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Testimony on the Development of Medical Education Programs to Respond to Biological, Chemical and Radiological Threats

Thank you for inviting me to testify before the Subcommittee this morning. I am Dr. Jordan Cohen, President of the Association of American Medical Colleges. The AAMC represents the nation's 126 medical schools, some 400 major teaching hospitals and health systems - including over 70 VA medical centers -, 92 academic and scientific societies representing nearly 100,000 faculty, and the nation's medical students and residents. When I came before the Subcommittee in November 2001, I testified primarily about plans for the Association's First Contact, First Response initiative. I would like to take the opportunity today to update the Subcommittee on that initiative and on the great strides the medical education community has made over the past 18 months in improving the level of training and knowledge of medical students, resident and physicians to prepare them for possible biological, chemical and radiological threats.

Shortly after I testified before the subcommittee in November 2001, the AAMC convened a meeting of representatives of medical specialty, medical education, nursing, public health, and scientific organizations, including the VA, to help us identify and develop educational and informational resources to aid physicians and residents who are likely to be the first to encounter victims of chemical, biological and radiological attacks. Designated the First Contact, First Response Initiative, the meeting provided an opportunity to discuss the development of educational resources to assure that residents and practicing physicians learn the essentials of the medical conditions that may be caused by terrorist activities. At the meeting, the specialty societies and organizations affirmed their commitment to developing and maintaining ways to distribute, especially via the Web, educational material for use by all interested parties. The Centers for Disease Control and Prevention also agreed to assist by providing the educational materials they were developing. Since that initial meeting, the AAMC has monitored the development of new resources and provided this information to our constituents as appropriate.

In my November 2001 statement, I also mentioned our plan to convene a panel of experts to provide guidance to medical schools on the relevant content that should be included in the medical school curriculum. This is an education model the Association has used with great success in the past on issues such as population health and medical informatics. The group we convened included experts in medical education as well as in preparedness for weapons of mass destruction (WMD). We had representatives from schools of medicine, nursing and public health, the CDC, and the Uniformed Services University of Health Sciences (USUHS). The group was asked to respond to two questions: What should medical students learn about bioterrorism (i.e., what are the appropriate learning objectives)? and what kind of educational experiences would allow students to achieve those learning objectives?

The panel reached general consensus that responses to bioterrorism events should be considered in the context of any threat - biological, chemical, physical or radiological - that may result in mass casualties. The experts agreed that it would not be productive to have medical students memorize the characteristics of all potential agents, but rather that education should focus on general concepts such as classes of agents and the various mechanisms of injury. Importantly, the panel noted that future physicians should understand the appropriate roles and responsibilities they will play during a WMD event, and how to coordinate with the public health system. The group identifies approximately 30 discrete learning objectives in which medical students should be able to demonstrate knowledge and skills; the objectives were divided into five broad categories:

• Basic Sciences;
• Clinical Sciences;
• Public Health System Interventions;
• Public Health Roles and Responsibilities; and
• Professional Ethics.

The panelists agreed that these objectives should be integrated across all four years of medical school through a combination of didactic and experiential learning exercises; several strategies were outlined to achieve these objectives, including the use of standardized patients, disaster drills, online study modules, and additional elective opportunities. The panelists felt that most medical students could achieve the appropriate competencies, given that the relevant issues were being incorporated into existing curricular offerings. Alternatively, schools with special interests or obligations, such as USUHS, could establish the objectives as required components of discrete, separately identified segments of the curriculum. The panelists also noted that many curricular resources will be required to implement the strategies, first and foremost being the education of medical school faculty. The final report will include examples of individual institutions that have developed unique educational opportunities that go beyond isolated lectures and may serve as models for other institutions.

I am pleased to report that the group has completed its efforts and a final report is due out next month.

In my previous testimony, I reported that a search of the AAMC's Curriculum Management and Information Tool (CurrMIT©) found that 10 medical schools had identifiable courses or sessions directly related to the potential effects of biological, chemical or radiological attacks. A recent comparable study showed that that number has increased to 23 medical schools. Please note that this represents the tip of what is certainly a rapidly growing iceberg. The CurrMIT tool is not designed to register the countless instances where potential terrorist agents are seamlessly incorporated into general courses such as microbiology, pharmacology, immunology or pathology. Essentially, the data show only show that identifiable classes or sessions dealing explicitly with these threats have more than doubled over the last 18 months.

What I have talked about so far is limited to the undergraduate medical curriculum. Graduate medical education, that is the education of medical residents, is also essential. It is in this phase of medical education that we can best prepare individuals who are most likely to encounter potential victims initially. A quick, informal poll of residency program directors elicited several responses describing how residency training programs have evolved to incorporate elements of biological, chemical and radiological concerns into the resident's learning experiences. Nearly all responding program directors noted the inclusion of speakers on relevant topics such as smallpox during grand rounds. Given the structure of graduate medical education, most of the residency learning experiences are experiential rather than didactic. Numerous institutions noted special seminars for housestaff, including the involvement of residents in disaster and HAZMAT drills. Several residency training programs have implemented unique training experiences such as the following:

• The University of Rochester School of Medicine is using of a high-fidelity simulator in its training;
• The University of Colorado Health Sciences Center requires preventive medicine residents to take a two-month rotation at state or local health department where they participate in the development of plans to deal with biological, chemical, and radiological threats; and
• The Geisinger Health System in Pennsylvania requires each of its resident to participate in a hospital/regional mass casualty drill and bringing in local energy plant officials to cover radiation emergency training.

The AAMC has also taken a leadership role in the collection and dissemination of information to medical schools and teaching hospitals. Our Office of Communications has established and maintains a Web site at that provides up-to-date information on initiatives at our member institutions. Divided regionally and by state, the Web site provides specific information about what schools are doing in this area. Examples include Marshall School of Medicine where students can attain a certificate in bioterrorism studies as part of a course in medical microbiology; the University of North Carolina - Chapel Hill School of Medicine, which has a course in disaster management for emergency medical residents and faculty; and the Medical College of Ohio which has a course in basic anti-terrorism emergency lifesaving skills.

Finally, I'd like to mention the Association's collaboration with the Centers for Disease Control and Prevention. Through this mechanism, the AAMC has been assisting with clinical education sessions on anthrax and smallpox identification and treatment, using a series of listserv email messages, Web broadcasts, as well as written materials. Additionally, the Association is working collaboratively with the CDC to develop educational materials dealing with smallpox immunization, which we are currently working to disseminate to all medical students. The AAMC also is helping the CDC establish collaborative relationships with other specialty societies and organizations in an effort to disseminate constituent specific information on bioterrorism and other threats.

In conclusion, I believe the nation's medical schools and teaching hospitals are doing an increasingly comprehensive job educating our nation's future health care workforce to identify and treat the effects of biological, chemical and radiological events. These experiences are being incorporated into all aspects of the medical school curriculum, as well as the residency training programs through a combination of didactic and experiential learning. Given that the majority of medical students and residents receive a portion of their training at a VA facility, these experiences are also of potential benefit to our nation's veterans. Through the formal affiliation agreements that 107 medical schools maintain with VA medical centers, the education and training of medical students and residents in these settings flows easily between the VA hospital and the university hospital.