Millennium Conference on the Clinical Education of Medical Students
April 28 – May 1, 2001
Sponsored by the Carl J. Shapiro Institute for Education and Research
at Harvard Medical School and Beth Israel Deaconess Medical Center
and the Association of American Medical Colleges
EXECUTIVE SUMMARY
In 1989, the New York Academy of Medicine and the Josiah Macy, Jr. Foundation co-sponsored a conference on the clinical education of medical students, Adapting Clinical Medical Education to the Needs of Today and Tomorrow.“ American medicine and the society it serves,” the conference proceedings state, “have been rapidly changing, and the clinical education of medical students has not been keeping pace.
”Twelve years later, little has been done to alter the clinical education of medical students to keep pace with the continuous rapid changes in the delivery of healthcare to the American public."
At the beginning of the twenty-first century, the Hopkins inpatient clerkship and ward team model embraced by Abraham Flexner in his landmark report on medical education in 1910 is still the predominant structure for clinical education. Yet, as Kenneth Ludmerer observes in his recent book on the history of American medical education in the 20th century, Time to Heal, in the 1990s, “for the first time in American history, a conflict appeared between the teachings of medicine and the environment of health care delivery.”
That conflict has resulted in a degradation in the quality of clinical education and a dramatic reduction in the time faculty spend teaching medical students and medical students spend learning clinical medicine through the experience of caring for patients.
Recognizing that the need to restructure the clinical education of medical students is an issue facing all medical schools, the Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center [Shapiro Institute], through the generous support of philanthropists Carl and Ruth Shapiro, decided to organize a national conference to develop solutions to the problems facing clinical education. At the same time, the Association of American Medical Colleges [AAMC] was embarking on an initiative to document the state of the clinical education of medical students in US medical schools, and to develop proposals for remedying any deficiencies that may be identified through its Project on the Clinical Education of Medical Students. The two organizations agreed to work together to convene medical education leaders from medical schools throughout North America to tackle the issues collectively and to develop strategies for improving the quality of the clinical education of medical students that can both guide changes in the clinical curricula of participants’ own schools, and also guide others embarking on similar reforms.
The Millennium Conference on the Clinical Education of Medical Students included leaders in medical education from 11 medical schools around the country chosen by a competitive application process from 48 schools that applied to attend the conference. The medical schools that participated in the conference represent a broad distribution of geography and types of schools, and include:
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Baylor |
University of California, Los Angeles |
|
Duke |
University of California, San Francisco |
|
Harvard |
University of Iowa |
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Mayo |
MCP Hahnemann |
|
Mount Sinai |
Uniformed Services University of Health Sciences |
|
University of Rochester |
|
Each school sent a team of four faculty, including a leader in medical education at the medical school, a leader in medical education at a major affiliated hospital, a clerkship director, and a residency program or associate program director.
CONFERENCE ORGANIZATION
The 2.5-day conference was organized as a working retreat, comprised of a keynote address, plenary talks, and breakout groups to address specific broad issues relating to medical student education. The Keynote Address, entitled “A Second Revolution in the Education of Physicians: Why Now?” and delivered by Jordan Cohen, M.D., President of the AAMC, outlined many of the issues facing medical education at the turn of the century and served as a call to action for the participants to “think out of the box” in developing broad and innovative educational proposals. “It is time,” Dr. Cohen urged, “to move rapidly to revolutionary views of clinical education, to identify the seeds of a modern-day Flexnerian solution, and to undertake a fundamental redesign of clinical education.”
Following a presentation by Donald Nutter, M.D., Petersdorf Scholar-in-Residence at the AAMC, that reviewed the state of clinical education in American medical schools today, the conference focused on three broad questions: 1) What to teach? 2) How to teach? and 3) Who teaches? Each of these issues was introduced by a plenary talk that defined more specific questions to be addressed, followed by break-out discussions in small, heterogeneous groups composed of team members from different schools and different disciplines. Each break-out group then presented a summary of its discussion of that particular issue.
Michael Whitcomb, M.D., Senior Vice President for Medical Education at the AAMC and Co-Director of the Conference with Steven Weinberger, M.D., Executive Director of the Shapiro Institute, introduced the issue of “What to Teach.” The break-out groups focused not only on curricular content, but also on mastery of skills and on integration of content across the curriculum. Dr. Weinberger introduced the issue of “How to Teach,” and the subsequent discussion centered on design of the required and elective curricula, transition periods in the curriculum, and the use of traditional as well as non-traditional teaching methods. Finally, Richard Schwartzstein, M.D., then Senior Rabkin Fellow in Medical Education at the Shapiro Institute, introduced the topic of “Who Teaches,” stressing issues relating to the composition and expectations of teaching faculty as well as improving the system for evaluating and rewarding faculty for their teaching efforts.
After considering these three broad areas, each medical school team met as a group to formulate proposals for educational innovation at their own school, based on the earlier discussions of the issues. As an introduction to the school team meetings, Charles Hatem, M.D., Director of Faculty Programs in Medical Education at the Shapiro Institute, reviewed the history of medical education reform over the past century, including some of the obstacles for reform.
COMMON THEMES FROM THE CONFERENCE
What to Teach
Conference participants uniformly agreed it is critical that the clinical and basic sciences be integrated, along with longitudinal themes and cross-disciplinary topics, across the 4-year curriculum. Graduation competencies must be established, and evaluation must be linked to prescribed competencies. One school even suggested printing graduation competencies on the back of student identification cards. To ensure that objectives are being met by each student, competency-based assessments must be conducted at regular intervals, e.g., at the end of Year 1, at the transition between the preclinical and the clinical curriculum, and at end of Year III. In addition, individual learning plans for students should be developed at the end of Year II based on a comprehensive assessment. Focus on non-clinical topics might occur in “intersessions” between clerkships or in senior seminars during the final year of medical school.
Centralizing the administration of the clinical curriculum within the medical school emerged as a strong consensus. Participants also agreed that clinical experiences should begin early, in the latter months of Year II. The traditional clerkships should be modified to facilitate a shift from team-centered learning to patient-centered learning for students. Clinical learning modules with core faculty should be created. Mentoring and opportunities for longitudinal faculty/student relationships should be expanded throughout the clinical curriculum.
The final year of medical school should be revised to include advanced experiences that both build on the scientific and clinical foundation begun in the earlier years of medical school, and also prepare students for the first year of post-graduate training. A course focused on the transition to internship might include topics ranging from managing common emergencies to teaching skills.
Who Teaches
Perhaps the strongest consensus that emerged from the conference is the need to establish organized structures for supporting faculty who teach in the form of core faculties, communities of scholars, or academies of medical educators. The role of clerkship directors must be enhanced, and expectations for clerkship directors must be defined. Clerkship directors should also engage in medical education research; participate in formal evaluation sessions; serve as agents of faculty development; and be provided the time and resources to accomplish these tasks. The education faculty must be empowered as change agents. They should have opportunities for leadership development and faculty development focused on education. Internal grants can provide protected time to pursue research questions with defined outcomes that can be published. Strategies for dynamic curricular revision must be developed. Think tanks should be established to develop a long-term vision for the curriculum and provide feedback to curriculum committees.
Lastly, mechanisms for recognizing and rewarding teachers will be critical to ensure excellence in medical education in the new century. Education faculty must be rewarded, especially academically, but also financially. Mission-based management and budgeting for medical education should be instituted, and faculty should be paid for teaching. An endowment for supporting teaching should also be raised. Funding for education research from internal as well as external sources should be made available for faculty to pursue academic interests in medical education.
SUMMARY RECOMMENDATIONS
The goals of clinical education should focus on the mastery of a core set of skills as well as on the acquisition of factual content. These goals must be formulated and presented more explicitly to both the students and the faculty.
Assessment of a student’s performance, particularly for mastery of the core skills, is a critical component of the educational process and must be conducted at critical points.
Topics that are not specific to a particular clinical discipline (sometimes called “orphan topics”) need to be integrated more effectively into the curriculum.
Greater integration is necessary across the curriculum, e.g., between basic science and clinical medicine, and across different specialty disciplines.
The organization and oversight of the curriculum should be centralized within the medical school rather than distributed to individual departments.
The educational experience needs to be centered more around the patient than around the inpatient team.
Better use needs to be made of the fourth year of medical school, and innovative educational programs need to be developed that link the fourth year to the overall educational goals of medical education.
Transition periods in the curriculum, e.g., from preclinical to clinical experiences, from medical school to housestaff training, are important opportunities and priorities for educational innovation and reform.
Development of a “core faculty” of medical educators is an important step toward addressing the problems facing clinical education in a period of increasing pressures on clinical productivity.
Better tools need to be developed to evaluate faculty as teachers, with the corollary that excellent teaching should be rewarded appropriately.
See Medical Education Retardation Why a Preceptorship Is Better
CONCLUSIONS
The Millennium Conference on the Clinical Education of Medical Students was a timely forum for discussion of the issues faced by medical schools and academic medical centers throughout North America. Faculty who attended the conference were energized around the common commitment all share to ensure the continued excellence of the education and training of physicians in the twenty-first century. One conference participant’s comments at the end of the conference summarized the sentiments of most who attended: “the conference affirmed for me that the direction in which we are heading is right and that we all need to have the courage of our convictions. Fundamental changes are required in the clinical education of medical students and must be undertaken, despite the strenuous resistance of a variety of stakeholders.” The challenge now is for each of the participants to serve as change agents in their own schools, and to bring the collective recommendations of the group of leaders in medical education who attended the conference to fruition in their home institutions.
As Ludmerer demonstrates in Time to Heal, this is a great challenge that will require leaders with
“the ‘ability to think outside the box,’ the flexibility to act quickly, the courage to act decisively, … the fortitude to make difficult and painful decisions for the sake of the general good, … [and] the wisdom to know what not to change—namely, the timeless core mission and values of the academic health center.”
Conference summary as per
is ended here. Comments below by RCB
The above emphasis is by RCB, this ability is not well demonstrated by the Accreditation Process, esp regarding Demands of Rural Practice
For summary recommendations with comments from Rural Medical Educators, see Millennium Conference and Rural Medical Education