Innovations in Medical Education: From Financial Aid to Pedagogy

Since the Yale School of Medicine’s (YSM) storied beginning in 1810, its philosophy of medical education has made it one of the world’s leading training grounds for outstanding physicians. Over the years, YSM has adapted its philosophy of education to meet the changing needs of its students and the evolving tenets of evidence-based medicine. Now, more than 200 years later, YSM finds itself at one of the most exciting yet challenging times in its history.

A Bold New Approach to Financial Aid

In an environment when crushing debt can create an insurmountable barrier to some of the brightest and most passionate students, YSM has committed to providing debt-free medical education. To achieve this, the school has set a goal of raising $100 million in new endowment funds for medical school scholarships that will allow students to graduate without the burden of loans.

As part of its commitment to curbing medical school debt, YSM recently reduced the maximum unit loan—which is the amount that students are expected to borrow to help cover the cost of their medical education—from $30,000 to $15,000 a year, depending on their need. After calculating family or student contributions, Yale covers the remainder of the cost of attending medical school with scholarships, which average $66,000 per year for each MD student.

But the challenge is to keep up with the overall cost of medical education, which has risen precipitously over the decades. In the late 1980s, for example, tuition, room and board, and related expenses at YSM totaled $21,239 per year. That figure is now inching toward $100,000 each year. A handful of students have graduated from YSM, which is not the most expensive medical school in the United States, with more than $300,000 of combined college and medical school debt.

Because tuition is only one part of student debt, YSM aims to do more than simply cover tuition through its debt-free pledge to students. “There are the living expenses of an individual who needs to live in a city and needs transportation to travel to their clinical teaching site,” said Jessica Illuzzi, MD, MS, deputy dean for education and the Harold W. Jockers Professor of Medical Education and professor of obstetrics, gynecology, and reproductive sciences. “And the increasing cost of food and gas is apparent to everyone. If you just erase tuition, many students still have to take out loans for other expenses.”

A Tradition of Generous Financial Aid to All YSM Students

Historically, endowments, grants, and scholarships have allowed YSM to uphold its commitment to providing generous financial aid for its students throughout their medical education. This includes those in the MD program, along with medical residents and physician associate (PA) students. The MD-PhD program, which has graduated more than 400 physician-scientists in its half-century of existence, is fully government-funded and does not require financial aid. In the 2020-2021 academic year, 148 students were enrolled in the MD-PhD program.

Financial aid also supports the cost of the school’s research program, which requires every graduating medical student to complete a thesis. MD students also can pursue a fifth year for research on a tuition-free basis through stipends that cover their living expenses. Approximately 70% of the YSM students take advantage of this opportunity.

Robust financial aid, along with an emphasis on nurturing creative leaders in medicine and science, is a key element of Yale’s philosophy of education. “YSM is unique among medical schools and its approach to medical education,” said Illuzzi. The Yale system of medical education creates an opportunity to engage in education in “a very innovative, creative, and self-directed manner, so that students can pursue their interests and passions while they’re earning their medical degree.”

Research as a Hallmark of YSM’s Medical Education

A steadfast commitment to research is also one of YSM’s many distinguishing traditions. It is one of the few medical schools that requires a thesis based on original research—a practice that began in 1839. The generous funding for this research also sets apart YSM. “Our Office of Student Research maintains several teaching grants from the National Institutes of Health to help develop physician-scientists as well as future clinicians who are very scientifically oriented, teaching them to push the field forward rather than learning it in the status quo,” said Illuzzi.

Sarwat Chaudhry, MD, associate dean for student research and professor of medicine (general medicine), believes that YSM’s emphasis on research creates an invaluable foundation for the students’ future. “The mission of the Office of Student Research is to enable students to understand the scientific method from the inside and to be able to communicate their research findings for maximal impact and to really be able to analyze data critically for the rest of their lives,” she said.

“The impact can be seen in the professional development of our students,” explained Erica Herzog, MD, PhD, associate dean for medical student research and the John Slade Ely Professor of Medicine (pulmonology) and professor of pathology. “Many of them also do a fifth year of research, and many are able to compete successfully for funding and for national awards in recognition of their work.”

According to national averages, about half of graduating medical students will publish a peer-reviewed research paper, added Chaudhry. “At Yale, we’re really proud that the figure is over 90%.”

A Changing Landscape for Today’s Learners

Meanwhile, as technological advances are moving medicine forward at breakneck speed, new opportunities in medical school pedagogy are driving an urgent need for YSM to evolve its teaching methods to meet the students’ needs and maintain its leadership role as a top-ranked medical school. For example, emerging evidence about how students learn requires the medical school curriculum to continue to evolve beyond the traditional lecture-style format.

“Learners have changed,” Illuzzi explained. “Students are so used to interacting with material on the internet and finding answers to their questions very quickly,” that many find lectures to be less compelling than other teaching methods. “Students can learn factual information from a book or online, but students also need to develop skills in critical thinking and clinical reasoning. They need to be good communicators and collaborators, and they need patient-centered interviewing skills,” she added.

Exciting Opportunities for Innovative Pedagogy

To address the changing needs of today’s medical students, YSM is introducing new teaching methods at various stages of the medical school curriculum. These include:

• Simulation. This has proven to be a highly successful domain, which is now being used to teach pharmacology. “We usually think of simulation as something that you would use to learn a skill set, like ‘how do you respond to chest pain?’” said Illuzzi. “But the faculty at the Yale Center for Medical Simulation have developed cases that teach about different medications, their side effects, and how patients react to them. And the students love it! We can hold a simulation session and get nearly 100% participation.” If a lecture is held on the same topic, she said, attendance may be less than 15%. Even though lectures are recorded for students who may wish to watch later, they are not engaging with the material in the same way, Illuzzi added.
• Problem-based learning. With this evidence-based pedagogy, students work in small groups with faculty members to hone their critical thinking and communication skills, while developing approaches to real-world issues. Both simulation and problem-based learning require committed faculty and additional faculty development, said Illuzzi.
• Virtual reality. These platforms allow students to wear 3D headsets and use remote controls to virtually “walk through” various organs. YSM is now using a virtual reality tool called Stanford Virtual Heart, which was developed by Stanford cardiologists, cardiothoracic surgeons, and technology experts. It provides an immersive experience for students to view blood flow within the heart in the presence of congenital anomalies, valvular malfunction, or arrythmias. Other such platforms also are available to help students learn about physiology, pathophysiology, and cell biology. “These are things that we need to integrate into our curriculum and even design on our own,” said Illuzzi. “And that obviously requires further innovation and funding.”
• Ultrasound. Handheld ultrasound is also being used to teach clinical skills at YSM. Just as students learn to use a stethoscope, they are being taught to use a handheld ultrasound to visualize the heart while listening to it. This skill can allow students to visualize other organs too, such as the liver, and blood vessels that may harbor clots. “YSM is training students in this skill from the very beginning,” said Illuzzi. “It may be that in the future, many physicians will be carrying and using a handheld ultrasound in their practice and not just wearing a stethoscope.”

More Hands-on Assessment

Throughout these endeavors, an overarching element of the student’s medical education is assessment. While the Yale system of medical education includes respect for student initiative and maturity, curricular flexibility, and close faculty mentoring, YSM’s accrediting body, the Liaison Committee on Medical Education (LCME), has emphasized standards that focus on a core group of competencies that extend beyond medical knowledge. Other competencies, such as clinical reasoning, communication, professionalism, and responsibility to society, also need to be assessed, explained Illuzzi.

YSM is developing milestones that students must reach in each of nine competencies and methods for them to monitor their own progress, she continued. While the Yale system of medical education emphasizes the importance of student ownership in self-monitoring, the LCME compliance standards require that faculty must be involved in reviewing that data with students.

For this reason, the 2022 medical education strategic plan prioritizes the development of a program to match each student with a faculty member, who will serve as a coach, partnering with the student to monitor their progress through their medical education, Illuzzi said. “Our model embraces the Yale system by continuing to support student autonomy and alternative pathways in attaining competency. It will preserve opportunities for creativity and pursuit of individual interests, such as advocacy, research, and leadership. Yale will continue to produce change-makers who have developed the skills and insights needed to move health care forward.”

A Challenge Worth Meeting

While all these developments carry the promise of an extraordinary new era in medical education at YSM, the central question is: How will the school advance its tradition of providing robust financial aid to its students, while also availing itself of the new world of pedagogy that is being adopted by the top medical schools across the country?

Gifts to YSM ensure the continued training of future scientific leaders and help address the world’s need for a larger and stronger physician-scientist workforce. To see the personal impact such gifts can have, a YSM student, class of 2023, perhaps summed it up best in a note to a donor: “I am living my best life and wouldn’t have been able to do it without your financial support. I couldn’t imagine going to any other medical school, and I am incredibly excited for my future here at Yale.”