Interview in Dr_ Battinelli
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Stacey Ishman: [00:00:00] Welcome back to the Academic Medicine Strategy Podcast. I am very excited to have the physician-in-chief and dean here with me today to talk about not only his new book but also his philosophy on how we should be building and moving medical education. So if you don't mind giving us a little bit of your background and letting everybody know who you are.
Dr. Batitinelli: Sure. Thanks very much. Thanks for having me. David Battinelli, MD. I'm an internist. I am the executive vice president and physician-in-chief at Northwell Health, and also the dean at the Donald and Barbara Zucker School of Medicine at Hofstra Northwell. The School of Medicine is a joint venture between Hofstra University and Northwell Health, the health system
Stacey Ishman: And can you tell us a little bit about the motivation for you to write the book?
Stacey Ishman: I know you have a co-author, so you obviously have been spending some time thinking through the way medical education should be done. But what made you decide now is the time to take it on the road and let everybody else know about [00:01:00] that philosophy?
Dr. Batitinelli: Yeah, sure. Without going too long into this we got together in 2008 the founding dean and myself Dr.
Dr. Batitinelli: Laurence Smith both working for what was North Shore LIJ then now Northwell Health. They were interested in building a medical school, primarily to transform a large clinical enterprise into an academic health system. Hofstra, the university, was also interested in building a medical school because the moratorium on medical school positions and new schools was lifted in 2003.
Dr. Batitinelli: There was clearly a shortage of positions for all reasons I'm sure many of you are aware of. And so we entered into the agreement to do this project. The agreement began in 2008. We opened our first class in 2011, and have since graduated obviously a little over 10 classes. And we thought it was finally time to be able to tell because we had some data on people who had graduated about what the successes of the school were because we took on some, as the title suggests, revolutionary changes [00:02:00] that were not necessarily accepted early on.
Dr. Batitinelli: And people were anxious to hear the story, but they didn't want to hear the story until we had enough experience to give them some results.
Stacey Ishman: So one of the big things that you've done is remove grades and class rank and rebuild assessment. And now that doesn't actually sound as revolutionary. I think a lot of other places have taken that on.
Stacey Ishman: But I would say 10 years ago or 14 years ago, as you put all the, the first class in there, it probably felt like a much bigger deal. So what made it so that you recognized that so early on, and what made those changes actually stick at a time when it felt n- not as commonplace as it's becoming today?
Dr. Batitinelli: Yeah. So that's a good way to put it. First and foremost it stuck because we started from scratch and we were the boss. We were simply convincing people who wanted to go along with this ride, and quite candidly, people who didn't wanna go along with the ride were no longer invited.
Dr. Batitinelli: So it really was an opportunity, which is very different than what somebody else has to do in terms of reforming their curriculum, which [00:03:00] says so if you don't agree with us, you're out." But what we did, those are some of the key points o- of the book. But really what we wanted to do was change the way medical education was learned and taught.
Dr. Batitinelli: One of our taglines is, "This is not about..." Th- rather, "This is all about how young doctors learn, not how old doctors teach." And the biggest issues in all of education across all venues, not just medicine, is that the educators need to keep pace with the generations. And everybody who is educated at a time believes that their education was perfect because by definition for they and their mothers, let's say, they turned out perfect.
Dr. Batitinelli: So we have to do exactly what they did, and that just... That's simply just not the, the way it should be. And as you recall, I'm sure from med school, that most med schools are in this two-by-two design, two years of what everybody called preclinical and then two years of clinical. And we decided that we would take that on.
Dr. Batitinelli: That's the primary thing we did. Our students are in clinical practice from the very first day of medical school. First trained as EMTs, and then [00:04:00] actually in five discipline-specific practices in a continuity relationship, doing OB, pediatrics, surgery, psychiatry and internal medicine or family medicine for the entirety of their first, what would be two years.
Dr. Batitinelli: We call it the first 100 weeks because everybody objected to this model until I changed it from years to weeks, and then no one seemed to care anymore. But and so we don't even want to use the word preclinical 'cause we're ne- we're not preclinical. And we thought that the best way to learn the science and to get the science to stick in this day and age when you don't need a lecturer because you can get information from anywhere, as can all the patients, is to learn how to apply the science to clinical care.
Dr. Batitinelli: And because we were such... we were governed in such a way that we had this enormous health system with a university and were permitted to do whatever we wanted, not necessarily hire just preclinical faculty from the university versus then go to a health system and get your clinicians. We had our [00:05:00] clinicians and our...
Dr. Batitinelli: And whatever faculty we wanted from day one. So we really, the biggest thing we did was we blended for four continuous years clinical practice and science.
Stacey Ishman: So I think you make a good point is that it isn't necessarily based on maybe the education of those of us who are teaching or the experience of those of us who are teaching, but how do you provide the faculty development so that the faculty can learn new ways of doing it and take on, the...
Stacey Ishman: Even the conversations we have about generational learners, and there's lots of pieces to this that are not just, "Here's what I learned 25 years ago," but how do I become a modern-day top-of-the-line educator, and what kind of faculty development do you provide for me to get there?
Dr. Batitinelli: So along the way, a- and where we got many of these ideas was from traveling around the country to the best institutions whether it was UCSF or Case Western, Penn, Harvard, BU, Hopkins.
Dr. Batitinelli: Most of the educators realized that the way we were delivering education really [00:06:00] was outdated, hard to change. The old saying of, no one will let 100 years of tradition interfere with progress, and they begged us. They said, "Listen, we got these great ideas. You guys, starting from scratch, you could do this."
Dr. Batitinelli: And, you know- Take what we have. We, there's no IP here. This is please- Yeah ... take these ideas. And so we did. And many of those ideas had to do with things like we don't have any multiple choice question tests. All our assessment is essays, orals, practicals, sim- stim- simulations, and standardized patients.
Dr. Batitinelli: The faculty love that because what do you learn from a, a multiple choice question test that they check- they checked B, it wasn't the right answer, C was. You have no idea why they put B down. When you're doing essays, orals, and a... You're able to actually coach and mentor students along the way.
Dr. Batitinelli: We developed continuity relationships where people see people grow through the period of time. So there were faculty that, didn't think this was the right way, and we didn't think they were the right faculty, but for [00:07:00] those faculty who actually do like watching students learn and develop it was an easy sell for them.
Dr. Batitinelli: Because what they were doing before, they didn't like at all. They would stand on the stage, they would give a lecture, half the class wasn't there, they get a multiple choice question test, and 50 million reasons why somebody wants to say that it wasn't a good question. Yeah ... this was a much more interactive and supportive environment.
Stacey Ishman: But there's still a skill set that we need to train our faculty leaders with. So the people who remained, they were excited but maybe didn't have coaching skill sets or some of those things. What do you do to help bake
Dr. Batitinelli: that in-
Stacey Ishman: for each- ... train
Dr. Batitinelli: them? For each part of our curriculum, we have certain faculty.
Dr. Batitinelli: So we have what we call PEARLS, which is our small group learning. And our faculty have to be expert facilitators because they're not allowed to give content. The content needs to be figured out by the students, and so they become expert facilitators, and we have huge programs that we bring people through.
Dr. Batitinelli: And I would say 80 to 90% of the people can learn the skill. There's 10 to 20% that just can't do it, [00:08:00] and so they don't. Bring clinicians into what we call structure. So we don't have anatomy and embryology and all of that stuff. We do it all at the same time. We have laboratory science, and so we have our real clinicians come in there and show you not just the anatomy of the liver, but the histology, the embryology, the diagnostic imaging, handheld ultrasound CTs, MR, everything at the same time, and we bring in hepatologists to do that.
Dr. Batitinelli: They're really good at hepatology. We don't ask the hepatologist to do the nephrology. A lot of the things that we talk about, I'm not being flippant, but it's somewhere between brilliant and dumb obvious. It's how you would do it if you were starting from scratch.
Dr. Batitinelli: Our clinicians, we bring our faculty in a continuity relationship. So when you and I were in med school or as a faculty member, we would rotate into different people's offices for two and three weeks at a time. By the time you got to know them, they got to know you, you were moved someplace else.
Dr. Batitinelli: Our relationships are one to two years in length. And if I was to have you as a faculty member, you would have only one [00:09:00] student for a period of two years intermittently over that period of time, and you would watch them grow, and you could teach them everything you want. So I bring somebody into an OR, within a couple of months they're first assisting in OR procedures in their first year of medical school because I'm confident that, first of all, they're very bright and they learn the skill because I taught them the skill.
Dr. Batitinelli: So yes, it... there is faculty development, but it's as much by matching the right faculty for what they already do well. So the promise to the faculty was, "I'm gonna ask you to do and teach what you do well."
Stacey Ishman: So the other thing I find interesting is that you're both a physician and chief in the hospital system and dean at a medical school at the same time.
Stacey Ishman: And so one of the things a lot of academic institutions deal with, more on the hospital side honestly, is how they retain strong faculty because the, maybe it's the match or maybe it's that we don't give them good introductions to what it's like to be in academic medicine. But how do you [00:10:00] create strong systems so that you can keep those faculty and you don't lose them over the first three to five years?
Dr. Batitinelli: So Northwell Health's a big place, right? So 28 hospitals, a thousand ambulatory sites, 100,000 employees, 15,000 doctors. And we had a big graduate medical education enterprise. We're the third largest in the country with 2,600 residents and fellows. So many of our faculty were already doing a lot of teaching-
Stacey Ishman: Yeah
Dr. Batitinelli: With respect to that. And so but our biggest challenge was trying to get them to incorporate some of the techniques we were using for medical students into the residents and fellows. And a lot of it has to do with, the typical control issues really. You need to trust the med students and the residents that they were able to do the work if you were able to give them that little bit of I don't like to use the word autonomy, because it's a graded amount of responsibility.
Dr. Batitinelli: So if you actually have a good eye on somebody in a continuity relationship, you have a much better sense as to how you bring them [00:11:00] along than if every couple of months they throw a whole bunch of new people in front of you. So a lot of it had to do with the model. Okay. And that continuity relationship brought a lot of fulfillment to the faculty.
Dr. Batitinelli: So much more than if I give you a different resident every couple of months.
Stacey Ishman: Yeah. Have you changed the residency in the same way that you've changed the medical school?
Dr. Batitinelli: A little bit. We're trying, a- again, we're relatively young, graduated 10 classes, but the residency training programs are seeing the benefits of some of the things that we have done, and much of that benefit isn't necessarily exactly what we've done.
Dr. Batitinelli: It's just always challenging yourself to understand what worked 30, 40, and 50 years ago doesn't work anymore. And, so I finished medical school in 1985. If somebody- In 1985 came to me to tell me about something that they did 40 years ago, 1945, which is what we were doing now. You got 19, 1920, 2025, somebody talks to somebody, that's 40 years ago.
Dr. Batitinelli: I, why would I listen to you? [00:12:00]
Stacey Ishman: Yes.
Dr. Batitinelli: It's just, it's old, it's antiquated, it needs to be challenged, and there are better ways.
Stacey Ishman: So o- one of the things in your book I really a- appreciated was thinking about the fact that this career is changing. I think that what you just said is perfectly right. What we're doing 40 years ago shouldn't be what we're doing today.
Stacey Ishman: What your graduates are learning today shouldn't be what they do 30 years from now. So what does it actually take structurally to prepare and keep faculty across that 30-year career and not just train them at the start? How do you help them evolve with the system?
Dr. Batitinelli: So part of it is to agree on what we're actually trying to solve for.
Dr. Batitinelli: So one of the things you may have seen in there is that we identified what we call five drivers, which are societal things that are going on that we need to solve for, that if we don't nobody else is going to, and there's still gonna be problems. And the five are, one, the continuum of care. It's horribly fragmented, and we need to do a much better job providing all the things patients want: access, continuity, et cetera.
Dr. Batitinelli: So we're trying to solve for that. The second is medical decision-making and uncertainty. We're basically training for [00:13:00] uncertainty. Our, that, that's what we do. Yeah. There's, th- there's, it's a myth that more data, everything's gonna become easier. The third is what we called social context and responsibility, which is now social determinants of health and disparity.
Dr. Batitinelli: We have a terrible problem with disparity. We have to make that better. The second to last, quality and effectiveness. It's not what you know, it's how you do it and what your results are. In the old days, we just assumed the guy with the highest mark on the test was gonna be the best practitioner.
Dr. Batitinelli: We now know that's not the case. And the last but not least but maybe most important, is scientific discovery, which is you need to be able to keep up with the science of the discipline and the profession that you chose over a lifetime. That's your real challenge. And if you can do that, you're gonna continue to be a good doctor.
Dr. Batitinelli: The data's pretty clear. Those who don't keep up they're the ones that get in trouble.
Stacey Ishman: Do you have structural systems to help the faculty do that over time? 'Cause all that sounds fantastic, but they're all busy. They're teaching, they're writing, they're doing discovery they're educating in your [00:14:00] system.
Stacey Ishman: So how do you bring them along with you?
Dr. Batitinelli: One of the easiest ways, or most effective in my opinion, is to be involved in education. So if you're out on your own and you've never seen a resident, you've never seen, So for example, in that, what others would call preclinical, what I talked about with the first 100 weeks many of those practitioners, they are not employed by the health system.
Dr. Batitinelli: They're completely voluntary physicians who've agreed to do it. Now, we got a lot of pushback in the beginning. It was like you're gonna have Joe Schmo, the obstetrician. That's not a faculty member here." I said, "That's the same person who delivered your kids, so if you don't think that obstetrician is good enough to handle a very first-day medical student in obstetrics, that's ridiculous."
Dr. Batitinelli: And so the reason that those practitioners signed on with us is that we got to write our own rules. We made them faculty members. We gave them all the rights and responsibilities of any full-time faculty member. All they ever wanted was not to be treated as second-class citizens. And [00:15:00] I'm not asking them to do high, advanced maternal-fetal fellowship training.
Dr. Batitinelli: I'm asking them to teach how to take care of women, deliver babies, and do preventative care. It's yeah, I used to use a Little League analogy. I would not hire Joe Torre to teach Little League. That's the majors. I just need somebody who, who understands children and development and likes what they do.
Dr. Batitinelli: So putting education close to them and not overwhelming them with rotating series of residents and fellows, just having one or two people, has been a home run.
Stacey Ishman: So it sounds like what you're doing is taking the natural love of medicine, people's intrinsic gifts in terms of educating and being clinicians, and really funneling them and channeling them.
Stacey Ishman: Is there a feedback system? I'm sure not everybody that you've done that with has worked perfectly from the start. So how do you help them develop that skill?
Dr. Batitinelli: Are you talking faculty or students? 'Cause it's a little bit- Faculty ... different. Yeah. Yeah, faculty. It's th- and they actually do remarkably well.
Dr. Batitinelli: Obviously I select people who [00:16:00] tell me that they're good physicians and that they have the single thing that I require, which isn't proof that you know how to deliver a baby if you're an obstetrician, which seems ridiculous. I'm only interested in your attitude you need to have a positive attitude, you need to have gone into medicine 'cause you like medicine, and you still like medicine, and you wanna figure out a way to continue to like medicine.
Dr. Batitinelli: And so our attrition rate's very low. Even people who have had to take a break for a little time because of a family or something else usually come back. It's, y- I think you said it right. It's how do you not beat it out of somebody, but actually nurture it and bring it along, given the fact that you are busy, you are strugg- you're raising a family you're practicing medicine.
Dr. Batitinelli: Times are more and more difficult. How do you help them adapt to that in a meaningful way and promote purpose in their careers? Yeah. No, I love that. I think I used to joke around that I used to hire people based on the Southwest Airlines model, which was all about [00:17:00] attitude. Totally ... 'cause I think we can train people to do almost anything.
Dr. Batitinelli: Yeah, I would get into involved... a lot of people in the beginning came and said, "I wanna be in the school. I teach this, I teach that." I'm like we don't do that, we don't do this." And they're like I'm gonna tell you the reason everything is wrong." And I'm like, "I don't understand why I would put you in front of any medical students.
Dr. Batitinelli: I don't need anybody to help tell everybody why the world is... First of all, they haven't even started in the world." Yeah ... yeah I agree with you. The attitude is key.
Stacey Ishman: I have five kids, and they are always telling me what's happening in the world. Yeah. So I learn a ton from them. And also, it's really exciting to see how much more engaged they are in things than I think I was at their age and in their development.
Stacey Ishman: So I, that's the beauty of getting to educate people is you, it's a two-way street in terms of the education.
Dr. Batitinelli: Yeah.
Stacey Ishman: My last question for you is, what do you see breaking in academic medicine right now that institutions are not naming yet or not working on yet? And I'd love to see this especially 'cause you have subverted the model quite a bit.
Stacey Ishman: So when you're looking around, what do you think we should all be paying much more attention to?
Dr. Batitinelli: I, I think the primary change that we will see in [00:18:00] medicine over the next five to 10 years will be how we connect with patients and how we connect patients to their therapies. Everybody knows the biggest issue is access, but that's because we have only one way to access, and that's an appointment.
Dr. Batitinelli: And I'm an internist by training. I know that more than 50% of the care I've delivered practicing for 25 years I could have done virtually if I had the right tools. And I don't mean telehealth 'cause there's no telephone involved, and I don't mean virtual 'cause that sounds wrong, that sounds unreal.
Dr. Batitinelli: It's some sort of connected care. In a screwy but maybe overly simplistic model I use is banking. The banks had an access problem. They solved the access problem by changing how they connected to the consumer, and it wasn't through a bank. It wasn't through b- tellers, and it wasn't through different hours.
Dr. Batitinelli: And I'm positive that with the advances in AI technology and what's coming, we will be able to connect with patients differently, and [00:19:00] if you don't understand that, someone else is gonna steal your business. At the same time, we're connecting patients with their therapies, right? So we were all terrible at monitoring and delivering good diabetes care because we had no way to measure glucose.
Dr. Batitinelli: Telling a patient to stick their finger eight times a day sounded good to the doctor, but it wasn't any good for anybody else. Yeah.
Dr. Batitinelli: Now you have a, a glucose... digital glucose monitor and friends and family do better than any doctor did. The same thing will happen in hypertension, peripartum, monitoring, will happen for everything.
Dr. Batitinelli: And if you're not willing, even though I don't have it in front of me right now, if you're not willing to understand that's what's coming, you'll be behind.
Stacey Ishman: I hope
Dr. Batitinelli: not. And we're teaching our students how to do, connected care, how to do all this, because the real gift of medicine is teaching patients how to best take care of themselves as much as they possibly can until they need you.
Stacey Ishman: So one of my side gigs is I'm the CMO of a Medicaid insurance company, and one of the things we talk about all the time [00:20:00] is HEDIS measures, which I'm sure many people out there are familiar with. And there are measures right now looking at tobacco use that ignore vaping and all the other things that are going on right now, and I think the things you're talking
Stacey Ishman: about make a ton of sense. We really need to catch up in order to make sure we're taking optimal care, and it is amazing to me every day how many things that we sort of trip over recognizing that we need to move forward in order to make sure that we're taking the best care of patients. So thank you very much for your time and for sharing the information from your book and for innovating for all of us for the last 15 to 20 years.
Stacey Ishman: And I look forward to seeing what happens next.
Dr. Batitinelli: Appreciate that. I appreciate the invitation
