Chapter 08: A History of Institutional Grand Rounds, The Core Curriculum, and the Physician's Assistant Training Program

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Chapter 08: A History of Institutional Grand Rounds, The Core Curriculum, and the Physician's Assistant Training Program

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Description

In this chapter, Dr. Freireich explains the Institutional Grand Rounds in greater detail, focusing on how it offers a multi-disciplinary perspective on a topic to appeal to a broad audience within MD Anderson. He discusses how he established the Core Curriculum, a program that all graduates students at MD Anderson are required to take and which he describes as the "best program in the country" because of the comprehensive view of cancer it provides. He also discusses how he believed that the new idea of a "physician's assistant" was worth pursuing, leading to the Physician's Assistant Training Program.

Publication Date

10-6-2011

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Building/Transforming the Institution; Multi-disciplinary Approaches; Research, Care, and Education in Transition; Education; MD Anderson History; Institutional Processes; Education at MD Anderson

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Tacey Ann Rosolowski, PhD:

I wanted to ask you for a little bit more detail about each of these activities. Institutional grand rounds, what did you do to transform that?

Emil J Freireich, MD:

What we did is instead of having a speaker talk for an hour about his research, we made it lively. We insisted on there being multiple speakers—three to four—because if you tell a guy, “I want you to tell me about your research. Take an hour,” he’s going to tell you everything. There’s going to be tables and the P values and such. And the only people who attend grand rounds in seminar are the people who are interested in that area—ten people. We’ve got 1,000 faculty. Ten people come. So in order to get people from all disciplines, it has to be multidisciplinary. So I managed grand rounds so that every session limits the speakers to fifteen or twenty minutes, so they have to present summaries. That means that anyone not working in the field will be informed about what he is doing. Secondly, we made the rounds multidisciplinary. So if we talk about laryngectomy, we have a surgeon or radiotherapist or medical oncologist. If we talk about apoptosis, we have a cell biologist, we have a clinician who is working on chemotherapy, and we have a guy working on DNA. So we make the rounds appeal to a broad audience; we make them lively and fast, so grand rounds is successful. We average about 150 people, not ten. It’s a fantastic academic institution. We record it. People who can’t come because of their clinic on Friday can watch it on their TV. I do it when I’m out of town. I watch it. It’s great education.

The core curriculum is mandatory. The GME committee—I’m an ad hoc member of the GME committee which consists of all the GME program directors. They elect the chair. I’m kind of an ad hoc member. I chair the curriculum subcommittee, and the curriculum subcommittee has members from all different graduate medical education programs. We review our core curriculum on a regular basis, and we analyze—the students testify as to the outcome. We get quantitative measures of whether they’re learning. They get a little exam with each thing. We have a report every quarter from Marilyn Greer’s department in academic affairs. So our core curriculum is really academic.

Tacey Ann Rosolowski, PhD:

How were the decisions made about what the core curriculum should include?

Emil J Freireich, MD:

Well, it’s me. I’m absolute dictator.

Tacey Ann Rosolowski, PhD:

So tell me, Dictator, what does the core curriculum—what was the logic of it?

Emil J Freireich, MD:

The logic of the core curriculum is if you come here to be a radiotherapist, the least you have to learn is the basics of oncology. You have to know biochemistry. You have to know pharmacology. You have to know medicine. You have to know cancer. You have to know lung, colon, breast, everything. So the core curriculum creates, for the first-year graduate medical trainee here, a core of oncology knowledge that you’ll only get at MD Anderson.

So if you’re going to be a surgeon, you’re going to know everything. If you’re going to be a gynecologist, you’re going to know everything. If you’re in medical oncology, if you’re a radiotherapist— So the graduate education committee voted unanimously that all first-year graduate medical trainees here are required to take the core curriculum. They are required to attend eighty percent of the sessions. If they can’t attend in person, they are allowed to do it online. We record them all, and they are on video. They are required to assess the course, whether it fulfills their needs or not, and I report regularly to the graduate education committee on how we’re doing. As I say, we have a committee of people who are interested in graduate medical education—multidisciplinary. We have educators, physicians, scientists, so on. We meet regularly and supervise it, so it’s really an academic exercise. It’s institution-wide.

Tacey Ann Rosolowski, PhD:

So what are your findings in the performance of the students and how they go on?

Emil J Freireich, MD:

It’s the best training program in the country. It’s highly effective. There are some subspecialties. Like people who come here to do radiology, they don’t like the core curriculum. But I keep pressing on their program director and say, “Look, you’re going to be a radiologist, go to Hermann Hospital, but if you come to MD Anderson, you’re an oncologist.” And oncologic radiology is going to be a specialty, so you better know about oncology. You’ve got to know about mitosis and metastasis and cell proliferation and chemotherapy and so on. So, at least for now, the training program directors all embrace it. As I say, the vote is unanimously in support of the program. It’s assessed and we present the results of the student evaluations, the faculty evaluations, and the performance of the students regularly at the graduate medical education committee which meets quarterly. We give a report at that meeting on how they’re doing.

Tacey Ann Rosolowski, PhD:

Now, that program started in 2000. How many students did you start with? How many students do you handle now?

Emil J Freireich, MD:

Well, we currently have—I’d have to look for those statistics, but all of the first-year graduate medical trainees are required to take it, so it’s 140 or 150, something of that order.

Tacey Ann Rosolowski, PhD:

Wow. We haven’t talked about the physician-assisted continuing education. That came in the same year.

Emil J Freireich, MD:

Well, we’ll deal with that briefly. I can’t recall the year, but it was while I was here that a famous chairman of medicine at Duke University—I’m blocking out his name right now, but it will come to me in a moment. He decided that there should be a career called a physician’s assistant. He invented the idea. The idea being that physicians are poor at some aspects of patient care. What they’re good at is their brains. He was very academic. His name was Don Seldin. No, that’s one of his students in Dallas at Southwestern. His name will come to me in a moment. But anyway, he created the idea of having a medically trained person who is not an MD but can do anything an MD can do physically but not make the decisions. That’s the doctor’s responsibility. He called them physician assistants. It was kind of slow to catch on. A number of academic centers began to do it, but being a great innovator that I am, I sensed immediately that something was important here. I was head of DT—

Tacey Ann Rosolowski, PhD:

What was it about the idea that you thought was so important?

Emil J Freireich, MD:

Well, I’m coming to that. I was head of DT, but I never separated myself from patient care. I insisted that if I was going to have a faculty, I would be at least as good, if not better, than everyone on my faculty. So I was the best doctor. If you had to consult somebody on leukemia, you’d come to me. And to maintain your competence, you have to practice. Not in the usual sense of tennis, you have to do patient care.

But as I got more and more administration, the department grew. We ended up with 250 employees and thirty faculty. It began to impinge on my patient care time. When I heard about this idea of a physician assistant, I was the first physician at MD Anderson to recruit a physician assistant. The first problem was how to pay them. So I went to the PRS and I convinced them that my income—that they could pay them the amount of income that my practice accelerated as a result of this PA. And within a year it was proven that the amount of income I generated with a PA was more than the PA’s salary, so the PRS has taken over the PA funding. So they’re funded just like the doctors, out of fees for service. The consequence is that the way it works is when I get a new patient referral from a doctor, he calls me. “Dr. Freireich, this is the chairman of the board of General Motors. He needs the best doctor in the world.” “Yes, sir. I’ll take him immediately.” He comes in and the first person he sees is my PA. The PA takes a detailed history, a physical. She spends an hour with the patient, and she can afford to because she’s not being billed at the rates I’m billing. When she gets done with all that, she orders all the laboratory stuff, and when everything is ready, she presents the case to me and I make the decisions. The consequence of that is the number of patients I can see has expanded by tenfold.

Well, the PA idea—my first PA—I can’t remember her name. The PA that really mattered has recently retired. She’s an absolute genius. I forget her name. Anyway, so the idea of the PA thing—it didn’t take a year for every doctor in the hospital to realize what had happened, particularly the surgeons and the medical people. They realized that if I’m in the OR four hours a day, three days a week, and patients are coming to the clinic every day, if my PA can do the histories and physicals, get all the lab stuff, I can come in and decide what kind of operation is needed and go to the OR. So it caught on immediately, and the number of PAs grew.

Kathryn Boyer—she’s retired. She married one of our faculty and had a baby. I still deal with her every day, but she was just fantastic. It takes a personality of a person who is excellent as a doctor but just goes so far. They don’t want the responsibility. So you can find people who love doing— It’s like nurses. They love doing the care, but they don’t want to make the decision as to whether you get your lung taken out or your brain fixed.

So anyhow, the PA program became very successful, and Kathryn Boyer formed an association—the PA Association. They had seminars, and they worked like the Graduate Medical Education Program. Although she founded it, I was the principal faculty member. Eventually we recruited a gal who was even better, the one who runs it now. I’m blacking out her name. It runs itself, and I just help them. I’m not administratively responsible for it. It’s a terrific program.

Tacey Ann Rosolowski, PhD:

So does MD Anderson train physician assistants?

Emil J Freireich, MD:

Yes.

Tacey Ann Rosolowski, PhD:

Okay, and then there’s also the Physician Assistant Continuing Education Program?

Emil J Freireich, MD:

Yes.

Tacey Ann Rosolowski, PhD:

So tell me about the differences between the two.

Emil J Freireich, MD:

Well, when the PAs are here, it’s like the core curriculum. If they work for a thoracic surgeon, they only do lung cancer, but they have to be competent in cancer. So they have a CME curriculum where they have to be competent in the new developments in leukemia and everything else. And that curriculum is run by the PA people themselves. Then the other question was—?

Tacey Ann Rosolowski, PhD:

Oh, I was interested in the actual training program for the physician assistants themselves.

Emil J Freireich, MD:

Well, there are formal training programs at the academic medical centers all around the country. We don’t have one. But the PAs who want to do—we have a graduate medical program for PAs. So the ones who get PA degrees from Baylor—most of them come from Baylor, some from the Health Science Center—they come here to do a clerkship. If they like oncology, they do graduate medical training here, and they become faculty.

Tacey Ann Rosolowski, PhD:

And then there’s the continuing education?

Emil J Freireich, MD:

Yeah, that’s the existing—to stay broadly based, like our core curriculum. They can’t just worry about themselves. They have to be competent in chemotherapy, what’s going on, what they’re patients might be eligible for.

Tacey Ann Rosolowski, PhD:

So the continuing education came in 2000, and I’m just interested in the way that’s the same year as the Core Curriculum. So there was this sense that, wow, there’s a lot going on. There’s a lot everybody has to keep up with. So that was the rationale. Interesting.

Emil J Freireich, MD:

Yeah. I give more credit for the PA program to the PAs than to me. I was just psychological support. But the Core Curriculum was my baby. Now, the Physician-Scientist Program—okay. So, when Tomasovic appointed me to this position as Director of Special Medical Education, it reduced my clinical time to thirty percent, and I had seventy percent of my time now for education. Prior to that, the educational activities were always grafted on my clinical administrators. Now I had a position, thanks to Dr. [Margaret] Kripke, where I could focus on education, which I love. And why did I tell you that.

Chapter 08: A History of Institutional Grand Rounds, The Core Curriculum, and the Physician's Assistant Training Program

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