A Word From the President

Instituting Improvement in Medical Education

Voltaire once said that the "art of medicine consists in amusing the patient while nature cures the disease." The French philosopher lived at a time when medicine was much more art than science, when physicians were little more than observers of a higher, and often unpredictable, force.

Needless to say, our expectations of physicians have changed considerably since the 1700s. The astounding advances in science and technology over the past 300 years have set the bar much higher for those who practice the "art" of medicine. And the quickening pace of those advances in recent decades has posed a serious challenge for medical educators: how do we maintain alignment between what (and how) our students and residents are taught, on the one hand, and the rapidly changing capabilities and expectations of our increasingly sophisticated and complex healthcare system, on the other?

In recognition of this challenge, the AAMC's strategic plan calls on the association, as the "Champion of Medical Education," to stimulate changes that would foster better alignment of the goals and content of medical education with evolving societal needs, practice patterns and scientific developments. Numerous voices from outside the AAMC (e.g., The Commonwealth Fund, Institute of Medicine) also have called on the association and its constituents to acknowledge the need for substantial educational reform to deal with perceived inadequacies in the preparation of physicians for contem-porary medical practice.

In response to these thoughtful admonitions, the association has estab- lished the Institute for Improving Medical Education (IIME). As an initial step prior to activating the institute, I thought it would be instructive to ask a group of deans — whose core responsibility, after all, is the preparation of future physicians — what they perceived to be the major shortcomings of our current system of medical education. An ad hoc committee of 10 experienced deans was appointed by the Council of Deans to take on this task and, after a yearlong comprehensive review, the group presented its report to the council's administrative board meeting last June.

The report acknowledged the longstanding successes that American medical education has enjoyed but identified many opportunities for improvement. It put forward a compelling vision of an even better future and offered a series of recommendations that will guide the development of the IIME's initial action agenda.

Major targets of opportunity for the institute's agenda were identified at each stage of the medical education continuum. Among the report's overarching themes were the following:

1. The clinical education of medical students is seriously outdated. Most schools continue to require clerkships in the same set of core clinical disciplines that were viewed as critical in preparing doctors for general practice in the 1950s. Many crosscutting topics of mounting importance in contemporary medical practice are generally given short shrift, if they are addressed at all. And despite strenuous efforts by many schools, students still receive a disproportionate amount of their clinical education in hospital settings that offer an exceedingly skewed spectrum of patient problems;

2. Many residency programs are not preparing their trainees optimally to care for the kinds of patients they will likely encounter in their future practices. The obstacles that need to be overcome include the deeply rooted traditions of specific clinical disciplines and unrelenting, non-educational service demands that teaching hospitals and their clinical faculties still expect residents to meet;

3. Continuing medical education is still dominated by ineffective modes of instruction. Despite efforts by CME leaders, the majority of continuing medical education activities that physicians pursue employ teaching methods that knowingly fail to change physician behavior and thus cannot be expected to improve the quality of care physicians provide to their patients.

Clearly, not all of the shortcomings of our current medical education system are going to be fixed overnight. Thus, the IIME intends to be around for a long time. Its primary purpose will be to foster educational innovations at every stage of physician education. Its modus operandi will include convening stakeholders through workshops, colloquia, symposia and retreats to forge consensus on needed improvements; commissioning white papers from recognized thought leaders; securing foundation and government grants and channeling the funds to constituent institutions to stimulate innovation; and formulating recommendations for AAMC policy and programs to advance the quality of medical education.

An external advisory board comprising individuals experienced in undergraduate, graduate, and continuing education will provide oversight for the institute's activities. A steering committee of senior AAMC staff will ensure effective coordination of the institute's programs with the association's operating divisions. Michael Whitcomb, M.D., senior vice president of the association's division of medical education, will serve as the institute's first director.

Dee Hock, the legendary figure who founded Visa and gave rise to the credit card, offered this sage advice: "Substance is enduring; form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving substance from the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference."

My hope is that the IIME will help medical educators modify the forms we employed to achieve our past successes in order to preserve the substance of high quality education for the benefit of the future.

Jordan J. Cohen, M.D.
AAMC President

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