Medical schools and teaching hospitals in the U.S. are renowned for producing the very best and brightest young doctors in the world.
But the nation's system of medical education, as good as it is, must make a series of dramatic changes in the way it prepares future physicians for the nation's rapidly evolving healthcare system, according to medical school deans.
Some schools have already moved forward in this process, adopting curriculum changes that foreshadowed recommendations in a new study commissioned by the Washington-based Association of American Medical Colleges.
The University of California at San Fran-cisco has "rebuilt the curriculum from the ground up from year one to year four," said David Irby, vice dean of UCSF's School of Medicine. One key element of this new system: Third-year clerkships, criticized in the AAMC report for teaching students through decades-old pedagogy, have been updated and inte-grated to include "intersessions" that provide weeklong wrap-ups on everything from ana-tomy to obstetrics.
"We pull all the students off the clerkship," Irby said, "and bring them in a classroom to deal with important issues-including medical ethics, evidence-based medicine or system-based practices, where they look at an entire population instead of individual patients."
At Northeastern Ohio Universities College of Medicine in Rootstown, officials have emphasized the use of simulators in the development of clinical skills and are now changing the curriculum to provide students with more longitudinal studies, that is, providing care to the same patient over the course of a disease rather than in an acute-care setting. They are also centering on "outpatient education," freeing students to spend time in the community to help hone their overall skills as both clinicians and physicians.
"The time is ripe for a reassessment of medical education," said Lois Margaret Nora, president and dean of the college. "I expect (the report) to have substantial impact."
In the AAMC study, medical school deans recommend a major overhaul of an educational system that often focuses on the same kinds of core clinical disciplines that were used as long ago as the 1950s to prepare doctors for general practice. What's more, the teaching and assessment of clinical skills are considered "inadequate," in part because many faculty members are more concerned with research and scholarship than with teaching students, the report concluded.
"I would say (the medical education system in the U.S.) is probably good, if not better than any in the world," said Michael Whitcomb, the AAMC's senior vice president of medical education and director of its Institute for Improving Medical Education. "Even though that may be the case, it's not good enough. The goal is to move from a very good system to one that is truly excellent."
Responding to the report, Jordan Cohen, president of the AAMC, called for "fundamental changes" in medical education.
Whitcomb said several reports in recent years have outlined "deficiencies in the quality of care" in the healthcare system, providing "a compelling case that we need to look very critically at the way we educate doctors."
The root problem, he said, is the failure to better coordinate the training provided by medical schools, graduate medical education and continuing medical education. Clerkships, he said, which generally occur in the third year of medical school, have not evolved signifi-cantly over a span of about five decades, triggering widespread concerns that they lack relevance today. He cited Irby's program as one of the innovators helping to spur change across the country.
For the most part, however, the "design and conduct of those traditional clerkships remain largely unchanged ... despite widespread concern about the relevance and value of many of the experiences students have during their clerkship rotations," said the AAMC report, released earlier this month.
Meanwhile, continuing medical education has failed to do its job of providing practicing physicians with the most current information to improve their knowledge and update their clinical skills. For many doctors, the annual exercise involves little more than racking up enough hours to satisfy vague accreditation standards, Whitcomb said.
"Anyone who has studied our approach to continuing medical education will tell you that the system doesn't work," Whitcomb said. "Just think about how important it is, especially in the modern environment, that (physicians) maintain clinical competency."
Among other recommendations, the report suggests medical schools and teaching hospitals develop and support faculty whose main responsibility is the education of students and establish rigorous assessment programs to ensure that students and residents acquire the knowledge and skills necessary to provide superior care. It also recommends continuing medical education programs that improve how physicians practice medicine.
Whitcomb said standards must be improved and enforced to ensure that continuing education serves a purpose other than simply satisfying some annual and arbitrary hourly requirement.
The AAMC is forming an advisory committee that will begin work in September to establish a time frame for addressing which issues to tackle first, Whitcomb said. "We don't want to at all imply that everything that goes on in medical education is bad," Whitcomb said. "But there does need to be very serious change."