As medical school graduates prepare to begin residency training in July, the American Association of Colleges of Osteopathic Medicine (AACOM) spoke with Sandra Snyder, DO, about an innovative new family medicine education and training program, the Transformative Care Continuum (TCC). The TCC program is a partnership between the Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) and the Cleveland Clinic to educate and train family medicine physicians with an emphasis on community health.
In addition to serving as site director for the TCC program, Dr. Snyder is the program director for the Cleveland Clinic’s Center for Family Medicine residency program and the chair elect of AACOM’s Assembly of Osteopathic Graduate Medical Educators Board of Directors.
The answers below have been edited for brevity and clarity.
Q: Did the osteopathic philosophy, which emphasizes whole-person care through a primary care lens, help inspire the innovative TCC program?
Dr. Snyder: The TCC program was built around the osteopathic philosophy. Knowing that we wanted to educate, train and graduate osteopathic family physicians, we changed our recruitment process to help us identify students with the values and qualities that great osteopathic family physicians should have. Instead of relying on board scores and class rank, we looked towards our colleagues in human resources to create unique, behaviorally based questions and incorporated situational judgment testing into our interview process. We prioritized empathy, adaptability, compassion and—understanding our current, changing medical system—grit. The National Board of Osteopathic Medical Examiners’ competency-based curriculum, which has a holistic approach to teaching medical students, served as the foundation for our curriculum. Throughout the six-year span of our program, we are also focused on teaching our students and residents osteopathic manipulative techniques, which are an effective adjunct to treating chronic pain, and are especially beneficial as we continue to respond to the opioid epidemic. The Osteopathic Postdoctoral Training Institution (OPTI) component was also hugely important. That connection between undergraduate medical education (UME) and graduate medical education (GME) within the osteopathic world, and the relationships we’ve been able to build because of the OPTIs, has enabled us to do this work.
Q: TCC students are engaged in direct patient care from their first day of medical school. How much hands-on experience do students receive during years one, two and three?
Dr. Snyder: From the first day of medical school, students are assigned to a team within our clinic, and they have the same preceptors over their three years of medical school. Because of this continuity, our students are able to advance their clinical knowledge within a short time. Most medical students get very little clinical exposure during their first and second years, and in their third and fourth years, they often rotate to a different clinical environment every month. Because our students are with us for three full years, we really get to know them, and they get to know us, allowing us to push them to a higher level, clinically. We also focus on teaching them skills that will help them make our healthcare system better. Our students all receive a Lean Six Sigma Yellow Belt, and they do quality improvement projects with an eye toward adding value to our practice. From their first year, they function as a medical assistant. In their second year, they work as care coordinators and patient educators, and as third-years, work like a typical third- or fourth-year medical student. Even though this program is only three years old, our students have already added value to our practice. They have improved some of our health maintenance recommendations and colon cancer screenings.
Q: TCC is a truly innovative program that is part of the American Medical Association’s Accelerating Change in Medical Education initiative. Do you see this type of program potentially transforming medical education in the future? Why or why not?
Dr. Snyder: Yes, for sure. Being personally involved in this program, I think this is the way to train. From our recruitment changes alone, we have been able to attract more candidates who are underrepresented in medicine because we’ve changed the metrics. We also teach our students population health skills and are very community-oriented and centered. One thing we’ve learned from the COVID-19 pandemic is that we have to improve our public health and primary care infrastructure and how we as primary care physicians relate to the community. Our students conduct a community needs assessment and are required to complete a community project. Because they have that six-year continuity with our clinic, our students and residents have the time to put down roots and really make a community impact. One of our students is very passionate about helping the homeless and finding sustainable solutions to common issues affecting this population. She worked with a community organization, Frontline, that provides sustainable housing and behavioral and mental health for unhoused patients. We now have a partnership with Frontline and will be able to continue strengthening this relationship over our student’s next three years of residency training. Another one of our students is very passionate about LGBTQ health. He found that a lot of the homeless patients he encountered were from the LGBTQ population. He worked with the AIDS Foundation and received a grant to expand point-of-care HIV testing. These are just two examples from a three-year program, which really shows how effective this way of training can be and the outcomes we can achieve if we continue down this path. I always call this program my immunity to burnout because of how much good my students have managed to accomplish so soon.
Q: The COVID-19 pandemic disrupted all aspects of our lives, medical education included. Early in the pandemic, lack of personal protective equipment caused major disruptions to clinical education. Did you encounter similar challenges with your students, or experience any others?
Dr. Snyder: We are on an accelerated path, so to get our students back in was our number one priority. We are already truncated by one year, and, with the way our program works, we received a time-sensitive National Resident Matching Program Match exemption. We had to graduate our students in three years, so when we learned that medical students were deemed non-essential, we knew that for us, no, medical students are essential, and we fought so hard to get them back. And they added so much value to our practice, because at the start of the pandemic, our clinic closed, and we were no longer allowed to see patients. As family medicine physicians, we were about to be deployed into the in-patient world, and we were worried about what would happen to our vulnerable patients who could no longer come to our clinic. We turned to our students, who created a process map and came up with a way to do social calls with our patients, checking in to see if they needed any help during the pandemic. Ultimately, our students only missed six weeks before we could bring them back, and because we have that continuity with them, we were able to get them caught up with anything they might have missed. Now, looking back, we think they gained so many valuable skills (e.g., How do you close a clinic? How do you create a process map?). We always reassure our students that because they’ve trained during a pandemic, they have amazing skills and should be confident in their training.
Q: The TCC program graduated its first cohort of eight students on May 8, 2021. How were these students selected for the program, and what makes a student a strong candidate?
Dr. Snyder: The selection process is very unique, because UME and GME recruit together. Six of us from the Cleveland Clinic sit on OU-HCOM’s admissions committee, along with three interviewers from OUHCOM. We look closely at the lived experience of the individual and focus on their big picture. Failure is the first step in learning, and some candidates have experienced failure along their journey to us, but when we talk to them and learn their stories, we can level the playing field and get a better understanding of whether they have the qualities to become an osteopathic family physician. We also make sure that our students know and understand what family medicine is. Reflecting on having this new class coming in, I do see, especially in the pandemic, that the skills we recruited them for have helped them to thrive, and they are now more than ready for residency. Our students also have the option of opting out into the four-year curriculum if the program doesn’t end up being a good fit. Our program is accelerated—it’s pretty intense—so we know it’s not for everyone, but we try our best to make the right connection. We also intentionally strive for a diverse workforce. To advance health equity, we need to have a workforce that looks like the communities we serve, and as a country, we need to be doing a much better job of that.
Q: Given the TCC program graduates medical students in three years, instead of the traditional four, how do you ensure students are learning all they need to know to be prepared for residency within the program’s accelerated timeline?
Dr. Snyder: The beauty of our program is that it’s a competency-based education. We fill out several competency evaluations for every student throughout the three-year process. Students also evaluate themselves with self-reflection, and we have the ability to tape them to allow for peer-review. These evaluations, in conjunction with our preceptor continuity, enable us to ensure our students are not only ready to practice but can gain additional skills. Another unique factor we are embarking on is that we are creating an “I-PASS” between UME and GME. Once our students come to GME, we will receive a competency-based I-PASS handoff so we can see where students might need more work in their residency training. This, in addition to the relationships we’ve built with our students over their three UME years, allows us to tailor our education plans to be more individually targeted. Another unique piece is that our UME TCC director, Leanne Chrisman-Khawam, MD, because she is in our clinic every Monday and Friday, will continue to be available for our students as they become residents, contributing to their overall wellness and growth. We are also able to do internal process improvements among our TCC and non-TCC students to identify any curriculum changes we can make or bootcamps we can offer to address any knowledge or skill gaps and make sure these are addressed at the UME level, as needed. I truly believe that the UME-GME connection and collaboration, and integrating UME into a residency clinic, which is unique among other accelerated UME-GME programs, is what makes the TCC program so successful.
Q: COVID-19 exposed the serious work we need to do to address health inequities stemming from socio-economic factors and social determinants of health. How are the program’s graduates helping to make a difference in these areas?
Dr. Snyder: The additional training our students receive in population health helps them understand how health systems work and how they are financed. They learn how to write a memorandum of understanding and how to lead a meeting, as well as skills such as trauma informed care, how to assess for social determinants of health and how to fill in those gaps. They work closely with an interprofessional team in their first and second years. In their first year, they are supervised by a nurse. In years two and three they work with a social worker, care coordinator and pharmacist, so they get a comprehensive understanding of the healthcare system and healthcare team. One of the lessons learned from the COVID-19 pandemic is that, in primary care, the interprofessional team is essential. Many of the health issues that individuals face aren’t clinical issues, they’re social determinants of health. Having the ability and skills to understand that, and to know how to connect patients to the appropriate resources and health professionals, is huge, and our curriculum emphasizes that, which will help our students succeed. Our students are given tools to help them see the big picture, allowing them to become change agents or system changers. We also do a lot of advocacy work, pairing it with health equity. Our students learn a lot about health policy, and we plan to continue this when they are in our residency. They are able to look outside of the clinic and into the communities they serve, which is often neglected in more traditional programs because our medical education system is so fragmented.
Q: The students in the TCC program are guaranteed residency positions and, after their training, a job in the community. What has the community reaction been to these students as patients have gotten to know them these past three years, knowing that they will stay to practice long-term?
Dr. Snyder: We can’t tell yet because we haven’t graduated anyone, but so far, the reception has been wonderful. People want a primary care doctor; they want a family doctor. A lot of family doctors are retiring, and not a lot of our country’s medical students are going into primary care, so to have a young primary care doctor who looks like the communities they serve, people are excited about that. The healthcare system is receptive of this too because they know our students and residents won’t be leaving to practice somewhere else. When we train our students, we align it with work that the Cleveland Clinic is doing, and we give them the tools not only to do the work, but to lead the work. We are hoping that they will become our system changers in the future and will integrate primary care more fully into the community. The opportunity for our students to have creative jobs because of their skillset is something to look forward to.
Q: As the first cohort begins GME training on July 1, 2021, what are your hopes for this first cohort of residents?
Dr. Snyder: I hope that they have an easy transition, that they embrace their clinical and community work and that the TCC and non-TCC students become a cohesive team, and post-COVID, I hope they make the world a better place. I think we have a lot of work to do in the areas of health equity and chronic disease post-pandemic, so I hope they keep their passion and desire for change. In talking with them, I think that coming to us has also been their immunity to burnout, because I think that this has been a very hard year for medical students. There’s this newer concept coming out called moral injury, which is a longing for meaningful work and a just system, and this past year, not only with COVID-19, but with racial violence and inequity, has really taken a toll on them. There’s not only the inequity, but the struggle of how do you fix it? I hope they stay connected to their passion and continue to work day-by-day to change the world while keeping themselves well.
Q: What advice would you give to other UME and GME programs interested in pursuing a similar partnership? From a GME perspective, what are the tangible benefits you have seen so far?
Dr. Snyder: I would give people the courage to try this, or to try something different. I feel that the current system is broken and the way we’re doing things isn’t necessarily working. Having the courage to think outside the box and try something new is important. We’ve flipped so many things during COVID-19. We should strive to keep that momentum going and change up the way we educate.
From the GME perspective, there are many tangible benefits. For example, you have a better way to recruit minority students who are underrepresented in medicine. You also have to match fewer residents, which saves both time and money. Now that I pre-match half of my class, I’ve cut my interviews down and have the associated cost savings, and I really like the process we have where we can listen to our applicants’ lived experiences. Also, the continuity of having students for an extended period of time is phenomenal. As educators, after a student’s third or fourth week, you may feel like you finally got them to where they need to be, but then they’ll soon be gone. When you have someone for six years, you can push them to a very high level and add additional skills to what they’ve already learned. We also have a direct connection to UME, making sure that we’re teaching students the skills they need to know. We also share costs among our UME and GME programs and can collaborate on grants. When you have two groups that want the same thing, everything becomes seamless. Always making the students add value is one thing I would wish every medical school could emulate. If we create a system where they add value, and they are part of our DNA, we are all better off.
For more information about the TCC program and its holistic approach to recruitment, please view this webinar presented on October 30, 2020 by Dr. Snyder, Leanne M. Chrisman-Khawam, MD, and Doug Harley, DO.