New rounds for med students

New doctors in 2020 will have a good bedside manner and work well with other caregivers while still possessing the medical and technical skills to provide effective patient care.

At least that's the goal of a number of reforms of the medical education system. Those reforms began in 2011 with limits on resident work hours and will continue with a new accreditation system for residency programs and a new medical school entrance exam. Also on the drawing board is a plan to develop co-training programs with other caregivers, including nurses and pharmacists.

A two-year, phased restructuring of the nation's physician-training programs—which includes focusing on education outcomes over process measures—begins in July 2013. In 2015 medical school applicants will start taking a revised Medical College Admission Test that includes new sections on critical analysis and reasoning and the psychological, social and biological foundations of behavior.

At the Association of American Medical Colleges annual meeting last year, and again at a news conference held this month to announce the MCAT changes, the organization's president and CEO, Dr. Darrell Kirch, cited a survey the AAMC conducted in 2010 that found that 85% of the public thought medical schools were doing a good or excellent job in educating new doctors in medical knowledge, but almost one-third said they were doing only a fair or poor job at developing their students' bedside manner.

As part of its plan to correct this, the AAMC board approved the MCAT revisions on Feb. 16. The changes to residency and graduate medical education programs were announced in a special report posted on the New England Journal of Medicine website Feb. 21.

Dr. Thomas Nasca, CEO of the Accreditation Council for Graduate Medical Education, said the convergence of these changes “is a little more than coincidence, but a lot less than by design.” Healthcare education leaders, he said, meet three or four times a year to discuss issues and actively look for solutions to common problems.

“It's coming from different organizations,” Nasca said of the changes. “But what I think is interesting—and what I think speaks to the quality of the commitment to this—is that they're all going in the same direction.”

Nasca said the restructuring of medical school accreditation removes small details “that some might say micromanage a program,” while maintaining core education elements. “We are creating a system that allows GME programs enhanced flexibility and the ability to innovate,” he said, describing how this particular reform was a response to what overburdened program administrators requested, but that the collective changes were a response by the education community as a whole to what the public was asking for.

Jorge Girotti, associate dean and director of admissions for the University of Illinois College of Medicine in Chicago, agreed but said it may take a while to notice a difference in the physician workforce. (The first doctors to take the test will enter the workforce in July 2020.)

“Will the exam change the nature of the applicant pool? It's too early to make that type of assessment,” Girotti said. It was hoped that the addition of a writing section to the test back in 1991 could lead to more well-rounded applicants who took English and literature courses to prepare themselves for this portion of the test, Girotti noted.

The writing section has been removed from the revised test. Girotti said the sections took too long to read and were hard to judge in a fair, standardized manner.

Adding behavioral and social sciences to the MCAT will accomplish the same goal, will be easier to measure, and will help applicants better prepare, Girotti said.

“There's a belief that, if you include it in the MCAT, students will understand its importance and take it as part of their undergraduate course load,” he said, adding that attempts at broadening the applicant pool to “nontraditional” pre-med majors have not always worked. “The AAMC has been publicly promoting that an applicant's college major is not as critical (for admission), but that hasn't swayed college students” from following traditional pre-med paths.”

UIC received 7,400 applicants for 300 positions this fall. Of those, Girotti said the rough breakdown was that 60% majored in biology, chemistry or biochemistry; about 20% majored in behavioral, economic, political or social sciences; about 12% were engineering majors; and the rest majored in humanities or some other nonscience subject.

Most students can complete graduation requirements for their majors while incorporating medical school qualification requirements in four years, though engineering students often have difficulty in this regard because their field has substantial requirements of its own for graduation, Girotti said.

At the AAMC, Kirch has suggested one way to avoid stretching out an undergrad career is for colleges to develop courses that satisfy multiple requirements, and at UIC, Girotti said a neuroscience course has become very popular, and it includes instruction in both physical and behavioral science.

Elizabeth Wiley, the American Medical Student Association's vice president for internal affairs, graduated from Smith College in Northampton, Mass., with a major in philosophy and a minor in women's studies, and is now attending the George Washington University School of Medicine in Washington. She said she had to take some courses after graduation in order to meet all her medical school requirements (and she also earned a law degree and a master's in public health policy along the way.)

Wiley called the changes a step in the right direction. One complaint she hears frequently from her friends who have gone on to residency programs is that “the things that are important are not necessarily the things they are evaluated on.” She added that she hopes the changes to the MCAT “will herald a new sort of era that will be part of a recognition of the mission of a physician.”

Wiley described spending the last month at a hospital in rural Hawaii with an “incredibly complex and underserved” patient population, and she's been impressed by the skill with which attending physicians and staff communicate end-of-life issues with intensive-care patients and their family members. “Before going into the details of patient care, they step back and get to know the family members and what their values are,” she said.

Dr. Robert Wigton, associate dean for graduate medical education at the University of Nebraska Medical Center College of Medicine in Omaha, has led his institution's GME program for 36 years and said he's seen steady, positive change throughout his career, but he credits Nasca for accelerating the pace. “He's a particularly good nuts-and-bolts administrator in terms of getting things going,” Wigton said, explaining that Nasca has been able to turn “idealistic concepts” into implemented programs.

“I think the aim of all this is to produce better and better-trained doctors,” Wigton said of the new GME structure that will use education “milestones” to judge a resident's competency in patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication.

Parts of the program were tested in internal and emergency medicine programs and at institutions in Singapore.

Nasca said the tests proved that outcome-based accreditation of a residency program was possible, and that it was also possible to track the development of a resident's professionalism and interpersonal skills.

Girotti said the next step, and one that he thinks would result in the most noticeable changes for patients, is the development of integrated training where medical, nursing, pharmacy and therapy students learn to work as a team. He says this concept has been the topic of much discussion, but little adoption—despite being vital to addressing how medicine will be practiced in the future.

This was echoed somewhat by Dr. John Prescott, chief academic officer for the AAMC, though he believes that the concept is taking hold. “I've seen more movement in the past year than I've seen in the previous 10, and I think it will only accelerate,” Prescott said, citing as evidence the formal creation on Jan. 25 of the Interprofessional Education Collaborative, whose founding members include the AAMC along with the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, the American Dental Education Association and the Association of Schools of Public Health.

“I think this is a challenging time for medicine in America,” Prescott said. “And I think these are the type of changes we need to be making to meet those challenges.”