all Dell Med students are obviously adults, Brooke describes herself as being “very adult,” given that her oldest son is just finishing college. She has two boys, and a girl who she “moved heaven and earth” to adopt from Ethiopia several years ago (her daughter was just six years old when Brooke, who was 39 at the time, first completed her application to attend Dell Med as a member of the school’s inaugural class). Brooke’s life experiences are varied…to say the least. In 1997, in her last year of college, she married her high school sweetheart. As she was graduating in 1998, she was also having her first son; then she had her second son; and then she decided that the right thing to do for her family would be for her to stay at home and devote herself to raising her boys. While her husband worked two jobs—as a pastor in their church and as the owner of a small software company—she home schooled her kids, supervised the building of their house, volunteered extensively in the community (where she is a certified local legend because of a shipping container she acquired—long story—and refurbished into a backyard pool). She also drove for Meals on Wheels, among many other activities. Heralding originally from Albuquerque, New Mexico, she is fluent in Spanish, which she aligned to her life-long interest in medicine, and helping others, to provide volunteer medical translation services for a time. And now, she is in medical school.
www.dellmed.utexas.edu
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Brooke Wagen Yet, given all that, when asked about her third year population health/distinction project, her response is an enthusiastic, “Oh…it’s so cool!” as she leans forward in her seat, and a wide grin illuminates her face. Brooke’s words come fast, spoken in a light, almost playful tone that communicates a sense of fun that could be described as incongruously appropriate, given the seriousness of her subject. “Its title is, ‘Exploring the Experiences of Aging in Place in Public Housing in Austin, Texas,’” she says. ‘And a lot of my inspiration came from my experience doing Meals on Wheels.” As a driver for the program, Brooke explains, she would first drive down to pick up all the nutritionally correct prepared meals that had been matched to her clients. Then she would drive them back home. Her route, conveniently enough, was right in her own neighborhood. So she would park in her driveway and then she and her children would make their rounds, delivering food to their neighbors. Though not a requirement, during her training as a driver she had been encouraged to actually look in on her clients, if possible since, quite often, for the elderly, or those with physical limitations of one kind or another, she could well be the only human contact they would have for the day. “So I started sort of assessing my clients,” she says, her smile softening a little. “Actually, I was trying to spot potential health issues. It wasn’t anything official, but it would be like, ‘Hey, I noticed that you're not really eating your meal. Are you doing okay?’ Or I would say, ‘Here, let me put this in the fridge,’ where I might find a stack of 10 uneaten meals. I remember one gentleman had this horrific looking rash on his arm. To the non-medical student me at the time, I thought it looked like leprosy. So I asked him, ‘How long has this been going on?’ He said that it had been going on for a long time, and that he had medicine for the problem, but it had run out, and he couldn’t figure out how to get more. He was in his eighties and super hard of hearing, so I asked him if it would be okay if I called his insurance company. After several phone calls I was able to get his prescriptions sent up to be delivered by mail since it was hard for him to get out of the house, being alone like he was. “It made an impression on me, probably because it wasn’t a unique circumstance. These were people who lived right near my house, and all they needed was for someone to connect a few dots for them. There were 60-plus housing units for seniors and people with disabilities right there in my neighborhood, and it made me wonder how many of them could be made more comfortable, could feel less alone, have their pain reduced or some other health-related problem addressed if someone would just offer to help. So when it came time for me to design my third-year community project, I thought about those people. I realized that I wanted to ask people like them to tell me their stories.” For Brooke, a person who helped her connect some of the dots in her own thinking was her faculty mentor, Rene Salazar, M.D., a professor in Dell Medical School’s Department of Internal Medicine and Assistant Dean for Diversity in the Department of Medical Education. “He was in clinical practice for years and years in California before he came to Dell Med,” Brooke says. “And he’s passionate about patient-centric care. He firmly believes that it’s not enough to just treat a patient. He says a clinician has a responsibility to ‘take care’ of a patient; which is a belief I very much share. He’s the person who first took me into the hospital space. I was still in my first year, so all I could do is observe; I couldn’t actually participate in our patients’ clinical care. But Dr. Salazar knew that I spoke Spanish, like a lot of our patients. So he encouraged me to just go talk to them. To ask them about their experiences with the health care system. Which I did. “Soon they were telling me what it’s like to have end stage renal disease, and what a trial it was getting to dialysis. They described how they were juggling all these different medications that they didn’t really understand, and how it made them feel overwhelmed. It wasn’t long before I realized that the time we were spending together was like a gift for both of us. For the patient, because they had someone to talk to who cared, and for me, because they were letting me into these private parts of their lives. They were trusting me. And it was such a lovely balance against all the learning, learning, learning, all the memorizing you do in your first year of medical school.”
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Today, Brooke is well into the third year special project she designed. As it turns out, another name for asking opened ended questions in a systematic way about a given subject is "qualitative research" (in which she is being mentored by Elizabeth Jacobs, M.D., Chief of Primary Care and Value-Based Health, Associate Chair for Research, Department of Internal Medicine and Professor, Department of Population Health, Dell Medical School). “I think the coolest thing about this project,” she says in a tone that hints that she is describing something of particular merit, “is that we didn’t start with some solution already in mind. We started by asking real people about their lives, and we’re listening to what they say. It’s very much in line with the perspective of Dr. Teisberg* in the Value Institute for Health and Care. I’m also partnering with our local housing authority on a comparative case study. By aggregating the responses of people who live in public housing close to my home, and others who live all over Austin, including in a high rise that’s right smack in the middle of downtown, I’m focusing my attention on the intersectionality of housing, healthcare, community neighborhoods, and the autonomous desires of older folks who are choosing to live and age at home, usually alone. “In addition to sharing the results of my research with our housing authority as a way of helping to inform their future work with senior health and wellness, the goal of my research is to publish; to add something of substance to the literature about a subject that will only become more relevant over time. Hopefully this work will enrich our national conversation about how good geriatric or primary care for older adults aging in place should work. Maybe we can help improve preventative care, or simply the ways in which older folks navigate the health care system. But first, before any of that can happen, we have to start by building trust.” A pause and arching eyebrow seem to indicate that Brooke is considering her words. “I guess my ideal outcome,” she says, “would be for my project to begin laying the groundwork for trust between people in this community. That’s why we started by asking questions, and listening to the answers. Hopefully, what we learn will contribute in some small way to helping the housing authority, local providers of health services, and clinicians associated with the Dell Medical School, improve the ways in which they deliver the kind of care the people in our community need, when, and most importantly, at least for this portion of the population, where, they need it. If we could help make that happen, that would be really beautiful.”
*Elizabeth Teisberg, Ph.D. is the Executive Director of the Dell Medical School’s Value Institute for Health and Care, and is a professor in the Department of Medical Education. She is the co-author, with Michael E. Porter, Ph.D., of the 2006 book, “Redefining Health Care: Creating Value-Based Competition on Results” which introduced the concept of value-based care as a methodology for health care system improvement.
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Year Four: Exploration Electives, Rotations and Internships 33
In the last year of medical school, students apply and interview for future residency—a process requiring a substantial investment of time. Not only does Dell Med’s curriculum build in space for this journey, the fourth year gives students the chance to explore residency disciplines and medical specialties through learning experiences like electives, clinical rotations and internships. In the spring of the fourth year, students complete a capstone experience that will help facilitate the transition from medical school to residency. Leadership focus: balance, perspective, and rising to new challenges.
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“Graduate Medical Education at the Dell Medical School is a journey of exploration in which we are discovering and testing new models of learning in the clinical environment. In our residency programs, we are training the next generation of medical professionals who will help lead us through a value-based transformation of all of health care driven by innovation, inspiration, leadership and discovery.�
Jonathan MacClements, M.D. Associate Dean and Designated Institutional Official (DIO) of Graduate Medical Education, Department of Medical Education Professor, Department of Medical Education; Department of Population Health Medical Director, WorkLife Occupational Health, Walk-in and Travel Clinic, UT Health Austin
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Residency Programs at the Dell Medical School Dell Medical School partners with Seton, part of Ascension Health Network, to provide formative clinical experiences in a range of specialties. •Currently, Dell Med offers residencies in Child Neurology; Dermatology; Emergency Medicine; Family Medicine; Internal Medicine; Neurology; Obstetrics and Gynecology; Orthopaedic Surgery; Pediatrics; Physical Medicine and Rehabilitation; Psychiatry; Surgery; and Transitional •Current Dell Med fellowships available include Arthroplasty and Value-Based Health Care Delivery; Cardiovascular Disease Fellowship; Child and Adolescent Psychiatry; Consultation Liaison Psychiatry Fellowship; Craniofacial and Pediatric Plastic Surgery; Female Pelvic Medicine and Reconstructive Surgery; Pediatric Emergency Medicine; and Pediatric Hospital Medicine www.dellmed.utexas.edu
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Nick Christian, M.D. “I am interested in being the change that I want to see in healthcare.” A brief conversation with a Dell Medical School resident who gives a whole new meaning to “working from home.” Nick Christian, M.D., currently in year two of a three-year residency in Internal Medicine at the Dell Medical School, is originally from Dayton, Ohio. He completed his medical education at Wright State University Boonshoft School of Medicine, as well as a Masters of Business Administration (MBA), also at Wright State. Since he is from Ohio, the results recently described in the March 2018 issue of Vital Signs, a monthly report published by the Centers for Disease Control and Prevention (CDC), did not surprise him at all. Based on data from the CDC’s “Enhanced State Opioid Overdose Surveillance (ESOOS) Program,” which compared quarterly trends in the 16 states hardest hit by the opioid epidemic, the Vital Signs article showed that, between July of 2016 and September, 2017, ED visits for suspected opioid overdoses increased by 35 percent overall. Among the top five of the 16 states most seriously affected by this systemic, societal problem, Ohio ranked as number four. “It’s really unfortunate,” Nick says, speaking over the bustling sounds of the Dell Seton Medical Center’s busy, stone and glass main lobby, where he is shaving a few minutes off an already rushed lunch break to talk about his experience as a Dell Med resident. “But the opioid epidemic really hit Ohio hard. With my interest in improving the way medical services are delivered to underserved populations, including the homeless and people facing addiction and other substance use disorders, I was very much aware of the problem. Actually, if it wasn’t for a good friend of mine who was a year ahead of me in his own residency training, I would almost certainly be doing my residency work in Ohio. But my friend matched to an emergency medicine residency here in Austin, and while I was reviewing my options and getting ready to settle on the place I wanted work, he called and said, “Nick, you really need to check out what Dell Med is doing down here in Austin.’ Well, he knew that I’m a musician, and he was pretty convinced that I would love the city, but it was only when he started describing what he was doing in his program that I realized that this place is something special.” Motivated by his friend’s recommendation, Nick started looking into the Dell Medical School’s graduate medical education programs. What caught his attention, almost immediately, was the school’s mission of serving the underserved, as well as its commitment to “rethink” how care is provided to populations broadly, and at risk populations in particular. He was also attracted by the program’s promise of a rigorous experience, anchored by the faculty’s national leadership credentials in value-based care and population health, as well as the corresponding research opportunities that were available in those areas.
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For Nick, the Dell Med experience so far has been… “Phenomenal; just amazing,” he says. “I’ve been fortune enough to get involved in a project called the ‘Buprenorphine Team.’ Buprenorphine is a medication used to treat opioid use disorder. Even though it is actually an opioid itself, when administered by a medical team in a controlled environment, it can help moderate withdrawal symptoms in people addicted to commonly used opioids like heroin or Oxycodone. Our team is studying how we can effectively start patients on this medication in the hospital, and then transition them back into an outpatient setting. This is important because substance use disorder is a very real, and rapidly growing concern in this country.” Obviously warming to his subject, Nick explains, “While it can start because of a conscious, voluntary abuse of a chemical, for a range of physical and psychological reasons it can also be an outgrowth of a patient’s exposure to a medication that was prescribed by a clinician for a perfectly legitimate medical concern. Either way, it commonly involves people who have had their use of an opioid take control of their lives in various ways. What’s also common is that withholding the drug can cause some really severe withdrawal symptoms, which, though they are rarely life-threatening, often feel, to the person going through them, like the end of the world. By introducing buprenorphine in a targeted, controlled way in the hospital, patients can avoid going into serious withdrawals, increasing the likelihood that the will commit to, and ultimately stick with a recovery plan.” Though his compassion for the patients he came to Austin to treat comes through in everything Nick says, the Dell Med residency also offered him more than just an opportunity to serve. Because his work is part of the distinctions track program, he regularly engages in learning sessions with experts in the medical research field, such as William Tierney, M.D. (Chair, Department of Population Health and professor in the Department of Population Health, the Department of Internal Medicine, and the Department of Oncology.)
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“Dr. Tierney has an international reputation for research in biomedical informatics, health system improvement and clinical database epidemiology,” Nick says. “He was part of a coalition that created an open-source electronic medical record that became the national EMR for a whole list of countries, like Kenya, Uganda, Rwanda, Bangladesh and the Philippines. The insights of people like him are just invaluable. From better understanding the procedural requirements of navigating the IRB approval process, to making some important networking connections, I have no doubt that the Dell Med distinction track has helped prepare me to pursue a career in academic medicine, or a career that is more research oriented. Which, by itself, is transformative because, before I started my Dell Med residency, I didn’t even realize that I was interested in an academic medicine type of practice.” Nick’s time is up, and he needs to return to his hospital duties. But discussing his new appreciation for the benefits of being part of an academic institution and the multiple layers of collegial and supporting professionals who all contribute to an exciting atmosphere of collaborative inquiry seems to bring his thoughts back to a more personal focus.
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“What I really want to do is create positive change,” he says, checking a text on his phone. “And I’m interested in being the change that I want to see in healthcare. I think that one thing about the idea of academic medicine that is so attractive to me is the opportunity to pay forward the cultural competence and the medical knowledge I’ll develop over time. I believe that it’s important to meet patients where they are; to understand how they live, what they think, and the challenges they face in their everyday lives. So I applied to become a missional at Community First! Village, a 51-acre master planned development that provides affordable, permanent housing and a supportive community for the chronically homeless in Central Texas. I was accepted and moved into the village in October because I found that it’s something that really speaks to me. There’s no better way to get to know a population than to actually live with them. I can honestly say that some of my best friends in Austin are my neighbors at the village, and the hardships that many of them have overcome inspires me daily. “I’m hoping that this experience will teach me ways that we can all better serve the underserved population, and hopefully, one day, like Dr. Tierney and the other clinicians I’ve met since coming to Texas, I might even be able to inspire the next generation of doctors to embrace every opportunity and option that comes their way.” When Nick completes his Dell Med residency, one option he is seriously thinking about is a fellowship in addiction medicine, so we may be hearing from him again, soon.
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Looking Ahead Because there is arguably no greater contribution anyone can make to the future of medical practice than the discovery of new knowledge, research is an important part of the Dell Medical School experience, particularly during the third “Innovation, Leadership and Discovery” year. Included in the various “distinction” routes students may choose to pursue is the “Basic, Clinical or Translational Research” track. As Chris Webb, Ph.D., Chief Research Officer and Associate Dean for Research at the Dell Medical School explains, decisions made early in the development of the school’s research capabilities aligned existing and emerging resources in a way that promises to maximize the potential value of research conducted by our faculty, staff and students. “On the day when we welcomed our first students,” says Dr. Webb, “Dell Med became the newest addition to The University of Texas at Austin, an institution that has a venerable history that goes back more than 135 years. The University already had well-established programs in Neurosciences, Integrative Biology, Molecular Biosciences, and others, which were all highly regarded for the outstanding work done by their faculty and staff. Instead of recreating basic science research capabilities inside the Dell Medical School, we coordinate with our university colleagues and utilize these remarkable science educators and researchers by creating a series of core medical education and research joint appointments. This allows the new researchers who join the Dell Medical School to augment our existing expertise by focusing their attention on translational research projects that promise to move new knowledge from the laboratory to the bedside quickly and efficiently.” Sue Cox, M.D., who is past president of the Association of Professors in Gynecology and Obstetrics, specialized in high-risk pregnancy for many years in her own clinical practice. For her, translational research is personal, and uniquely important.
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“In my own work,” she says, “I was interested in the causes of preterm labor. As part of my practice, I oversaw the collection of amniotic fluid samples from women who experienced preterm labor, as well as from women who underwent routine amniocentesis to screen for genetic abnormalities. In the lab, I used these samples to look for bio-molecular markers that might indicate a preterm delivery was imminent; and I will never forget the day when one of our routine assays returned a result with a specific marker that was astronomically high. I remember thinking, “this must be a preterm labor patient who came in with an infection and delivered rapidly.” When I checked on the patient, I found that she did in fact have a preterm delivery and a post-partum infection, and that her baby had complications. So that translational work took an observation that we made in the laboratory, and directly affected the way we monitor pregnancies today. The laboratory can be, when utilized in a thoughtful and systematic way, directly connected to improvements in clinical care, which is particularly exciting, and gratifying.” Dr. Webb agrees. “By presenting a broad range of opportunities across the translational research spectrum during the third year distinction experience,” he concludes, “we offer our students the opportunity to gain an understanding of the fundamentals of laboratory science, and how to better converse and interact with scientists. We also hope that this educational opportunity will demonstrate, in the same immediate and tangible way that Dr. Cox described in her own experience, how critically important it is to understand the concept of ‘health-relevance.’ This is a way of understanding how the observations and discoveries made in the laboratory may ultimately be translated into the clinical space where they may positively impact the lives of patients everywhere. The inherent immediacy of that experience, of seeing new knowledge positively affect a real patient’s life, is a uniquely tangible connection between the intellectual work that is the essence of an academic medical center, and the practical expression of that work in clinical practice. We genuinely believe that this collaboration between basic science and translational research will make a real difference, not only in the professional development of our students, but in the lives of the patients they will go on to treat as they pursue their own unique medical careers in their own unique ways.”
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“As a society, we all need innovative physicians and other health professionals who focus their energy and creativity on improving the entire system of health and health care. At the Dell Medical School, we prepare our students to positively impact the lives of individuals, communities and populations by inviting every person, every patient to become active, collaborative partners in the process of getting and staying healthy." S. Claiborne “Clay” Johnston, M.D., Ph.D. Dean, Dell Medical School Vice President for Medical Affairs, UT Austin Frank and Charmaine Denius Distinguished Dean’s Chair in Medical Leadership
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