The master’s degree program replaces the associate degree program to train physician assistants that began in 1971 as a partnership between the School of Medicine and Foothill College, a two-year community college in Los Altos, California.

The new program is designed to meet the expanding role of PAs in today’s changing health care environment, said Susan Fernandes, PA, clinical professor of pediatrics and of medicine (cardiology).

“Today’s PAs practice in all areas of medicine,” Fernandes said. “They are leading community health centers, front stage in the health care policy arena, leaders in the classroom and changing health care delivery through innovation and research.”

For the first time, Stanford will offer a master of science program designed to train physician assistants as both clinicians and future leaders in health care.

“As health care access improves, we need to equip medical practitioners with the skills to meet growing demand,” said Lloyd Minor, MD, dean of the School of Medicine. “This new master of science program for physician assistants helps health care teams navigate that complexity and provide precision health: personalized treatment when disease strikes and proactive and preventive care that keeps people from getting sick in the first place.

Designed for a class of 25 to 30 students, the 30-month program will emphasize training alongside medical students in coursework and clinical care. It will also require students to choose a scholarly concentration within one of four fields: community health, health services and policy research, clinical research or medical education.

“With the increasing emphasis on coordinated, team-based care as supported by the Affordable Care Act, it is critical that the School of Medicine be able to create an integrated, team-learning environment to educate the biomedical scientists and clinicians of the future,” said Robert Harrington, MD, professor and chair of medicine.

The master’s degree program replaces the associate degree program to train physician assistants that began in 1971 as a partnership between the School of Medicine and Foothill College, a two-year community college in Los Altos, California.

The new program is designed to meet the expanding role of PAs in today’s changing health care environment, said Susan Fernandes, PA, clinical professor of pediatrics and of medicine (cardiology).

“Today’s PAs practice in all areas of medicine,” Fernandes said. “They are leading community health centers, front stage in the health care policy arena, leaders in the classroom and changing health care delivery through innovation and research.”

The role of the PA, one of the fastest growing professions, has expanded in part due to a shortage of physicians nationwide and the need to meet the growing demands of an aging population, Fernandes said. She and Rhonda Larsen, PA, clinical assistant professor of pediatrics, helped design the new program.

“We are trying to educate the next generation of PA leaders,” Larsen said. “No other program sets out to do this.”

PAs treat patients as part of a health care team, collaborating with physicians and other providers, Fernandes said. They often provide a broad range of health care services that may include conducting physical exams, ordering and interpreting medical tests, diagnosing illnesses, developing treatment plans, prescribing medication and assisting in surgery.

The curriculum will emphasize training in the foundational sciences during five academic quarters, followed by a year of clinical clerkships. There will be clerkships in obstetrics and gynecology, internal medicine, ambulatory family medicine, pediatrics, surgery, psychiatry and emergency medicine. In addition, students will have several elective rotations that will allow them to specialize in their field of interest.

“This is a new direction for Stanford, which has been traditionally a very research-heavy medical school,” said Andrew Nevins, MD, clinical associate professor of medicine (infectious diseases) and medical director of the new program. “There is little training of advanced practice providers such as PAs. There is no school of nursing, no pharmacy school. This is an opportunity for Stanford to make a mark on this rapidly growing field.”

Republished with permission from the School of Medicine’s Office of Communication & Public Affairs.

Academic diversity
“We expect candidates to come from a diverse set of academic backgrounds — from humanities to computer science, medicine or engineering, for example,” says Sonoo Thadaney, MBA, director of education programs for the SPRC.

She adds that “the curriculum is designed for graduates to work in such various activities as public health, public policy and community health, and they might start out as individual contributors in an organization and then eventually become founders or executive directors of nonprofits or leaders in government agencies. Another group of graduates might use this degree to become better-informed medical practitioners. Others might use their degree in combination with coursework in the world of performing arts — for instance to create theater aimed at inspiring healthy behaviors.”

Interdepartmental teamwork
Within six months of approval by the faculty senate, the CHPR became part of dual degree programs with the Graduate School of Business and the School of Medicine. Currently, the CHPR and the master’s program in science and genetics and genetic counseling are adding tracks from each other’s programs into their respective curricula. Soon, the Stanford Center for Women and Sex Differences in Medicine (WSDM) will add a track with the CHPR as it relates to prevention.

“The CHPR boasts an interdisciplinary faculty representing public health, medicine, behavioral sciences, biostatistics, epidemiology and other disciplines,” says faculty director and associate professor Jodi Prochaska, PhD. “In addition, the CHPR program brings the science of what’s being done at Stanford out into the community. The program pairs master’s candidates with community programs so students can gain hands-on experience with needs assessment, program development, evaluation and dissemination.”

Q:  You’ve been running the program since 2013. How has the MD Capstone Experience structure — and content — of the class changed over time?
John Kugler: When we started it, we picked three major themes: a clinical skills piece, a clinical knowledge piece and what we were calling advanced communication. Our goal from the beginning was to keep everything practical. For example, these are the things that will keep you from feeling terrible during your first four months of residency.

Jeffrey Chi, MD, and John Kugler, MD, have been talking about medical education since they met as interns in 2005, and it’s become the guiding focus of their professional lives. They spend their days in a shared office on the Stanford campus, where they bounce ideas off each other, collaborate on courses and engage in lively discussions. 

They’re both drawn to the idea that education — and the commitment to training the next generation — creates confident, comfortable physicians who, in Kugler’s words, are “extremely resilient and well prepared.”

Four years ago, Kugler and Chi, at the behest of then-medical student Vivian Lei, began Stanford’s preparatory education course for senior medical students. The course, titled MD Capstone Experience: Preparation for Residency, provides an introduction to a variety of necessary skills and prepares attendees for the precarious transition from medical student to practicing clinician. During a recent interview, Kugler and Chi, who are both in the division of hospital medicine, discussed the origins of the course and their vision for the future. 

Q:  You’ve been running the program since 2013. How has the MD Capstone Experience structure — and content — of the class changed over time? 
John Kugler: When we started it, we picked three major themes: a clinical skills piece, a clinical knowledge piece and what we were calling advanced communication. Our goal from the beginning was to keep everything practical. For example, these are the things that will keep you from feeling terrible during your first four months of residency. 

We made a few changes the next year: We expanded the course from three days to a full week of class — which went well — and we added in some things like making sure they practiced patient “hand-offs,” which is a big issue in medical education right now. 

And this year we’re going to incorporate actual patient experiences. Our students will partner with an intern in the hospital and learn from that person in real time.

Q:  Many medical schools have similar capstone courses. What, in your opinion, makes this course unique? 
Jeffrey Chi: Other places have graduation courses, but we are lucky to have the resources that we do, which allow us to do more. For example, we wanted to teach students how to respond to pages and how to communicate with nurses, and so we actually assigned them patients that they follow throughout the course. So our students actually draw on things they did the day before and decisions they made previously to influence their future decision making. It’s hard not to have lectures and didactics, but I think the amount of simulated immersion that we are doing is unique. 

I would say the emphasis that we have is survival — boot camp. We know that the medical students are smart, we know they can look up almost anything, but this is geared toward your first few months in internship: What are you going to do during that first month or that second month when you are put into a situation when you don’t have the time to sit down at a computer and look stuff up? You are going to call for help, obviously, but what do you do in those first 10 to 15 minutes when nobody’s around, so that you don’t feel like your heart rate is going faster than the patient’s? 

Q:  As you scale up, what are your visions for the future for this program? 
Jeffrey Chi: The course is being considered as a graduate requirement for Stanford School of Medicine students in the near future. So, we’re going to have to scale this to the order of roughly 90 students. Right now we’re getting the word out so people can plan their schedules well in advance. We’ll hopefully learn enough from this year’s course to scale this to an entire class in the next few years. 

John Kugler: We may need to offer the class three different times, and we are probably going to cap the numbers in each cohort to about 30 students so they can have a meaningful patient simulation experience. And while we’ve been doing a one-week course, we’d ideally like to move to a two-week course, which we will try for 2017. 

We made a few changes the next year: We expanded the course from three days to a full week of class — which went well — and we added in some things like making sure they practiced patient “hand-offs,” which is a big issue in medical education right now.

And this year we’re going to incorporate actual patient experiences. Our students will partner with an intern in the hospital and learn from that person in real time.

Q:  Many medical schools have similar capstone courses. What, in your opinion, makes this course unique?
Jeffrey Chi: Other places have graduation courses, but we are lucky to have the resources that we do, which allow us to do more. For example, we wanted to teach students how to respond to pages and how to communicate with nurses, and so we actually assigned them patients that they follow throughout the course. So our students actually draw on things they did the day before and decisions they made previously to influence their future decision making. It’s hard not to have lectures and didactics, but I think the amount of simulated immersion that we are doing is unique.

I would say the emphasis that we have is survival — boot camp. We know that the medical students are smart, we know they can look up almost anything, but this is geared toward your first few months in internship: What are you going to do during that first month or that second month when you are put into a situation when you don’t have the time to sit down at a computer and look stuff up? You are going to call for help, obviously, but what do you do in those first 10 to 15 minutes when nobody’s around, so that you don’t feel like your heart rate is going faster than the patient’s?

Q:  As you scale up, what are your visions for the future for this program?
Jeffrey Chi: The course is being considered as a graduate requirement for Stanford School of Medicine students in the near future. So, we’re going to have to scale this to the order of roughly 90 students. Right now we’re getting the word out so people can plan their schedules well in advance. We’ll hopefully learn enough from this year’s course to scale this to an entire class in the next few years.

John Kugler: We may need to offer the class three different times, and we are probably going to cap the numbers in each cohort to about 30 students so they can have a meaningful patient simulation experience. And while we’ve been doing a one-week course, we’d ideally like to move to a two-week course, which we will try for 2017.

The Critical Care Component
Lin says that “one thing that has really drawn residents into this program is the critical care component. The ICU is really the intersection of medicine and anesthesia. You’re encountering critically ill patients with severe pathologies, so you need skills in acute resuscitation and advanced medical support that anesthesiologists are accustomed to providing in the OR, but you also need to treat the underlying pathology that landed them there in the first place, which is more aligned with the work of internal medicine physicians.”

Michael Lin, MD’s daily schedule mirrors that of a normal, busy anesthesia resident: early call times, long hours in the operating room and a flurry of patients and cases.

Once a month, however, Lin’s schedule deviates from the norm.

On these days, Lin will start early — around 6 a.m. — when he arrives at Stanford Hospital to begin preparations for his first anesthesia case of the day. By the time he gets himself prepped and situated it’s about 7 a.m. — the typical time when cases begin. He’ll spend the next five hours standing in the operating room anesthetizing patients.

At noon, he’ll leave his fellow anesthesiology residents behind in the OR, change out of his scrubs and walk over to the Stanford Internal Medicine clinic, where he’ll spend the rest of his day treating outpatients as a medicine resident.

Lin’s hybridized schedule is a hallmark of Stanford’s combined Internal Medicine-Anesthesia Residency, a unique five-year training program for residents interested in both specialties. Medicine-anesthesia graduates are board certified in both fields, and are poised to pursue careers focused in critical care, but they might choose another field where combined training would make sense, such as pain management or cardiac anesthesia.

The Critical Care Component
Lin says that “one thing that has really drawn residents into this program is the critical care component. The ICU is really the intersection of medicine and anesthesia. You’re encountering critically ill patients with severe pathologies, so you need skills in acute resuscitation and advanced medical support that anesthesiologists are accustomed to providing in the OR, but you also need to treat the underlying pathology that landed them there in the first place, which is more aligned with the work of internal medicine physicians.”

The Internal Medicine-Anesthesia Residency is structured as a five-year combined program, which basically saves a year for the person who wants training in both specialties. Residents spend their first postgraduate year in internal medicine, their second year in anesthesia and years three to five split equally between the two disciplines. Because of the parallel skills that are being acquired from both departments, the resident can cut out about six months of training in each discipline.

A Natural Fit for Stanford
“For us, this combined program makes perfect sense,” says Ron Witteles, MD, director of the Internal Medicine Residency Training Program. “We have very strong departments in both internal medicine and anesthesia at Stanford. Those two departments have historically been close. In fact, we’re one of the relatively few academic institutions whose ICUs are run jointly by the departments of medicine and anesthesia.”

With 10 residents currently participating in the combined program, Stanford is the largest of only four such programs in the United States. “Not only are we the largest, but more than half of all the U.S. medical graduates who are training in med-anesthesia in the nation are currently in our training program,” Witteles adds.

Lin, who will be the first person to complete the combined residency program — in June 2017 — sees many benefits of incorporating into his practice his training as an anesthesiologist and his training as an internist.

“It does give me a little bit more perspective that I think is helpful in counseling patients and in my own management of those patients both on the medicine side and on the anesthesia side.”

The Internal Medicine-Anesthesia Residency is structured as a five-year combined program, which basically saves a year for the person who wants training in both specialties. Residents spend their first postgraduate year in internal medicine, their second year in anesthesia and years three to five split equally between the two disciplines. Because of the parallel skills that are being acquired from both departments, the resident can cut out about six months of training in each discipline.

A Natural Fit for Stanford
“For us, this combined program makes perfect sense,” says Ron Witteles, MD, director of the Internal Medicine Residency Training Program. “We have very strong departments in both internal medicine and anesthesia at Stanford. Those two departments have historically been close. In fact, we’re one of the relatively few academic institutions whose ICUs are run jointly by the departments of medicine and anesthesia.”

With 10 residents currently participating in the combined program, Stanford is the largest of only four such programs in the United States. “Not only are we the largest, but more than half of all the U.S. medical graduates who are training in med-anesthesia in the nation are currently in our training program,” Witteles adds.

Lin, who will be the first person to complete the combined residency program — in June 2017 — sees many benefits of incorporating into his practice his training as an anesthesiologist and his training as an internist.

“It does give me a little bit more perspective that I think is helpful in counseling patients and in my own management of those patients both on the medicine side and on the anesthesia side.”

Nguyen’s goal for each of her mentees is to complete at least one first-authored publication. This requires a focused project that they can finish in less than two years.

Nguyen meets with her mentees individually as often as once or more a week during their research month and as needed. And she gives each of them what she describes as a “one-hour introduction to epidemiology/study design in a nutshell.”

Alina Kutsenko, MD, is the third-year resident being mentored by Nguyen. During her research period in the Nguyen lab, she found that patients with hepatocellular carcinoma differed in presentation, treatment and survival according to whether they had concurrent metabolic syndrome. She has presented these data at two major academic conferences and has a first-authored publication currently in press. 

All residents at Stanford are guided by a core mentorship group consisting of a senior and a junior faculty member as they pass through rotations, choose a specialty, prepare a curriculum vitae (CV) and begin to make career plans. In their second and third years, residents have a research block of up to one month each year — free from clinical responsibilities — which often involves a different mentor to introduce them to academic research. Here, three faculty mentors tell how they approach this opportunity — with a few specific results their residents have achieved.

A Very Experienced Mentor
Mindie Nguyen, MD, MAS, an associate professor of gastroenterology & hepatology, is currently mentoring a third-year resident, three second-year residents and one intern. 

With experience mentoring three to five residents annually for many years, Nguyen says, “I tailor it to each of them depending on their clinical and research interests and what they need the most from me, and I am always conscious of their timeline. They generally need to show results of their work by the time of fellowship application, which is usually only about a year to two after meeting me.”

Nguyen meets individually with each resident, asks them about their background and what they enjoy, and reviews their CV and prior experience. She describes for them the types of studies her lab does, examples of prior residents’ projects and the data she has available to them. Then she lets them choose a topic: liver cancer, fatty liver disease, hepatitis B or hepatitis C, and then a specific project from available options. 

Nguyen’s goal for each of her mentees is to complete at least one first-authored publication. This requires a focused project that they can finish in less than two years.

Nguyen meets with her mentees individually as often as once or more a week during their research month and as needed. And she gives each of them what she describes as a “one-hour introduction to epidemiology/study design in a nutshell.”

Alina Kutsenko, MD, is the third-year resident being mentored by Nguyen. During her research period in the Nguyen lab, she found that patients with hepatocellular carcinoma differed in presentation, treatment and survival according to whether they had concurrent metabolic syndrome. She has presented these data at two major academic conferences and has a first-authored publication currently in press. She is also working on her second project, building on the niche she has developed with liver cancer and metabolic syndrome.

Transitioning from Mentee to Mentor
Sometimes a successful mentee becomes a successful mentor in just a few years. This was the case for assistant professor Mintu Turakhia, MD, a cardiac electrophysiologist; Alex Perino, MD, a cardiology fellow; and three residents who began the project as interns, during the fall of 2015.

Perino, who had been mentored by Turakhia for several years, describes the project: “This year, Mintu enabled me to assist in the mentorship of George Leef, Andrew Cluckey and Fahd Yunus on a grant-supported project we call SMASH-AF (systematic review and meta analysis of ablation strategy heterogeneity in atrial fibrillation). Published success rates of AF ablation procedures ranged from 20 to 90 percent. Our goal was to figure out what drove this significant variation in outcomes. We performed a massive systematic review, screening 9,000 articles, ultimately including 400 that met our criteria, which had more than 540 treatment arms and 65,000 patients, with over 400 unique variables abstracted per article.” 

He continues: “We also utilized a research group structure and philosophy that increased mentee responsibility, resulting in greater mentee growth and project productivity.” 

Leef provides an example of mentee responsibility: “Alex and Mintu wanted us to take an active part in creating the abstraction rules. Since we were the ones reviewing the articles, we were in the best position to adapt the rules as new situations arose, and it was also a valuable learning experience for us.”

The first four abstracts from this remarkable meta-analysis were submitted to the American Heart Association for its annual meeting in November 2016; two were accepted as poster presentations. Perino anticipates an additional 25 hypotheses to explore from the massive database, and “this is just the tip of the iceberg,” he says.

Perino credits Turakhia with providing a template for him to follow as a mentee. “Mintu did not just give me work to do,” he says; “he taught me how to be independently productive.” About this particular project, Turakhia says, “What’s cool here is teaching these residents about team science and collaboration early in their careers.”

Residents Delving into Residents’ Responsibilities
The final mentor-mentee project focuses on a topic of particular interest to residents: trying to find the sweet spot in balancing their inpatient responsibilities with their duty to outpatients who have problems or questions between appointments. There was a fair amount of anecdotal information among residents about finding the right balance, but there were no data.

The senior author and a mentor of the residents on this project, clinical associate professor of hospital medicine Jeffrey Chi, MD, had requested that data be retrieved from EPIC, Stanford’s electronic health record, in 2013. A year later he received a data set that contained information about all the things that residents did that were recorded in EPIC. It was a treasure trove.

At that point, Chi recalls, “While I could guide the research methodology, ultimately the residents know the right questions to ask. They know where the stress points are.”

The residents who took part in the project were Jason Hom, MD, Jonathan Chen, MD, PhD, and Ilana Richman, MD. Additional mentors were Baldeep Singh, MD, who is a clinical professor of general medical disciplines, and Casey Crump, MD, PhD, who at the time was director of the Center for Primary Care Research.

Chi and Hom had worked together throughout Hom’s residency and “had already established a good working relationship,” according to Chi. He was confident that Hom and his colleagues were both accomplished and highly motivated. 

Hom explains that they wanted to address “a topic relevant to house staff that has implications for how residency programs design inpatient and outpatient responsibilities. Jeff had done a great job of acquiring a difficult-to-acquire data set, and we wanted to use it to try to answer that question. It was nice to generate some solid data to help inform the discussion.”

The resulting manuscript was published in BMC Medical Education in May 2016. The results were not surprising: They found that at the time of the study it was difficult for residents on busy inpatient rotations to pay equivalent attention to outpatients with between-visit problems.

Hom states, “Stanford is wonderfully supportive of residents and very innovative in its approaches, and based on resident feedback, Stanford now employs a popular ‘firm system’ that uses team-based care to help with patient between-visit problems, which improves the trainee experience and also patient care.”

He continues: “We also utilized a research group structure and philosophy that increased mentee responsibility, resulting in greater mentee growth and project productivity.”

Leef provides an example of mentee responsibility: “Alex and Mintu wanted us to take an active part in creating the abstraction rules. Since we were the ones reviewing the articles, we were in the best position to adapt the rules as new situations arose, and it was also a valuable learning experience for us.”

The first four abstracts from this remarkable meta-analysis were submitted to the American Heart Association for its annual meeting in November 2016; two were accepted as poster presentations. Perino anticipates an additional 25 hypotheses to explore from the massive database, and “this is just the tip of the iceberg,” he says.

Perino credits Turakhia with providing a template for him to follow as a mentee. “Mintu did not just give me work to do,” he says; “he taught me how to be independently productive.” About this particular project, Turakhia says, “What’s cool here is teaching these residents about team science and collaboration early in their careers.”

Residents Delving into Residents’ Responsibilities
The final mentor-mentee project focuses on a topic of particular interest to residents: trying to find the sweet spot in balancing their inpatient responsibilities with their duty to outpatients who have problems or questions between appointments. There was a fair amount of anecdotal information among residents about finding the right balance, but there were no data.

The senior author and a mentor of the residents on this project, clinical associate professor of hospital medicine Jeffrey Chi, MD, had requested that data be retrieved from EPIC, Stanford’s electronic health record, in 2013. A year later he received a data set that contained information about all the things that residents did that were recorded in EPIC. It was a treasure trove.

At that point, Chi recalls, “While I could guide the research methodology, ultimately the residents know the right questions to ask. They know where the stress points are.”

The residents who took part in the project were Jason Hom, MD, Jonathan Chen, MD, PhD, and Ilana Richman, MD. Additional mentors were Baldeep Singh, MD, who is a clinical professor of general medical disciplines, and Casey Crump, MD, PhD, who at the time was director of the Center for Primary Care Research.

Chi and Hom had worked together throughout Hom’s residency and “had already established a good working relationship,” according to Chi. He was confident that Hom and his colleagues were both accomplished and highly motivated.

Hom explains that they wanted to address “a topic relevant to house staff that has implications for how residency programs design inpatient and outpatient responsibilities. Jeff had done a great job of acquiring a difficult-to-acquire data set, and we wanted to use it to try to answer that question. It was nice to generate some solid data to help inform the discussion.”

The resulting manuscript was published in BMC Medical Education in May 2016. The results were not surprising: They found that at the time of the study it was difficult for residents on busy inpatient rotations to pay equivalent attention to outpatients with between-visit problems.

Hom states, “Stanford is wonderfully supportive of residents and very innovative in its approaches, and based on resident feedback, Stanford now employs a popular ‘firm system’ that uses team-based care to help with patient between-visit problems, which improves the trainee experience and also patient care.”