from AAMC web site by Dr. Jordan Cohen
will work to develop counter to misconceptions as well as good points of article
Executive Summary
What's New in Medical Education?
Everything.
Although today's medical students learn many of the same fundamentals of doctoring that their professors learned in the medical schools of 20, 30, and 40 years ago, much of what they learn about the science of medicine, caring for patients, and providing service to their communities is radically different from medical education in decades past.
Over the past century, medical education has evolved to meet the changing needs of a rapidly growing and developing society. In this new century, medical students confront developments that their predecessors never imagined--from managed care and a multicultural society, to palmtop computers and medical informatics, to the genetic code and harsh realities of public health that include domestic violence, homelessness, and AIDS, to learning new ways to enhance health care quality while minimizing medical mistakes. The tools for teaching and treatment that served yesterday's doctors are inadequate for tomorrow's doctors. And America's medical schools are responding to this ever-changing world with exciting curricular innovations designed to prepare future physicians for practice in the 21st century.
The Association of American Medical Colleges (AAMC) has devoted a great deal of time and effort to effectively illustrate these changes in medical education. Two new reports that detail academic medicine's "Quiet Revolution" are a result of the AAMC's efforts. The Milbank Report, a collaborative effort between the AAMC and the Milbank Memorial Fund, examines in depth and detail the curricular reform and renewal process at 10 U.S. medical schools. Meanwhile, a truly unique supplement to the September issue of the AAMC journal Academic Medicine offers "snapshots" of the profound changes occurring in the curriculum at 130 of the 141 allopathic medical schools in the United States and Canada.
From Lecture Hall to Community Clinic
Not long ago, the typical learning environment for most medical students, until the very end of their training, was a jammed lecture hall. Today's medical students learn on their feet: in the exam room, in the clinic, and in the community.
Where once the lion's share of medical treatment was delivered in the hospital, on an in-patient basis, today most people receive medical treatment in the ambulatory care setting. Chronic illnesses, disease prevention, and health promotion now rival acute illness as the main focus of most medical practices. Through rotations at walk-in clinics, community health centers, rape crisis centers, schools, and shelters for the homeless and survivors of domestic violence, today's medical school curriculum provides a wealth of opportunities for students to learn in these new environments. Between the 1992-1993 and 1996-1997 academic years, time spent in ambulatory clerkships increased by four weeks, from 11 weeks to 15 weeks. Today's medical student also must learn to practice in the new health care delivery system, now dominated by managed care. Many medical schools now integrate managed care precepts and experiences throughout their curricula, teaching students the specific communication, management, and clinical skills they will need in a managed care environment. Schools partner with area managed care companies for an exploration of the subject that goes beyond lectures and into practical problem-solving. The goal: to teach students the values, attitudes, and skills necessary to provide quality care while maximizing the use of resources.
In specialized environments, the 21st century medical student also learns about particular aspects of patient care. As the population ages, for example, medical schools add further training in geriatrics into their curricula, with clinical rotations in community programs for seniors and retirement homes. In 1985, 82 percent of medical schools taught geriatrics as part of a required course; by 1997, 95 percent of schools included geriatrics training in the required curriculum.
Patients Educating Physicians, Physicians Educating Patients
In the modern medical school, a teacher doesn't always wear a white coat or carry the title "M.D." Quite often, the best "teaching" comes from the patient. In the old days of medicine, the doctor spoke and the patient listened. In today's medical schools, there's an increased focus on making sure that the doctor takes time to listen as well. Doctor-patient communication is an essential element of the contemporary medical school curriculum, and medical students have their first patient encounters much earlier in their medical school experience than did their predecessorsÑfrequently, during the first week of their first year in medical school.
Increasing numbers of medical schools are using standardized patients to test their students' clinical skills. Standardized patients, who are either trained volunteers acting in the role of a patient or are actual patients, give students the opportunity not only to test their medical knowledge but also to hone their communications skills. Between 1992 and 1997, the number of schools that used standardized patients to instruct students in doctor-patient communications skills rose from 47 percent to 80 percent. Medical schools are also developing more standardized patient scenarios that help students confront difficult issues like a patient's decision to forego treatment, doctor-patient confidentiality, and do-not-resuscitate orders.
When it comes to complex subjects like spirituality and death and dying, patients are often the best teachers. In hospices and homes, medical students frequently now have the difficult, but life-changing, opportunity to partner with patients who have life-threatening illnesses, following their progress and learning in a deeply personal way about the process of death and dying. Nearly all U.S. medical schools (96.1 percent) include education about death and dying in existing courses, and nearly half (44.1 percent) offer a separate elective or required course in end-of-life care.
In fact, at many medical schools, patients and their families are becoming part of the faculty, in a movement known as "patient- and family-centered care." This partnership between the providers of medical services, patients, and their families promotes higher levels of satisfaction for everyone, better health outcomes, and cost savings. Patients and their families use their personal experiences to teach medical students what it's like to live with a chronic illness or face a diagnosis of terminal illness. Frequently, these patients and family members sit on committees that help plan and evaluate medical school curricula, making sure that the patient's viewpoint is heard in every classroom and every clinical experience.
New Scientific Advances Create New Educational Challenges
During the past two decades, a literal revolution in the biomedical and clinical sciences has occurred. From the mapping of the human genome to the cloning of human stem cells, to the availability of exciting new therapies and treatments for both acute and chronic illnesses, today's medical students have a host of tools at their disposal that would have seemed like science fiction to their predecessors. But these new treatment options also present a host of new educational challenges.
Medical schools have expanded the range of curricular offerings in rapidly expanding subjects such as genetics, both in stand-alone courses and by incorporating new genetic and other types of knowledge into existing courses at both the basic science and clinical level.
With new knowledge arises new ethical challenges for the physician. Should scarce medical resources be used to exhaust all possible chances to save a premature infant, even if the child is unlikely to survive and will be gravely impaired for life if he does? How should a physician discuss a patient's religious objections to a new type of treatment? What privacy risks do new advances in genetics and biotechnology pose for a patient? In a growing number of medical ethics courses, students learn early on to confront these tough challenges and to communicate effectively with their patients about them.
Students are also learning the skills needed to apply the precepts of evidence-based medicine to their clinical decisions. Evidence-based medicine integrates individual clinical expertise with evidence from a broad base of externally conducted systematic research. Most medical schools (88 percent) offer students the opportunity to learn the skills of evidence-based medicine, fostering in them the ability to make better decisions in an increasingly complex medical world.
Virtual Patients Provide Real-Time Education
Advances in information technology have transformed the educational process for today's medical student. Medical schools are working to create technologically savvy graduates, preparing them to use medical informatics in a wide variety of ways to better serve their patients.
Through computer-assisted instruction, medical schools are enhancing learning experiences in ways never before possible. Students are meeting "virtual patients" online and through CD-ROM, supplementing their bedside experiences with virtual encounters that provide instant feedback.
Online curricula now provide medical students with instant, easy access to all the learning tools they need, at the times that they need them. Many medical schools have computerized large chunks of their curricular resources, from texts and graphic images to video and sound. These online systems allow students to review the latest clinical research, get instant explanations about different diagnoses, and use computer-based medical decision support to reinforce their knowledge and skills. In 1998-1999, 99 of the 125 medical schools included medical informatics in their required course offerings.
Telemedicine technology is also broadening the horizons of today's medical students. They're learning to do remote telemedicine conferences with patients in rural areas, facilitating the availability of health services to populations that have difficulty getting access to care.
Going Beyond a Diagnosis
The America today's medical student sees could hardly be more different than that of the 1960s and 70s. Our society is more ethnically and culturally diverse than ever before, and it has developed new respect and understanding for the importance of a broad variety of spiritual traditions. But even these positive changes pose their own unique challenges, and at the same time our society is confronted with the ugly realities of sexual violence, homelessness, and domestic abuse. Today's physicians stand on the front lines of these issues, and today's medical students are learning to deal with them in hands-on ways.
For example, almost 70 percent of medical schools offer some formal training in cultural competence, and 14 percent plan to introduce it in the curriculum. Medical students are learning to deal openly, sensitively, and respectfully with languages, cultures, and beliefs that are unfamiliar to them, through such experiences as overseas study programs, rotations in culturally diverse communities, and formal training on the role of culture in health care.
Today's medical students also learn to serve the growing needs of their communities through a variety of community service projects. Many of these initiatives, while sponsored and encouraged by medical schools, are initiated by the students themselves. Under supervision from faculty physicians, students provide medical treatment at walk-in drug and alcohol rehabilitation centers, provide care for homeless women and children, teach healthy behavior in elementary schools, and serve in rural communities that lack access to care. Between 1996 and 1999, medical students doubled their voluntary participation in programs that bring care to underserved populations. In 1999, over 69 percent of medical students provided this type of voluntary care--and almost invariably, these students reported that they "received" much more than they "gave" during their volunteer experiences.
Renewal Is An Ongoing Process
In addition to renewing, enhancing, and expanding the ways in which medical students learn, medical schools in the 21st century are reinvigorating their commitment to medical education in a number of other ways. More and more medical schools are exploring new avenues to better support programs associated with their educational mission. Medical schools are stressing their fundamental commitment to their educational missions by considering ways to value excellence in teaching as they have historically valued new excellence in research. And they are establishing clear outcomes, learning objectives, and assessment systems to better measure how well their students are learning.
The progress already made by medical schools in transforming the medical education process to reflect the needs of our rapidly changing society has been nothing short of revolutionary. Perhaps most important, medical schools have come to understand that there is no endpoint to curricular evolution. Instead of setting a deadline for completing a process of curriculum reform, medical schools now see themselves as engaged in a continuous process of curriculum renewal.
Our single greatest challenge in teaching new physicians in the 21st century remains the one that has confronted medical education throughout its century of reform: melding keen medical competence with compassion and professionalism in a continually evolving health care system. Through the ongoing process of curricular evolution and renewal, America's medical schools are working to meet that challenge by pairing innovative new teaching strategies with the time-tested foundations of medical training. Thanks to the Milbank Report and the Academic Medicine supplement, we have a clear picture of their success in meeting that challenge, a success that is indeed worthy of celebration.
Closing Essays
Learning, Doctoring
By Rebecca M. Minter, M.D.
As I drove to the hospital this Sunday evening (post-call after a non-stop night of trauma and other surgical emergencies) to learn everything there is to know about neuroendocrine tumors of the pancreas for a Grand Rounds presentation I have to give next week, I struggled a bit finding the "inspiration" to write this essay. I was tired and overwhelmed with all of the things I needed to get done in the next few days. However, when I stopped off in the ICU to see a sick patient that has been making a slow but sure recovery, and saw the sheer joy on her husband's face as he heard her speak for the first time in two months, I found my inspiration.
Throughout medical school and residency we deal with many ups and downs, each of which is amplified further when experienced through the filter of fatigue and the fear of harming someone. We all learn to deal with these stresses in our own ways, and each of us finds something that sustains us throughout our training.
Like many other medical students and residents, I've found my sustenance primarily in my interactions with my patients. Even the worst of days is brightened by a 10-year-old boy with cancer demanding that you--and only you--remove his surgical drain, or by an elderly patient asking that you be her new primary care doctor. (Not a very good idea for a surgeon, but flattering all the same!)
In addition to being a critical source of feedback, both positive and negative, our patients remain our greatest teachers. It has been a lot of fun watching our brand new, bright-eyed and bushy-tailed third-year medical students take care of their first "real" patients. On morning rounds, I have to laugh as our patients tell us that they will definitely be up walking in the halls later, because they promised Paige, our third-year medical student, that they would.
Watching Paige interact with her patients reminds me of how much I learned as a medical student just from taking the time to listen to and talk with my patients. I think it is a lesson that we all need to be constantly reminded of, particularly in our current culture, which often encourages us to see more patients more quickly. I think we must be extremely careful not to alienate our patients, and further jeopardize the fragile patient/physician relationship because we are in too big of a hurry. We simply must make time. We must constantly place ourselves in our patients' shoes, and imagine how we would feel if never allowed to complete a sentence, or felt that we were holding someone up from something more important.
My 83-year-old grandfather was recently in a terrible car accident and was flown to a level-one trauma center. For days, I was frantically trying to get information from the hospital. My mother and aunt would attempt to convey to me what was going on, but they don't have any medical training, and I could not get his surgery resident to return my calls, no matter how many times I tried. Ultimately, I asked the nurse to let him know that I was paging his attending and he suddenly found the time to call me back. When he did call, he was actually quite apologetic, but as you can imagine, I had little interest in hearing about how busy he had been.
When a loved one is sick, he is your only concern. Now, whenever I find myself rushing with patients, I try and step back into the shoes of the worried granddaughter, rather than the frazzled surgery resident, and give them the time I expected when I was in their position.
My second source of inspiration for this talk actually came as I worked on my Grand Rounds presentation. I found myself getting excited about learning something new, and
about putting together a presentation that I could use to teach my fellow residents, medical students, and faculty. I believe that the constant exchange of information that occurs in academic health centers, as inquisitive medical students and residents ask questions, leads to the highest caliber of patient care and the application of the most current technologies and therapies. We're constantly being pushed to research different topics, and we are then held accountable by our inquiring patients, medical students, junior residents, and attendings.
The changes in undergraduate and graduate medical education have been dramatic since I began medical school. Medical informatics has absolutely exploded. Medical students now have computer terminals at their lab carrels where they can access PubMed and do head and neck dissection using virtual reality software. By the time these students hit residency, they are able to assimilate data with a new degree of efficiency and organization. This generation of students has grown up in the world of evidence-based medicine. The old answer, "Because that's how we always do it," no longer cuts the mustard. They want to see the data.
In addition, the physician/patient relationship has changed dramatically. Our patients are far more educated about their diseases and their health. This is a positive trend. As students and residents, we are now learning that you no longer tell patients what you are going to do for them, but rather discuss various options with them, allowing them to choose a plan of action.
This age of information overload is also teaching us that we must be familiar with all possible therapies for a particular disease process, both conventional and alternative. As physicians, we must be careful not to ridicule alternative therapies. Sometimes our patients come to us with difficult diseases such as terminal cancer. To bluntly announce to them that the shark cartilage they've been ingesting is useless, when they are certain that it's helping, is completely insensitive, and only serves to alienate patient from doctor. Instead, we should be able to explain why specific treatments are appropriate or inappropriate in specific situations.
The Internet has no filter, and our patients depend upon us to be that filter, but not in a dictatorial way. The undergraduate medical education curriculum has incorporated many of these principles with courses that focus on evidence-based medicine, communication skills, cultural competencies, and in some schools, an introduction to alternative medicine. The graduate medical education curriculum is also in a period of transition, with a greater emphasis being placed on the application of evidence-based medicine principles and better communication skills. The old excuse, "Oh well, don't mind him, he's just a surgeon," is no longer an acceptable explanation for outbursts or poor communications.
As I move through my residency, heading toward a career in academic medicine, I do, however, see many future challenges for medical education in the clinical arena. Despite the great curricular changes that have occurred in undergraduate medical education over the past several years, graduate medical education has been slower in adapting. With the exponential increase in medical technology and informatics, residents and students often find themselves reeling, trying to figure out where to even begin. In addition to all of the new information we are expected to assimilate, there is little filtering of archaic methodologies that are rarely if ever used in this day and age.
Additionally, as academic centers are forced to compete in the marketplace, faculty are being pushed to increase revenue, which leads to less time available for teaching and mentoring. In this kind of environment, I fear that students also run the risk of becoming marginalized during their clinical rotations. Their interactions with patients are shorter and fewer than they once were, as are their opportunities for learning procedures. Faculty feel these pressures as well. However, they are often not compensated for teaching, and find themselves with more daunting documentation requirements and patient care responsibilities. Our next challenge will be to take many of the outstanding, innovative curricular developments that have taken place in undergraduate medical education, and adapt them to the graduate medical education curriculum.
Based on the tremendous progress documented in both the Milbank report and the Academic Medicine supplement, I have no doubt that we have the tools and the talent to meet these challenges. Medical education in this country continues to evolve, setting ever newer and higher standards. As we move into the 21st century, we will tackle these challenges head-on with progressive and innovative ideas, ensuring that future physicians will continue to be compassionate, competent ones. The opportunity to practice medicine is a great privilege, and when asked by students considering a career in medicine if I would do it all over again, I never hesitate before responding, "Absolutely!"
A Family's Perspective on Medical Education
By Juliette Schlucter
Absolutely everything matters when you have a sick child.
In 1991 when our then 11-month-old son and our soon-to-be-born daughter were diagnosed with Cystic Fibrosis, I had many more questions than answers. Desperate to get my son Will and daughter Julia the best medical care available, I thought my toughest questions would be about their lungs, their prescriptions, their prognosis.
Those would have easy answers.
A far more difficult lesson would be learning how to navigate the complex web of American health care. Learning how to live with illness, not just for this one infection but for a lifetime. Learning how to develop a trusting partnership with our physician amidst a culture that fosters doubt and second-guessing of a once sacred relationship. Learning how to communicate with a medical team about our family's culture and our way of dealing with illness.
In learning to live with chronic illness, our family has had to learn to cope with a lot of the same challenges that our physicians must face.
For example, we struggled with information overload. We had to sort through overwhelming amounts of information from texts and the Internet for that one study or protocol that might make a difference. We learned to partner with doctors around information in a way that supports a trusting exchange. It's much more difficult than it sounds for a patient to make sure she knows what is valid, appropriate, and accurate, while at the same time making sure her physician doesn't feel challenged and threatened by her need to be informed.
We also coped with the uncertainty of treatments. The more we know, it seems, the more we don't know, and that is never more true than in medicine and dealing with a chronic illness. Our family had to learn to cope with the uncertainties of symptoms, treatments, and outcomes. We faced the difficult truth that there are no easy answers with a disease like Cystic Fibrosis. It's a tremendous challenge to build a trusting relationship when both the patient and the doctor feel vulnerable in the face of uncertainty.
As a parent my daily uncertainties revolve around making medical decisions for my children: Is this a lung infection or just a cold? Should I visit the ER tonight or should I wait and call the doctor in the morning? Are we really ready to be discharged and will homecare be effective? How can I ask for a second opinion and still come back to this good doctor? Could alternative medicines be the answer for my sick child? How do I sort through all this information on the Web, in my library... what is valid? Where do I even begin?
What will I gain? And worse yet, what will I lose?
As uncertain as I may feel about medical decisions, I am certain about my expertise in caring for my family. I am certain about when my child is in pain. I know how he wants to be comforted. How he can take medicine in the classroom. What information our family needs. How our family copes.
For all the uncertainty that I have as a parent, I know that my doctors face many uncertainties of their own. Will this patient trust me? Is this the right approach for this family? Will the insurance plan cover these tests? Will I have enough time to spend with this family?
It is an uncertain time to be a patient; it's an uncertain time to be a doctor. And there is no more difficult place to be then in a world of uncertainty.
But with the development of patient and family-centered care, it's a new world for medicine--neither my doctor nor I must face these uncertainties alone, or pretend that they don't exist. Instead, we collaborate as partners to share our strengths and manage our uncertainties. Sharing expertise--learning from my doctor how to make medical assessments at home and teaching my doctor about my family--this is the core of Collaborative Medicine.
Collaborative Medicine requires a new set of skills: diagnostically, for treatment plans, and for ongoing relationships. At the Children's Hospital of Philadelphia, the commitment to Collaborative Medicine is so intertwined in their philosophy that they partnered with us--a group of parents that formed a Family Faculty to teach new physicians about healing health care. It is a curriculum based not on science, but on our own practical wisdom.
In the eyes of a busy doctor, what's paramount may be the medical data and science: the tests, the protocols, and the prognosis.
In the eyes of our family, what's paramount are all the realities of our daily lives. A child's fears, a parent's desire to protect, a family's hope.
At The Children's Hospital of Philadelphia, our education programs are now devoted to bringing these two worlds together--right where they should be. If the science, the genetic code, the medicines and treatments are the heart of medicine then surely everything else--our hopes, our fears, our need for a doctor who understands them and our need for compassion--is the soul of medicine, and we found out we could not separate the two. We couldn't compromise the need to have the best science, the best medicines, and the very best research with our need for a doctor who knew and understood us, who listened and could take the time, who cared, who understood how to heal not just how to cure. It is impossible to trade one for the other. Nor should anyone have to.
I want every medical student to know all of the science that will bring physical healing and I equally want him or her to know the power of words. I want them to know the impact a doctor has when they choose words that support human partnerships. Like being able to say to a patient:
I want to know what is happening.
I understand how you feel.
I believe I can help.
I hope we can beat this.
What matters to patients and families is not just what the doctor says, but how he says it. The echoes of our doctors' words played on and on long after we learned the technical meaning of Cystic Fibrosis. So now, families like ours teach medical students at The Children's Hospital of Philadelphia how to deliver news to families. We teach about effective communication strategies so these medical students may learn first hand the difference their words can make. We teach about living with illness in a way that no student can learn from a textbook.
These programs are integral to the creation of fine physicians but they are a small piece of a complex puzzle that must be devoted to the same values. This includes the mentoring experience these young physicians will receive from senior medical staff. These values must be modeled by senior doctors in order for them to be reinforced. These values must be supported when we look at financial models of health care and how we "incent" physicians to practice good medicine.
If today we are celebrating "A Century of Reform," then this event, in this millennium year, is a beacon for the path before us. It speaks volumes that I am here today, a consumer of health care, invited to share the podium with Dr. Jordan Cohen and other distinguished leaders. That as a family I am viewed as a core collaborator in academic medicine at The Children's Hospital of Philadelphia. These achievements are symbols of the great opportunity in medical education to share the expertise of physician and patient.
Sharing expertise and practicing Collaborative Medicine takes courage and trust, for both the patient and the physician. Medical education must be committed to teach tomorrow's doctors that in the practice of medicine you enter one of the most vulnerable human partnerships. Medical education must teach the skills necessary to forge these partnerships in the face of many uncertainties.
I want the doctors of tomorrow to know that when all the formal teaching is over and I walk in to your office my need is for medical care for my child, but my desperate hope is that you have the same stake in my child's health as I do.