It's been more than a century since the Flexner Report helped transform medical education from a mishmash of proprietary schools into rigorous academic training at elite universities, grounded in biomedical science and closely supervised clinical practice.
All of the nation's 144 accredited medical schools still follow that model for their 83,000 students. The curriculum is badly in need of an overhaul.
Training in 21st century medicine must be aimed at creating health team leaders. To be effective in today's healthcare settings, physicians must understand the science and practice of medicine, of course.
But they also must be able to work closely with other professionals, understand population health and health policy, and know how to work within the social and economic constraints now pressing down on the systems where most of them will spend their professional lives.
The good news is, the winds of change are blowing.
Last week, the American Medical Association held a conference to celebrate efforts aimed at transforming academic medical training, including some of the programs funded by its small grants to 11 leading academic medical centers.
The initial results look promising. They included a collaboration between Consumer Reports, the Albert Einstein College of Medicine and Brown University's Warren Alpert Medical School to teach Choosing Wisely—the unnecessary practices each specialty should avoid. The next generation of specialists might not learn about that on rounds at teaching hospitals where those lessons haven't become standard practice.
The Emory University School of Medicine is independently funding a quality improvement lab. Given that earning physician “buy-in” is one of the hardest tasks facing hospital administrators when they initiate quality improvement programs, having young doctors on staff to whom such activities are second nature would be a welcome relief.
The New York University School of Medicine has created courses in population health management and the creative use of big data. Students have access to the state's comprehensive database of de-identified patient records so they can learn how to analyze differences in outcomes and costs at various hospitals.
Penn State's College of Medicine has launched a patient navigator program staffed by medical students. The idea is to have them learn about the healthcare system from the patient perspective. An empathetic understanding of those realities enables patient engagement. The traditional mindset—doctor knows best—makes that almost impossible.
Medical education reform advocates understand the practice of medicine is changing rapidly. There is far more technology available. And the rapid expansion of knowledge—embodied in fast-changing clinical practice guidelines—requires intellectual flexibility and a willingness to use new communication technologies in practice settings.
Yet every survey about physician burnout notes that the biggest complaint from doctors practicing today—including most of the young ones—is that they spend too much time entering data and not enough time talking to patients. That's not why they got into medicine.
The current generation of health information technology is wondrous at billing and collections. It has been an epic failure in clinical practice.
While the AMA should be commended for its support of revamping medical education, its lobbying on behalf of the existing base of physicians has not been so forward-looking. Its local affiliates continue to promote laws that limit opportunities for physician assistants and nurse practitioners, whose expanded ranks will be crucial to building a more efficient and effective healthcare system.
It won't help if schools train doctors to be team leaders only for them to discover upon entering private practice or hospital employment that those opportunities are limited or nonexistent. The AMA notes that getting older doctors to work two years longer will reduce the long-term demand for new physicians by 25%. Raising the ratio of physician extenders to physicians would go much farther—and save the healthcare system a ton of money in the process.
The New England Journal of Medicine's preview of the 100th anniversary of the 1910 Flexner Report recalled that educator Abraham Flexner, a decade after his report came out, warned that medical education needed constant updating to reflect changing social and economic circumstances.
“He would undoubtedly support the fundamental restructuring of medical education needed today,” the authors wrote. A few courses at 11 universities barely scratches the surface of what current and future medical students need and want.
This editorial has been updated to reflect the fact that not all the programs highlighted at the conference were funded by the American Medical Association.
