Leaders in Medical Education

Dr. Joseph Shapiro, Dean of the Joan C. Edwards School of Medicine at Marshall University

Osmosis Team
Aug 4, 2016

Dr. Joseph I. Shapiro is currently Dean of the Marshall University Joan C. Edwards School of Medicine. Dr. Shapiro received his bachelor’s degree in mathematics at the University of Pennsylvania in 1976, his medical degree from the University of Medicine and Dentistry of New Jersey in 1980, followed by a residency in medicine at Georgetown University (1980-83). He received his nephrology training at the University of Colorado (1983-86) where he subsequently joined the faculty and was promoted through the academic ranks in the Department of Medicine with a joint appointment in the Department of Radiology; from 1992-97, Dr. Shapiro was also an adjunct professor of physics at Denver University. Dr. Shapiro joined the University of Toledo (then called the Medical College of Ohio) in 1997 as Professor and Chief of Nephrology. He was selected to be Chairman of Medicine after a national search in 1999, and he was appointed Associate Dean for Business Development in 2006.

He relocated to Marshall University to serve as Dean for the Joan C. Edwards School of Medicine in 2012.

Dr. Shapiro has had a career which blends education, clinical practice and research. He is board certified in both internal medicine and nephrology as well as licensed to practice in the state of Ohio. Dr. Shapiro is the author or co-author of more than 200 research papers and book chapters and holds a number of patents; he has also been involved with several start-up companies which were based on these patents. Dr. Shapiro has been well funded throughout his career receiving a number of grants from the NIH, AHA and the US Army, as well as industrial sponsors. His research interests range from basic and translational science where he studies the effects of renal failure on cardiac structure and function to clinical where he has worked on analgesic nephropathy and renal artery stenosis. He has served on a number of editorial boards as well as the national finance committee for the American Society of Nephrology, and he has received a number of academic honors including election as a Fellow of the American Heart Association as well as the Arnold P. Gold Humanism in Medicine award.

How did you decide on a career in medicine?
Wow. “My mother told me to be a doctor” sounds really lame, but it is sort of true. Once I learned that I wasn’t going to be a professional athlete (and believe me, it wasn’t even close), I was ambivalent between theoretical mathematics and medicine. I decided on medicine pretty much at the last moment, strongly influenced by my mom. She was a single parent (my dad died when I was young), and a very, very clear thinker. She knew me very well, and advised me that I’d be happy as a doctor. She was absolutely right; my life as a doctor has been spectacular. I can’t imagine I would have been anywhere near as happy if I chose mathematics instead.

What were a few key steps in your journey from an aspiring medical student to your current position as Dean of the Joan C. Edwards School of Medicine at Marshall University?
I think the key point is that there wasn’t a lot of “intention” or “strategic planning” to become a dean. I figured out pretty early on, while I was still at the University of Colorado as a renal fellow, that I really liked academic medicine, and I wanted to have a career where I would get to do research, teach and see patients. In order to effectively do research, you need to get grants so I learned how to apply for and (at least often enough) get grants to support my research. After doing this for about 10 years, I was offered a section chief job at the VA. Next I was offered a division chief job in Toledo, and within a couple of years, the medicine chair in Toledo became open. I did that as an interim for about 9 months, and I was awarded the “permanent job” after a national search. About 10 years into that position, I got the idea that I might want to be the Dean of a medical school so I began applying for jobs. The position at Marshall seemed to be a good fit, and I was offered that job in 2012. The pretty much brings us to the present. I still like the things I liked before, and I still get to do a little of each of them, but I must admit I spend the bulk of my time doing administration now. 

What is the greatest difference between the clinical side of medicine and the administrative side?
Clinical medicine is how I define myself. I am first and foremost, a doctor even though I practice very little these days. Clinical medicine gives you an opportunity to really impact individual patients’ lives as well as have a platform for effective, experiential teaching of junior faculty, housestaff and students. In addition, you get the inspiration for your research (at least it has worked out that way for me).

However, there is an enormous multiplier of your impact with administration. You can do things that impact the entire school, hospitals even the community. That said, a lot of what you do comes to naught. Your day may be filled with meetings that don’t have a big impact, but every so often, you are able to effect a hospital merger or recruit a new faculty member that brings a new service line to your medical center. When things work, they can turn out to be “very big”, but again, a lot of what you do doesn’t have very tangible consequences. With clinical practice, it seems like your time is well spent pretty much all the time.

What was/were the most memorable experience(s) during your medical education?
I can, of course, remember my first day of internship like it was yesterday (it was > 35 years ago). I remember rounding with a colleague who had just completed his internship, and I recall feeling so darn scared that this “real” doctor was giving the beeper to me. When he left me to handle the ward by myself, I was absolutely terrified.

I would bring up another experience that happened much, much later. I was already the Medicine chair at U Toledo, and I was rounding on the nephrology service. We admitted a patient with transplant graft dysfunction. We biopsied this patient and found no histological evidence for rejection. I instructed the intern to lower the cyclosporine dose by a certain amount and add myocophenolic acid. Unfortunately, he misunderstood and stopped the cyclosporine, altogether, and I missed this on the discharge summary. A couple of weeks later, my partner called me from the clinic and asked me why I stopped the cyclosporine on this patient as he now was clearly rejecting. Anyway, I immediately called the patient up, took ownership for the mistake and apologized. Not a “non-apology apology” like “I’m sorry things are not going well” but an honest, sincere apology where I took responsibility for my pretty massive mistake (hey, there is a reason attendings sign off on discharge summaries). The patient assured me that he understood, that he was sure I had lots on my mind, everyone made mistakes, etc., and that he knew he’d ultimately be fine (which he was, we were able to turn around his cellular rejection although I want to emphasize that this rejection episode was absolutely, positively my fault). The patient also thanked me for reaching out to him and being honest. I have to tell you, this experience not only made me pay even more attention to details, but I have been truly awed by the strength and compassion of some of my patients.

What do you think is the biggest challenge facing physicians today?
I think that biggest challenge is avoiding and “employee-employer” relationship with the health care organization that employs them and remembering, at all times, that their primary duty is to their patients. Private practice is being replaced by employment by large multispecialty groups, hospitals, FQHCs, academic practices and other health care delivery organizations. The private practice consisting a single doc or a small group of docs is almost remarkable, and I expect economic pressures will eradicate them altogether in the not distant future. Sadly, this means that someone other than the patient is writing the physician’s paycheck, and this worries me. Just like it is hard to avoid being influenced by medical device companies and pharmaceutical companies that “buy you things”, it is very, very hard to not be influenced by the corporate thinking of a hospital when that hospital employs you. However, the core of medicine is the doctor-patient relationship. If we start thinking about patients as clients or customers, we are on the road to perdition.

In a time where technology is rapidly advancing and there is a push toward “precision medicine” initiatives and moving medical records to electronic databases, how can we best streamline this process while keeping in mind patient privacy?
Medical records SHOULD be computerized and available to other practitioners. Absolutely. If banks treated financial records like doctors’ offices did medical records, you’d find another bank that same day. However, the systems that we currently have are much too focused on billing documentation rather than providing medical information in a readily analyzable format. I believe that we need to dissociate the two. We have to document what needs to be documented and not fill forms with pages and pages of nonsense to justify levels of care. We somehow have to bring back some trust that physicians will bill insurance companies and federal payers an appropriate amount for care rendered and use the documentation to share key data and thinking with the patient, other care providers and themselves. 

There is an enormous debate these days as to whether resources should be primarily allocated to fighting diseases or the distal causes of diseases. What are your thoughts on this issue of proximal causes versus distal causes?
It is very clear than “an ounce of prevention is worth a pound of cure.” Putting public health efforts into cutting our society’s sodium intake will yield far, far more than providing 22nd generation renin inhibitors to patients with resistant hypertension or placing drug eluting stents in renal arteries (which still happens despite the recent ASTRAL and CORAL studies). Unfortunately, we aren’t as sure about many of the public health measures as we are treating established diseases. As a physician, I don’t know how to reliably get patients to lose weight, stop smoking and exercise more. I don’t know how to get people to stop drinking or using recreational drugs. By its own statistics, the success of alcoholics anonymous (AA) in achieving long-term remission from alcoholism is about 5%. This is scary stuff as the consequences of poor life style choices are profound. That said, it may be that the biological insights we need to perform better public health measures will come from work with “distal” causes. Although health care costs continue to rise, the truth is that the quality of our lives is getting better as the duration of our lives grows longer. I’m cautiously optimistic that we can improve the efficiencies of health care as we shift focus toward prevention.

What are most the important facets of an undergraduate’s application to medical school from an admissions perspective?
I’m going to answer your question with a joke. A man is searching for his car keys on the roof of a parking structure under a light. Another man comes along and upon being informed what is going on, dives in and assists the first man. After about 5 minutes, the second man tells the first that the keys are just no-where to be found. The first man says that he’s not surprised as he knows he dropped his keys about 20 yards away. The second man is stunned and asks why he was looking for the keys in the wrong spot. The first man says “well, the light was so much better where we were looking.”

With admitting medical students, we know that the phenotype of a great doc has less to do with their intellectual capacity as assessed by undergraduate grades and MCAT scores than other factors that are much harder to measure. Essentially, “the light is better” when you weigh the GPA and MCAT scores of one applicant against others. I will stipulate that the process is pretty fair to the applicant pool, but it doesn’t make all that much sense.

For example, GPA and MCAT have some predictive capacity for performance on licensure exams. However, they aren’t all that great even for that. Within an institution, the predictive value of GPA and MCAT on step 1 or step 2 CK scores is only about 5-15%, and absolutely no one believes that a doctor’s MLE scores give a complete “rating” of his/her performance as a physician. That said, I see a light at the end of the tunnel. As we get better at assessing the competencies of our training (and practicing) physicians, we can see what attributes best predict these competencies and modify our selection process accordingly. That said, I think it is a little bit premature to use holistic interview strategies when we don’t really know how to assess the final product much less what characteristics predict that.

At Marshall University, it is a little bit easier for our admission committee. Our mission is to train an excellent workforce for West Virginia and central Appalachia. We know the demographic features that predict whether students will contribute to this mission. Yes we use GPA and MCAT as well, but frankly, this is more to establish that students accepted into our program can do the scholastic work. As the undergraduate GPA and MCAT are inherently flawed for this, we also have a MS/MD program that allows students who did not achieve competitive marks on undergraduate GPA and MCAT to prove their scholastic ability in the classroom with medical school classes. 

How do you foresee medical education changing in the next few years?
The elephant in the room is the curriculum. Essentially, our current curriculum is the product of adding more and more information to the curriculum developed in response to Abraham Flexner. Even now, it is extremely easy to add and very, very hard to take away. I think that we will ultimately move to a set of different curricula, depending on what type of physician a student plans to be. I would further guess that we will “take the 4th year back” somehow, probably by accepting students into residencies much earlier in the academic process. At present, US students apply to > 50 residency programs, on AVERAGE. The interview process, not to mention “audition” electives essentially eats up the first ½ of the 4th year. We have to find a way to change this, make it relevant again and also decompress the first 2 years, which are (to my mind) way too hard for many students.

Essentially, I see a de-emphasis of some preclinical subjects (perhaps some moved to undergraduate prerequisites) and expansion of required subject matter into the fourth year as absolutely necessary. The “track” idea may also be necessary to make medical school manageable in the future. The good (and bad) news is that the medical school faculty “own” the curriculum. Massive changes to the curriculum won’t happen by decree but rather by a consensus being formed amongst brilliant, independent thinkers. Kind of reminds me of a great quote from Winston Churchill (I’ll paraphrase) that democracy is the worst form of government except for everything else. Probably true about curriculum reform.