Deans' Report Charts New Course for Medical Education

Responding to growing concerns about the quality of physician training in the United States, a group of deans issued a report that details the shortcomings of the current medical education system.

The report, “Educating Doctors to Provide High Quality Medical Care — A Vision for Medical Education in the United States,” acknowledges the longstanding successes of American medical education but also raises a few red flags.

“The report certainly should not be construed as stating that the current system is in any sense a failure,” said Darrell Kirch, M.D., dean of Penn State University College of Medicine and one of the report’s contributors. “Rather, the goal is to move toward a system that is in a much better position to respond to dramatic changes in population demography, science and systems for healthcare delivery and financing.”

Written by 10 medical school deans who were appointed by the Council of Deans, the report is the first project of the new Institute for Improving Medical Education (IIME), an AAMC entity that aims to examine ways to improve medical education across its continuum.

The findings in the report will serve as a blueprint for the institute’s future projects and activities, which will include efforts to reform the clinical education of medical students and residents and to integrate updated core content into medical schools’ curricula. An external advisory committee will provide oversight for the institute’s activities. Michael M.E. Johns, M.D., executive vice president for health affairs at Emory University, is chair of the IIME External Advisory Committee.

Issues of Concern

Among the report’s main contentions is that clinical education of undergraduate medical students is seriously outdated.

Most medical schools continue to require clerkships in the same set of core clinical disciplines that were viewed as critical for general medical practice in the 1950s, even though experiences in other disciplines would be highly relevant for students preparing for careers in modern medicine.

“In many ways the current educational continuum is, for very under- standable reasons, organized primarily around specialty areas and disciplines,” Dr. Kirch said. “Topics that do not fall clearly under the purview of a particular discipline, such as end-of-life care, the use of information technology or medical economics, tend to have been relatively neglected.”

Another issue of concern is the fact that residency programs may not be preparing trainees properly to care for the kinds of patients they will encounter in their future practices. The design and conduct of residency programs have not been founded on a clear, data-based understanding of the kinds of patients residents will care for most often after graduation and of the scope of practice that they will be expected to provide, according to the report.

Instead, residency programs are heavily influenced by the tradition and culture of specific clinical disciplines and by the patient care service needs of teaching hospitals and their clinical faculties.

Dr. Kirch believes that programs should train residents to deal with their future patient populations by teaching them about the country’s current demographic complexities.

“Our nation is undergoing dramatic changes, with the rapid growth of the older segments of the population and increasing cultural diversity,” said Dr. Kirch. “Not only is the patient population changing, but healthcare systems have become unbelievably complex in the way information is handled, services are delivered, and resources must be managed.

“To respond to all this, residents need curricular experiences that go beyond traditional medicine to give them the skills to deal with this complexity,” he continued.

A third red flag raised by the report concerns the adequacy of the country’s continuing medical education (CME) system, described by the deans as “ineffective.”

Peter Deckers, M.D., also a member of the IIME’s External Advisory Committee and dean of the University of Connecticut School of Medicine, thinks that CME can play a major role in avoiding medical errors and adverse events in practice. The current forms of CME — written multiple-choice and re-certification exams “that virtually everyone passes” — are not effective mechanisms, in his opinion.

“The test materials do not reflect a time when the patho-biologic and bioethical complexity of the diseases we treat and the medical and surgical diagnostic and therapeutic tools we use are becoming increasingly complex,” he said.

In order for the CME system to be effective, rigorous competency-based re-licensure must become an imperative, he continued. “This process must be specific for what a physician does. Not only must one pass tailor-made examinations, but personal practice performance data must be regularly examined. CME alone is not enough.”

The above admonitions only emphasize the important role that the IIME will play in years to come, according to AAMC Senior Vice President Michael Whitcomb, M.D., the institute’s director.

“The work of improving medical education will never end,” Dr. Whitcomb said. “Not all of the shortcomings of our current medical education system can be fixed in the near future. For both of those reasons, the IIME needs to be around for a long time.”

—Suria Santana

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