Imagine the brain, its various pieces highlighted like a Technicolor yarn ball. Now imagine you can pluck out the pieces, the frontal lobe, the cerebellum, the thalamus. From the middle you grab the basal ganglia. There, in front of your eyes, two little conches. You enlarge them, turn them around.
This is what you can do when human bodies are made digital. Using virtual cadavers is one of the ways that the not-yet-open Kaiser Permanente School of Medicine is planning to reinvent how to teach medicine.
In the last decade, a lot of questions have arisen about how America should evolve its healthcare system to be less costly and more caring. The proffered solutions range from changing how we pay for health services to thinking more holistically about what prevents people from staying healthy. As part of the discussion, medical schools have gone under the microscope. Several are already making changes to curricula to reflect the challenges of treating patients today. But one school has a chance to build a new framework for medical students from the ground up. Kaiser Permanente’s medical school is set to open in the summer of 2020. The school will take a technology-forward approach that teaches students how to treat with compassion.
Bringing cadavers online
Rather than teaching anatomy through slicing into medical cadavers, Kaiser Permanente’s School of Medicine will have large touchscreens displaying body parts in 3D, ready for digital dissections. Students will also learn to navigate the human body through virtual reality headsets and mannequin bodies. With the flick of a sonogram wand, students can pull back muscle and tissue, or inspect cross sections of organs.
Jose Barral, chair of biomedical sciences at Kaiser Permanente’s School of Medicine, says that students learn just as much through digital renderings as they do through physical cadavers. “Retention is about the same as the traditional cadaver dissection,” he says. “The difference is efficiency. They do it much faster and it allows for prolonged and frequent exposure.” Students will not only have access to the touchscreens in the anatomy lab, but the school will also give them tablets so they can access the same software at home.
The school will still have plastinated cadavers, which are human bodies that have been pre-dissected and preserved. The reason for having these real human parts is primarily to show students how human bodies vary. “We are more different on the inside than we are on the outside,” Barral says.
We are more different on the inside than we are on the outside.”
But for both learning about body architecture and practicing making cuts, the school prefers the virtual version. The founding dean at Kaiser Permanente Medical School, Mark Schuster, says that first-time medical students are often shocked at how different human bodies are in vivo from the cadavers they learned on. Cadaveric muscles, for example, exist in a sort of in-between state that is neither flexed nor relaxed. They can also decay and often smell like embalming fluid.
For several reasons, including financial expense, cadavers have been on the way out for more than 20 years. Back in 1996, schools were already introducing virtual dissections on desktops conjured via CD-ROM. By 2018, doctors were considering whether cadaveric dissections were necessary at all. In a poll, 58% of doctors, including surgeons, felt that cadaver dissections could be replaced. Technology has also advanced so much that students can not only turn body parts over in the air, witnessing their various folds and shapes, but they can work with digital humans that can behave like sick bodies.
Through a virtual reality headset paired with a dummy body, students can practice treating patients in various states of distress. “We can vary their heart rate, we can give them a heart attack, we can deliver a baby,” Schuster says. “Students can inject, can learn how to put in an IV and draw blood.”
Redesigning medical school
Kaiser Permanente’s medical school makeover isn’t just about technology, though that is a piece of how it intends to teach medicine differently. The school is attempting to reinvent medical school from top to bottom. It will eschew lecture-style classes in favor of small groups. There will be a nutrition kitchen where students will learn to cook meals for themselves and how to share healthy recipes with patients. Students will also be taught to consider mental health as well as physical. The program integrates biomedical science (physiology, anatomy, and biochemistry) with diagnosis and treatment.
Schuster also wants students to understand not just how to practice medicine, but how to navigate the larger system—an area called health system science. They’ll learn health policy, how billing works, and the hurdles that individuals face in getting care. To see how all these disciplines operate together, students will work at community health centers that cater to Medicare and Medicaid recipients.
“When you tell the patient they need to exercise more, do you find out whether they live in a neighborhood where they can go out for a run at night or is it too dangerous? Is there a park down the block that’s dark at night, but if there were lights put in, everybody would use it, including your patient?” Schuster says.
He believes that teachers should be helping students understand how they can problem-solve barriers to healthy living for their patients. “If your patient can’t call Parks and Recreation and get them to put in lights because they’re just one citizen, can you as a physician with an MD at the end of your name and the confidence that comes from taking care of many patients in that community call Parks and Recreation and point out to them the value of putting in lights?”
It soon became clear [students] did not even know the basics of Medicare or Medicaid.”
Medical schools have traditionally focused more on medicine and treatment than environmental factors. In recent years, doctors have bemoaned how underprepared medical students are for operating inside of the healthcare system. In January 2018, Dr. Rusha Modi, a faculty member at the University of Southern California Gehr Center for the Implementation of Science, wrote an op-ed complaining about medical students’ illiteracy on public health. Through chatting with medical residents on rounds at the county hospital where he worked in 2017, he found they knew very little about an important healthcare bill being considered at the time. The bill, put up by Republican senators Lindsay Graham and Bill Cassidy, would have repealed the Affordable Care Act.
“The students had no idea what this bill contained,” he wrote. “Their lack of knowledge extended beyond the fights over repealing the Affordable Care Act. It soon became clear they did not even know the basics of Medicare or Medicaid.” Medical schools, he concluded, are failing to prepare the doctors of tomorrow for the world they are heading into.
Beyond the biological
This call for changes at med school comes as the healthcare system at large is rethinking patient health. Healthcare centers are thinking more broadly about how to incorporate mental healthcare into physical healthcare, or how to factor in various external aspects about a patient, such as where they live, into treatment plans.
In turn, some medical schools are already shifting the curriculum to give doctors a stronger foundation for practicing medicine in this new world. In 2011, the American Medical Association gave 11 schools $1 million to reinvigorate their programs with the larger health system in mind. That has lead to health systems science becoming a core part of the curriculum in at least three schools: the Mayo Clinic School of Medicine, Pennsylvania State College of Medicine, and A.T. Still University School of Osteopathic Medicine. The AMA has since called on all medical schools to incorporate more health systems learning into their programs.
At Kaiser Permanente’s school, a focus on health systems will also mean looking at doctor burnout, which has not only led to high suicide rates among doctors but also to substandard care for patients. Students will be taught tactics of resilience. “We will have two psychologists on staff, and students will be expected to see them at least three times during the first few months of school,” Schuster says, adding that it’s harder to feel stigmatized when everyone is seeing a therapist.
“We are really trying to spend time thinking through what is most useful for students—what will help them learn how to be outstanding doctors.”