AAMC Reporter: February 2007
A Word from the President:
"What Would Flexner Really Think?"
With the 100th anniversary of Abraham Flexner's revolutionary
report drawing near, we increasingly hear the
suggestion that we need a new report, or some "call
to arms" to stimulate a new wave of medical education
reform. But what is the reality? Do we need a
new "revolution" to sweep away the current system, or
is our work headed in the right direction? Is the real
issue that of collectively accelerating our pace toward
realizing our aspirations?
This spring I will attend my 30th year medical school
reunion. Upon reflection, I find the culture of innovation
that has prevailed since my graduation to be remarkable.
For me, small-group learning experiences
were limited to "peripheral" electives; simulation technology
referred to crude audiotapes of heart sounds; I
never encountered a standardized patient; and developing
essential communications skills relied largely on the
hope that students would successfully translate lectures
into meaningful interactions with patients!
In each of these areas, innovations are now so mainstream
that their impact may be taken for granted. But
failing to recognize their transformational effects does a
tremendous disservice to the many in our community
who have worked tirelessly and creatively to reinvent
our teaching of medical students. In this first of three
columns which will contemplate what Abraham Flexner
might think about medical education today, it is well
worth considering some of the major changes that have
reshaped undergraduate medical education since I
received my M.D. 30 years ago.
Education linked to specific learning objectives—One of the most fundamental changes began in the
1980s when medical schools began structuring their
curricula with specific learning objectives in mind.
This key concept now is central to the Liaison Committee
on Medical Education accreditation standards
which require faculty to develop educational objectives
describing "what students are expected to learn, not
what is to be taught."
Integration of "orphan" topics and new science—Responding to demographic, cultural, and social changes,
as well as scientific discoveries, medical schools in the
last 30 years dramatically expanded their curricula to
include topics that transcend individual specialties. They
now teach subjects ranging from geriatrics to pain management;
palliative care; emerging public health threats
such as biological and chemical terrorism; domestic
violence and other socio-behavioral issues, and new
knowledge areas such as molecular genetics.
Simulation and other technologies—Standing in stark
contrast to the barely intelligible audiotapes I mentioned
earlier are whole body simulators (computerized patient
mannequins) that provide interactive training opportunities
for students to sharpen physical examination
skills, perfect techniques, and practice team-based
critical care. Additionally, virtual patients (interactive
Web-based or software programs that simulate complex
clinical cases) are being used to engage students in more
challenging treatment scenarios. These and similar
new technologies are now being used by 79 percent of
medical schools.
Honing communications skills—Communication
skills are no longer left to chance, nor are they viewed
solely as the ability to take a patient's history. Students
are directly taught to assess family, lifestyle, and socioeconomic
factors that may be influencing patient behavior
and/or affecting care. Through experiences in cultural
competency, they learn how to view matters from
the patient's unique perspective. And now, in addition
to being part of the curriculum at nearly every medical
school, these skills are formally assessed as part of
the USMLE.
Small-group learning experiences and case-based,
problem-based learning (PBL)—The large lecture hall
packed with hundreds of students so familiar in my
medical school days now accounts for less than half
of scheduled contact time at the majority of medical
schools. To the minimal extent I experienced such small
group settings, few of them involved "core" curricula as
they do today. PBL, a small-group learning experience
introduced just as I started medical school, where faculty-mentored undergraduate medical students learn
interactively, is now used by 82 percent of schools.
This is just one example of educators' recognition that
core science is taught most effectively when linked to
its clinical application.
Standardized patients in structured clinical assessment—Beginning with Howard Barrows and Paula
Stillman in the 1970s, the use of actors trained to present
specific symptoms and histories to students in clinical
settings is now part of the curriculum in 57 percent
of medical schools. Standardized patients are used to
give students feedback as they develop clinical skills and
to assess their level of performance before graduation
in Objective Structured Clinical Examinations.
Migration from the hospital to ambulatory
settings—Paralleling the trend in health care delivery,
students and residents increasingly learn and train in
diverse ambulatory settings, including doctors' offices,
clinics, nursing homes, hospices, and even prisons. In
2006, medical students spent approximately 35 percent
of their required clerkships in ambulatory venues.
Competencies, the emphasis on outcomes, and
acceptance of accountability—A major step forward
in assessment is the trend toward competency-based
learning and outcomes, where the focus is on learner
performance. Initiated by the Accreditation Council for
Graduate Medical Education with its establishment of
six core competencies for resident education, this innovation
is having an increasing impact on physician education
at all levels of the medical education continuum.
What would Abraham Flexner think? I am convinced
he would be excited to document these innovations,
and that if he were to visit our schools, his end-product
would not include a list of schools that should be
closed. Rather, I expect he would provide a list of best
practices to emulate, noting that too many of us are not
yet fully utilizing these teaching advances. I am certain
he would commend us on our progress, but also demand
that we not rest on our laurels, encouraging us
to redouble our efforts and challenging us to explore
new frontiers of innovation. In my next column, I
will address changes that have reshaped graduate
medical education.
Darrell G. Kirch, M.D.,
AAMC President
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