Speaking the Language of Medicine - Dr. Marios Loukas, Dean of the St. George's University School of Medicine

DR. RISHI DESAI: Hi, I'm Dr. Rishi Desai, and today on Raise the Line, I'm happy to welcome Dr. Marios Loukas, Dean of the St. George’s University School of Medicine. In his 15 years at SGU, he's also been Dean of Basic Sciences, Dean of Research, a professor, and Chair of the Department of Anatomical Sciences. Prior to joining SGU, Dr. Loukas taught anatomy, histology, and radiology at Harvard Medical School's Department of Education and Development. Thank you so much for being with us today.

DR. MARIOS LOUKAS: Good to see you, Rishi.

DR. DESAI: Maybe just to start out, to help our guests get to know you, do you mind just backing up and telling us a little bit about your story and what got you first interested in medicine, and specifically, anatomy?

DR. LOUKAS: Yes, so as the song says, "A long, long time ago...." I was always interested in medicine. So, I joined Warsaw Medical School in 1994, and I finished medicine. I was very interested also in research. I was very interested in that aspect of medicine. At the same time, I did a PhD. So, I finished with an MD-PhD. 

Anatomy and pathology was my main interest back then. So, I did extensive research. Through that pathway of both medicine and research, I ended up doing mainly academics, teaching, and research. It was a long journey in many different countries— very fulfilling, obviously. It was something that I always was interested in, searching and developing new knowledge. I think that was one of my interests very early on as a kid, even. That was something that intrigued me and I wanted really to take the step further. 

As with anatomy, it was my first exposure to medical school. There were a lot of interesting things going on. With the years, obviously, we became very serious. We started doing serious research and our main focus was to create and develop new surgical techniques that improve the current ones, or create brand new ones that solve medical problems that we didn't have or don't have a good approach to them. So, I and a group of other people from different universities, and here at St. George’s University, we collaborate and we develop a lot of new surgical anatomy techniques, surgical techniques that are based on the anatomy knowledge. So that's our main focus. Of course, through that involvement in anatomy, I became also the president of the American Association of Clinical Anatomists a couple of years ago. I'm really invested in anatomy. We were writing chapters for the big Gray's Anatomy. I have several books in anatomy, and so on.

DR. DESAI: Every medical student and many other health science students' introduction to clinical medicine is, when they go to school, they learn about anatomy. It's like a roadmap to the human body. It can be very daunting, very challenging to tackle all the different nomenclature and the pathways that can be like learning a new language. That can often be a scary experience. I'm just curious, as you've suggested, that has become a big cornerstone of your life. What do you think that a lot of students get wrong about how they approach anatomy, maybe psychologically or emotionally, so that, currently, they're feeling very scared and daunted, but how ought they to feel?

DR. LOUKAS: Yes, I think there's a lot of enthusiasm, obviously, because typically anatomy and biochemistry are the first subjects that a student will be exposed to in medical school. I think generally, in medical education, one of the things that is lacking—and I think you do a great job as a company, and you're helping a lot on that aspect—is that many students and many faculty at the same time, or even clinicians, they don't really know how to study. I think one of the issues in medical education nowadays is, what's the most appropriate way to study and what's the most appropriate way to study for the individual? Many times, we try to put everything together as if one shoe fits all, but it's not exactly like that. There are different variations. 

Until the students get accustomed to finding their own way, there is a transition period. During that transition period, obviously, there are some difficulties—again, with the nomenclature and so on and so forth. But overall, I think sometimes it's also the right passage. When I went to medical school, obviously, anatomy was not an easy subject. I had to go through that transition. After a while, it becomes part of you. I mean, it's impossible to be a physician and not be able to speak the language of medicine, which really is anatomy.

DR. DESAI: That makes a lot of sense. You got deep into medicine. It sounds like you have a deep passion for anatomy and many other topics, as well. Then you went into an administrative track. So, I'm just curious, what led to that change in your career, and what appealed to you about being a leader in healthcare?

DR. LOUKAS: It was an interesting passage because being part of the deep academics means a lot of research, a lot of teaching. Certain opportunities arose. One of them was to become the chair of the Department of Anatomical Sciences here at St. George’s University. So, after being the chair, the next step is, for most people, to continue that trajectory, to go into a more administrative position. Certain things I had to keep, certain things I had to give away. Obviously, my teaching responsibilities had to get less and less and less. I kept my research as much as I could, obviously, so I still have a lab. I still have postdocs that are running it. However, my teaching has been less. 

Then I became the Assistant Dean for Basic Sciences. Then, I became a dean of research. After that, I became the Dean of Basic Sciences for about six years. Being the Dean of Basic Sciences means that I'm responsible administratively for the first two years of medical school. And last year in January, I became the dean of the entire medical school, which means that I'm responsible for the entire school. 

I never saw administration as a job. I mean, I always had a vision and a mission to make it effective for the students, effective for the faculty. So, it's a vehicle how to make the situation, or how to make the life of everybody, better. Making life better means how the students can learn the materials more efficiently, how they can become better doctors, which eventually improves healthcare. I think that's the whole thing that administration can do, versus myself just teaching one subject. Here, we think far more globally. We think far more three-dimensionally. As we say, we see the tree, and we see the forest, and we see multiple forests. It's a far more complex way of thinking, being the dean. It has a certain complexity, which, as I said before, is part of the research. I always would like to create new knowledge and new outcomes out of certain positions in my life.

DR. DESAI: I'm curious, because you sit in this very unique spot, to have you share with me how you see St. George’s University Medical School being different. What are the things that you stress and emphasize? What are the things that, during your tenure and maybe in the years to come, you'd like to see more of? Any of those kinds of features that set it apart as a school.

DR. LOUKAS: Yes, SGU has some important history and tradition. Some of the facts that we have seen, again and again, is that for the last decade, we are the largest source of doctors in the United States healthcare system. I think that's an important fact of who we are. We're really providing an important help and an important element to the US healthcare system. I remember, since I was a medical student, that the US always had doctor shortages in certain areas, especially primary care providers. That is a couple of facts that existed, and will still exist due to the aging of the population and of the doctor workforce. Those are also important. 

My school, St. George's University, has a very important mission and vision, which is to provide, or be an international hub for, the development of primary care providers. We train our students to be primary care doctors and fill that gap, that very, very important gap. There are many studies, many talks, about how to tackle that problem, but the medical schools need to be the ones to help bridge that gap by providing a medical education that is completely geared to address that issue. It will be very, very hard if we, as a school, didn't talk about the issue of primary care. This is something that our school primarily does. I think we're really doing a great job. 

The data speaks for itself. Last year, we had over 900 students that matched in mostly primary care specialties. As I said, in the last decade, we are the number one provider of doctors in the US. So, all those things, I'm very proud of them, and I'm looking to continue on that trajectory and address that issue, not only in the United States, but also internationally in other countries.

DR. DESAI: That strikes home for me. When I did residency, our program was very, very focused on zebras, not horses. So there were some residents in our program that actually dropped out and went elsewhere for their residency training, because they felt they were not getting a good primary care training. 

I'm curious, based on what you said, what are some specific examples of choices you've had to make as a university to help promote primary care training, to help emphasize it? Help me understand, from your vantage point, what's a classic decision you had to make where you could have gone either way—reasonable people would go either way—but you chose to go A, versus B, to help promote this kind of primary care ethos?

DR. LOUKAS: First of all, our basic sciences are located outside of the United States. They're located on a great island, in the great nation of Grenada. So, a student by definition, when they start medical school with us, is getting exposed to a different country and different culture, away from home. They're exposed to a different healthcare system. Other schools, for example, will try during the summer breaks to say to their students, "Go and get some exposure to other healthcare systems and then come back and see how everything works and get that experience." Our system and our program are built upon living on an island that is far from home for the majority of our students, and they have to adapt. They have to be resilient. They have to work with different cultures and different ethnicities and religions. That whole diversity is really who we are. 

Not only diversity between us, but also living in a very diverse location, which is outside of our home, and home means our own country. That, by definition, gives the students that first kick that this school is really for primary care. The same exposure that the students are getting on the island of Grenada, their clinical exposure, is in a very primary care setting. They have different weekends on diabetes day, high blood and blood pressure day, and so on and so forth. I think those are some of the elements we have done. 

Obviously, the curriculum is built in a specific way, which is far more technical, but I think our identity of being a school outside of the United States, and producing or developing doctors that are going to serve the primary care, gives them that advantage, that they lived outside and they're able to be exposed to conditions that fit primary care. That's the hallmark.

DR. DESAI: That's awesome and very specific, and I can totally understand that.

DR. LOUKAS: I can give you also a technical example, which is also very interesting.

DR. DESAI: Yes.

DR. LOUKAS: For example, our curriculum 10 years ago introduced very, very strongly the use of ultrasound. We took the opportunity 10 years ago because we had a big anatomy convention here on the island. The American Association of Clinical Anatomists' national meeting took place in Grenada. The program back then was developing with ultrasounds, and we took the decision to really invest in teaching our students with ultrasounds. So, the ultrasound teaching in our curriculum is geared towards primary care. That's a very, very important tool that I think every primary care physician, should have. We teach ultrasound to our students all the way from day one, till they finish basic sciences. At the end of basic sciences, they're getting POCUS certified. Again, the vision for that—and I'm going a little bit more technical...

DR. DESAI: I love it. No, please continue.

DR. LOUKAS: Yes. Specifically, to address that aspect, you're going to become a primary care physician; what type of tools are you going to have in your hand to address the different issues you're going to see in the best possible way, and improve the healthcare you're providing to your patients, especially if you're in areas that the hospital is far, or a very specialized center is quite far? Can you, at least, make some initial diagnosis? Can you at least establish a picture, and have a better picture of what your patient needs, and so on?

DR. DESAI: Yes, that's awesome. I'm a huge proponent of everyone being taught ultrasound the same way we teach how to use a stethoscope.

DR. LOUKAS: Exactly.

DR. DESAI: It's such a basic skill nowadays that if you haven't learned it, it's a shame. I'm glad you used that example, because that's very relatable. Why do you think other schools don't run to that kind of curriculum? It seems to me that learning ultrasound is good for a generalist, a specialist...everyone ought to know how to do that. It's just such a basic skill nowadays. I'm curious, what sort of feedback do you hear from your other colleagues, other deans?

DR. LOUKAS: That's a very interesting question. The curriculum is set; it has so many hours. So, whatever you need to introduce, something else needs to come out.  Of course, nobody wants to take something that belongs to them. The physiologist, the anatomists, nobody wants to do that. Here at SGU, I'm very proud to say that we have an amazing faculty, in all disciplines. There are no egos. Everybody's playing for the team, which is a little bit rare to see in academics. We're really proud, I'm personally really proud to be part of the faculty here. 

So, the anatomists changed their course from a pure day section to a cross-section course so their hours were liberated, and those hours were given at the beginning, to teach ultrasound, together with anatomy. For example, we would see a dissected forearm or a dissected arm in the lab, we'd have the lecture, the small groups, and then, we'd have another lab with standardized patients and try to identify the same anatomy in an ultrasound. The students loved it. The faculty loved it. 

In the next step, the physiologists followed and wanted to also show certain things in the heart and the lungs...

DR. DESAI: That's awesome.

DR. LOUKAS: That made knowledge transfer much easier, and then, the clinical skills, and so on and so forth. Then it became, this is who we are. We have the stethoscope, we would hear the heart. We would say that somebody had mitral regurgitation. "All right, let's put the ultrasound and let's see what it really looks like, and let's measure." Many things made sense. Many pathologies made sense because you can visualize them. You start looking, you start identifying. 

In Grenada, we have a lot of standardized patients. We do everything on standardized patients. We do not particularly like it when students do it one to another, so we have taken that out of the equation and everything happens to standardized patients. Now, the student needs to introduce themselves, so they become very good with interview skills. They have to explain what they plan to do. They're properly dressed. They're properly addressing the standardized patient. So, it really simulates real-life scenarios. It, again, improves the education of the student tremendously and in a very short period of time. 

The learning curve is really acute and very high when we're talking about learning, and makes it fun. It's a very interesting tool. I mean, somebody can really visualize things. When you're talking to a patient, it's a little bit abstract when you talk about the kidney in relationship to stenosis of the renal artery for hypertension. When you visualize it, then whatever you say makes sense, and the knowledge, the experience, becomes powerful.

DR. DESAI: This entire thing makes so much sense, because ultrasound is applied anatomy. You can actually see the value of anatomy when you see the value of the ultrasound. Same with physiology. If you see a Doppler of the heart, "Oh, okay, I can see if you don't get the right pressure-volume loop, the heart's just sort of quivering, and I can see that now." So that all makes sense. I think that's a lovely example.

DR. LOUKAS: Even central venous catheterization, which is the gold standard, it makes so much more sense for a student to visualize it than just reading it in a book. When you have that picture in your mind, typically, you will not forget it. It stays with you for life.

DR. DESAI: It also shows you, or teaches, a lot of respect, I think, for the ultrasonographers, for the EKG techs, all the people that are bringing these assets to you. When you get to understand them more deeply, you're like, "Wow, is that artifact, or is that pathology?" You start understanding how good it is if you have someone good, and how valuable that is on the team.

DR. LOUKAS: Also professionalism. I think performing it on a standardized patient, you're really on professional behavior and you do everything you know. There are many lessons from that exposure, which is geared toward primary care. It's geared also, loosely, towards specialties. It's a powerful tool, to say the least.

DR. DESAI: We're a teaching company. We like to fill knowledge gaps. I'm just curious, is there anything, any topic that you'd like to educate us on that you think the general public doesn't know enough about? It could be related to the university, or to medical teaching in general—anything that you've come across that you'd like to share?

DR. LOUKAS: I think Osmosis, personally, is one of my favorites. I will always go to YouTube and try to see some things. I think you're explaining so well the pathophysiology of certain things. I believe one potential element, which I mentioned a little bit before, is to create the best practices for a student to learn. I think creating a couple of nice animations and videos—that you do so well, to give to any student some tips. Spacing and interleaving, the different theories that we have developed or have learned from the psychologists, are important for retaining knowledge, short-term and long-term. They will be really spot on, because many of our students, and many of the parents, don't know exactly what options the students have available. 

Maybe sometimes, they took it from their experience, which is limited because when I studied back then, those theories were not part of everyday knowledge. I think you can hit the spot at being very specific. We could all direct our students, "Oh, before you start medical school, why don't you watch this Osmosis video, which is so important...to show you that there are, let's say, 10 different tools where you can better and more efficiently learn the materials for a short- and long-term memory.” It applies to everything.

DR. DESAI: Totally.

DR. LOUKAS: It doesn't apply only to medicine. It applies to engineering, history, law, everywhere.

DR. DESAI: First of all, thank you for the praise. Coming from you, that's very meaningful and very kind. We do have a course—I'm going to send you a link, on how to teach and learn...

DR. LOUKAS: Oh, that's good.

DR. DESAI: ...that our team put together. That does cover some of this. But I want you to give me feedback based on what you see when I send it to you, afterwards, and see if it meets the need. 

Your career is fascinating. The language you speak is a language that I know a lot of our students will understand, in terms of thinking about clinical medicine and basic sciences and all the rest. Yet you're also doing something that's really profound. You're changing lives and shaping the way that people actually learn in a high-need area, which is primary care. Any advice you can offer students that may be coming out and saying, "Hey, this person"—meaning you—"has a really interesting career. How did they get there, and what should I be thinking about now?”

DR. LOUKAS: Yes. Medicine, for me, it's a way of living. You constantly have to be optimistic and love humanity. You need to really love what you do. Medicine is not about the money, the prestige, or the glory. It can be part, I think sometimes, of who we are, but it's not the reason that 99% of the physicians chose that pathway. I think there is nothing more fulfilling than to ease the pain of a patient, or to see somebody who is sick be healthy again and continue their life and live for many, many years. I think that feeling is powerful and humbling at the same time. 

I think they need to be exposed, before they start medicine, to see if it is really what they like. Speak with a lot of doctors. Be optimistic. It's part of the job. You have to be very, very optimistic, on the happy side. That means the glass is always half-full, never half-empty. And you need to love your fellow humans. That's the whole point, that you're here to treat patients. When you treat patients, they are in pain. They can be angry. They can be depressed. You need to love waking up in the morning and going to the hospital, or to your clinic, and treating those people. That's something that I've had since I was a kid. Medicine totally fits me. 

Now somebody will say, "But you're an administrator." I think the relationship here, it's the level of impact you can have. I think by being a doctor, you can treat one patient and a couple of patients, even several patients during the day. By being a dean in a medical school, you can affect the lives of thousands of doctors, or students who will become doctors. They can become better doctors, and you can influence healthcare. I think the impact is the difference that I was always looking for, how I can make the bigger impact to improve things in a larger scale. That's why it's something that I love, because I can see the outcomes. 

For example, introducing an ultrasound in our curriculum. For the last 10 years, we're talking about at least 6,000 students that got an experience, the tool and the skill that definitely has improved the way that they treat their patients. That kind of scalable response, that's very intriguing to me. That's why it's fascinating. We'll try to see how we can improve the healthcare system on a large scale. We're a big school; we have a lot of students. So that's a step up.

DR. DESAI: Totally. That's wonderful and a huge, huge impact that you're making. So thank you for sharing that advice, and probably a good note to end on. Thank you so much for being with us today and sharing your insights. That was wonderful.

DR. LOUKAS: Thank you very much, Rishi. It's always good to see you.

DR. DESAI: I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.