Is it time to transform medical education?

In the Oct. 2006 issue of the GME E-letter, we described the work of the AMA's Initiative to Transform Medical Education (ITME) to address educational gaps throughout the medical education continuum by:

• Recruiting medical students on their capacity for life-long learning, self-reflection, and emotional intelligence
• Encouraging team-building within medicine and across disciplines and professions
• Implementing new evaluation models, including 360-degree assessments, team grades, and self appraisals
• Inculcating and rewarding curiosity, humility, and humanistic values
• Promoting faculty development to mentor these qualities

We noted that our system of medical education has changed little for 100 years. Meanwhile, revolutionary changes have occurred in health care, public expectations, and regulatory requirements.

Below are the responses we received from readers, with identifying information removed.

Some of the values that you ignored for prospective physicians are the qualities that got American medicine to where it is today--stubborn, idealistic, nonconformist, iconoclastic, independent thinkers, who rejected playing along. 
 
A recent example was the dogged work of the Australian physician (who eventually migrated to the US) who discovered H. Pylori. That physician persisted in promoting its existence despite organized medicine's ridicule and reluctance to go along. It took 15 years before his tireless work was acknowledged and accepted. It was some additional years before he won the Nobel prize for his work. 

He was obviously not a team player. Why would you want to skew personalities of prospective physicians to those who would go along to get along?

If you want to improve medicine then here is how you do it:

• Increase the basic science portions of the classes so that physicians in training, like their forebears, get full-year courses in physiology, going through Guyton's Textbook of Medical Physiology from cover to cover; pharmacology, going through Goodman and Gilman's The Basis of Pharmacologic Therapeutics from cover to cover; and pathology, going through Robbins textbook of Pathology (not the abridged version). 
• In clinical courses go for full-year courses in obstetrics, going through Williams' Obstetrics cover to cover, and in pediatrics a full-year course featuring Nelson's Pediatrics, cover to cover. The list goes on and on. 
• Don't send medical students into the hospitals until they have completed their didactic coursework and are ready to really get benefit out of patient interactions. Teach a full year course in physical diagnosis and teach stethoscope skills again. 

We used to have a wonderful educational curriculum that was extremely intense and immersive. Today the curriculum gives medical students typically one semester of each of the aforementioned subjects, if that.

The curriculum might need to be five years long.  However the students would come out much better prepared.
 
In terms of post-medical school, reformat residency training so that the first year in each speciality is completely didactic and immersive in several major textbooks in that field, covering didactically both the general and subspecialty aspects of the field. After that, the residents' fund of knowledge would be much increased, and they would be much better able to participate in patient care effectively. This would also would adding a year to residency training. 

Most medical students starting out are conscientious, sympathetic, sincere people. When they finish school $150K+ in debt, however, then need four to nine years to start earning a living, they are oriented toward getting a good-paying specialty and location for survival.Very few have inherited millions in a safe offshore trust.

Medical organizations should concentrate on getting doctors out of debt and out of the courthouse. My many years as the only child adolescent psychiatrist in an orthopedic hospital for children made it clear that medical education needs to enhance the humanistic, philosophical components or its core curriculum. The stereotype of the surgeon is inaccurate, but broadening their abilities would do much to reduce that image.  I strongly support the ITME concept. 

Money is a key factor in specialty choice, and in the choice of medicine as a career. At the same time, it is imperative for students to understand that medicine is a field where they will have to give of themselves and exhibit high morale and altruism, sometimes without direct reward.

Some medical schools, in the interest of saving money, are giving short shrift to students' education by compressing and suppressing courses in basic sciences (eg, anatomy). Students can’t simply jump into case studies without having acquired some basic knowledge as well as a sense of ethics and professional responsibility. In the long run, this trend will be detrimental to patient care.

In addition, faculty members (both basic sciences and clinical) should be reminded that they are examples and role models. They need to exhibit ethics and show the highest standard of commitment to education, spending time with students and sharing their experience with them.

Unfortunately, none of the 10 points in your ITME e-mail contain a discussion regarding funding of GME. The ACGME competencies project is a completely unfunded mandate. I fear that ITME will be the same. Furthermore, the ACGME requires programs to utilize validated instruments to measure educational outcomes when it itself has no outcomes from validated or unvalidated instruments to prove that the competencies project will accomplish its mission. No large scale pilot project was ever undertaken.

The ACGME requires appropriate institutional support but does nothing concrete to enforce that requirement. Despite the billions that go to hospitals each year to support GME, more and more of the burden of time and money is being passed on to practitioners. Neither the ACGME nor anyone else has any auditable documents to indicate what percentage of the billions of GME dollars being given to hospitals is actually being spent on GME.

Until the AMA insists that the ACGME pay serious attention to GME funding and insist on full transparency and accountability of hospital GME dollars, I must doubt either the sincerity of the AMA or consider it naive.

As a contributor to textbooks of obstetrics and gynecology, and of pediatrics, I would like to bring to your attention an additional problem in GME that is impeding progress from the viewpoint of a medical scientist but is overlooked by the medical practitioner.

It is the willingness to present in our textbooks illness or serious abnormalities as of “unknown” etiology and present management based on symptoms. A good example in obstetrics and gynecology is “preeclampsia/eclampsia.” It is not surprising that the outcome of such intervention is far from optimal (which the authors prudently avoid to mention).

Our leading clinicians are often decades removed from progress in basic sciences, and therefore are not attempting to provide scientific validation for their recommended interventions.

Having spent more time pursuing basic sciences than most academic clinicians, I recommended to my coauthors of textbooks that they have their manuscripts reviewed by appropriate members of the basic sciences faculty. I do not think that anybody paid attention to this suggestion.

The other obstacle to us as educators is created by organizations that design and update the written examinations taken by the young physicians after completing their residency programs.

The updating is a process that is not shared with the residency program directors. Residents must assume that the textbooks, eve if in some respects outdated, give the expected answers to the questions given in the examination. This makes the residents uninterested in current information published in our specialty journals, irrespective of the reputation (eg, NEJM). Even textbooks are cautious to include recently available information, if such information is not available in other textbooks of that specialty. 

Such obstacles obviously impede medical education in the US, which used to be identified as the unquestioned leader just a few decades ago.

Learning what to do, and not why to do, does not promote intellectual curiosity among our students.

In addition, the institutional review boards have not helped us to generate new and clinically important information.

I am a neonatal fellow with a long-standing background in biomedical research. I recently attended an academic medicine conference along with many other fellows who had interests and backgrounds in academic medicine. I left the meeting deeply concerned on the condition of this system.

All fellows at this conference, from whom I heard, expressed serious concerns related to their training towards careers in academic medicine. Among the major concerns were:

• The amount of unsupported student loan debt
• Time for family and child-raising
• Time limitations related to their clinical responsibilities
• The high level of competition for grant funding

Yet medical schools continue to recruit and advocate for and, at times, pressure young physicians and physicians-in-training to pursue careers in academic medicine.

Medical schools need to have heightened awareness of their advocacy for such careers. Their desire for their graduates to succeed in academic careers is not necessarily in the best interest of the trainees. Academic medicine careers are extremely demanding and pose possible ethical issues related to time spent towards clinical training. These issues should be presented to prospective candidates in a careful and thoughtful manner that takes into consideration not only the interests of the medical schools but also the interests of the candidates.

In my opinion, medical schools should only advocate for academic careers on an individual (ie, non-global) basis. The candidates should be made well aware of the demands and limitations of this career path. Prior to graduation, the school should assist their candidates interested in academic medicine careers by directing them towards specific programs designed to accommodate their career and personal life goals. Medical schools should also provide assistance and ongoing guidance to their candidates after their graduation. Candidates should also be advised to seek a support system to monitor their progress.