Leaders in Medical Education

Dr. Marc Triola, Director for the Institute for Innovations in Medical Education at New York University

Thasin Jaigirdar
Published on Sep 5, 2014. Updated on Invalid date.

Dr. Marc Triola is an Internist, an Associate Professor of Medicine at NYU School of Medicine. the Associate Dean for Educational Informatics at NYU, and the Director of the Institute for Innovation in Medical Education at NYU. He has previously spoken at TEDMED, speaking on if "." He is a strong advocate for Medical Informatics for its ability to improve Medical Education. We are excited to feature him on today on our blog.

Explain your background and how you got involved in medicine? I completed my undergraduate education at Johns Hopkins University where I was exposed to a world class biomedical experience as was really inspired by the diversity of careers in clinical medicine as well as the opportunities for research. Medicine appealed to different aspects of my personality and curiosity. I was fortunate to go to NYU for medical school where I also stayed for my residency and served as a chief resident.

What made you pursue a fellowship in Medical Informatics and how did you get involved in Medical Education? I did a two year fellowship in Medical Informatics at Mt. Sinai.  As I went through my clinical training, it became clear to me that the intersection between IT and the three missions of the healthcare system: clinical, education, and research was of critical importance and something I wanted to delve much more deeply in. Its this intersection that is the essence of Medical Informatics.  This was a space I wanted to learn more about and it really appealed to my own personal interests.

After I finished my fellowship, I came back to NYU School of Medicine as a junior faculty member and started a small section of clinical medical informatics within the newly-created Division of General Internal Medicine. I ended up reconnecting with a man who has been one of my life-long mentors, Dr. Marty Nachbar. He is one of the fathers of educational informatics and ran an educational innovation laboratory at NYU School of Medicine since the mid-80s.   His group focused on inventing new information technologies to improve medical students education, such as in improving the understanding and visualizing of complex physiologic processes. By the early 2000’s, he had grown his lab into a world class premier educational informatics unit that had a multidisciplinary team including developers, instructional designers,  and education research faculty. Marty gave me the life-changing opportunity of being assistant director of this lab and I instantly fell in love with it.   The team was among the best I had ever seen and it was an exciting time for NYU School of Medicine.  I was simply in the right place at the right time to be fortunate enough to join such an amazing team.  Over the past few years, that lab grew into a Division of Educational Informatics, and now an Institute for Innovations in Medical Education.

I had seen that you had published an article about a "3-year MD" program. I understand that NYU has implemented such a program. Could you go over part of the reasons why you advocate for this kind of program and if you could change some other things in Medical education, what would they be? You can read more about the NYU School of Medicine Three Year MD Degree here.

There is a growing call across medical education to take a careful look at the cost and duration of our system of training. As we have seen over the years, medical training has been increasing in duration and definitely increasing in costs. Its a good time to re-examine education and training models which have remained largely unchanged for over 100 years.   We now have much more sophisticated ways to measure the competence and expertise of medical students and residents. Standard sets of competencies and ‘entrustable professional activities’ recently issued by the AAMC gives us a framework for competence for graduating medical students. NYU was sensitive to the national call and to  articles by Ezekiel Emanuel and others that laid out the opportunity to rethink the duration of training and costs both personal to the trainee and to society itself. An abbreviated medical school training, shorter in time, but tightly coupled to residency training has numerous benefits.  Practical benefits include one year fewer of debt;  you become a full fledged physician one year sooner and as a result, could conceivably see hundreds more patients in that time.  Most importantly, if done right, these programs can deliver an educational experience that represents a truly integrated continuum from medical school into practice.   Tight mentorship exists with the residency they will be joining - imagine years of mentored development prior to becoming an intern within that program!

These factors contribute to NYU, and a growing number of other schools, being thoughtful to different types of education models. One model is a three year program where the student is admitted to residency at the time of admission to the medical school. In the case of this model, a student needs to know what they want to do and the physician type they want to be.  This is not for everyone:  it’s a unique group of students (~10% at NYU School of Medicine) who are sure based on their experiences both educationally and personally. It introduces a concept of medical education not being a series of time bound training periods disconnected from one another. It’s more of a progression with learning in this model that is now present at NYU.

Another interesting model is the Education in Pediatrics Across the Continuum (EPAC) program. Four schools who have students with early interest in pediatrics have developed a specialized program that uses competency achievement, rather than duration of training, to trigger the transition to residency. This is interesting because it is focused more on showing competence and not simply competing the previously expected four years of medical education.

What Changes would you like to see in medical education?

One of the greatest challenges for medical education is that we need to train physicians to practice in an environment that will exist 6-10 years from now, not one that exists right now. This has not been much of a problem in the past given the relatively modest pace of change in healthcare in the past few decades. However, with the Affordable Care Act, new technology, and electronic medical records, the change of pace in the healthcare world is increasing every day. It is important that medical education programs are forward-thinking about the competencies their graduates will be challenged with when they enter a complex and complicated work environment many years down the line. Educational forecasting to teach emerging topics and competencies that have not been traditionally part of the medical school curriculum will be critical to prepare providers to thrive in a future environment.

Another thing that needs to change is needed adaptation to the fact that healthcare is moving out of the hospital and into the ambulatory setting. Medical education had been traditionally based in the hospital. Students and residents still need to learn acute and hospital-based medicine, but they also need to know how to work within, and be a leader of, an ambulatory care system. It is a challenging and intense environment, more so every day. Determining new models for funding UME and GME training in the ambulatory space, and new roles that trainees and students can play in outpatient practices, will be important.

You are a Physician at Manhattan VA Hospital, Associate Dean for Education Informatics, Associate Professor, and Director for the Institute for Innovations in Medical Education. It really speaks to the flexibility of a Medical degree. I was wondering how you manage your obligations, what are some of the challenges you faced along the way, and what advice would you give for someone who might be interested in a similar career path as you?
In academic medicine, physicians serve many roles. They do research, take care of patients, and teach. Balancing roles is a constant calculus that is changing over time. There is no formula to it and it can vary quite a bit from one person/specialty to the next. One thing I would emphasize is that medicine is truly something where you are a life-long learner. Even more than balancing different roles and jobs is to be constantly learning new things and being open minded about the changes happening around you. You should keep up to date with medical and clinical literature as well as the advances in medical education and research. It is sometimes hard to balance things because the different roles I serve are in competition with different rewards and sets of incentives. All three roles are important, and every physicians wants to do more of each and does their best to balance things.

As for advice for someone wanting a similar career path, the most important first step is to find a home in an academic medical center, one that has these three missions: clinical care, research, and teaching. Academic medical centers have tremendous opportunities, diverse groups of faculty, students, trainees,  and staff. If you interested in different opportunities or emerging areas, academic medical centers are the place for you since they are rich ecosystems of people doing diverse things. I am biased in this, but I think that having some knowledge and skills in technology and informatics is going to be key for all academics because so many of the current innovations and solutions in research, teaching, and clinical care all rely on them. Having a fundamental understanding of how informatics impacts things, at least a minimal understanding, is a core competency.

Where do you see the future of medical education going?

I see that medical school is going to be changing a lot with respect to the diversity of our students, both in their different goals and experiences they have, as well as the different characteristics they have. We are moving towards an increasingly diverse student body in medical education. We will be moving away from a one-size fits all education program, which in its defense has done very well these past 100 years  to make sure we have competent physicians in this country. Different educational pathways, based on a student’s career goals/interests as well as their personal characteristics will likely become more common.

Healthcare systems, quality of care, efficiency, and value of care are all tremendously importantly in clinical practice and I hope that we see those topics more prominently in our curricula.   There is also the growing trend of treating medical education as a continuum where the worlds of medical school and residency are less siloed and more integrated.   Under this approach, the individual student, as they are life-long learners, are really supported in a trajectory that can adapt to how fast and slow they move through it.  Inter-professional education is also of growing critical importance.  Lastly, we are seeing a great shift towards competency-based education and assessment, such as the new Next Accreditation System in the GME world.