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AAMC Reporter: April 2007
A Word from the President:
"Medical Education: The Transformational Challenge"
While giving due credit to the innovations taking hold in
undergraduate and graduate medical education as discussed
in my two previous columns, a major challenge is
before us. How can we truly integrate the entire medical
education continuum to comprise a meaningful, continuous
whole for each individual physician? All recent
innovation will have limited impact unless we confront
the fundamental fact that we continue to treat the education
of a physician in a highly compartmentalized way.
Rather than viewing the making of a doctor as an evolving,
continuous development of mastery, we view it as
essentially independent segments of premed, medical
school, residency, and continuing education. To ensure
physician competence over a career lifetime, we simply
must address this counterproductive discontinuity.
Many professional, regulatory, and accreditation entities
have an interest in the different segments of medical
education. Linking these segments into a true continuum
will require bringing these entities together in an
unprecedented way for meaningful dialogue. One effort
already well under way is the Physician Accountability
for Physician Competence (PAPC) initiative, conceptualized
two years ago by the Federation of State Medical
Boards. The result has been bringing together a broad
group of stakeholders for open dialogue about accountability
for competence as it develops across the career of
a physician. Earlier this year, 65 participants from 42
national organizations, ranging from medical organizations
(including the AAMC) to stakeholder groups
representing consumers, payers, and regulators, met
at a fourth PAPC summit. The result was a dynamic
focus on developing a strong alliance to implement
"a meaningful, integrated, non-duplicative system of
accountability for physician competence across the
education-training-practice continuum."
Participants at the PAPC summit also discussed ongoing
work to develop a document defining public expectations
for continued physician competence. The document,
currently titled "Good Medical Practice – USA" (and
modeled after the "Good Medical Practice" document of
the United Kingdom), will be widely circulated for comment
later this year and discussed in more depth at
the fifth PAPC summit this October. The PAPC is
a truly extraordinary process of collaboration, and
for more information I encourage you to visit
www.innovationlabs.com/summit/summit4.
The focus of PAPC on competence is only one aspect of
addressing the discontinuity in the medical education
continuum. As a community, we must apply the same
creative energy we used in developing the focused innovations
I discussed in prior columns to reexamining our
one-size-fits-all approach to medical education. The following
are a few questions to start the process:
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Can we finally rethink what we believe premedical
"requirements" should be? Do we have an imbalance
among math and physical science and the life sciences?
Have we too long neglected the social and
behavioral sciences? Should we use premedical education
to provide an initial grounding in subjects ranging
from ethics to health economics?
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Should we be more flexible about the time individuals
spend in a given segment of the continuum? If students
enter medical school well prepared in science,
do they really need four full years of study? Similarly,
could residents directed toward certain specialties
enter training earlier, thereby shortening their formal
medical school education?
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With new technology like simulation becoming an
increasingly critical part of training, should learners at
any level who demonstrate rapid acquisition of procedural
skills be allowed to advance more quickly? If
physicians do not perform a procedure regularly,
should they be required periodically to demonstrate
those procedural skills on a simulator?
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In the area of testing, should we shift away from cognitive
acquisition toward the demonstration of competencies?
And in doing so,might we consider the use
of portfolios that follow students from entry into
medical school through practice?
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With the emergence of "maintenance of certification"
efforts by most boards, can periodic specialty recertification
and licensure be better linked (or even merged)?
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Could physicians on different paths be given more
flexibility; i.e., rather than requiring everyone to
demonstrate the same factual knowledge base, can we
move to a learning environment much more suited to
the different career pathways physicians will pursue?
Could this flexibility be extended to "retraining,"
either for those out of practice for a period or for
those wishing to change specialties?
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If patient-centered care is a vitally important goal,
what does that mean in terms of the skills, experience,
and habits of mind that physicians should possess
throughout their career lifetime?
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Finally, in raising such possibilities, is it time for us to
acknowledge that personalized education for physicians,
like personalized health care for patients, is the
wave of the future?
Our willingness to examine these and other questions is
testimony to one of our community’s greatest strengths:
dissatisfaction with the status quo and desire for continual
improvement. However, this restlessness for
improvement should in no way be mistaken as an
indictment of the current system as a failure.
Returning to the original question that motivated
this series of three columns-whether we need a new
Flexnerian-like revolution to sweep away the current
system-nothing could seem more unwise. I personally
believe that when individuals today invoke the name of
Flexner, it is because they sense our need to move into
this new frontier of linking the all too discontinuous
segments of medical education in a transformative way.
The strength of academic medicine today is far beyond
what Flexner could imagine, especially given the world
in which he lived. Now it is up to us to fully capitalize
on our innovative instincts and speed the transformation
of the continuum.
Darrell G. Kirch, M.D.,
AAMC President
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