Educating Physicians

A Call for Reform of Medical School and Residency

Molly Cooke, David M. Irby, Bridget C. O'Brien

• Publisher: Jossey-Bass
• Year: 2010
• ISBN:
  9780470617649
• Edition: 1
• Topic: Education
• Subtopic: Higher Education

EDUCATING PHYSICIANS

The current blueprint for medical education in North America was drawn up in 1910 by Abraham Flexner in his report Medical Education in the United States and Canada. The basic features outlined by Flexner remain in place today. Yet with the past century's enormous societal changes, the practice of medicine and its scientific, pharmacological, and technological foundations have been transformed. Now medical education in the United States is at a crossroads: those who teach medical students and residents must choose whether to continue in the direction established over a hundred years ago or to take a fundamentally different course, guided by contemporary innovation and new understandings about how people learn.

Emerging from an extensive study of physician education by The Carnegie Foundation for the Advancement of Teaching, Educating Physicians calls for a major overhaul of the present approach to preparing doctors for their careers. The text addresses major issues for the future of the field and takes a comprehensive look at the most pressing concerns in physician education today. The key findings of the study recommend four goals for medical education: standardization of learning outcomes and individualization of the learning process; integration of formal knowledge and clinical experience; development of habits of inquiry and innovation; and focus on professional identity formation.

Like The Carnegie Foundation's revolutionizing Flexner Report of 1910, Educating Physicians is destined to change the way administrators and faculty in medical schools and programs prepare their physicians for the future.

PART ONE

TODAY’S PRACTICE, YESTERDAY’S LEGACY, TOMORROW’S CHALLENGES

1

EDUCATING PHYSICIANS

CONTEXT AND CHALLENGES

CONTEMPORARY MEDICAL EDUCATION would be unrecognizable to physicians in nineteenth-century America. Preparation of doctors then was a relatively informal and unfettered affair: admission standards were lax, and in most instances only a high school education was required. The curriculum consisted of sixteen weeks of lectures, repeated for eight months of instruction. There was no patient contact or laboratory experience, and all matriculants graduated with an M.D. degree regardless of academic performance. Teachers were typically practicing physicians who gave instruction part-time as a means of supplementing their income (Ludmerer, 1985, 1999). Medical schools varied in both organization and quality, ranging from elite university programs to small for-profit enterprises. With no accreditation standards, many of these medical schools were of poor quality indeed. With no certification or licensing requirements, many practicing physicians were marginally competent, if at all. It was virtually impossible for members of the public to know if the medical care they received was quality or quackery.

The document that changed medical education and practice was the Flexner Report of 1910. Challenged by highly variable physician performance and the lack of standards in medical education, the American Medical Association’s Council on Medical Education, under the leadership of Dr. N. P. Colwell, conducted a survey of medical schools and found many of them wanting. However, as a membership organization the AMA was in an awkward position if wholesale condemnation of medical education was required. Therefore, in 1908 the AMA sought the help of the newly formed Carnegie Foundation for the Advancement of Teaching to conduct a comprehensive study of medical education in North America. Henry Pritchett, president of the foundation, commissioned not a physician but an educator, Abraham Flexner, to lead the study. The choice of a non-physician was astute; as Flexner later recalled, “Dr. Colwell and I made many trips together, but, whereas he was under the necessity of proceeding cautiously and tactfully, I was fortunately in position to tell the truth with utmost frankness” (Flexner, 1940, p. 115).

By the time Flexner and Colwell visited all 155 medical schools in the United States and Canada in 1909 and issued his report in 1910, the basic framework of contemporary medical education was already taking shape. The transformation that shifted medical education to its current rigorous, science-based form began in the mid-nineteenth century with the rise of experimental medicine in German universities, where research laboratories empirically confirmed or disproved hypotheses about mechanisms of disease. This experimentalist approach challenged the established medical culture, in which both learning and practicing medicine were based on tradition and the works of ancient physicians. American physicians, attracted to Germany and laboratory research, returned from visits abroad imbued with this spirit of scientific medicine and determined to adopt the model for preparing physicians at their universities, which included Chicago, Cornell, Harvard, Michigan, Pennsylvania, and later Johns Hopkins, where the empirical approach to medicine achieved its zenith. Through the efforts of these reformers, medical education was brought into the university and medical laboratories were established along with teaching hospitals (Ludmerer, 1985).

In preparation for his site visits, Flexner visited Johns Hopkins, where his brother Simon had studied medicine before becoming the first director of the Rockefeller Institute for Medical Research. There he spoke to leading physicians who had strong opinions about what a medical school should be, having created one only twenty years earlier. Flexner adopted the Johns Hopkins model as his standard, comparing the schools that he visited to it.

During his site visits, Flexner encountered a number of excellent university-based programs of medical education that met his criteria. Flexner believed that medical practice must be firmly rooted in the foundation of science, not in superstition, speculation, and uncritical empiricism. He saw inculcation of scientific curiosity and methods of investigation as essential to medical education, drawing a parallel between research and practice: “No distinction can be made between research and practice. The investigator, obviously, observes, experiments, and judges; so do the physician and surgeon who practice their art in the modern spirit. At bottom the intellectual attitude and processes of the two are—or should be—identical . . . . If this position is sound, the ward and the laboratory are logically, from the standpoints of investigation, treatment, and education, inextricably intertwined” (Flexner, 1925, pp. 4, 6).

The Flexner Report

Because medicine is a science-based practice, Flexner argued, medical schools should be housed in universities, which should also have teaching hospitals, and scientific inquiry should be the modus operandi from the laboratory to the hospital. To ensure that all North American medical education achieved the desired standards, Flexner proposed a number of features of a four-year M.D. degree, which have become common requisites:

• High admissions standards, including requiring a bachelor’s degree with a strong science focus, rather than merely a high school degree, as was typical at the time

• A university-based medical school to train students to think like scientists, furnishing two years of basic science instruction instead of a mere eight months of lectures

• Two years of supervised clinical experience by university-based physicians in a teaching hospital

• Experience in investigation through supervised immersion in laboratories and clinical settings

• Instruction by physician-scientists who could move effortlessly from the research laboratory to the bedside and back

In his report, Flexner identified a number of medical schools that did not fit the Johns Hopkins University template, generally small proprietary schools that appalled him, as the acerbic characterizations in his report make clear. He decried their poor quality of instruction, facilities, faculty members, students, administrators, and clinical training. The impact of Flexner’s report was amplified by the muckraking journalists of the era, and within a decade approximately one-third of the 155 medical schools closed or merged with other schools. Unfortunately, several of the schools that closed had offered the only access to medical education available to women and African Americans, a situation that was not rectified until the 1970s.

The Medical Profession’s Response

Within a decade of publication of the Flexner report, accreditation, certification, and licensing procedures were put into place to protect the public and monitor (and, when necessary, sanction) schools of medicine. Accreditation processes for schools of medicine were fortified, and the National Board of Medical Examiners (NBME) established the NBME Part Examination program. State medical boards, which had begun to license practicing physicians in the mid-1880s, reorganized their coordinating entity, formerly the National Confederation of State Examining and Licensing Medical Boards into the Federation of State Medical Boards (FSMB), founded in 1912. The current licensing sequence, the United States Medical Licensing Examination (USMLE), was introduced in the early 1990s and replaced the NBME Part Examination and the FSMB’s Federation Licensing Examination (FLEX) program. Founded in 1915 in response to the call of the Flexner report to assure the public that all graduates of U.S. medical schools were competent, NBME saw its scope of authority as covering five years: four years of medical school plus one of internship. Likewise, the AMA’s Council on Medical Education regarded its role as extending through this fifth year, and in 1919 it published “Essentials for Approved Internships” and a list of “approved” internships. By 1923, there were enough intern positions to accommodate all graduates of U.S. medical schools.

Specialization and Graduate Medical Education

For the first half of the twentieth century, most physicians worked as general practitioners, caring for adults and children, performing surgeries, and delivering babies. Consequently, for most physicians the general internship year was appropriate preparation, and there was no need for a period of training devoted to specialization. However, some graduates of the internship sought more advanced clinical education. At that time, specialty training was seen as preparation for those graduates who planned careers as faculty members and clinical investigators. This advanced training was accomplished mainly through completion of a program in a degree-granting school of graduate medical education or by pursuing further intensive university-based clinical training, called residency. Both routes had a strongly academic character. In 1925, only twenty-nine hospitals in the United States offered residencies, and even up to World War II a small minority of medical school and internship graduates sought residency training (Ludmerer, 1985).

Reminiscent of the variability of undergraduate medical education prior to Flexner, rigorous advanced residency programs coexisted through the 1920s along with inadequate “short courses,” as brief as two weeks, after which a physician would declare himself a specialist. Beginning in 1917, but predominantly during the 1930s, specialty boards were founded, with their major goal to define and standardize the duration and content of advanced training and to administer a specialty examination after which a physician could call himself a specialist. By the end of the 1930s, hospital-based residency programs supplanted the freestanding schools of graduate medical education, but still 75 percent of medical school graduates pursued an internship only and practiced as general practitioners.

After World War II, residency positions increased dramatically, and residency programs, which had been a pyramid shedding trainees who were perceived to be less academically promising along the way, were restructured so that essentially everyone who began a residency could complete the course of training. The advanced clinical training and preparation for a career in clinical investigation that before the war had been the purpose of residency training was shifted to a postresidency phase called fellowship. Then, in the early 1950s, graduate medical education underwent systematic expansion. A number of factors underlay this growth. The advent of private, employer-based insurance during World War II increased the demand for care at teaching hospitals and generated enthusiasm on the part of teaching hospitals for resident manpower; the higher prestige of specialty, and ultimately subspecialty, medicine decreased interest among medical school graduates for classical general practice; and even in those relatively early days of modern medicine, the complexity of the field made competent practice over the broad array of primary specialties difficult.

Since 1938, the number of first-year residency positions has consistently exceeded the number of graduates of U.S. medical schools; the difference is made up by graduates of U.S. schools of osteopathy (which were not part of this study) and the graduates of allopathic medical schools outside the United States. Residency positions and the dependence of teaching hospitals on resident participation in patient care have continued to the present.

Postwar Expansion

The period after World War II saw expansion in medical schools, more biomedical research, and growth in residency education. Medical schools expanded in size and number in response to increasing federal support for research, primarily through the National Institutes of Health (NIH). This funding went primarily to research-intensive medical schools and their associated university teaching hospitals. Consequently, smaller community-based medical schools that had no teaching hospitals and community hospitals did not undergo this expansion (Association of American Medical Colleges, 2008).

In the 1960s and 1970s, federal and state governments funded major expansion of medical schools in response to a perceived physician shortage. This was also a time of curricular innovation, with creation of the organ-system curriculum at Case Western Reserve University and the problem-based curriculum at Michigan State University, McMaster University in Ontario, and the University of New Mexico (Papa & Harasym, 1999), approaches that we describe in Chapter Three. Another significant trend emerged in this period: creation of offices of medical education to bring faculty members from schools of education into medical education to help with evaluation, faculty and curriculum development, and, later, educational technology. Offices of medical education are a unique phenomenon in education for the professions; as we describe in Chapter Six, they have helped to guide many curricular reforms.

Medical schools were also reshaped by the rising demand for medical care and expanded federal funding of Medicare and Medicaid, a trend that continues, as we describe in Chapter Five. Prior to 1965, the year in which Medicare was created, medical schools were small organizations with few faculty members; clinical practice revenues accounted for less than 3 percent of total school revenues (Watson, 2003). In contrast, by 2007 clinical revenue had increased to 40 percent of total revenue, and the number of faculty members in clinical departments expanded comparably (Association of American Medical Colleges, 2008). Medicare and Medicaid funding has not only moved the country toward a one-class system of care but has also transformed teaching hospitals from providers of charity care to providers of care to the poor, covered by Medicare or Medicaid. This change in the financing of clinical service set in motion a gradual shift in medical schools toward more direct patient-care, a larger number of clinical faculty, and dependence on clinically generated revenue. This growth in the clinical enterprise offered expanded learning opportunities for students and residents because of the greater number of patients seen and the emerging medicines and technologies available (Ludmerer, 1999).

This expansionary era led to soaring health care expenditures in the 1970s, which in turn ushered in an era of cost containment and a variety of regulations designed to limit expenditures by Medicare and Medicaid. This placed great pressures on teaching hospitals in the 1980s to reduce costs, increase efficiency, and become more price-competitive, thus challenging their ability to offer a quality learning environment for medical students and residents. As a result, university teaching hospitals became an increasingly difficult place within which to learn because of shortened lengths of stay, growing acuity of patient problems seen in inpatient settings, and expanding use of complex technological and therapeutic modalities in patient care.

Quality Improvement in Patient Care

By the 1990s and the first decade of the twenty-first century, it became evident that these external pressures on medical schools and teaching hospitals had led to deterioration of the conditions under which clinical education takes place, sparking concern about patient safety, resident duty hours, and minimum competencies of medical graduates. Several Institute of Medicine studies called for greater attention to the quality of patient care and reduction of errors, stimulating improvement efforts across the continuum of medical education and in hospitals nationally (Committee on Quality of Health Care in America, 2000, 2001; Committee on the Health Professions Education Summit, 2003; Association of American Medical Colleges, 2004). Simultaneously, the long duty hours of residents and the lack of sleep associated with working up to 120 hours a week were connected to patient safety concerns and resident well-being. Under threat of congressional legislation, the Accreditation Council for Graduate Medical Education (ACGME) imposed rules on resident duty hours, resulting in a cap of eighty hours a week. Many residency program directors and clinical faculty resisted this constraint because they were concerned that residents would not have enough experience to competently perform difficult procedures, care for a variety of patients, and assume professional responsibility for their patients. Many hospitals resisted because they were dependent on cheap labor from residents and changes would raise their fixed costs. However, all have accommodated this new rule and are working to mitigate its potential adverse effects on education.

Quality improvement in patient care has now become a major movement in American medicine. It is incorporated into the ACGME competencies for all residents. Two of the six competencies relate to quality improvement: practice-based learning and improvement (learning from one’s own patients and improving their care), and systems-based practice (working within and improving health care systems of practice). The other competencies are medical knowledge, clinical reasoning, patient communication, and professionalism. Medical schools have elected to use similar competencies for undergraduate medical education as well. Competencies identify general, nondomain-specific areas of performance expected of all trainees at every level of development and have stimulated curricular innovations in graduate medical education and undergraduate medical education (Irby & Wilkerson, 2003).

Increased Specialization

During the 1990s and early twenty-first century, funding for biomedical research from NIH doubled. The result of this expansion was a more intense focus on molecular medicine and breakthroughs in diagnostic and therapeutic modalities. As more knowledge and technology developed, physicians began to narrow their areas of focus, resulting in subspecialization and sub-subspecialization. Prior to 1970, there were nineteen specialties and ten subspecialties approved by the American Board of Medical Specialties (ABMS). Today, ABMS recognizes 24 specialties and 121 subspecialty members (http://www.abms.org/About_ABMS/ABMS_History/).

With ever-increasing specialization, new clinical roles and relationships unimagined by Flexner have arisen. Physicians care for patients in partnership with a variety of other health professionals, such as nurse anesthetists, physician assistants, and clinical pharmacists. As specialization proliferates, companion phenomena have emerged: interdisciplinary patient care teams and research. Although frequently identified with outpatient primary care, generalist physicians who can identify key clinical priorities and integrate input from specialists play a greater role in the hospital as well. Known as hospitalists, these physicians work exclusively in the hospital, caring for patients and coordinating care between a variety of hospital specialists.

The Business of Medical Education

Regardless of specialty or subspecialty, physicians are educated and practice within systems of health care. At the macro level, health care in the United States is a $2.1 trillion business annually and consumes about 16 percent of the gross domestic product. This industry is uncoordinated, and in spite of spending approximately twice as much on health care as do other developed nations, the United States achieves health outcomes unsatisfactory by many standards (Ginsburg et al., 2008). Even among those patients with private or pub...

Table of contents

• Title Page
• Copyright Page
• THE PREPARATION FOR THE PROFESSIONS SERIES
• Foreword
• Acknowledgements
• ABOUT THE AUTHORS
• Introduction
• PART ONE - TODAY’S PRACTICE, YESTERDAY’S LEGACY, TOMORROW’S CHALLENGES
• PART TWO - LEARNING THE PHYSICIAN’S WORK
• PART THREE - EXTERNAL PRESSURES AND INTERNAL FORCES FOR CHANGE
• PART FOUR - MEETING TOMORROW’S CHALLENGES: A VISION OF THE POSSIBLE
• REFERENCES
• NAME INDEX
• SUBJECT INDEX