Back to Front PageVOLUME 6, NUMBER 4

AAMC Project to Examine Medical Students' Clinical Education

By Barbara Gabriel

Donald Nutter, M.D., and Michael Whitcomb, M.D., are spearheading a comprehensive review of medical students' clinical education.

Despite extensive curricular reforms in the first two years of medical school, the clerkship model around which the third and fourth years are organized has remained virtually unchanged for the past quarter century. As a result, clinical curricula may not be adequately preparing students for residency or laying the educational groundwork for future medical practice.

"We may be on the verge of a crisis in the clinical education of our students," warns AAMC Robert G. Petersdorf Scholar-in-Residence Donald Nutter, M.D. Dr. Nutter, together with Michael Whitcomb, M.D., AAMC senior vice president for medical education, is spearheading a comprehensive review of the state of clinical education that will address not only the clerkship curriculum itself but also the role of clinical educators and the learning environment.

Concerns about the clinical education of medical students have been expressed for nearly two decades. A report issued by the AAMC's Panel on the General Professional Education of the Physician (GPEP) in 1984 noted a number of problems with the third and fourth years and called for a comprehensive review of students' clinical education. More recently, case studies published in an extensive AAMC/Milbank Memorial Fund report, "The Education of Medical Students: Ten Stories of Curriculum Change," released in September confirmed the difficulty of making substantive changes in years three and four.

Dr. Nutter, former executive associate dean and professor of medicine at Northwestern University Medical School, explains that clinical clerkships continue to revolve around the treatment of hospitalized patients suffering from acute diseases. To better reflect the changing health care environment, their scope should be expanded to address disease prevention, chronic care, rehabilitation, and the management of patients in ambulatory venues, he says. While these subjects have, in many instances, been introduced in preclinical curricula, they are far less frequently extended into the clinical years.

Evidence also indicates that clinical learning experiences for students lack clear learning objectives or adequate methods for assessing student performance. In addition, the largely student-driven fourth year of school appears an insufficient conclusion to medical school education, Dr. Nutter says.

Of equal concern is the growing pressure on clinician-educators who are critical to student learning and mentoring. These educators, Dr. Nutter explains, are increasingly required to care for more patients, generate additional clinical revenue for their practices, and meet the heightened regulatory demands of managed care. These obligations leave precious little time for teaching, turning dedicated clinical educators into an "endangered species."

Making matters worse, as clinical education moves to ambulatory sites, learning teams traditionally composed of students, interns, and residents are becoming fragmented. "Residents are either not present or don't have the time to assist students," says Dr. Nutter.

Changes in the clinical environment appear to have hindered students' learning as well. The combination of technological advances that have changed the face of health care and managed care systems that focus primarily on cost containment has created an environment that is "an obstacle to good clinical education," Dr. Nutter says.

Thanks in part to generous support from the Josiah Macy, Jr. Foundation, Drs. Nutter and Whitcomb hope to complete unprecedented, in-depth research on the state of clinical education and to start crafting suggestions for curricula revision this year. To that end, the project team will review relevant literature; study databases and reports from the AAMC and the Liaison Committee for Medical Education, including the AAMC Graduation Questionnaire and the Curriculum Management and Information Tool (CurrMITT); and conduct site visits to a number of representative medical schools.

Information: Donald Nutter, M.D., (202) 862-6169

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08 February 2005