Many years ago, I thought I was going to be a mechanical engineer. My studies revolved around case-based learning and field work, all of which I enjoyed immensely. Then I learned about biomedical engineering and decided to go to medical school.
For the first two years of medical school, my education focused on classroom didactics and instruction, with little to no involvement in what was happening with patients in the real world. It was laying a foundation, but my classmates and I also wanted and had hopes to experience what it really meant to be a doctor.
Not until my third and fourth years of medical school, and then my residency, did I get the opportunity to participate in clinical rounds and interact firsthand with patients. What a difference that made! Now I was part of a problem-solving team that shared information and observations with the goal of improving patient outcomes (and it appealed to the engineer in me).
As a fourth-year medical student, I helped take care of patients at a community hospital confronting a brand-new disease, known at the time as Gay-Related Immune Deficiency, or GRID, but which turned out to be AIDS. Daily, we had group conversations about how to deal with one patient’s mysterious pneumonia. I played a direct role in this patient’s survival because I was sent to the library to scour the medical literature. There, I found a new report from California about six men in the Los Angeles area who had pneumonia that didn’t respond to routine therapy—the same problem my patient was experiencing. Armed with this information, our team determined how best to treat him, and he recovered.
In another instance, I was doing a family medicine rotation at a community clinic, where an older and experienced doctor gave me the case of an 80-year-old female patient with “inexplicable” neurological symptoms. The week before, I’d attended a lecture on STDs, so I asked her about her sexual history and whether she’d ever had syphilis. She replied that her husband 30 years ago had been diagnosed, but she had never been tested herself. “Inexplicable” case solved.
For me, looking back, these stories hold a few different lessons.
First, as clinicians, we need access to the right knowledge for the right patient at the right time. In the first case, I had to uncover new knowledge by stumbling over it in the library to understand and help my patient; in the second case, I happened to hear a lecture and have the right—older—knowledge at my fingertips. In both cases, fortunate, yes, but is that the best way to learn how to care for patients? It worked, but probably not the best path for learning.
Second, curiosity and open-mindedness led me to the right answers. Interestingly, I took a sexual history for both patients, which, though critical to solving their problems, wasn’t the norm at the time. In the 1980s, taking a sexual history was turning out to be very important, but medicine still hadn’t caught up, and doctors mostly weren’t asking “uncomfortable” questions. My inexperience with medical culture turned out to be a blessing, not a curse. And it should be the same for everyone. We should bring new knowledge and curiosity into a system that sorely needs it.
Those kinds of experiences were exciting. They fed my hunger for knowledge and engaged me with my peers in working out solutions that would help our patients. For me, they reflected what medical practice should be: collaborative, rooted in ever-changing and advancing evidence, and focused on patients and their communities.
But here’s the thing. Once you leave the medical school environment and your residency and/or fellowship, all that often disappears. Medical practice becomes much more insular. If you’re a doctor in a medical practice, you go to the office in the morning; you go home at night. You may or may not see a small number of other practitioners during the day. You don’t have the opportunity for shared learning experiences; you’re too busy. And after a while, you feel isolated as a professional and maybe even dissatisfied with what you’re doing.
It doesn’t have to be that way, though. There are ways to recapture the excitement of learning and problem-solving with colleagues.
For me, that way is Project ECHO, a global learning community first started at the University of New Mexico Health Sciences Center in Albuquerque – and that we took up here at the University of Chicago – that supports the spread of new knowledge and best practices. ECHO is kind of like hospital rounds on Zoom, except it is directed at outpatient care in the community. It engages a range of clinicians—including specialists, primary care physicians, nurses, physician assistants, community health workers, and more—in multi-directional learning and knowledge-sharing for the purpose of improving patient outcomes.
Each ECHO session begins with a brief didactic by an expert specialist on a given topic, then moves on to a case presentation by a participant, typically a community practitioner. After the case presentation, experts and fellow participants dig deeper into the problem, asking questions, making suggestions, and offering resources. The session concludes with a recommended plan of action for the presenter to follow. ECHO programs are ongoing, so that participants can develop a real community of learners freely sharing knowledge and exploring new questions.
What’s most powerful to me is the “all teach, all learn, all support” environment that is highly interactive. Participants bring all their knowledge and experience to bear on the problem at hand and collectively improve patient care. It truly is a unique and supportive professional learning community.
ECHO started 20 years ago as a solution to New Mexico’s severe shortage of physicians trained to treat hepatitis C. It proved to be a highly effective way to engage a range of professionals in ongoing communities of learning and knowledge-sharing. Today, ECHO learning communities operate around the world, addressing dozens of health and social issues and engaging tens of thousands of learners.
At the University of Chicago, in 2010, we were just the third academic medical center in the world to adopt the model, right behind the University of Washington. We now operate more than two dozen ECHO series annually that focus on such topics as childhood obesity, diabetes, COVID-19, hepatitis C, hypertension, opioid use disorder, mental illness, women’s health, and more. Since 2016, we’ve been what’s called an ECHO Superhub, providing training and support to other organizations that are either running ECHO programs or are interested in starting one. We have worked with organizations in other U.S. states and with organizations worldwide, including in Canada, Germany, Uruguay, and Australia, to name a few. Last September, we launched, in partnership with the Tongji University School of Medicine in Shanghai, the first ECHO program in China. Today, more than 1,400 ECHO programs have been developed around the world.
I remember the story of a doctor who participated in our pediatric obesity ECHO. Although pediatric obesity may not often be seen as a complicated issue, it can be tricky for doctors to work with families effectively and get them to change their motivation. “After years of not making a difference, I’m finally seeing BMIs go down with ECHO,” this doctor told me.
Another doctor at an FQHC in Washington state insisted that participation in ECHO be written into his contract when it was time for him to re-up with the health center.
We’ve even done a few ECHOs here with residents, including one on ADHD with residents in a community program who didn’t have access to specialists. They deeply valued the opportunity to share their cases and experiences with our ADHD experts. We did a study on our program’s impact and found that ADHD diagnoses increased significantly because participants were better informed and more comfortable addressing this condition.
People who participate in Project ECHO love it. They love participating in case-based learning. They love connecting with their peers. And they love that ECHO is grounded in what’s happening in the real world – and that their own real-world experience is contributing to the learning of others. It was what I thirsted for when I first started my medical education.
I believe that it is time to incorporate ECHO into the medical education workstream – to make it a formal part of medical education, starting with medical students, all the way through the current medical education program, and well beyond graduation from residency and fellowship, benefiting those working in the community and, most importantly, their patients. It’s important for you as medical students to know about Project ECHO—and, even more, to experience it. Once you do, I hope that you will seek it out—even demand it—throughout their education and their professional careers.
ECHO programs are free and open to all practitioners. All you have to do is find one of interest and register. As I mentioned, we operate dozens of ECHO programs at the University of Chicago.
I can envision ECHO series that give medical students in their first two years recurring clinical exposure. Imagine an ECHO series specifically for medical students where they can hear about cases from community practices that they often aren’t exposed to. Many medical students think that primary care is boring, but nothing could be further from the truth. By participating in ECHO, they could hear about real cases that primary care physicians are working on. It will help increase the desire for students to pursue primary care, a critical goal for our health care system.
ECHO could also bring together medical students from different schools to discuss their common challenges. Chicago has six medical schools. What learning might surface if the students from those schools had the opportunity to interact with each other on an ongoing basis and share their experiences?
You don’t have to settle for the status quo. Demand better. Demand – and build – a system that supports lifelong professional learning.
To start, I urge you to learn about ECHO and try it. Once you do, I feel confident that you will demand it. What’s more, you will enjoy participating in ECHO programming throughout your careers.
Daniel Johnson is a pediatrician.
