Editor-in-Chief of Academic Medicine, Dr. David Sklar
Jun 5, 2014
Academic Medicine is the flagship publication of the Association of American Medical Colleges, and for good reason. Each month it is filled with commentaries, research reports, and other articles related to improving medical education. From reducing medical student debt to promoting interprofessional collaboration, Academic Medicine articles have a real impact on the dissemination of ideas within medical education, and almost assuredly have affected your medical training at some point.
We had the distinct opportunity to speak with the Editor-in-Chief of Academic Medicine, Dr. David Sklar, who also serves as Associate Dean of Graduate Medical Education and Chairman of Emergency Medicine at the University of New Mexico School of Medicine. He describes his path to medicine and Academic Medicine, and shares advice that medical students can take to heart.
How did you decide on a career in medicine and, eventually, academic medicine?
I first became interested in medicine through international experiences. Before medical school I was a teacher in the Philippines. During my time there, I witnessed the devastating health effects of a typhoon that ruined the lives of several of my students and their families. I recognized how vulnerable they were to a sudden health problem and how limited I was as a teacher of English to be able to help, which was one reason I became attracted to medicine.
My next international experience was working in a clinic in Mexico immediately before starting medical school, which was the subject of a book I wrote called La Clínica. It was there that I realized how large the gap was in terms of available resources such as clean water and electricity, which made me start thinking about how we actually deliver health care.
Then when I started medical school, like most people I got pretty hooked into the science of medicine and realized there were huge gaps and questions that needed to be answered. It was a revelation to realize that so much of what we did in medicine was not based on scientific evidence, but rather a custom that had come down through the years, which wasn’t necessarily wrong, but did not have a strong scientific base. That helped me develop an interest in academic medicine and questioning whether we could improve the status quo.
What made you pick emergency medicine as a specialty?
Around the time I began medical school, emergency medicine was barely recognized as a specialty. Most of the people who worked in the ED came from a variety of backgrounds, ranging from internal medicine to surgery, and rotated through the department when they were on call. Emergency medicine wasn’t really defined as a specialty in and of itself till the late 1970s and early 1980s.
My personal decision to pursue emergency medicine was actually made during my internal medicine residency. While I rotated through the ED I began to really enjoy the diverse mix of patients and their presenting issues. The ED seemed to be the place where patients whose problems had not been diagnosed came. These were often people who had not seen many doctors, if any. Another aspect of the ED that I liked was that it seemed to be a level playing field where everybody was treated pretty much the same way. We didn’t know which of our patients was the banker or the maid, and we didn’t care because we triaged based on severity of their symptoms. It was likely the same thing I found attractive about global health, and it seemed that my personal contributions would be more meaningful in this environment.
Emergency medicine also appealed to the writer within me because there were so many interesting stories. Even people whose medical problems were not very serious often had such fascinating lives. For example, a 90-year old with shortness of breath could tell me about how she’s seen the world change over the course of nearly a century.
One other part of emergency medicine that drew me in was the fact that it was a new field, which offered many opportunities to make significant contributions. I became a program director in emergency medicine and ultimately chairman of the department. Later on I started branching out into other areas of healthcare because I realized that problems in the ED could be viewed as the proverbial “canary in the coal mine” reflecting broader issues, such as lack of access to primary care clinicians. That is how I became more involved in health policy and understanding the delivery and payment systems of our health care system.
Can you describe your journey from writing as a hobby to serving as Editor-in-Chief of Academic Medicine?
I always enjoyed writing, even as a high school student. It was something that I found I could do well and receive a lot of personal fulfillment in the process. Writing helped me reflect and make sense of the world, which was instrumental in my individual development. This is one reason I’m excited to see narrative and reflective medicine being integrated into many medical school curricula.
I made the transition from writing as a hobby to writing as a profession primarily during my years as program director of an emergency medicine residency. I had the good fortune of having a number of trainees who were very talented writers. My program encouraged residents to do projects, ranging from research to community service initiatives. One of my students, Frank Huylar, decided to write a book about his experiences in our emergency department. Initially I was dubious about the feasibility of completing such a significant undertaking as a resident, but Frank was persistent. I decided that we could write in parallel and critique each other’s stories so that we would challenge each other and develop our crafts together.
I started writing about experiences I had from that clinic in Mexico. I had previously written drafts of stories from that time, which I found and rewrote. Meanwhile he was writing his stories, which blew me away in terms of their quality. Eventually he published his book, The Blood of Strangers: Stories from Emergency Medicine, which is still used in many schools and classrooms around the country. Admittedly, my book took a lot longer.
This experience re-energized my passion for writing and I soon realized that I had to be as serious about writing as I was about medicine. The skills to be a really good writer required the same kind of discipline and feedback as those to be a really good clinician. In terms of Academic Medicine, I became a member of the editorial board about 10 years ago due to my involvement with the AAMC as a medical educator. I became increasingly involved with editorial duties and when the previous Editor-in-Chief, Dr. Steven Kanter, decided to step down I applied and was selected in 2012.
I imagine that the position gives you an unparalleled pulse on the state of medical education and academic medicine. What have been the best parts of the role in your opinion?
You’re right in that serving as an editor of a journal is an excellent opportunity to educate yourself and be exposed to new ideas. When I receive a manuscript to review in many cases it’ll be about a topic I’m not very familiar with, so I have to go back and read other papers. It’s really a constant educational experience. I feel very fortunate that I am able to continuously interact with people who are doing research to improve medical education and, eventually, the overall health care system.
One of the things I try to do in my editorials each month is to connect some of the articles I’m reading about with real experiences that I have with students, residents, educators, and patients. That is when my pieces are most successful, by illustrating a scholarly idea with a real-life, relatable story.
As was the case with the recent editorial you wrote about mistreatment? (Mistreatment of Students and Residents: Why Can’t We Just Be Nice? Academic Medicine 89(5):693-695).
The whole issue of mistreatment is an embarrassment for us in academic medicine. Most of us go into the field with the idea that we want to be good role models and teachers. We want to do things better than when we were students and residents. This problem has persisted despite efforts by many bright and motivated people. I think that’s really unfortunate and we need to relook at the whole problem and think about ways we can change the learning environment. Perhaps the ACGME approach of doing site visits is one way that we can address some of the issues that have resisted our efforts.
How do you manage your time between clinical duties at the University of New Mexico and editorial duties at the AAMC?
I travel to Washington DC at least once a month for meetings at the AAMC. I probably work in the emergency department about once a week, though that depends on how many other meetings I have to go to. It’s invaluable to continue seeing patients as it grounds me and it makes some of what I write feel more relevant. If you’re going to work clinically you also need to maintain level of expertise that requires ongoing experience. Otherwise you begin depending on your residents and colleagues, which is not ideal especially if you serve as an educator.
You’ll see a lot of physicians who serve as administrators or in other roles who give up clinical care. I think they lose familiarity with what it’s like to grapple with some of the inefficiencies with the healthcare system. They become much more focused on the data and finance aspects, and lose some of the personal touch, which is really very important in terms of our identities as physicians.
What are the top three things you would change about medical education?
As far as the learning environment, one of the issues that would probably improve it would be a more longitudinal experience with one’s supervisors. One problem that students encounter is that they have an attending for one week and then rotate out. They don’t have a chance to develop a relationship with an attending who truly knows them, which can be a challenge when it comes to both personal and career development. Some institutions are now changing the educational structure so that there are longer-term advisorial relationships between students and faculty. For example, we’ve seen the development of learning communities where students get to know a group of faculty and faculty get to know a group of students.
Another important change is to address the issue of student debt. Graduating from medical school with a debt burden of hundreds of thousands of dollars affects students in many ways, such as specialty choice and stress level. If we really want our physicians in the future to focus on population health, and I think we probably do, there ought to be a stronger relationship between their commitment to the public and our commitment to them in supporting their education. Can we make medical education free to students? I know someone has to pay for it so what would be an alternative way?
One more thing, I think we need to change medical education to prepare our future clinicians for changes in our healthcare delivery system. What I mean by that is that we should be looking at health care in many different ways, for example by asking questions related to Don Berwick’s Triple Aim: How do we improve health care? How do we improve health? And how do we do so at lower costs? These aren’t necessarily the questions we’re asking in the medical education setting, yet they are important enough that maybe they should even influence whom we admit to medical school.