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The Chase years

Yale Medicine Magazine, 2006 - Autumn


Six years ago, Herb Chase came to Yale to improve medical education. As he leaves, he and others reflect on his legacy.

Herbert S. Chase Jr., M.D., was living a life in New York City that suited him well. He’d been a professor at the Columbia University College of Physicians and Surgeons for 22 years, where he’d been honored for his teaching skills. His wife and two sons were happily engaged in city life, and he enthusiastically attended the opera whenever his schedule allowed. But in 2000, David A. Kessler, M.D., then dean of the School of Medicine, asked him to come to Yale as deputy dean for education, and Chase felt as though he’d been offered the key to the Promised Land.

What appealed to him about the medical school was the Yale System of Medical Education, with its emphasis on critical thinking in a nongraded, noncompetitive environment. Although Yale in many ways adheres to the traditional approach to medical education—two years of basic science courses followed by two years of clinical training—Yale’s educational philosophy encourages students to become independent and scientific thinkers and places the responsibility for learning and mastering critical thinking on them. That philosophy struck Chase as the ideal environment in which to teach future doctors. The mandatory thesis, with its focus on independent, original research, appealed to Chase’s long-held belief that medical students need to learn to think like scientists. “The values of the faculty and administration were directly compatible with mine,” Chase recalls.

But when Chase got to Yale, he soon realized that the Promised Land had suffered serious incursions; its inhabitants were restive and outside forces threatened the very qualities that had made it an academic paradise. An ever-expanding curriculum was consuming time that students once devoted to their theses and the unstructured exploration of medicine—posing a direct threat to the Yale System’s commitment to self-directed lifelong learning. Meanwhile, the Liaison Committee on Medical Education (LCME), the accrediting body for medical schools, said that students’ clinical skills needed to be formally assessed. (The accreditation process is about to get under way again at Yale.) In other words, mandatory testing—another move at odds with the core values of the Yale System.

“I didn’t realize how far the actual practice of the Yale System had deviated from its philosophy,” Chase says. He spent the next six years trying to recast the School of Medicine into the place he’d found so enticing. To reduce classroom hours and create a more fluid curriculum, Chase merged courses in related disciplines and integrated basic and clinical sciences. He worked with the anatomy faculty, William B. Stewart, Ph.D., and Lawrence J. Rizzolo, Ph.D., to revamp the course for first-year students, turning it into a national model, and in a deviation from the traditional distinction between science and clinical years, he implemented the Clinical Skills Program that provides rigorous instruction and assessment during the first two years of medical school.

These changes generated both angst and accolades among faculty and students. The general view, however, is that Chase reaffirmed the central importance of teaching at the medical school and created a framework on which his successors could build.

Last December Chase announced his plans to resign at the end of the academic year in June. He has since returned to the Columbia campus to explore the role of scientific training in medical decision making and to test his long-held theory that doctors who are scientifically trained will be more cautious when prescribing drugs or utilizing new technologies. Had he stayed at Yale longer, Chase says he would have set his sights on creating an integrated four-year pharmacology curriculum and expanding students’ training in the analysis of medical literature.

Easygoing, but with a clear vision

Chase, a trim man with bright eyes, has the comfortable charm of someone who wears his self-confidence like an old cardigan. He laces his remarks with self-deprecating humor, easily acknowledges what he doesn’t know and is generous in his praise of others. At a recent talk, he graciously accepted a clarification from the audience, scribbling notes in the margin of his speech.

But underneath this easygoing façade, Chase had a clear-eyed view of what he wanted to accomplish. He took suggestions and entertained other views, but in the end he did what he thought was best, even if it ruffled some feathers.

“In a job like Herb’s, you need to have a vision, and you need to go with it,” says Dean Robert J. Alpern, M.D., Ensign Professor of Medicine. “You try to build consensus, and some people will agree with you and some people won’t, but you need to decide where you’re going to go.”

"Herb had a difficult job,” says Asghar Rastegar, M.D., associate chair and professor of medicine. “He attempted to bring a lot of people together.”

Nancy R. Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean for student affairs, says that before Chase came to Yale the academic program was more “laissez-faire.” But the faculty was frustrated by students’ poor attendance in classes and small discussion groups. “Herb was the first to say, ‘If they’re not coming to class, maybe it’s because the teaching is bad. We need to make sure the teaching is good so they have a reason to come to class.’ He was also the first person to say, ‘We need learning goals and objectives, so students know what the point is they’re supposed to be getting.’ He brought an educator’s eye to this, not just a doctor’s. That was something that really had never been here before.”

Chase recalls arriving at Yale to be told that people were “unhappy” and that he needed to “fix” the curriculum. “My diagnosis, which took me a while,” he says, “was that the curriculum couldn’t be improved upon, but we had to get back to the basics—good teaching, good lectures and more structured courses.”

Making sure education matters

A key part of Chase’s response was the creation of a centralized leadership, through a system of committees that would empower the faculty to oversee the educational program and curriculum development process. His leadership structure is built around committees overseen by the Educational Policy and Curriculum Committee, composed of faculty and students.

Reporting to this committee are three subcommittees: a curriculum committee, which oversees what is being taught, and two assessment committees, preclinical and clinical, which oversee how it’s being taught. “What Herb did was to elevate the importance of education in the administration. He created an organizational infrastructure to support education,” Alpern says. “Yale needed to make this transition, and Herb led it.”

Historically, the academic departments at Yale and elsewhere have decided independently how best to teach their disciplines. They derive their autonomy and authority from their clinical and research contributions—and they pay the professors’ salaries. But Chase determined that the educational enterprise required a centralized oversight to impose a structure of cooperation, standardization and quality control. He consolidated and streamlined lectures, cutting them down from an hour to 40 minutes so students would have more time to pursue independent studies. And he insisted on a lesson plan for every lecture in the first two years.

Some professors opposed these moves—they feared students were getting shortchanged on vital information. “There’s a natural tendency to want to teach all the new things in your discipline,” says Robert H. Gifford, M.D., HS ’67, Chase’s predecessor as deputy dean for education. “That’s fine, but there aren’t enough hours in the day or days in the week. Somewhere, somehow, you’ve got to cut.”

During his tenure, Gifford also tried to reduce the number of hours students spent in class. “ ‘Integration’ was what we called it then, but of course the departments resisted. It would be easier to move a graveyard than to change the curriculum at the medical school.” Gifford says department chairs are highly protective of their turf. “The departments are very strong and take a lot of pride in what they do,” he says. “They don’t want to give up any of the accolades or attention by doing anything that would diminish their standing.”

But if Chase’s ideas received a cool reception from some faculty members, they were warmly embraced by students as a welcome return to the ethos of the Yale System. Aaron Remenschneider, president of the Medical Student Council last year, calls Chase “a dedicated advocate for the students.” Referring to the deputy dean’s efforts to reduce classroom time, Remenschneider says, “There is so much happening on campus, students love that time to go to the hospital and shadow a specialist, to take an elective, to research their thesis project or to study.”

Marcus Coe, M.D. ’06, co-president of the Class of 2006, says he used his free afternoons to take part in two research projects. The first looked at the mechanical properties of human cervical spinal ligaments. For the second project, he spent time with the community cardiothoracic surgery department studying what effect, if any, delayed surgery has on late presenters with a certain type of aortic dissection.

“I’m busy, but I also had time to get married, own a dog and do other things,” Coe says. “Whether it was intended or not, it does free students up to lead a more balanced life, both inside and outside medicine.”

These enthusiastic appraisals stand in sharp contrast to students’ initial reaction to Chase’s initiatives. An unintended consequence of his early efforts to build more free time into students’ academic schedules was that many of the basic science courses were concentrated in the first year. That meant that more exams were also concentrated in the first year. And he and the faculty had instituted mandatory qualifying exams in the second-year modules.

Students balked. A group of nine banded together and, calling themselves the Yale System Preservation Initiative, wrote to alumni asking for their support of a petition that all self-assessment exams remain optional. Chase rescinded the mandatory module exams and began a dialogue to find ways to assess students without exams. By the time of Chase’s farewell reception in May, two members of the initiative joined other students in singing Chase’s praises.

Since then, classroom time has been reduced by 25 percent, the ratio of small-group sessions to lectures has increased, and exams have been placed on the Web, so students can take them on their own schedule. Courses are now structured with the goal of finding ways for students to retain what they’ve learned in class so they can apply it to the treatment of patients.

The molecules-to-systems integrated curriculum, for example, coordinates material from the biochemistry, cell biology and histology, and physiology courses. The three course directors work together to decide which course should discuss which topics. A lecture on the biochemistry of membrane biology might be coordinated with a lecture on the cell biology of membranes, which will then be linked to a lecture and workshop on the transport of ions and solutes across membranes.

“I like to think we cleaned the jewel that is the Yale System,” Chase says. “We dipped the diamond in ammonia solution.”

Assessing clinical skills

Another major challenge came as a result of the LCME determination that the accrediting authority had no way of knowing whether Yale medical students were learning clinical skills. Margaret J. Bia, M.D., professor of medicine, who was appointed the new director of clinical training in 2001, agrees that the clinical skills program needed help. “It was kind of thin. You were assigned to a tutor and attended lectures on how to talk to patients, but there wasn’t much real practice,” she says.

Acting on the LCME mandate, Chase provided the resources and support to Bia to create a program that combines rigorous clinical skills building during the first two years with assessments at the end of the third year conducted at the University of Connecticut Health Center. At the UConn test site students see seven standardized patients and perform a focused history and physical on five “patients” and a focused history and counseling on two.

Students are given 20 minutes for each “patient,” then have five minutes to write down their top three diagnoses. Yale faculty members are on hand to review the cases with students and do remediation if needed. Chase took this assessment a step further with the preceptor program, which increased student contact with senior faculty for bedside teaching, case discussions and student presentations. It appears to have worked—in the most recent round of the national boards, Yale medical students had a 100 percent pass rate on the exam’s clinical skills component.

In addition to the assessment gap, the LCME found that Yale lacked a program for teaching communications skills and discussing end-of-life issues. As a result, students now participate in a workshop on delivering difficult news, offered during the internal medicine clerkship, and a behavior modification counseling workshop, offered during the psychiatry clerkship. A new end-of-life curriculum has been introduced for third-year students.

“The attitude used to be, ‘Just go into the wards and you’ll learn something,’ ” says Chase. “We’ve changed it so that it doesn’t take any more time, but it’s much more focused.”

An emerging problem

Still looming, however, at Yale and medical schools across the country, is a challenge with no easy answers. For more than a century, clinical education has been based in the inpatient environment of teaching hospitals, but those learning experiences are far less relevant now that hospital stays have become shorter and more treatments are done on an outpatient basis. “The greatest challenge facing medical schools is learning to treat patients with chronic diseases,” says Michael Whitcomb, M.D., senior vice president for medical education of the Association of American Medical Colleges (AAMC) and director of the AAMC’s Institute for Improved Medical Education. “They may go to hospitals for the management of complications, but the focus needs to be on preventive and post-care. We need to shift an awful lot of the educational experience out into other sites.”

According to Whitcomb, 100 million people in the United States have one or more chronic diseases, and that number grows every year. Moreover, 75 percent of all health care spending goes to care for that population. “It just makes sense that students get training in caring for those patients.”

Medical schools know they need to adapt their curricula, but one overriding obstacle stands in their way: money. “Education is the stepchild of academics,” Chase says. “It doesn’t bring money in, it only uses it up.”

“It’s very difficult to sustain this enterprise as a by-product of whatever else we do,” says Rastegar, who served on an education committee convened by former Dean Kessler to evaluate the curriculum. “Research money has gotten tighter, clinical can barely pay for itself, and there’s no way a clinician can make his or her salary and teach at the same time.”

“Yale has an army of fabulous clinical practitioners who basically teach gratis,” Chase says. “But the day of the freebie is gone. You get what you pay for, and if you don’t pay for it, you devalue the activity and you guarantee no innovation.”

To reward faculty for teaching, Chase has implemented such programs as the Society of Clinical Preceptors and the Society of Distinguished Teachers, which recognize and celebrate faculty whose level of commitment reaches beyond the ordinary. The Society of Distinguished Teachers has a modest endowment, but not enough to support teaching to a significant degree. Chase says the most direct solution is the creation of an endowed teaching academy. With respect to the curriculum, he recommends that his successor develop avenues for students to receive more patient-centered and longitudinal-care experience.

Despite the challenges, Chase has confidence in the Yale faculty’s deep-seated commitment to preparing students to be the best doctors they can possibly be.

In thinking about the future of medical education at Yale, Chase was reminded of the day his older son celebrated his bar mitzvah. That morning, when Chase popped his head into his son’s bedroom and saw a look of doubt, he began to wonder if his son was prepared to get through the ceremony. But at the synagogue Chase watched the cantor interact with his son and his worries evaporated. “I knew he would never let my son fail, and I’ve always held him up as a model for what we as teachers should strive for. Our job is to guarantee our students’ success.” YM