AAMC Reporter: September 2009

A Word from the President: "Can Medical Education "Fix" the Health Care System?"

As this column is being written, the usually quiet congressional summer recess has been marked by disturbingly rancorous debate regarding how to "fix" our health care system. What began as an important opportunity for citizens to dialogue with policymakers and learn about health care reform instead has become a major distraction from the overarching issue confronting us. The real issue is that, as a nation, we cannot achieve meaningful reform unless we go beyond insurance coverage and transform our care delivery and reimbursement systems in tandem.

From the perspective of academic medicine, I have been struck by the number of people outside our community (including some influential policy-makers) who express the belief that if we simply improved medical education and residency training, that effort in and of itself would address the nation's health care problems. While it is natural for the public and policymakers to look to medical education—especially in our role as stewards of the next generation of physicians—it is erroneous to think that we (or any other community) can singlehandedly "fix" our exceedingly complex and often dysfunctional health care system. In fact, I would argue that it is precisely the environment created by this dysfunctionality that causes some of what our students learn about being effective doctors to become "unlearned" when they enter the real world of health care. Additionally, this dysfunctionality is the reason why many of us feel as if we continually are swimming upstream in tackling complex issues such as the primary care "crisis."

For example, some policymakers continue to hold us solely responsible for the shortage of primary care doctors, asking "Why don't medical schools 'compel' more medical students to choose this career path?" Within academic medicine, I am certainly among those who believe we must redouble our efforts to create a medical school climate that gives proper prestige and recognition to primary care. In fact, during a recent meeting of the AAMC Advisory Panel on Health Care, the participants focused on the need to change our culture in order to encourage primary care interests.

But no matter how hard we work to support primary care better within the academic medicine community, our efforts will be undermined by a health care system that financially undervalues it in comparison with procedures performed by specialists. Only by designing a health care delivery system directed toward high-quality, patientcentered care, as well as by rewarding providers in a manner aligned with promoting the health of the public, will the "right" numbers of disciplines and specialties follow.

I also have heard the refrain "if you just educated students appropriately, then health care wouldn't cost so much." As educators and practitioners, we strive to help students and residents learn about the value equation in care and about the principles of systems-based practice. Could we do a better job? Absolutely, and our community is to be commended for the many efforts now underway.

For example, in a recent brief survey of graduate medical education leaders in our member hospitals and medical schools that sponsor residency programs, we learned that of the six Accreditation Council for Graduate Medical Education competencies, systems-based practice was the one they viewed our community as doing the "least well" in training residents. The AAMC has been working to strengthen this competency by encouraging our most innovative members to share their ideas and practices about systems-based practice. Notably, the spring 2010 meeting of the Group on Resident Affairs will showcase innovations in developing resident competence in teambased and value-driven care. But even this important effort will be undermined if young doctors leave their residencies to work within a reimbursement system that rewards volume—and not the value—of care provided.

That the nation is looking to medical education for leadership in the health care debate is a good sign. We welcome the spotlight and the opportunity it presents. I cannot think of another professional community that continually works to self-assess more than academic medicine does. But as a community, we need to leverage the current national sense of urgency about health care to demonstrate how medical schools and teaching hospitals are uniquely positioned to lead the nation in change and innovation.

In my July column, I talked about the notion of regional alliances called healthcare innovation zones (HIZ). In these HIZs, academic medical centers, freed of regulatory constraints and reimbursement disincentives, would serve at the nexus of integrated delivery systems and partner with others to provide comprehensive and community care. Since then, this concept has gained greater traction both within the Beltway and among our constituents. In July, Representative Allyson Schwartz (D-Pa.) introduced H.R. 3134, the Healthcare Innovation Zone Act of 2009, which called for planning grants to conduct pilot programs of HIZs. Last month, we met with 18 teams from our institutions and health systems to discuss challenges and opportunities associated with HIZs.

Healthcare innovation zones would not just be platforms to innovate around new care delivery models, but also to innovate with regard to medical education curricula and training across the continuum of education. Moreover, they would help ensure that what we teach students and residents is not undone during residency or later in practice. As we approach the Flexner report centennial, many are calling for "new models" of medical education. An HIZ might be the perfect laboratory in which to conduct targeted experiments.

Just as there must be greater recognition that the delivery and financing of health care must be changed in tandem, so, too, must there be recognition that medical education works in tandem with other facets of health care reform. Now that the summer town halls are behind us and Congress is back in session, it is time to work together to ensure a physician workforce that will embrace and sustain change over time.

Darrell G. Kirch, M.D., AAMC President and CEO