The Three-Year MD: A Radical Rethinking of Medical Education

It has been more than a century since Abraham Flexner issued his seminal report on medical education, setting in stone four years -- two years of basic science followed by two years of clinical training -- as the time required to earn a medical degree, irrespective of a student's preparation or educational experience. Over the past three decades, however, the required post-graduate training period for a medical student has increased substantially. Meanwhile, the time spent in medical school has remained unchanged.

Today, medical school applicants manifest unprecedented levels of sophistication and quality, along with enormous potential to make significant contributions to society. Yet they enter the workforce older, typically burdened with crushing levels of debt. It is time for the current academic setting to address the training needs of the 21st century student and to recognize that the diversity of their talents and backgrounds will be better served by choice and differentiation in medical education.

In a recent "Perspective" essay published in the New England Journal of Medicine, we argue for the radical rethinking of medical education, and suggest that shortening medical school education is one approach to address the need for change in the post-Flexnerian era. Doing so would offer highly qualified students the opportunity to fulfill their medical school requirements in three years, without compromising the quality of their education. Additionally, earning a medical degree in three years reduces the cost of medical school by an estimated 25 percent, while adding another year of income for students by allowing them to enter the workforce earlier and practice longer.

Knowing that our students come to us better prepared, this fall NYU School of Medicine offered a select group of students the opportunity to enroll in our new three-year medical degree program. Additionally, we guaranteed those students residencies in NYU Langone postgraduate training programs, circumventing the time, money, and angst involved in auditioning for competitive residency programs -- a process that today largely consumes the fourth year of medical school -- and providing these students greater continuity between their undergraduate medical training and their residencies.

Obviously, this is approach is not for everyone, and we do not promote the three-year pathway as the only solution. Even the best students learn and excel at different paces, and some students will opt into masters or doctoral programs, or perform undergraduate research that will extend their training.

To the naysayers, we suggest that Abraham Flexner never envisioned students in the 21st century entering medical school armed with a comprehensive high-school and college educational background, or the dramatic shifts that have occurred in the delivery of health care. Armed with sophisticated educational opportunities, some with advanced degrees, they arrive to the classroom more committed and better prepared than ever for the rigors and challenges of practicing medicine. It is critical that American medical schools explore effective ways to streamline the education process. Providing choice for students to allow individualized growth and progression is one option -- one we believe will suit students, and the health of our nation, better.

source: http://www.huffingtonpost.com/robert-i-grossman-md/the-threeyear-md-a-radica_b_4032607.html

What ails medical education today?

Rote learning and quality of education has killed the essence of medical education. Students must be told not to fear failure as a learning process


Rote learning has killed the essence of education. To get near-100% marks in entrance examinations, students are encouraged to memorise facts. The whole education process isconstructed to check the recall capacity of students. Thus, trained and tutored students become memorising masters. Memorised facts, of course, slowly disappear from the association area of the brain within a couple of months, unless you keep memorising them daily.

This method of study could be detrimental in medical education where students should be able to understand and logically reconstruct the facts to get to the root of the real issue in disease management. The bad habits learnt in school persist through life. In medical education, students need to ask six important questions: who, why, where, what, when and how. Unless the student (especially if s/he becomes a teacher later) listens to these six questions and learns everything that way, it will be dangerous for patients.

The rote method of study also makes students subservient to what is being taught or written in the textbooks. They will never be given an opportunity to question any of the tenets being taught. Now, we also know that textbooks in medical college are mostly ghost-written by drug and instrumentation companies that want to brainwash young minds in medicine with their philosophy of do-it-fix-it strategy. Catch them young is their plan of action. What doctors do not get to study in medical school is much more profound than what they do get to study.

A simple example will illustrate this point. Physics teachers teach students that laminar flow of fluids cannot exert any lateral pressure on the flowing pipe. If they exerted any lateral pressure, the flow cannot go on! Students memorise this and get into the medical school only to find that blood pressure is the lateral pressure exerted on the vessel wall by the flowing blood. What is taught at school and at medical school are opposed to each other. However, students and teachers never ever get to realise this contradiction. They never think that everything in this universe flows by whirling and how the blood flow inside a closed blood vessel system flow is laminar. This blood flow eventually opens into a huge lake of capillary network of nearly 500,000 kilometres of capillaries where even a red blood cell cannot move freely as the capillary lumen is smaller than the diameter of a red cell! Nature has made the red cell into a dumbbell to facilitate movement through capillaries!

Since logical thinking is not what our educational system imparts, we do not realise that if the blood flows by whirling, how could our reductionist chemicals reduce the blood pressure for the good of the organism? An audit of 17 blood pressure lowering clinical trials reported in the six best medical journals of the world by Professor Uff Ravneskov and colleagues showed no significant difference between drug-treated hypertensives and those who followed lifestyle changes and dietary adjustment. This study did not audit the adverse drug reactions in patients who were on life-long treatment with chemical drugs. It could have been a prohibitively high incidence.

Medical students are made to believe that circulation of blood is solely due to muscle contractions of the heart. Of course, by the time they reach this stage of learning, students would have forgotten what they learnt in embryology—that we did not have any heart until the 20th week of gestation in the mother’s womb. Who pumped blood and circulated blood in the foetus until then? This is the ghost of memorising learning that was taught to our students in school. The earlier we change that, the better for mankind. The rot in the teaching-learning process is crying out for change.

The most dangerous omission in medical, nay, any education is the lack of ethical and moral content. We must teach students not to lie to their conscience. They must also be told that it is better to fail than to cheat. How else could one tolerate senior professors spreading white lies to make enormous amounts of money from drug companies, by creating new (non-existent) illnesses to facilitate drug companies to sell their drugs?

Professor Dr BM Hegde, a Padma Bhushan awardee in 2010, is an MD, PhD, FRCP (London, Edinburgh, Glasgow & Dublin), FACC and FAMS.

source: http://www.moneylife.in/article/what-ails-medical-education-today/34707.html

The Future of Medical School

As medical school enrollment begins to surge, medical schools must begin to close the widening gap between how students are trained and the future needs of the nation's health care system. Through its "Accelerating Changes in Medical Education" initiative, the American Medical Association (AMA) is already taking a step forward to close this gap by investing $10 million in innovative ideas designed to align medical student training with the quickly changing health care landscape. 
 
The following 11 recipient medical schools were selected for their bold, ground-breaking projects designed to alter medical education in a very big way

New Dual Degree Program

The Warren Alpert Medical School of Brown University

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Flickr by Alpert Medical School
Thanks to the grant award the Warren Alpert Medical School of Brown University will receive from the AMA, the school will move forward with its plans for a new dual -degree program in medicine and population health. The novel MD/ScM program will help develop physicians who, with training focused on public health, can be future leaders in community-based primary care. "The goal is to educate a new type of physician leader with a primary care background and the skills to promote the health of the population they serve," said Dr. Phil Gruppuso, associate dean for medical education. "The course of study will emphasize teamwork and leadership, population science, and behavioral and social medicine." According to the school's website, the funds will be used for planning, piloting, creating an admissions process, and evaluation. 

Enhanced Systems Based Learning Curriculum
Penn State College of Medicine

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Flickr by pennstatenews
With plans to implement a new component in its medical education curriculum in which students will serve as “patient navigators” it’s no wonder Penn State College of Medicine was among those chosen for this award recognizing and supporting innovation. The school will use its award to create Systems Based Learning, a new component of their curriculum. According to the school’s website, this new addition will allow students to serve patients in a meaningful way during their education, preparing them to work within all aspects of the nation’s evolving health care system. Penn State COM was the only school in Pennsylvania to receive the AMA grant and says the grant will position the school as one of the nation’s innovators in medical education. “As one of the nation’s leading integrated health systems, Penn State Hershey is in an excellent position to teach medical students how to provide excellent care while also helping their patients better understand and navigate a rapidly changing health care system,” said Dr. Harold L. Paz, CEO of Penn State Milton S. Hershey Medical Center and Penn State Hershey Health System, Penn State’s senior vice president for health affairs and dean of Penn Stat College of Medicine. “Ultimately, this will prepare our students to be better clinicians as well as effective leaders ready to develop innovative solutions for improving the quality, efficiency and accessibility of care.”

Curriculum 2.0
Vanderbilt University School of Medicine

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Wikipedia by Dansan4444
Designed to coach students how to become life-long learners, Vanderbilt School of Medicine’s Curriculum 2.0 may have been exactly what the AMA envisioned in what the future of medical education should look like. From introducing students to a clinical site
in the second month of medical school to self-assessments, personalized learning plans, faculty coaching, and curricular flexibility, Vanderbilt School of Medicine’s Curriculum 2.0 “represents the departure from a highly regarded, but traditional medical school curriculum to a complex, integrated, collaborative and flexible course schedule that includes less traditional lecture and more clinical and case-based experience.” The school will use its grant money to support changes within its Curriculum 2.0, as well as pay for enhancements in the school’s informatics infrastructure supporting student learning. “This is a validation that Curriculum 2.0 represents some of the most exciting and innovative ideas for medical education,” said Bonnie Miller, M.D., senior associate dean for Health Sciences Education. “It is just what the AMA is looking for. Through its grant, the AMA hopes to disseminate best practice to medical educators throughout the nation. We believe this funding and collaboration will allow us to accelerate the changes we hope to bring about with Curriculum 2.0, and to rigorously evaluate the curriculum’s effectiveness.”

From Flexner to Flexible

University of Michigan Medical School
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Flickr by University of Michigan MSIS
With a new curriculum that will put medical students in front of patients earlier in their  training, the University of Michigan Medical School is creating a way for students to build skills while working with patients and other health care professionals. Furthermore, the school plans to place a lot of attention on helping students develop leadership skills and their professional identity. According to the school’s press release announcing the award, the proposal continues the school’s long tradition of emphasizing accountability throughout the learning process, and strong training in the scientific underpinnings of human disease and also adds greater flexibility in how students will progress and choose to focus on certain areas. “We need to bring medical education into the 21st century,
where data-driven, team-based health care, grounded in science and quality, and informed by ethical, social and patient-centric factors, is the norm,” said Rajesh  Mangrulkar, M.D., associate dean for medical student education, associate professor
of Internal Medicine and Medical Education, and Principal Investigator of the proposal. “Our new curriculum will ensure we produce doctors who will be ready to lead changes in different aspects of health care that will have an impact on patients and their communities.” 

New Comprehensive Core Curriculum

The Brody School of Medicine at East Carolina University
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Wikipedia by Luca Masters
The Brody School of Medicine at East Carolina University will receive funding to train its students under a new comprehensive core curriculum in patient safety and clinical quality improvement. As with other innovative approaches, ECU will feature integration with other health-related disciplines to foster interprofessional skills and prepare students to successfully lead health care teams as part of the transformation. “Our medical schools today not only have the imperative to teach the art and science of medical care, but to train our graduates how to work in, and improve, complex health systems,” said Dr. Elizabeth Baxley, senior associate dean for academic affairs and professor of family medicine in the Brody School of Medicine. “Preparing students to work in teams with other health professionals is a hallmark of the needed changes, as is a better  understanding of the ‘health’ of a community and how we can positively impact that.” The grant will also be used to fund training for faculty members who will be tasked with teaching the new program. Faculty will work to engage students more actively in their own education through various strategies, including but not limited to, e-learning, simulation, problem-based learning, clinical skills training and targeted clinical experiences.

Integrated Care Coordination and Analysis Curriculum

New York University School of Medicine
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Wikipedia by Jim.henderson
Through the combined efforts of NYU’s Division of Education Informatics and NYU Langone Medical Center’s Clinical Integrated Network (CIN), NYU School of Medicine plans to roll out its new Integrated Care Coordination and Analysis Curriculum (CCAC) as soon as next year. According to the press release announcing its grant award, the CCAC project will feature innovative technology solutions and CIN’s collection of clinical practice data for the creation of a new program that will allow students to manage an authentic panel of patients within the CIN. “Our hope is that this robust curriculum will prepare our graduates to meet the future needs of the ever evolving healthcare delivery system by giving them the tools and skills necessary to care for not just an individual patient, but for an entire population of patients,” said Marc Triola, M.D., associate dean for education informatics, assistant professor of medicine, director, Division of Educational Informatics at NYU School of Medicine, who is the principal investigator for the CCAC initiative. Using what they call, ePortfolio, students will be tested and evaluated to measure their progress, serving as a way to integrate a variety of data, including computer-based exams, simulation center performance, clinical evaluations, and patient logs.

Bridges Curriculum

University of California - San Francisco School of Medicine
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Susan Merrell / UCSF
In an effort to “reboot” the medical school curriculum, the University of California San Francisco is transforming physician training through its Bridges Curriculum. Preparing students to contribute more than clinical expertise, the school hopes to will train students to collaboratively and continuously innovate to improve the country’s health care and biomedical discovery systems. The school says they will provide “authentic workplace learning experiences that leverage the talents and commitment of students to improve health today while sustaining these skills in future practice.” “We are excited that
the AMA has recognized the importance of UCSF’s vision for a curriculum designed to prepare graduates who are experts in providing patient-centered care, as well as in working collaboratively within interprofessional systems to continuously improve the quality, safety and equity of health care for all,” said Catherine Lucey, M.D., vice dean for education at the UCSF School of Medicine.

M.D. Curriculum Transformation
Oregon Health & Science University School of Medicine

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Wikipedia by M.O. Stevens
In 2012, Oregon Health & Science University School of Medicine was ahead of the game
when it launched its Curriculum Transformation initiative, which will now be amplified and accelerated thanks to funding from the AMA grant. Through the initiative, 
the school is looking to answer the question: What will society need from physicians and
health care professionals over the next 20 to 30 years? “Transforming medical education
is essential to maintaining and enhancing education excellence at OHSU, and to  contributing to the evolution of Oregon and the nation’s health care landscape,”
said Dean Mark Richardson. “The physician of the future will require different skills as we move into a new era in which genetics, health care reform and technology will exert strong influences on the future health care landscape.” Some of the school’s guiding
principles behind its innovative curriculum include acknowledging the different learning styles among students, emphasizing student-centered instruction, active learning over passive learning, and application and synthesis of knowledge in critical reasoning
over memorization.

Accelerated Competency-Based Education in Primary Care Program
University of California Davis School of Medicine

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Wikipedia by Coolcaesar
Focused on an elite group of medical students committed to careers in primary care, the University of California Davis School of Medicine’s innovative training comes in the form of an unconventional program called the Accelerated Competency-based Education in Primary Care (ACEPC). The program, which will be funded through the AMA’s grant
award, keeps students for three years, including training and education during the  summer. Through the program’s partnership with Kaiser Permanente, students will
have the opportunity to gain clinical experiences, gaining immediate and valuable exposure to patient-centered clinical practice. Additionally, students learn patient-focused communication, population health, chronic disease management, quality improvement, team-based care and preventive health, emphasizing providing care to diverse and undersreved patients. “ACE-PC is an intensive, integrated, current approach to education for a subset of highly motivated students who know what medical specialty they want to pursue,” said Tonya Fancher, UC Davis associate professor of internal medicine and principal investigator for the grant. “The need for generalists is greater today than ever before and is expected to grow as health-care reform is implemented. We applaud the AMA for being a catalyst in addressing this critical need.”

New Second Degree Option
Mayo Medical School

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Wikipedia by Jonathunder
To speed change in medical education, Mayo Medical School has created a new model for undergraduate education that gives students the option of completing a master’s degree in the science of health care delivery as they earn Mayo medical degrees. In  collaboration with Arizona State University (ASU), Mayo will expand its reach to the Phoenix metro area. “The health care landscape is changing so quickly, and we need to ensure that medical education keeps pace,” said Michele Halyard, M.D., vice dean of Mayo Medical School. “We are eager and ready to implement the transformative changes needed, such as the science of health care delivery degree, with ASU to respond to the future needs of patients.” According to the school’s website, the master’s degrees  components include social and behavioral determinants of health, health care policy, health economics, management science, biomedical informatics, systems engineering and value principles of health care.

Virtual Health Care System Curriculum
Indiana University School of Medicine

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Photo Courtesy of Indiana University
To prepare students for practice in a changing care delivery system, Indiana University School of Medicine will introduce its novel virtual health system curriculum, utilizing a teaching version of an electronic medical record that incorporates actual patient data - with identifying information removed. The school hopes that its innovative approach to training students will provide the realistic environment needed to develop clinical decision-making skills. In addition, students will have the opportunity to monitor health care decisions and costs, compare their decisions to those of practicing physicians and to
their peers, and learn how huge quantities of data and genomic information are changing the way health care is delivered. “It’s critical that students learn about how systems of care delivery affect the health of their patients and about how patient and social factors impact both health and disease,” said Dr. Gusic, Dolores and John Read Professor of Medical Education and professor of pediatrics. “Importantly, this proposal meets our institutional mission to advance health in the state of Indiana and beyond by promoting excellence in education and patient care.” 

source: http://www.premedlife.com/1/post/2013/09/the-future-of-medical-school-a-closer-look-at-how-eleven-medical-schools-are-changing-the-look-of-medical-education-for-tomorrows-doctors.html

There Is A Serious Shortage Of Primary Care Doctors And It's Only Getting Worse

Approximately 5,000 new graduates enter primary care training each year. The problem is, we need a lot more than that.

The U.S. will face a shortage of more than 90,000 primary care physicians by 2020 and 130,000 by 2025, according to nonprofit firm the  Association of American Medical Colleges (AAMC).

But it gets worse. Under the  Affordable Care Act, also known as Obamacare, millions of formerly uninsured people will have access to health care. It's estimated that 14 million people will be enrolled by 2014, which means the demand for physicians is crucial in the coming years. Not to mention America's population is aging fast.

Primary care doctors already have to see more patients than non-primary doctors on a daily basis and they don't get much time to spend with each patient, according to a new study conducted by Nerdwallet Health. They also make , on average,  65% less than non-primary care doctors, yet are required to go through similar years of higher education, completing eight years of undergraduate and graduate education and at least three years in residency, for a total time investment of more than a decade.

Physicians who work in g astroenterology, orthopedics, and radiology — the top ranked medical specialties — have an average salary of  $365,000, whereas physicians who work in pediatrics, family, and internal medicine — the lowest ranked medical specialties — bring home around $177,000 annually.

After graduation, the median annual stipend for residents and fellows is around  $55,750, yet 79% of medical school graduates acquired education debts of over $100,000 in 2012, the study found. The average medical school debt last year was  $166,750.

When you consider high tuition cost, years of intense study and training, and an influx of patients primary care doctors are faced with while making considerably less money than other speciality doctors, it makes sense that medical students want to maximize their incomes by choosing a higher-paying specialty.

Below is a chart by Nerdwallet Health comparing doctor compensation with other factors, including total hours worked and weekly  patient visits among the 15 most common medical specialties:

medical specialties

NerdWallet

What should be done to fix this shortage problem? Should medical school take a step to encourage students to go into primary care? Please let us know in the comments section. (Vivian Giang)

source: http://finance.yahoo.com/news/serious-shortage-primary-care-doctors-201600535.html

Teaching Empathy in Medical School

Technology is becoming increasingly integrated in our every activity, including the practice of medicine. Nowadays, robots are capable of providing assistance in surgical procedures, they enable doctors to visit with patients remotely, and some are even starting to make diagnoses and treatment decisions. Such space age innovations raise the question: are actual doctors still necessary? As the current and former deans of Weill Cornell Medical College, we feel that the answer is a resounding yes. Nothing can replace the human interaction between a doctor and a patient.

Still, recent reports in the media have described a widespread problem of physician burnout. Faced with the complexities of our healthcare system, doctors are working longer hours, seeing more patients, and being overwhelmed with administrative paperwork. Emotionally and physically exhausted, they may not be able to empathize and provide the best care to each and every patient. Physician burnout is a serious issue that not only affects the medical care that people receive today, but it also contributes to an ongoing shortage of doctors that could have adverse consequences long into the future.

At Weill Cornell, we want our students to develop lifelong habits of empathy that will stay with them throughout their medical careers. Our goal is to produce doctors who are highly proficient in both the scientific and the humanistic aspects of medical practice, so that they remain focused on treating the whole person, not just the outward signs of their diseases.

In our experience, most young people aspire to become doctors because they truly want to help others. When students first start medical school, they are often very empathetic. They are idealistic and desire to become healers, caring for rich and poor alike. Sometimes, however, the ability to connect emotionally with patients decreases during medical school, residency, and on into a doctor's career. One study has shown that empathy significantly declines in the third year of medical school, when extensive exposure to clinical settings typically first occurs.

Being able to connect emotionally with patients makes them feel supported and understood during what are often very stressful times in their lives. Having a compassionate doctor can also positively affect a person's health. A recent study looked at diabetic patients and found that those who had physicians with higher empathy scores were more likely to have blood sugar and cholesterol levels that were under control. One explanation for this finding is that patients may be more likely to follow instructions if they trust their doctors and feel personally cared for. In another study, patients with colds were seen either by doctors in a standard visit or by doctors who had received special training to make direct eye contact, touch patients, and spend more time with them. The people who rated their doctors as the most empathetic recovered from their colds sooner than the rest of the group.

Some institutions have begun to offer empathy training for their clinicians. At Weill Cornell, we have a number of initiatives that aim to cultivate empathy and humanistic values in our students. Last year, we launched an innovative pilot program that will eventually give students the opportunity to follow one or more patients over the course of their entire four years of medical school. Currently, one first-year and one second-year student are paired together under the supervision of a faculty mentor. Students build relationships with patients by attending doctor's appointments with them, contacting them regularly, and conducting an annual home visit to understand how their diseases impact their daily lives. Students are asked to keep a reflective journal about their experiences, and they participate in monthly mentoring sessions where they discuss psychosocial issues relevant to their patients. A major goal of the program is to prepare students to deliver empathetic, socially, and ethically responsible care by providing them with exposure to patients from the very beginning of their training.

Weill Cornell also has a longstanding Humanities and Medicine program that is designed to help students better understand patient experiences through literature, art, and music. We bring artists and writers to campus to speak to students, and we have electives that allow students to approach medicine through the study of art at a museum and by reading literary pieces. We recently introduced a third-year seminar on "Mindful Practice and the Art of Medicine" to encourage self-reflection. In addition, a group of medical students launched a journal last fall, called Ascensus, which explores the humanistic side of medicine through poems, art, prose pieces, and even a musical number contributed by members of our community.

Similarly, our Music and Medicine Initiative gives students the opportunity to continue pursuing their passion for music during their medical training. Each year a group of students performs at our commencement exercises at Carnegie Hall. Music and Medicine participants also perform at various benefit concerts at the medical college and for patients and families at our affiliate, NewYork-Presbyterian Hospital. We have partnered with The Juilliard School, which provides musical mentors for our students, and in return we offer specialized medical care to their musicians and organize seminars on performing arts medicine.

Another way to teach students to be open, respectful, and engaged with patients of every kind is to encourage international experiences, which help to broaden their experience of the world. At Weill Cornell, we have a very strong global health program, particularly in Qatar, Tanzania, and Haiti, where many of our students, faculty, and residents participate in educational exchange programs. Almost half of our students take international electives during the summer and have rich experiences seeing very different kinds of patients and health care facilities than they would normally be exposed to.

Our students have also started initiatives of their own, such as the Weill Cornell Community Clinic, which has provided free or low-cost primary medical care to uninsured patients since 2006. Under the supervision of an attending physician, students handle all medical and administrative responsibilities for about 350 patients each year. Another example is the Weill Cornell Center for Human Rights, which provides forensic medical evaluations to survivors of persecution seeking asylum in the United States. Founded in 2010, it is the first student-run asylum clinic at a US medical school. So far, 30 clients have gained asylum or another form of legal protection, and 187 students and physicians have been trained to conduct evaluations for people seeking asylum.

Educational programs and initiatives such as these underscore the fact that a person's health is affected by a myriad of socioeconomic, cultural, and behavioral factors, in addition to biological ones. An increased awareness of the human and social components of health characterizes the current field of medical education in general. For example, the Medical College Admission Test (MCAT) is being revised so that the humanistic aspects of medicine will be addressed more directly. Beginning in 2015, students will have to answer questions in the behavioral and social sciences and the humanities. Major aims of the revised MCAT are to promote a more holistic understanding of health and to ensure that future doctors will be able to empathize with patients from a diversity of backgrounds. This approach represents a major shift in the test, which has traditionally focused almost exclusively on the physical and biological sciences.

As medical educators, the most important message that we can send to our students is this: "Keep the patient at the center of everything you do." Patients visit doctors seeking help and hope. They are looking for guidance during difficult times, and they need to be treated with compassion and sensitivity. Technology--whether a robot or a DNA sequencer--can provide a lot of information and make our jobs easier, but there is no substitute for a caring relationship between a physician and a patient.

In the fifth century BC, Hippocrates wrote: "Where there is love of humanity there is also love for the art of medicine." Our goal at Weill Cornell is to instill the art of medicine, not just the scientific method, in our students. We want our young physicians to be technically proficient, but perhaps more importantly, we want them to empathize and to heal.