Clarence Braddock, MD, MPH, a nationally recognized medical educator and former Executive Vice Dean and Vice Dean for Education in the David Geffen School of Medicine at UCLA, joins Euan Ashley on The Future of Medicine to explore how we train future doctors, why changing long-established systems can be so difficult, and what leaders often misunderstand about creating meaningful change.

Braddock describes how experiences ranging from serving as a physician in the Navy to teaching trainees and studying conversations between doctors and patients shaped his thinking about what medicine asks of both clinicians and educators.

The conversation then turns to medical education itself. Braddock challenges assumptions that have shaped medical school for generations and discusses newer approaches, including simulation-based learning and a growing shift away from expecting physicians to function as encyclopedias of medical knowledge. As AI and other technologies increasingly bring information directly to the point of care, he argues that tomorrow’s doctors will need to become skilled and responsible consumers of knowledge.

Braddock and Ashley also examine the human side of organizational change. Drawing on lessons from major curriculum reforms, Braddock explains why the process of change can strain colleagues and institutions, and ultimately, why he concluded that how change happens can matter even more than what is changed.

Together, they discuss shared decision-making, the evolution of medical training, AI in medicine and what medical schools should be preparing their graduates to do in the decades ahead.

The Intro

“The things that each of us learned in medical school, by the time we're a second-year resident, were obsolete.”

Clarence Braddock helped lay the foundations of one of the most important ideas in modern medicine: that patients should be real partners in decisions about their own care.

“Focus on the how, and the what will take care of itself.”

Before shared decision-making was even a phrase, he was studying how doctors and patients actually talk — and where those conversations break down.

“And he said to me, ‘You know, I'd rather bleed to death than have a stroke.’ There's something elegant in that simplicity.”

From Stanford undergraduate to Navy physician to one of the country's leading voices in medical education, his career has been a long argument for rethinking how we train doctors.

“And you realize how incredible it is that we as human beings can actually perform under that kind of pressure at such a high level.”

In this conversation, we discuss what it really means to share a decision with a patient, the art of leading change inside a complex institution, and how we should train the physicians of the future. 

Welcome to Stanford Department of Medicine's inside look at the future of medicine.

The Transcript

Dr. Euan Ashley: Well, Clarence, welcome back to Stanford, and welcome to the Future of Medicine.

Dr. Clarence Braddock: Thank you very much.

Dr. Ashley: It's such an honor to have you here, and in particular to give the Kelley Skeff Lecture, which you have just done as part of our medical grand rounds here at Stanford. Wonderful talk, and I look forward to really diving deeply into the topic. As I mentioned earlier in our conversation, you've been such a legend at Stanford over many years, and of course your more recent history is at another institution — we're going to hear about your work there. But first, I love with our guests on the podcast to go back in time and learn. I'm always really interested as to why people first got into medicine. In my case, wanting to be a doctor is one of the earliest memories I have ever had — at like five years old, I would tell friends of my parents. But everybody has a different route. So I'd love to hear about yours. When was the earliest moment you knew you wanted to be a doctor and be part of the medical community?

Dr. Braddock: Well, it's a great question. I actually think of three influences, none of which are particularly exciting. The first was that I realized at a young age I really loved science. I remember getting my library card, going to the public library, and checking out these giant books about biology or evolution. I was like eight — I couldn't read most of them, but I felt smarter just checking them out from the library. So I really loved science. And then I remember, I think it was seventh or eighth grade, you take these aptitude tests, and the goal of them, we were told, was to say what aptitudes you have and how they could shape your future career when you grow up. At that time I had been thinking, maybe I'll be a lawyer when I grow up. So I took the aptitude test and sat down with the counselor afterwards, and they said, Well, you know what? You're really good at science and math. Maybe you should not be a lawyer. Maybe you should be a doctor. I thought, Okay. The third influence is probably the most embarrassing: I got hooked on doctor shows growing up. 

Dr. Ashley: Now we get to the real story, right?

Dr. Braddock: Yes. First was Ben Casey — of course, he's a neurosurgeon, and he's this grumpy but really super smart doctor. Medical Center was about an internist, and it was played by Chad Everett. I can't remember what the doctor's name was, but I watched every episode. I just loved the idea of being in the hospital, and both the challenge of being a physician but also the service part of it. So I decided at a pretty early age I wanted to go to medical school, and I was laser-focused on that through high school and college and beyond.

Dr. Ashley: Oh, amazing. I do wonder about that question of TV, or the creative medium, as a way of inspiring — of course, reading biology books and science books was an important part of that too. But we're back in a moment where there's a very popular TV show, The Pitt. Do you watch The Pitt? Some Stanford faculty helped advise the show; certainly lots of my friends are now watching it. It won a lot of awards, and we may have another generation of people inspired by what is actually a very realistic show, I think.

Dr. Braddock: I think one of the interesting things about that show — and it's not always true with medical shows — is that they can really depict, obviously in a dramatized way, what it's like to be a physician in a particular setting. And I think that's one that really has captured some of the chaos and pressures in a big-city emergency room trauma center. Obviously it can turn people off, but I think there are some messages there about the vulnerability, but also the rewards, of being a physician that may get some people excited about that kind of career.

Dr. Ashley: Yeah. And I think ER, in a former era, did that — although I know my emergency department colleagues wish they hadn't called it ER, since the emergency department is much more than a room, right? But I think what that show and The Pitt both share, other than Noah Wyle the actor, is that sense of realism. Maybe more happens in the average episode than happens in a shift. 

Dr. Braddock: I'll tell you one thing: when I watch The Pitt, and some of the just horrendous, tense situations, I actually feel it. I'll get flashbacks to being in a code or some other kind of emergency medical situation where you just have to perform. And you realize how incredible it is that we as human beings can actually perform under that kind of pressure at such a high level. It's actually pretty amazing. So it's really a very powerful emotional experience to watch that show.

Dr. Ashley: Yeah, the actors have said that they're now getting recognized everywhere, and so they're used to people either mistaking them for doctors, or doctors and nurses and others coming up to them and saying, “Thank you for recognizing what we do,” or My family can talk to me about my job for the first time. We'll come back to some elements of that, because education has been such an important part of your career, and there are lots of avenues toward education for the public. Sometimes these TV shows educate about medicine as much as many other things, and it's been great to see that show, for example, take on social elements of our practice as well. So that was you then. We're back to high school, right? You're focused on becoming a doctor. Tell us more.

Dr. Braddock: So I went here, to Stanford, for undergrad, and it was a tremendous experience. I remember coming here and, like many a freshman, having a little bit of imposter syndrome. Fortunately for me, it motivated me to work really hard and do well. And medical school was a very important and formative experience — I went to the University of Chicago — formative in a number of ways. Obviously the training, and I think back, not to date myself, but back in the day, so to speak, as a medical student you did a lot. That's not so true now, for many good and maybe not-so-good reasons. But we drew blood, we ran it down to the lab, we waited at the bench to get the results, and ran them back to the ward. So there were a lot of parts of that that were very formative.

Dr. Ashley: Probably the paper chart, too. 

Dr. Braddock: Yeah, the paper chart. The other thing I recognized then was some of the dynamics between physicians and other health professionals — I remember, not always in good ways. Some physicians could be arrogant and dismissive of nurses or respiratory therapists or dietitians, and that stood with me. One of the things I remember is commenting to a resident about this, and him saying, Yeah, I don't like it either. And he told me about a practice he had, which was that when he would look in the chart and read the nurse's notes or the dietitian's notes or the PT/OT notes, he would sign them. He would say thank you and sign his name. And I just thought that was a really lovely practice — just a small way of recognizing these colleagues as part of the healthcare team, way before we talked about the healthcare team in the broader sense. Those kinds of lessons stuck with me a lot.

Dr. Ashley: No, that's important. It's always been a team, of course. And I think you're right — in some ways there was some advantage to the paper record, because people were physically writing, and they usually wrote just the key things because you couldn't write any more. Now we're trying to navigate digital health records, and I do feel we've lost a little bit — there's some fragmentation of the team dynamic, just because of the many draws on people's time. I think sometimes they're only communicating through the record, which definitely isn't the best way. 

Dr. Braddock: And there was something about the physical chart, because I still remember the chart rack on the ward, where you would run into people — a consultant or the nurse — and there's something about the physical interaction that can get lost. Certainly a lot of that has changed since the pandemic, in terms of the ways in which we interact so much in online, digital ways, which can be very efficient. But at the same time, we need to make sure that we have the kind of chance interactions that can be very helpful, particularly in complex patient care situations.

Dr. Ashley: Yeah. Well, I think those early experiences — it's interesting that you point out the good things, of course, that inspired you to think, This is the life I want, but also some things that might need to change. You were already, maybe at an early stage, thinking, This is a profession I'm proud to become part of, but there are also some things that maybe I could help change for the better.

Dr. Braddock: Right. When you're starting out, you think about that mostly with regard to what kind of physician you want to be, and starting to form your own professional identity. It's interesting, because when I was in medical school, we didn't talk about professional identity, but there's now a whole literature and field around promoting the development of professional identity. It may seem a little out of the medical mainstream, but I think it's vitally important, because there are ways in which each person needs to understand their own why, but also to really think about how role modeling can be a positive force — but also a negative force. We see that in — we were talking about The Pitt — you see different ways of being a physician being modeled, and you see characters calling one another out for role modeling in one direction or another. And I'm sure you do too: you think back to positive and negative role models. I should back up. Medical school, even then, was very expensive. So I looked at the prospect of medical student loans and decided to join the Navy. I was on a Navy scholarship in medical school, which meant I did my internship and residency training in internal medicine in the Navy, but also I was aboard a ship for a year as a medical officer. Very interesting experience. And strangely, that was my first introduction to anything resembling public health and prevention, because most of my work as a ship's doctor was not taking care of sick people — the sailors were young, strapping men who rarely got sick, except for some embarrassing illnesses, which we'll leave off the air. But we did have guys who worked in the engine room subject to heat stress; we had mechanical injuries from all kinds of work that they did. So I learned a lot about the importance of public health and prevention in that work, and years later, for that and other reasons, after residency and being out of residency a number of years, I went back to get an MPH at the University of Washington.

Dr. Ashley: Amazing. That resonates with me. My father also actually spent some time in the navy — the British Navy — and was a ship's doctor there, a surgeon lieutenant commander in the Royal Navy. I grew up seeing him be a GP, and he was a big inspiration for me to go into medicine, but also hearing his stories of being a ship's doctor, some of which overlap clearly with your experience.

Dr. Braddock: Yeah, definitely. Back to the things about medicine and forming your own sense of the kind of physician you want to be: after getting out of the Navy, I started working at the San Francisco VA. I was working in urgent care — junior faculty, entry level, just grinding away. But I really loved teaching, and I sort of figured that out my last year in the Navy. I worked at a Navy teaching hospital — there used to be a Navy hospital in Oakland that's long since gone. But I really enjoyed teaching. I enjoyed it because I recognized the residents and attendings who had taught me things, and it felt good being able to pay that forward. I also recognized, a little bit selfishly, that teaching is another way of learning. You learn more medicine as you teach others, and it keeps you on your toes, and I really liked the feeling of professional growth. So that's what led me to gravitate toward academic medicine in the first place, with a real emphasis on teaching. So I was doing that for a number of years, and I got this email — I think it was an email. Maybe email didn't exist yet. What year was it? Early '90s.

Dr. Ashley: Probably a memo, then — the early '90s were the earliest email.

Dr. Braddock: I think it probably was a memo, and it was announcing this program at Stanford led by Kelley Skeff. The VA had worked out an arrangement with Kelley's program where the VA would fund you — you could apply as a VA physician to attend Kelley's program. So I did, and to my great luck, I went there in 1992. And honestly, you know Dr. Skeff's work well — being in that month-long, immersive learning about teaching and learning, being videotaped teaching and getting that feedback, was transformative. It really poured gasoline on the fire of my passion for teaching and learning and education. So that really launched me, in the coming years, into more and more opportunities career-wise to focus on education, sometimes small. I was also doing bioethics training at the time, and really doing work on shared decision-making, trying to take that as a way to also try to change the field. So many times when a patient is having a procedure, large or small, or even making basic medical decisions, you have the sense that they didn't really always have a good sense of what they were deciding. And as you know, it's an enormous challenge — the complexities of medicine, trying to explain that to patient and family, at the same time knowing that it's their life, it's their body — you want them to be involved. I got really interested in this question during my fellowship, which I was doing at the University of Washington, just asking myself: how do other doctors talk to patients about routine medical decisions? I knew how I did it — right or wrong, good or bad — but I was curious. My fellowship director, Steve Fihn, a general internist who ran the fellowship program, introduced me to Wendy Levinson, a well-known patient–physician communication specialist who at that time was practicing in Portland. She had this collection of audiotapes of doctor–patient office visits — like a thousand of them — and I began working on devising a way to analyze decision-making. I got to be very interested, and that led to a lot of interesting projects looking at decision-making around cancer screening, or in the intensive care unit — using a similar method to look at the quality of decision-making in encounters between doctors and patients, or doctors and patients' families. Through that work, we could empirically understand and then offer guidelines or guidance about how to make those conversations better. And it happened to be at a good time, because this was really a time of the pivot to so-called patient-centered care — more awareness of the importance of the patient in decision-making.

Dr. Ashley: Yeah. We should pick that apart a little bit, because maybe our audience doesn't remember quite as well an earlier era when decisions were often very much led by the doctor — this era of paternalism, where patients almost expected it, and at some level doctors sort of expected that patients would come and decisions would be more than led — almost made — by the physician. Whereas in today's world, it's almost strange that the concept of shared decision-making is something we even have to state and give a name. However, it's actually really important that we do, for all the reasons I think your work helped lay out. In order for a patient to be a shared decision-maker, they have to understand, in their world and their language, with their values and their context, what it is that you as a doctor are offering them. 

Dr. Braddock: Yeah.

Dr. Ashley: And that's not so straightforward. In my practice as a cardiologist, I deal with sudden death and the risk of sudden death — young patients, often with inherited cardiovascular conditions like hypertrophic cardiomyopathy or dilated cardiomyopathy. Trying to talk to those young people about their risks, in a life when they're 20 years old, and their risk of sudden death — I can give them a number or a percentage. But how to come to a shared decision with them about whether, say, to have themselves protected by having an implanted defibrillator placed — those are hard decisions. And actually, this concept of shared decision-making is very much at the forefront of the new guidelines now. You were doing this years ago.

Dr. Braddock: Right, right. 

Dr. Ashley: But we think of it as almost a very modern idea. It shouldn't be, but it is.

Dr. Braddock: No, it is. But my work was really focused on identifying the gaps in practice, and others at the same time were developing models and tools to really focus on — once you have the mental model of shared decision-making in the mind of the physician and the patient, it still begs the question of how you package the information for a complex decision for a layperson. And I appreciate what you're saying about the guidelines. I think one of the challenges today, now that shared decision-making as a concept is more widely recognized, is to make sure that it doesn't inadvertently morph into a kind of abdication of the role of the physician. So the role of the physician is no longer to say, Well, I've decided you need an X — you need an implantable device, and we're going to do it next Tuesday. But it's also not to say, Well, you could do an implantable device, or you could not — you let me know what you decide. There's a space in between, which really is a dialogue. This starts to segue into some of the pressures on physicians today. In academics, we have a little bit less of this, but even so, because of the competitive nature or the pressures on the financial side of the practice of medicine, we have seen the amount of face time that we have with patients shrink. And there's really no way to have nuanced conversations, particularly when there's a lot of technical information or probabilities to try to impart, when you're constrained by time. So I understand the struggle that physicians have to really do shared decision-making in a meaningful way. I think what we're seeing is the development of tools to support that. I worked for a long time with an organization that created so-called decision aids — basically videotapes or informational pieces that try to condense the key, salient features of a decision into understandable parts, to try to jumpstart the education of the patient. But you're right: the key thing is not to give them a mini-lecture in medicine, but to give them sufficient information to have a sense of the gist of the decision that's before them. And I don't envy the challenge of that with 20-year-olds who have an inherited cardiac abnormality — I imagine that can be very tricky.

Dr. Ashley: Well, and I appreciate very much your emphasis on them, because for each person it's a bit different — the level of information they want, the level of autonomy and decision-making they want, and how that information should be presented. It really is very much personalized medicine — personalized communication, for sure. Because we still have — and you can think of examples too, and maybe they're often much older patients, maybe they're from a very traditional background — patients who very much, though we push against it, say, You just decide for me. “What do you think, Doc?” Because that's what they're used to. But for some people, that's what they need or want. I think the key at the end of the day in the communication is understanding where the patient is at and trying to be there for them, whatever that is.

Dr. Braddock: And even with that, I've had this conversation with many a physician: there is a challenge, because you do feel a sense — if the patient says, “You know, that's a lot, Doc. Why don't you just decide? I trust you” — it does tug on you. I've thought a lot about, and talked with many colleagues about, how to respond to that. And I think there's a way to not take agency from the patient, but also not abdicate. It's a very fine space, and it really exists in acknowledging: Well, this is a lot of information. Based on how I know you, and what I know about you, I'm imagining what's really important to you is X. And given that, I find myself wondering if you might want to do this. It's a way of letting them in — recognizing that you're not really asking them to make a medical judgment. You're asking them to tell us something about themselves that can be helpful. I remember one patient — this is from years ago, in the days when we treated AFib with warfarin, so that puts you in context. I was talking with a patient who had chronic, intermittent lower GI bleeding, and we could never identify the source. He had every test and scan and scope you can imagine. It was intermittent and usually manageable, but then he developed AFib and had to go on anticoagulation. One time we were talking, and I was trying to talk about all the probabilities and the risks and this and that, and he said to me, You know, I appreciate all that, and I'm thinking to myself: I'd rather bleed to death than have a stroke. And I thought, well — there's something elegant in that simplicity. He understood the trade-off, right? I didn't ask him that question, of course, but I did recognize that he had gotten to some point of understanding. So it's that kind of statement or trade-off — really asking patients to talk about the states of life and the balance they, individually, would make between possible outcomes, more than the facts and figures.

Dr. Ashley: No, I think that's really well put. Because often the patient will say, Well, what would you do? Sometimes it's phrased, What do you think? But sometimes it's, What would you personally do? And I think we're trained to push back a little from that and say, Well, I could tell you what I would do, but what I would do isn't what's important. Because my approach, let's say to risk, could be different from yours. We may be faced with the same information, but we might make different decisions. But the other part — because I'm very sensitive to the fact that one thing we do have is this broad experience of seeing very many patients over the years, and our individual patients generally don't have that. They have the experience of usually just themselves. So I sometimes try to paint a picture: Here's the range of avenues my patients will take, and I can give you a sense of where people end up falling. That sometimes can give them a calibration that makes them feel a bit more comfortable choosing where they might fall.

Dr. Braddock: I like that strategy, and I think the idea of saying some people think about it this way also helps to normalize it. There's no right answer — it really is your own value-weighing. So I think it's a really great approach.

Dr. Ashley: So much of this is relevant to what was actually your main topic today, and the main topic of your career, which has been, of course, education — medical education — and thinking broadly about the curriculum and curriculum reform. One of the things I was thinking as you were talking is that medical education has a long and storied history, and we have quite a lot of good information about hundreds of years of medical education. Certainly medical schools back in Europe, including the one I was at, have been around for hundreds of years. I used to wonder as a medical student if my curriculum had been around for hundreds of years.

Dr. Braddock: Seems that way sometimes, right?

Dr. Ashley: I got involved in a curricular reform process as a medical student. So it was particularly interesting to hear you reflect on that process from about 20 years ago here at Stanford, but also the more recent work you've done at UCLA. Talk to us a little about how you go about thinking about updating medical education for today.

Dr. Braddock: I appreciate the question. It's so interesting to reflect on that over the years. So many little stories come to mind, which really are about — just as you did — questioning: why do we do it this way? And how did that come to be? And the answer is, Well, that's the way we've always done it. I mean, think about it: for decades. It really started off in the early part of the 20th century, with the revolution after the Flexner Report, when US medical schools championed the model at Johns Hopkins of two years of classroom and bench learning followed by two years of clinical training. And you think, gosh, that's a long time ago. That model made sense then, but it wasn't divined from above. It wasn't really evidence-based. It was just sort of a shot in the dark. And I find it fascinating that now, in those medical education circles, the debate is, Well, should it be two years and two years, or 18 months and two and a half years? — which really aren't the questions, right? The question is: what makes sense? Several years ago, a very prominent senior faculty member here at Stanford called and invited me to lunch. I was like, Oh, sure. So we sat down to lunch, and he looked at me and said, Why is it that in medical school you wait two years? This is what they're going to be doing their entire life. Why do you wait two years before you start having them do what they're going to do the rest of their career? In engineering, everyone takes some basic courses, and then you diversify — mechanical engineering, chemical engineering — and they start actually doing the stuff that they're going to do for the rest of their career right from the beginning. And I had no answer. I had no answer, because this is the way we do it — that's not an answer. So once you have those experiences that make you think there's nothing that's etched in stone, you start realizing: if you were starting from scratch, how would you design a medical school? And there's no right answer to that. But then I started getting curious about what was happening around the country. I came across a new school — it was Hofstra, a new school started in New York — and I knew the inaugural dean. I was talking to him one day, and he said, Well, the first thing we have our medical students do is eight weeks of training as an EMT. I said, EMT? He said, Yeah. We want them, first of all, to come into medical school with some actual training in doing something that can actually help patients. Because when is the first time a medical student can actually help a patient? Even when they start doing their clinical training, they've got a lot of book knowledge, but they haven't always had the practical experience to actually be helpful. And the second reason was for them to begin identifying with being a clinician. It was a fascinating idea — again, not the be-all and end-all, but a fascinating concept: to flip it on its head and place them in that emergency medical training situation where they're actually ministering to patients directly. Then I found myself imagining all these different things, and then thinking about the change process. As I talked about in my talk, like any of us, we have what we think are bright ideas, and we tell everybody, This is a bright idea — we should all do this, and everyone kind of looks at you and says, Uh, maybe. So I learned the hard way about bringing about change. And then, fortuitously, I got involved with the ABIM — the American Board of Internal Medicine. The ABIM was going through — you know this well — this huge crisis of confidence among board-certified physicians about what these boards, particularly board recertification, were really about. We were trying to figure out a way through this, and the CEO brought in these management change theorists, and that's where I first got exposed to some of these concepts. It was mind-blowing to think about how there's this whole body of thinking and research around how to change that we have largely ignored as leaders, in whatever venue you're talking about. And not that you always need a major theory to guide you.

Dr. Ashley: But the fact that people have thought about this a lot before, and have studied change that works well and change that doesn't work well — as scientists, particularly, we should probably pay attention to that.

Dr. Braddock: Exactly, exactly. So then I became really a student of the change process, and it helped tremendously by the time I did go to UCLA. And when I went, they weren't agitating for curriculum change. But I began asking questions like: are we satisfied with these outcomes? Are we satisfied with this? And you'd hear from faculty, No, I wish this, or I wish that. And that started to become a groundswell: maybe we should do some change. And I think, had I not had those experiences, I might have taken more of a force-feed approach to it. 

Dr. Ashley: Well, you had a lot of really interesting lessons, I think, because you spoke to lots of other people who'd been part of the change management process, understanding other places that have made similar changes. And I thought it was particularly interesting that you picked up on certain prototypes — and missteps, potentially, or thorny areas that you could sidestep with prior knowledge. Maybe talk about that.

Dr. Braddock: Yeah. During this process, I visited all these different medical schools — people that I knew, largely, but a good number of schools — and basically just talked, like we're talking, not in any structured way. Just an interview. I'd say, Talk to me about the change process. What was that like? Tell me a story. That's what I'd say: Tell me a story. And I'd listen, and they would talk, and they would describe it in kind of a historian's voice: We did this, and we did that. I'd listen, and I'd say, Well, what was that like for you? They'd say, Well, you know, it was this and that. It was hard work. How did it impact you? And after asking that two or three times — How did it affect you? — they would start to talk about different things. It was really hard, because it split a lot of the good friendships that I had. People got on different sides of the same debate. That was really hard. Or, I was working so much it started to impact my family. And you realize that change is so much about the how — in terms of how it affects us — that we don't pay attention to. And these archetypes I talked about, in some ways, can be descriptions of the casualties of the change process if we go about it in an artless way. That was really one of the big take-homes for me from that research. It was unbelievable to go from place to place and realize, wait a second — I've heard this story before, at the last place. It's a different person, and the details and history differ, but the core message is the same. 

Dr. Ashley: History was repeating itself in many ways. And that seemed like a really good way of informing yourself as to how to move forward. I was struck — you said this a couple of times,and it's a striking statement at face value — that the how of change matters more than what you change. Tell me how you came to that, because it seems very counterintuitive. Not that how isn't important, but the fact that you would say it's even more important how you go about making the change than the details of exactly what it is you do.

Dr. Braddock: Well, thank you. I think there are two senses of that. One is that there are these risks of really personal, interpersonal trauma from a change process that is not done in accordance with some of these principles — whether that's a QI project, or reorganization of the lab, or any example. The winners and losers — it has profound effects that can ripple. The other thing is that if you believe the what is the most important thing, what that suggests is that you've already decided that the what is the most important thing, and that the what you're thinking about is the change that needs to happen. And there's a humility that we have to have about the change process, which is to say: I think I know what the change should be; you think you know what the change should be; we have all these other people — and really, we don't know what the change should be. If we design a process where all our voices are heard, we can be agnostic as to what the change might be. If we agree that things aren't working well and we'd like them to change, then you focus on the how, and the what will take care of itself. Yeah. There's a way in which it is counterintuitive to the way we think. We think: we've got to decide we're going to change, then we'll put a committee together and ram it through. That's actually the flip. And — I can't remember who asked the question in the Q&A — it is vitally important that there be a kind of collective sense that something is not working in some way, and everybody says we need to change. But designing that process and running it in a way that aligns with all these principles of organizational change will assure that, whatever the destination is, you will minimize the chances of these casualties, and people will develop a sense of ownership around the outcome — which will help it to sustain and continue to grow, and help lead to excellence. So that's how I came to that realization, which, as you say, is a little bit counterintuitive, but really important.

Dr. Ashley: We have a lot of medical students, obviously, who come to grand rounds and who listen to our podcast. Give them a sense of what conclusions you reached. What does the curriculum look like today in a way that is different from before, and how do you see the continuing evolution of how we teach medical students to become doctors?

Dr. Braddock: It's a great question. I'd say there are some really fascinating developments in terms of teaching approaches which are very much worth noting: the rise of simulation-based teaching modalities, ranging from task trainers to full mannequin-based simulations and standardized patients, that create an entire way in which medical students can actually apply their skills sequentially, from a simulated environment to a real environment. That can improve their confidence and their competence in being ready to actually be contributors to patient care. That's been a huge development. I think shifting our emphasis from knowledge mastery to becoming a savvy consumer of knowledge has been a big paradigm shift — in medicine, not just in medical education. And medical schools have been slow to pivot from I've got to teach them all of this book and that book and this other book. So that's still, I'd say, a work in progress. This segues a little bit — I don't pretend to be an expert at all in AI, but I think there's a lot of interest in how AI factors into the training of future physicians, let alone the practice. And I think that's a story yet to be fully fleshed out. But one insight is that leveraging technology to bring knowledge to the point of care — if we as physicians can be responsible consumers of that, in every way, shape, and form — can remove this barrier of the physician needing to be the encyclopedia of medical knowledge in their practice, because that's just impossible. Back in the early part of the 20th century, when Flexner wrote his report, medical knowledge was much more finite. But it's not possible now. The things that each of us learned in medical school, by the time we're a second-year resident, were obsolete. I think those are two paradigm shifts. And I think the guiding principle I would offer to medical students, and to medical school leaders, is: really do the work to imagine the prototypic graduate. What will they be doing? What kind of impact will they have in the world? That's one question. For some medical schools, it might be, We want all of our graduates to be out in our state, providing care to our people. There are many medical schools where that is a very clear vision, and that medical school's curriculum is going to look like that. At a place like Stanford or UCLA, we want our graduates to be outstanding physicians, and we imagine them having an impact beyond the care of the patient right in front of them. We want them to be excellent at that — but there's an and. And that and could be any number of things. It could be research and discovery. It could be leadership and advocacy. It could be the next generation of transformation of the electronic medical record, or AI. It could be anything. But that begets a very different kind of experience, because if you want them to do something and, then you've got to create experiences that allow them to discover both what that and is and how best to do it. I think for a medical student, it's to start to think about: do I want to be an outstanding physician, or an outstanding physician and — and to try to find a medical school that best aligns with what they're about and what they imagine their future career to be.

Dr. Ashley: That's an amazing note to end on. Clarence, you are a giant in medical education. We think of you here at Stanford as one of our very own. Thank you for coming back, and thank you for joining us at the Future of Medicine.

Dr. Braddock: I really appreciate it. Thanks to you.