November 4, 2001

Jordan J. Cohen, M.D., President of the Association of American Medical Colleges (AAMC), issued the following statement, today, at the Association's 112th Annual Meeting in Washington, D.C.:

Our Compact with Tomorrow's Doctors

Read Dr. Cohen's Proposed Compact.(14KB - .pdf)

"The images of heart-wrenching horror that flooded our TV sets on September 11 are still fresh in everyone's mind, and will no doubt remain there for a very long time. In that incomprehensible tragedy, who were among the first on the scene to help? Firefighters and police, thank God. But so too were doctors, nurses, and all manner of health care professionals.

"Let me mention just one example illustrative of the myriad acts of selfless professionalism in evidence that day. Tom Terndrup, chair of emergency medicine at the University of Alabama at Birmingham, was in Brooklyn at a scientific meeting when the first plane hit the World Trade Center. Tom, along with the nurses, paramedics, and other doctors in attendance -- nearly all of whom were there representing academic medical centers -- went immediately to the crisis scene, provided on-site treatment for survivors, assisted with triage, and then spread themselves out to various New York City hospitals to volunteer their services. All without having to be asked.

"The utterly unconditional response of these non-New Yorkers in the face of human need, as well as the astounding readiness of the health care organizations in New York and Washington, and the intrepid valor of their personnel, came as no surprise to anyone - that's who we are. And the resulting heartfelt expressions, on TV and elsewhere, of admiration and awe for the humanitarian outpouring of health care workers resonated with most people's deep-seated image of medicine as a moral enterprise.

"In recent years, however, that deep-seated image of medicine, and of the manifest need for humanitarian physicians, has been badly tarnished by the bashing that our profession has taken from much of the media. You know the stories I mean: Doctors' decisions being overruled by managed care bureaucrats. Doctors not having enough time listen to, or to truly care for, their patients. The high cost of malpractice insurance driving doctors out of business.

Do Young People Still Want to be Doctors?

"In the face of all these downbeat messages, do young people still want to become doctors? Or put another way, if your children or grandchildren asked you whether they should pursue a career in medicine, what would you say? Here on the AAMC's 125th anniversary, as we're facing the challenges of the future, that question deserves an honest answer. Considering the downward trend in the applicant pool, the answer could well be "No." For five years in a row now, the numbers have been falling for both men and women as well as for all racial and ethnic groups.

"One conventional explanation for this apparent waning of interest in medicine is that it reflects nothing more than the mirror image of the business cycle. When opportunities in other sectors of the economy are booming, some college graduates who might have chosen medicine opt for alternatives, many of which, of course, promise a much faster track to gainful employment.

"Another possibility is the apparent loss of autonomy that doctors used to enjoy. As everyone knows, few doctors in practice are their own bosses any more. If not actual employees of a health care system of some kind, most doctors practice within the confines of contractual obligations that constrain their decision-making freedom significantly.

"A third possible source of discouragement for potential applicants concerns money and the dire predictions that physicians' incomes are on the decline. This issue is of particular concern given the huge debt burden that most medical students are forced to bear. I needn't remind you that over 80% of our graduates are indebted and that the average debt load for that group is now just shy of a cool $100,000. We can only speculate about how many outstanding candidates for medicine are being lost to the profession simply because the prospect of incurring such a large debt is too daunting for them and their families to contemplate. This concern is, of course, especially worrisome for youngsters from disadvantaged backgrounds. Time doesn't permit a full discussion of this complex issue today, but it is one that demands serious attention by all of us.

"There is a fourth, theoretical possibility that I think is contributing to the decline in medical school applicants, and that is the perception that doctors no longer command respect -- worse yet, that they are being oppressed by, rather than any longer being guardians of, the health care system.

"Unfortunately, that viewpoint is championed by not a few practicing physicians, who do view themselves as oppressed and who are among the most persuasive of those advising students not to pursue a career in medicine. I have no idea what fraction of practitioners feels this way, but it is clearly large enough and vocal enough to have contributed to a growing perception that medicine no longer deserves the wholesome reputation that most of us grew up with.

"And it's not just doctors who are voicing concern about the state of American medicine. Rosemary Stevens, the noted sociologist and respected student of American medicine, believes that the overarching societal view of medicine underwent a substantial change over the past few decades. She writes: "No longer seen as working quietly for the public good, the American medical profession took on sinister, even antisocial characteristics in its role in the culture at large. Some influential critics also revised the profession's history from a glorious narrative of success to a more ominous tale of hubris." How could such a widespread view of contemporary medicine not be influencing many idealistic young people to seek fulfillment in some other line of work?

"So, what's the bottom line concern here, and what does it have to do with us in academic medicine? Obviously, if medicine ceases to be attractive to the best, the brightest, and the most idealistic and public-spirited of our young people, we have a lot to worry about. Not just as medical educators but as future patients.

"My concern is not so much about today. We are still getting many fantastic students of just the kind we want. I'm sure we'd all like to get even more, but what if my supposition is correct? What if many prospective applicants are rejecting medicine for reasons we have never seen before - because they perceive future doctors, not as enjoying a fulfilling career, but as enduring a lot of adversity? If true, we are ill-advised in the extreme to remain complacent about our continuing ability to pick and choose among a surfeit of wonderful applicants.

"For openers, we need to realize - and we need to broadcast to the world - that the transformations occurring in the practice of medicine are not, by any means, antithetical to idealism, and are certainly not destined to victimize doctors. As the stewards of medicine's future, we must be prominent among those who paint a realistic picture of the fabulous opportunities and gratifications that lie ahead for the next generation of physcians. More about that in a moment.

Time to Address Current Realities within Medical Education

"But before we address misperceptions about the distant future of medical practice, we must address some current realities within medical education itself -- realities that I fear are also dissuading many promising college students from seriously considering a career in medicine. The first is the way we select students for admission to the profession, and the second, and even more important, is the way we acculturate the students we do admit to become professionals by the time they finish their formal education.

The Admissions Process

"What about the way we pick students for admission? My concern here is the imbalance that currently exists in how we convey to applicants the selection criteria we use. I'm referring, of course, to our tendency to under-emphasize, because they are harder to measure, the personal characteristics we are seeking in our applicants, and to over-emphasize the more easily measured indices of academic achievement.

"I know how tough this issue is. And please don't misunderstand me; in no way am I suggesting that native intelligence and academic prowess are anything less than essential for success in medical school, or for becoming an effective physician or scientist. What I am suggesting, however, is that our admission processes do not project to prospective applicants the degree to which we value, in addition to GPAs and MCAT scores, those other essential attributes we prize: altruism, fervor for social justice, leadership, commitment to self sacrifice, empathy for those in pain.

"That many idealistic students do make it through the process, despite the distorted signals we send them about what we are looking for, is no guarantee that sufficient numbers will continue to do so going forward. If more such intelligent and dedicated idealists were to perceive that we would give as much weight to what's in their hearts as to what's in their heads, a career in medicine would no doubt attract them strongly. As it is, I'm persuaded that many don't perceive this balance in our selection criteria, and turn away convinced that medicine is for grade-grubbing Philistines but not for them.

"To balance the strong message we send about the importance of grades and test scores with more visible evidence of our co-equal interest in humanistic attributes, let me offer six ideas for you to consider:

"1. Use MCAT scores and GPAs only as threshold measures. Rather than giving more weight to higher scores, why doesn't each school decide for itself, from data available from its previous students, what level of GPA and MCAT performance is sufficient for predicting success in clearing the high academic hurdles of medical school -- and leave it at that. We would send a powerful signal to those intelligent idealists who are currently eschewing medicine if they knew that, once having met the academic achievement threshold, they would be evaluated solely on the basis of their humanistic qualities, their penchant for serving others, their leadership abilities, and so on.

"2. Even more daring, how about beginning the screening with an assessment of personal characteristics and leave the GPAs and MCAT scores 'til later. Rather than looking first for reasons to reject an applicant -- like evidence of a lackluster start in college, or a bad semester, or a C in an organic chemistry, or a "7" on an MCAT subtest -- why not look first for reasons to accept an applicant - like evidence of deep-seated social awareness, of having triumphed over adversity, of personal sacrifice for the benefit others - and only then consider the statistical predictors of mastering our challenging curriculum. Approaching their task in this way, admission committees might well find many instances in which truly compelling personal characteristics would trump one or two isolated blemishes in the academic record.

"3. Look even more favorably than you do now on the more mature applicants, those who chose some other field at the end of college, but who awakened several years later to medicine as their true calling. Such students often manifest a depth of motivation that not only predicts success as future physicians, but also provides inspiration to their fellow students.

"4. Stop using the average MCAT scores and GPAs of our matriculants as if they were valid measures of the relative quality of our schools. Take a look at the devastating critique of the U.S. News & World Report's rankings of the "best" medical schools in this month's Academic Medicine and see if you don't agree with what the authors have to say. In accepting without objection the use of such misleading measures as average MCATs and GPAs, let alone in ballyhooing them in our own promotional materials, we reinforce the public perception that they are, indeed, our principal criteria for admission.

"5. Use past experience to improve our ability to spot the truly outstanding prospects. As a general rule, it doesn't take long for a consensus to emerge among faculty and staff about who among each entering class of students are destined to be the best, most caring, most compassionate physicians. They are the ones who win the humanism awards, who tutor their classmates, who are elected class representatives, who are the pacesetters for student-initiated community service activities, and so on. Why don't we look back at those students' credentials at the time of admission and see if we can find some common characteristics that might be helpful in sharpening our ability to identify such stars among future applicants. And let's use even more of those star students as recruiters and as full-fledged members of our admission committees.

"6. Help us devise better tools for evaluating students' personal characteristics. It's too easy to assume that the so-called soft qualities we're looking for are beyond our ability to assess any more accurately than we do with our present crude measures. I just don't believe that. But we'll never know for sure unless we try. For starters, I have directed the AAMC staff to see what we can do to develop better tools, and I urge all of you to give thought to this tough problem. Not only because we may actually succeed in improving our selection process, but also because there are surely many more dedicated and intelligent idealists out there who would recognize our efforts to seek better measures of character traits as a strong signal that we want them as colleagues.

The Acculturation Process

"And speaking of colleagues raises the second unique contribution we, as medical educators, can make to enhance the image of medicine for prospective applicants. And that is to come to grips with the way we acculturate our students and residents to become our professional colleagues after we admit them. Unless we can covert our learning environments from crucibles of cynicism into cradles of professionalism, no amount of effort on the admissions front end is going to suffice.

"If we wish to increase the attractiveness of medicine for those intelligent and dedicated idealists, we can't continue to kid ourselves about our tarnished reputation as responsible educators. You know as well as I do, we are viewed in many circles as making frankly dehumanizing demands both on our students and on our residents. Many in the general public are convinced that we purposely haze students and residents as some kind of rite of passage. How, they ask, can medicine be all it's cracked up to be if it allows its own acolytes to be treated harshly in the process of educating them?

"However discomforting those perceptions may be, the fact remains that we do appear to systematically replace some of the nascent virtue evident in our matriculants with a lot of cynicism by the time they finish their residencies - cynicism arising both from the way they are treated and from the way their mentors model - or fail to model - the avowed values of the medical profession. We have tended to assume that the good people we admit to medical school will remain good no matter what kind of behavior we visit on them or parade in front of them. All the evidence points the other way.

"If we wish to deepen rather than drain that reservoir of nascent virtue, we are going to have to do more to reconcile the values we actually teach our students and residents with the values we profess to teach them -- what my old Stony Brook colleagues Coulehan and Williams have called the tacit versus the explicit values of medicine. I urge you all to read their provocative article in last June's Academic Medicine entitled "Vanquishing Virtue: The Impact of Medical Education." It is but the latest in a long string of passionate pleas for us to address the gap -- arguably the growing gap -- between what kind of doctors we say we want our students to become, and what kind of doctors we actually teach them how to be. In our various courses and pronouncements on rounds, for example, we talk about the importance of caring, compassion, empathy, respect, and fidelity, and about what it means to be a good physician -- about the need to be trustworthy, honest, and committed primarily to patients' welfare. That's the visible, explicit curriculum.

"In the hidden, implicit curriculum that students actually experience in their day-to-day interactions, they typically encounter different values. Our learning environments tend to revere, in Coulehan and Williams' words, "objectivity, detachment, wariness, and distrust of emotions." And because those implicit lessons are endlessly repeated, and are imbedded in actions rather than just in words, they are much, much more powerful and enduring. The result is that technical skills come to be valued more highly than interactive skills. More important, our idealistic students who hear us say one thing and see us do another are often quick to sour on virtue, many opting instead for cynicism.

"No matter how successful we are in attracting idealistic, properly motivated students to medicine now or in the future, we have little hope of delivering the same number of idealistic, properly motivated doctors to society unless we can close the gap between rhetoric and reality.

"I know I'm preaching to the choir here. We all want to find ways, not only to make medical school and residency training more humane, but to ensure that what we value is indeed what our students and residents learn from us. I don't have a magic solution to offer - there is none, of course, - but I do have a concrete suggestion to make that might help move us a little further in the right direction.

An Explicit Statement of our Commitments

"You may think it hokey, but why don't we prepare and disseminate an explicit statement of our commitments, something along the lines of a "Compact Between Teachers and Learners of Medicine"? You'll find at your seats a draft of the kind of thing I have in mind. You should know that I'm taking a cue here from an effort of the ABIM Foundation in which I was privileged to participate. The Foundation spearheaded the development of an international "Physician Charter on Professionalism" because it wished to bolster the resolve of individual practitioners to withstand everyday temptations to engage in conduct that falls outside the norms of the profession.

"By analogy with the Physician Charter, which will be discussed at a session tomorrow, our Compact would articulate, as a statement from the collective of organized medical educators, some guiding principles and the norms of conduct we expect of individual faculty members, especially in their roles as models of professional mores for students and residents. It also would spell out the norms of conduct we expect of individual students and residents as members of a learning community in the process of becoming professionals.

"Our Compact could be useful, it seems to me, not only for bolstering our resolve to sustain professional norms of conduct, but also for signaling to applicants that we do indeed have values that are consistent with their expectations of us. Indeed, it could form the basis for a visible social contract, one that faculty and students might actually sign during orientation to medical school and that we might prominently display as a continuous reminder of our aspirations. If you wish to pursue this suggestion, please feel free to use the draft document I distributed as a point of departure for your own version of such a Compact. You'll also find it on our website.

"As you will see, there is nothing new about the commitments called for in my draft. They are all reflected one way or another in a wide variety of activities already well rooted or well under way in our community. Consider the myriad curricular reforms undertaken by virtually all schools in the last decade, as summarized in last September's Supplement to Academic Medicine; the LCME standards on maintaining a supportive learning environment and on preventing student abuse; the ACGME's standards upholding residents' well being; the focus on professionalism embodied in our Medical School Objectives Project; the AAMC's guidelines on "Appropriate Treatment in Medicine;" our annual awards for humanism and for community service; and the Association's new policy guidance for GME. And then there's the widespread adoption of the White Coat Ceremony promoted by the Arnold P. Gold Foundation, and on and on.

"My hope is that by adopting, discussing, refining, reviewing and, ultimately fulfilling the commitments called for in some version of a Compact Between Teachers and Learners of Medicine, our community, collectively, can exert more self-discipline and, in the process, prepare our students and residents to face the future with confidence that the profession they inherit will be a true calling, and not just another beleaguered occupation.

"We dare not fail in this task. For the medicine that our students and residents will inherit has never, in the history of mankind, been more flush with promise. Our job is not only to ensure that our graduates are fully prepared to convert that promise into reality. We also must communicate that promising future broadly to the public so that interest in pursuing a career in medicine remains commensurate with the enormous possibilities that lie ahead.

"Beginning with the absolutely breathtaking science that will underpin the future practice of medicine. The power that future practitioners will have to treat, to cure and, most marvelous of all, to prevent disease is awesome. As we in the academy know better than anyone, the real transformation that medicine is undergoing has its origins, not in managed care -- for goodness' sake! -- but in our very own laboratories. The confluence of advances in molecular biology, in genetics, and now in stem cell research is propelling us unstoppably towards a future that previous generations couldn't even begin to imagine. Having the honest-to-God tools to make life so much better for so many people gives idealism an action plan it has long dreamt of but has never had.

"As if the power of modern medical science weren't enough, the power of new information technologies to transform the practice of medicine is an additional boon to future physicians and patients, one that is certain to expand the scope and effectiveness of medicine in countless beneficial ways. What better way for an idealistic member of the information generation to satisfy his or her yearning to help people than to participate directly in this phenomenal expansion of medicine's capacity to care for those in need?

"And, finally let's not forget the most fundamental and most enduring of all of medicine's attractions, the doctor/patient relationship itself. Stripped of all the trappings -- both the negative trappings of medicine's headlong lurch into commercialism, and the positive trappings of medicine's increasingly powerful tools to do its job -- stripped of all that, we are left with the fundamental reason for medicine's existence in the first place: the universal need for help when we're sick or injured. That's what we witnessed so vividly on September 11. And the opportunity to fill that need is what appeals above all else to the young people we are seeking to be our students.

"By strengthening our explicit commitment to the ethical underpinnings and moral imperatives of the doctor/patient relationship, and by making that commitment unmistakably visible to applicants, to our students, to the public at large - and to ourselves -- we can ensure that the best and brightest continue to clamor for entry into medicine, the most appealing of all possible human endeavors.

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The Association of American Medical Colleges represents the 125 accredited U.S. medical schools; the 16 accredited Canadian medical schools; some 400 major teaching hospitals, including 74 Veterans Administration medical centers; 91 academic and professional societies representing nearly 88,000 faculty members; and the nation's 67,000 medical students and 102,000 residents. Additional information about the AAMC and U.S. medical schools and teaching hospitals is available at www.aamc.org/newsroom.

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The Association of American Medical Colleges is a not-for-profit association representing all 129 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 68 Department of Veterans Affairs medical centers; and 94 academic and scientific societies. Through these institutions and organizations, the AAMC represents 109,000 faculty members, 67,000 medical students, and 104,000 resident physicians. Additional information about the AAMC and U.S. medical schools and teaching hospitals is available at www.aamc.org/newsroom.

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