MEDICAL EDUCATION: CHANGES AND CHALLENGES
Nicolaos E. Madias, M.D. In the next few minutes, I plan to address briefly several themes concerning contemporary medical education in the United States. Although I will draw largely from my experience at Tufts, a private, non-profit medical school, the patterns I will describe essentially typify the educational trends in most American schools. The overarching theme in medical curriculum reform is to produce physicians who are well trained to meet contemporary societal expectations. Prior to the 90’s, and for several decades, the general blueprint for medical education in the US had been the 2+2 model encompassing roughly a 2-yr instruction in basic sciences followed by a 2-yr exposure to clinical disciplines. Please note that students enrolling in American Medical Schools have completed college education that includes a rigorous premedical curriculum. Although time-honored and relatively successful, this blueprint became the subject of intense scrutiny in the early 90’s on various grounds. A number of concerns were articulated that led to corresponding initiatives: The temporal separation of basic sciences from clinical disciplines was creating a sense of lack of relevance to the students vis-à-vis their chosen profession and led to early exposure to clinical medicine, essentially from day 1 of enrollment. And although basic sciences still dominate the early phase of the curriculum, the direction is toward contemporaneous exposure to both types of disciplines throughout the instruction period. Thus, considerable exposure to clinical material occurs during the first two years of the curriculum, including instruction in patient interviewing, the relationship of the physician to patients and the society, introduction to clinical skills, physical diagnosis, problem-based learning, addiction medicine, and clinical selectives in practitioner’s offices. Conversely, during the clinical years, a major effort is being made to relate clinical problems to their basic science by emphasizing the pathophysiology of disease and organizing basic science/clinical medicine modules. There has been increasing recognition that the “silo” mentality of departmental thinking of the past few decades, with rigidly compartmentalized knowledge, is not serving well current societal needs. Rather, interdisciplinary thinking/knowledge/application is required to meet today’s challenges. And there is growing appreciation that future advances will emerge through approaches that do not respect disciplinary boundaries and are on the fringes, not the center, of traditional disciplines. To this end, great effort has been made toward interdisciplinary course integration. For example, the biochemistry of lipoproteins is followed by the pathological implications of dyslipidemias, and that by nutritional and pharmacological approaches to management. The goal is a curriculum that is case-based, limits unplanned redundancy, and weaves strands of basic, clinical, and social sciences through all courses, thus simulating the way that health and illness are conceptualized. Lectures had been the dominant mode of instruction--a “parade of stars” that by wide accounts is the worst instrument for learning. Major emphasis is now being placed to limit lectures and replace them with small-group sessions that emphasize interaction between instructors and students. And problem-based learning has been at the heart of our curriculum; students work in small groups on clinical cases under the guidance of a facilitator in ways that emphasize framing of questions, development of research and critical reasoning skills, integration of basic and clinical concepts, and group interaction and communication. Traditionally, the in-patient service of large academic medical centers had been the home of clinical instruction but this practice ignores the fact that only a tiny fraction of patients seeking medical care are actually hospitalized in teaching institutions. As estimated in a recent article on the ecology of medical care in the US, of 1000 community persons, on average each month, 800 report symptoms, 327 consider seeking medical care, 217 visit a physician’s office, 65 visit a complementary or alternative medical care provider, 21 visit a hospital outpatient clinic, 14 receive home health care, 13 visit an emergency department, 8 are hospitalized, and less that 1 (actually 0.7) is hospitalized in an academic medical center. Thus, increased emphasis has been placed on clinical rotations in ambulatory clinics and physicians offices to expose students to the actual sites of delivery of care and many of the issues related to the management of chronic diseases. There had been little instruction on disease prevention, nutrition, geriatrics, and evidence-based medicine, but the new curriculum strives to address all these topics from various angles. Finally, the current direction is toward limiting formal instruction over the first two years of the curriculum to the morning period and reserving most of the afternoons for independent study. This direction discourages information overload and emphasizes imparting on the students the skills and attitudes for a career of self-directed and life-long learning. Students should view completion of their medical school years as the beginning, not the end, of their medical education. Are there barriers to curriculum reform? You bet there are. Among them, various degrees of faculty apathy and generic resistance to change, resistance to relinquishing departmental “ownership” of courses, limited number of faculty, financial constraints, and disparate quality of ambulatory experience. Nonetheless, if there is strong institutional will and support, curriculum reform can be achieved. Change should be generated by those most immediately involved in education, i.e., faculty and students, under the guidance of a dynamic Office of Educational Affairs and an energetic Curriculum Committee. Curriculum review must be ongoing and systematic. And mutual respect, honesty, teamwork, and trust among all stakeholders are essential for effective change, whether radical or incremental. Physicians have long practiced alternative career options while continuing or not their role as caregivers. Some become public health officials, hospital administrators, international consultants on health issues, or biomedical researchers. To upgrade their credentials for such careers, many physicians have sought to earn additional degrees. Physicians with combined degrees are essentially “translators” between medicine and other disciplines that deal with health-related issues, thereby creating bridges between disciplines. In response to the interest and societal need for such “translators”, many schools have developed combined degree programs that allow students to earn a medical degree and a second advanced degree, usually concurrently. Tufts has taken a leadership role in this direction and has created the largest cadre of combined degree programs. The carefully integrated MD/Master in Public Health Program allows the medical student to obtain within the regular 4-yr span training on health promotion and disease prevention from a population-based perspective. Even more careful integration was necessary to create the 4-yr MD/MBA in Health Management Program, which provides students with a foundation in business problem-solving and health-care management. The 5-yr MD/Master in Law and Diplomacy Program in collaboration with Tufts Fletcher School of Law and Diplomacy prepares physicians to relate principles of international law, politics, economics, and business to health care throughout the world. The MD/Master in Bioengineering Program in collaboration with Tufts School of Engineering prepares students with a bachelor’s degree in Engineering to become physicians with expertise in the application of advanced technology to medicine. Seven or eight years are required for the combined MD/PhD Program in one of nine biomedical fields preparing physicians for a rigorous career in biomedical research. Fully 20% of the Tufts medical students are now enrolled in a combined degree program. I should emphasize that medical school requirements are not compromised in any of the combined degree programs. Our goal is that the students become “physicians first and foremost” even as they gain additional knowledge and skills in another discipline. Maintaining a medical curriculum up to date is an enormous challenge to faculty. Health sciences information is increasing at a dizzying pace. Information technology is also growing at a tremendous speed. Medical students of today--the Nintendo generation--command sophisticated computer skills and expect advanced computer services, web access, and online resources. Faculty overload and widely dispersed teaching sites contribute to the challenge of providing current and appropriately filtered medical information. In response to these challenges, many schools have developed on-line curriculum resources. Tufts has developed a uniquely powerful such instrument, the Tufts Health Sciences Data Base, that is changing the way our teachers teach and our students learn. Its integration, scope, flexibility, expandability, adaptability, and resiliency are unparalleled in medical education and were recognized two years ago by the CIO Magazine Enterprise Value Award, a national award usually reserved for high tech innovations created by major corporations. Offering access to students and faculty essentially anywhere, anytime, it combines the capabilities of a digital library, a course delivery system, and an administrative curriculum management system. The large majority of the first two-year courses are now available on line, including syllabi, video clips, lecture slides with audio, self-assessment quizzes, previous exams, full bibliographic search engine, and other elements. Students appreciate the easy access to course materials, efficiency, availability of zoomable images similar to a microscope; the ability to integrate and juxtapose materials--text, video, audio--on the same screen from a number of courses; and the ability to personally annotate any text or image viewed on line and easy storage and retrieval of these notes on demand. Thus, the Data Base is transforming the way our faculty teach, integrating methods, facilitating the exchange of key educational resources, promoting collaboration, and advancing interaction with students. It transforms the way our students learn providing efficiency, prompt availability to review, and enhancing their skills for life-long learning. It provides quality control and subjects to scrutiny course materials. It leverages limited time and resources. And there is increasing support to make the HSDB infrastructure a model for a national/international instrument for medical education. Advancing the quality of medical education depends on accountability, and accountability requires a rigorous evaluation system. The system must incorporate multiple avenues for obtaining student and faculty input on the quality of the training experience and just as many ways of responding to feedback through dissemination of critical analysis and constructive action. At Tufts, we require every student to provide an online evaluation of every course and clerkship through the Tufts Health Sciences Database; compliance is virtually 100% but more impressive are the thoughtful and constructive comments. These evaluations, reviewed for immediate action, are also used in the more formal, in-depth peer review performed every three years on all required courses and clerkships at the level of the Curriculum Committee. The 40-member Curriculum Committee that includes 8 student members functions as the regulatory body but also a sounding board and a source for new ideas and projects for curriculum reform. Feedback loops in each part of the evaluation system ensure that all stakeholders remain informed and are provided time to respond. As a result of this evaluation process, change occurs that can involve any element of the curriculum. Between these in-depth reviews, faculty evaluators present annual progress reports to the Curriculum Committee noting what corrective actions have been taken, how have they fared, and what remains to be done. One of the greatest benefits of this evaluation system is that it encourages collaboration between faculty and students. Most important, accountability reflects academic responsibility--the price we must pay for academic freedom. Society expects medical schools to produce physicians who are well-trained in the biology of disease and its diagnosis and management, but also who share the noblest aspirations of the medical profession, the fabric of humanism, and the preparedness to serve as compassionate healers. The efforts of medical schools to teach students the skills of forging this uniquely intimate partnership--that of the patient-doctor relationship--are occurring against the backdrop of a widely perceived erosion of professional values. The emergence of for-profit hospitals; the increasingly corporate culture of the non-profit academic medical center; the pervasive odor of money; and growing concerns about full disclosure, conflict of interest, and the interface between business and medicine, all function to erode professional values. It is against this backdrop that medical schools must work to reaffirm a culture of professionalism. At Tufts, we have made an effort to introduce professionalism into every aspect of the curriculum and medical school life. For example, weeks after enrollment, a so-called “White Coat Ceremony” is conducted for the entering class in which students receive their first white coats from faculty advisors. It is a symbolism of the early indoctrination of students into the medical profession, a ceremony emphasizing the Hippocratic oath, and the core values of doctoring. Later on, during a first semester course exploring the physician’s relationship with patients, society, and the health care system, students wrestle with clinical ethical dilemmas and compose abbreviated, personal Hippocratic oaths. These oaths are printed, mounted, and returned to the students in a brief ceremony on the first day of their physical diagnosis course in year two, emphasizing the sacred patient-doctor relationship. These ceremonies are mutually reinforcing and according to students, affirm the values that led them to pursue careers in medicine. Several faculty members have assumed the responsibility to meet with students in small groups and lead discussions on professional values and the school’s honor code, and how professionalism can be promoted and assessed. The evaluation system for our curriculum that I outlined earlier, has been designed to reinforce professionalism. Students are encouraged to comment freely but respectfully when evaluating their educational experiences and faculty, and are given feedback on the quality and appropriateness of their remarks. Students and faculty committees, particularly those dealing with conflict resolution, are established with ground rules for mutual respect, thereby modeling the behavior expected of health care professionals. The Sharewood Project, an inner-city free clinic for the indigent population fully run and administered by students under faculty-advisors supervision, reaffirms in practice the ethical values of medicine. We recognize, however, that promotion of a culture of professionalism depends critically on how the students perceive the behavior and values of our faculty, not during ceremonies, lectures, and small-group discussions, but at the working site, during the everyday interaction with each other and their patients. It is this part that remains a daunting, formidable challenge. More than ever today, it is imperative to transmit to our students the concept that physicians can have only one master--their patients. More than ever today, it is essential that we teach our students the sharp distinction between "treating the disease" and "caring for the patient". More than ever today, we must impress on our students that Francis W. Peabody's famous aphorism still holds true: "the secret of the care of the patient is in caring for the patient."