Building a Better Doctor

The Virginia Tech Carilion School of Medicine is one of the nation’s smallest medical schools, with an average of 42 students per year, and among its youngest. But these facts haven’t stopped the school’s administrators from taking on a big mission: creating a new kind of doctor for a new world of medicine. If anything, fledgling status has proved to be a distinct asset.

“When you’re starting from scratch, you have a big advantage,” says Daniel Harrington, M.D., vice dean of the medical school and vice president for academic affairs at Carilion Clinic. “You’re able to create something that is different.”

And it’s that word—different—rather than small or young, that perhaps best describes the school. In less than a decade since it welcomed its first class in 2010, Virginia Tech Carilion has earned national recognition for innovation. The medical school has reached for bold, new approaches to every aspect of creating new clinicians, from how it admits applicants to how it instructs them to how they interact with the community around them.  At a time when doctors must stay current with dizzying technological and biomedical breakthroughs, the need has never been greater for clinicians to be sensitive to the human side of medicine. The product of a partnership between Virginia Tech, a renowned research institution, and Carilion Clinic, a health care system with a long tradition of community-based medicine, the Virginia Tech Carilion School of Medicine seems almost uniquely qualified to produce doctors with abundant skills on both sides of that equation. The process begins with the application.

Finding the Best Candidates

From the start, the school’s leaders believed that traditional admissions benchmarks such as academic grades, standardized test results, and formal interviews—while important—failed to reveal key characteristics about which candidates have not just the work ethic and technical skills, but also the human skills required to be effective clinicians.

To help admissions officers gauge those vital qualities, applicants—who now average more than 4,000 for those 42 annual spots—undergo a “multiple mini interview” process, originally developed at McMaster University in Hamilton, Ontario. Virginia Tech Carilion was among the first U.S. schools to recognize its advantages. Applicants arrive in Roanoke over a weekend, where they have the opportunity to meet and mingle with faculty members, administrators, and current students and learn about the school’s patient-centered curriculum. But the heart of the weekend is a full Saturday of one traditional interview and nine decidedly nontraditional interviews.

For the nontraditional sessions, applicants rotate through interview stations. At each one, the applicants read a brief scenario that evokes a medical or ethical question. They then enter a room to have an eight-minute conversation with a member of the community to share their thoughts about the scenario.

 “The interviewer might be a faculty member, a minister, a retired physician, a teacher, or a shopkeeper,” says Dr. Harrington. “That person won’t have seen the student’s CV or background.”

All interviewers have an interest in the medical school and are trained in the interview process. Otherwise, though, the conversations are unscripted, without right or wrong answers. According to Richard Vari, Ph.D., senior dean for academic affairs, “This process gives the interviewer an inside look into the student’s ability to think quickly, reason through a problem, and perform under stress.” Questions and follow-ups can help determine how, for example, a student responds to being put on the spot—with equanimity, or by becoming combative. All of this amounts to much more than a feel-good exercise in community relations. Applicants who excel across the multiple mini interviews can rise to the top of the pool, in some cases ahead of those whose college grades and board scores are better.

The Human Side of Medicine

Once the interviews and the application process have yielded a carefully chosen class, the students begin their journey through the medical school’s four “value domains”—basic science, clinical science, research, and interprofessionalism. These form the basis of the school’s approach to medical knowledge and clinical skills, woven throughout all four years. A central tenet of Virginia Tech Carilion’s educational philosophy is developing compassionate and scientifically minded future physicians, and one way this happens is through problem-based, patient-centered learning.

“We teach clinical skills and clinical reasoning from the very first day of medical school,” says Dr. Vari. “It’s not saved for years three and four, as in some schools.”

Working in groups of seven, students meet three times a week to learn about actual patient cases. The focus at first is on science and clinical diagnosis. When the students are studying the cardiovascular system, for example, they may be presented with a case study of a patient dealing with a cardiac or systemic vascular condition.

“By examining the case, the students uncover all they know about the cardiovascular system—the anatomy, the physiology, the pharmacology,” says Dr. Vari. “More important, they uncover what they don’t know.”

Over the course of the week, the students research the condition on their own, then present back to the group, offering one another constructive feedback on the strengths and weaknesses of their reasoning. After a final team discussion on Friday, next comes a crucial step—the chance to meet the actual patient who has been the subject of the week’s study. According to Dr. Vari, it’s a chance to drive home to medical students that the enzymes, blood type, heart rate, biochemistry, and pharmacology they’ve been analyzing all week add up to someone with a life, a job, a family, and emotions.

“What they’re now exploring is the human side of this patient who happens to have this disease,” says Dr. Vari, who adds that less than 5 percent of medical schools are able to offer patient wrap-ups. “It puts the learning of their basic science, clinical reasoning, clinical skills, research, and interprofessionalism in the construct of a real human being.”

“It’s a wonderful way to learn,” Dr. Harrington says. “Our students have thrived with this model.”

Vital Community Connections

Members of the community play an important role in helping students learn how to interact with patients, ask questions, and diagnose conditions. The medical school’s 10 exam rooms serve as home for the standardized patient program, where students, starting in their first year, examine “patients” simulating conditions the students are currently studying. While the standardized patients undergo significant training in order to represent various conditions, they do not necessarily have medical backgrounds, says Tracey Criss, M.D., associate dean for clinical science, years 3 and 4.

“The program brings a sense to the community that our standardized patients are part of educating our students,” Dr. Criss says. “Community members really feel like a part of the school. They’re helping educate the students to be better caregivers, as physicians, when they graduate.”

As the students proceed through their years, the simulated situations become more complex, testing both their medical acumen and their ability to handle delicate and often emotional situations, including issues involving quality and safety. Dr. Criss describes one scenario in which a student must inform a patient and a family member that, due to medical error, a chest tube has been inserted on the wrong side of the body. In the tenseness of the moment, the fact that the patient and family member are playing roles seems not to matter.

“Our students don’t know, when they walk in the room, how that simulated patient and family member are going to react,” Dr. Criss says. “Sometimes they respond with calmness and sometimes with fear, anxiety, and anger. Students have to spontaneously react to the emotions of that patient.”

Research as a Core Requirement

Research, something not always prioritized at other schools, plays an integral role at the medical school. Regardless of the medical specialties they hope to pursue, all students must become “scientist physicians”—a term coined by Michael Friedlander, Ph.D., senior dean for research at the medical school, to describe both the primacy of the doctor’s calling and the essential role that research plays in it.

Research is central to all four years of training, totaling more than 1,200 curriculum hours. In years 2 through 4, each student is allotted $1,000 a year for supplies, and each is expected to produce an original research project starting in the first year, culminating with a final manuscript of publishable quality in the fourth year. The need for that emphasis may seem obvious for someone bound for a career at a major teaching hospital. But why so for someone hoping to serve as, say, a primary care physician in rural Virginia? As Dr. Friedlander sees it, training students in a scientifically rigorous context aims to create a more complete clinician.

“You approach all your patients and all medical situations from a human perspective, but also from a rigorous scientific perspective,” says Dr. Friedlander, who also serves as executive director of the Fralin Biomedical Research Institute at VTC. “You are versed in the most contemporary scientific understanding of the patient’s condition, and you have actually done biomedical research. Moreover, when you don’t know the most scientifically validated approach to a particular issue, you have the skills, confidence, and knowledge to find that information and deploy it on your patient’s behalf.”

Dr. Harrington adds, “By the time students graduate, they understand how to ask questions and are skilled in finding the answers.” That idea dates back a decade or more, when Dr. Friedlander, then a faculty member at the Baylor College of Medicine, served on a national task force of the Association of American Medical Colleges and the Howard Hughes Medical Institute dedicated to the scientific foundations of future physicians.

“Medical education was not keeping up with the scientific revolution in the biomedical science space,” he recalls. “There has been a revolution in molecular biology, molecular genetics, neuroscience, computational bioscience, and other areas. Even as advances were profoundly influencing how medical conditions are diagnosed, medical schools were still teaching medical students the same old way.”

Dr. Friedlander saw the opportunity to help forge new approaches to teaching at the foundational level of the nascent school. “From day one, students are exposed to possibilities for doing research,” he says. “They meet researchers from the Fralin Biomedical Research Institute and the main Virginia Tech campus in Blacksburg, research–oriented physicians from Carilion Clinic, and leading scientist physicians who visit from across the country to present the latest advances while aligning with the students’ current classes and patient case presentations.”

The results have been impressive, with students involved in nearly 60 published papers and more than 250 presentations at regional, national, and even international medical meetings. “We think we’re putting out something the country badly needs,” Dr. Friedlander says. “Even with all the new algorithms and electronic medicine, electronic health records, and computational capabilities, we need people who understand the science of medicine and are ready for the next big changes.”

Learning Across Professions

Even as Virginia Tech Carilion strives to create superior individual clinicians, a key driver of the school’s educational philosophy is that no doctor is an island. Studies have shown that flawed communication among health care professionals accounts for some 70 percent of medical errors. With that in mind, the school became the first in the country to integrate interprofessionalism across its entire, four-year curriculum. In conjunction with another pioneer in adopting shared learning—Jefferson College of Health Sciences, now known as Radford University Carilion—future doctors study with tomorrow’s nurses, physician assistants, and allied health professionals.

“They’re learning roles and scopes, conflict resolution, and team-oriented best practices,” says Dr. Vari. Teamwork, he notes, increasingly personifies “the art of medicine and the practice of medicine.” The students examine ethical dilemmas in health care, approaches to leadership, and strategies for overcoming personal biases and other issues.

“It’s preparing them for the real world of health care where they’re going to have to work with colleagues who aren’t physicians,” Dr. Vari says. In some cases, lessons in teamwork and empathy move beyond the confines of medicine. As one part of the program, for example, students work together to prepare nutritious meals for needy members of the Roanoke community. In one of the most intensive exercises, the medical students work with students in other health professions on disaster drills. Administrators may simulate the aftermath of a serious interstate accident, a terrorist attack, or a natural disaster. Students, given pieces of information, must respond in real time, assess the condition of trained “patients,” and, most of all, work together to solve problems and save lives.

“They’re paying a lot of attention to the patient, and at the same time they’re gathering information from other team members,” says Dr. Criss. “What you see is students recognizing the value of the team approach.”

Innovation Across the Board

These creative approaches to medical education foster a spirit of innovation that permeates the school. In 2010, for example, Virginia Tech Carilion, with the support of Sonosite, Inc., integrated advanced portable ultrasound machines into the curriculum, enabling students to master an evolving technology that will be essential to their ability to offer patients the best care. In 2018, the school purchased newer, state-of-the-art portable ultrasound equipment to enhance the students’ mastery of the skill.

The school is also one of the few in the country to make oral health part of the curriculum, thanks to philanthropic gifts and a partnership with Delta Dental of Virginia, amid growing awareness of the key role that oral health plays in a patient’s overall well-being. The drive to innovate is sure to continue under Virginia Tech Carilion’s new dean, Lee Learman, M.D., Ph.D., who sees the school’s size and youth as major advantages in advancing the mission of innovation guided by its goals to create new doctors for a new world. Where will this grand new experiment in medical education ultimately lead? Ever the researcher,Dr. Friedlander says, “We don’t have enough data yet.”

It may take 15 or 20 years to determine whether Virginia Tech Carilion’s innovations are truly helping to produce better clinicians. But what he does hear are stories—and they’re great. “We hear wonderful, wonderful things,” Dr. Friedlander says. “Our graduates are star residents in their programs, highly regarded by the physicians mentoring them. And residents from other medical schools are wowed not only by their knowledge, but also their ability to move facilely between scientific discovery and the delivery of quality clinical care.” Dr. Learman agrees. “I anticipate that, over the next decade, we will go from being one of the most outstanding new medical schools,” he says, “to one of the most outstanding medical schools in the country, period.” 

A New Dean, Building on Success

When Lee Learman, M.D., Ph.D., took over the helm of the Virginia Tech Carilion School of Medicine this summer, he began with the intention of listening. “One of the most important aspects of my first year will be to think deeply about the strategic planning process for the school of medicine with broad stakeholder input,” the new dean says.

He’s looking at how the school might expand while keeping in place what makes it special—the individualized attention for students, the focus on research and patient-centered learning, and the strong connections to the community. With 25 years as a leader in medical education, Dr. Learman is no stranger to helping young medical schools succeed. He most recently served as senior associate dean for graduate medical education at Florida Atlantic University’s Charles E. Schmidt College of Medicine, which opened its doors in 2011.  

“I’ve always been attracted by several elements I see as high priorities at the Virginia Tech Carilion School of Medicine,” Dr. Learman says. “These include humanism and professionalism in medicine, as well as the scientific basis of medical practice.” Dr. Learman adds that he appreciates the school’s emphasis on its connections with the community. “A top priority will be deepening my understanding of our community,” he says, “and by that I mean not only the Roanoke community, but the larger community of people who care about this medical school and want to see it grow and succeed.”

By Charles Slack