As the medical school class of 2014 starts its journey this fall, its students face a far different landscape than their 2004 counterparts. They face global challenges in their own backyard, underserved populations, health care reform and rapidly changing technology and professional roles.
Yet these students benefit from the scrutiny and wisdom of some of the nation’s leading medical educators in shaping their training to be more relevant for the ever-evolving landscape.
“It’s difficult to design a learning environment to prepare people for a lifetime of practice that will have continuous change,” said David Irby, PhD, vice dean for Education in the UCSF School of Medicine. “We can’t prepare physicians to enter practice in 2010, because most will continue to train for about ten more years. Once they enter the profession, over the next three to four decades, it will change even more rapidly.”
Earlier this year, Irby and two colleagues – Molly Cooke, MD, a professor of medicine and director of the Haile T. Debas Academy of Medical Educators at UCSF, and Assistant Professor Bridget O’Brien, PhD – published the results of their five-year study of medical education in the United States.
They share their lessons learned and recommendations for the future in “Educating Physicians: A Call for Reform of Medical School and Residency,” which calls for a new vision in medical education to attain the next level of excellence.
“There is a need to motivate continuous learning and improvement across the whole arc of medical training,” the authors wrote. “Those who teach medical students and residents must choose whether to continue in the direction established over a hundred years ago or take a fundamentally different course, guided by contemporary innovation and new understanding about how people learn.”
A Century of Knowledge
The report, which was sponsored by the Carnegie Foundation for the Advancement of Teaching, comes exactly a century after Carnegie published the groundbreaking evaluation of medical education by Abraham Flexner in 1910 that created the medical education system as we know it.
The Flexner report was among the first to call for a university-based medical education, with two years of basic sciences and two years of clinical experience in a teaching hospital. It advocated for rigorous training based on scientific inquiry and discovery. That, in turn, helped focus the field on both scientific excellence and consistency in medical training.
Over time, the accretion of new material also has led to a medical educational program that is inflexible, excessively long and not learner-centered, with poor connections between formal knowledge and experiential learning, and inadequate attention to patient populations, health care delivery and effectiveness, according to the new report.
“It standardized what physicians know, but not what they’re able to accomplish for patients,” Cooke said.
That’s no longer good enough.
“Medical education needs to substantially broaden its focus from what the learners know about diagnosing diseases to helping them become more effective with making patients healthier,” she said. “We need to focus people’s attention not on what they know, but on how patients are doing.”
For the Carnegie report, the authors looked at the best practices and innovations across the nation’s 130 medical schools, while applying the latest insights on how we learn.
The result is a set of four recommendations for overhauling medical school:
- Standardize learning outcomes – rather than time spent in training – and individualize the learning process to recognize different learning styles.
- Integrate formal knowledge and clinical experience, while training physicians for their varied roles beyond the clinic.
- Cultivate habits of inquiry and improvement, such that students are motivated and committed to continuously improving the quality of care.
- Focus on professionalism, building on clinical competence, communication and interpersonal skills, and ethical and legal understanding, alongside accountability, humanism and altruism.
The Heart of Medicine
Irby, who is receiving the 2010 Karolinska Institutet Prize for Research in Medical Education this fall, has dedicated his career to advancing the understanding of clinical teaching, sharing best practices through faculty development and publications, and continuously improving medical curricula. He is being recognized by Karolinska in particular for his finding that medical expertise is necessary, yet insufficient, to become a great teacher in medicine.
“The practice of medicine is a moral education at its heart,” Irby said. “It’s doing the right thing for patients, with reliability, dependability, and altruism, and looking at what we aspire to as a profession and imparting that to the next generation. That’s an under-represented part of the curriculum.”
Along the way, the team had some surprises, including the strength of surgical education in this country. With a strong focus on technical competence and more time spent with the students, professors of surgery were among the best able to assess their students’ skill level and adjust their training accordingly.
“I took this as a challenge to us,” Cooke said. “We need to be equally good at knowing what to look for to measure competence in other areas. Right now, we treat that strictly on a time basis. We treat people with 12 months of experience all the same, but it defies logic that they would all be the same.”
Bringing it Home
They also learned some lessons to apply at UCSF. Among those were the efforts at University of South Dakota, Harvard University and other institutions to create longitudinal, integrated clerkships.
“One of the difficulties of clinical education is the discontinuity in the practice setting,” Irby said, with a revolving door of on-call faculty, residents and student rotations. “No one knows anybody for very long. You need longitudinal mentoring and guidance so you constantly know where your learners are and can guide them along their career.”
Those examples informed their national recommendations, but also had an impact at home, leading to structured clerkship programs at Parnassus Heights, San Francisco General Hospital, the San Francisco Veterans Affairs Medical Center and UCSF Fresno. Those include the Parnassus Integrated Student Clinical Experiences (PISCES), an innovative partnership among medical students, patients and faculty to train outstanding, patient-centered doctors. PISCES includes 16 students each year, pairing them directly with one faculty member in each of seven specialties to offer an in-depth perspective on hands-on care, as well as more individualized training.
“This clerkship model addresses our study’s major concerns about discontinuity,” said O’Brien, who is conducting a national study of such programs.
Building on the study’s recommendations, the UCSF curriculum committee has approved several changes, according to Helen Loeser, MD, associate dean for curricular affairs. Those include plans for competencies, milestones and portfolios; better connection of clinical experience and formal knowledge; greater individualization of the learning process; and continuing emphasis upon inquiry and improvement.
But back “at home” other issues are being addressed, as well. Among those is the need under health care reform for physicians to collaborate not only among those in their own profession, but also with other health care providers.
Being a physician today means being part of a team of health care professionals working in complex systems, explained Sam Hawgood, MBBS, dean of the UCSF School of Medicine and vice chancellor for medical affairs.
“Our students are being trained to learn and work collaboratively with peers and faculty from all schools,” Hawgood said. “The model of the doctor as a one-on-one provider of care no longer drives our curriculum.”
That will be crucial under health care reform, as clinical pharmacists, advanced-level nurses, dentists, and other health care providers take on a more central role in patient care. In response, UCSF is expanding its educational breadth and working to integrate interprofessional training, foster collaborations and coordinate academic calendars to cross-train all of its students.
“We have a long history at UCSF of welcoming our students as equal partners,” Hawgood said. “We’ll be looking to them for ideas on how we can make our new systems work, how we can make innovations real. Students are an integral part of our culture, and as they learn from us, we learn from them.”
Read more about the report on the Carnegie Foundation website.
Irby to Receive International Prize in Medical Education Research
UCSF Today, September 8, 2010
Fostering an Academic Culture at the Forefront of Health Sciences Education
Chancellor’s website, July 16, 2010
UCSF Works to Expand Interprofessional Education
UCSF Today, April 26, 2007