Medical Education:
Lighting a Fire
Learning Objectives
At the completion of this session, the
participant will be able to
• Describe the history of Medical Education
• List the challenges and gaps in Medical
Education
• Identify the components of the “Ideal
Medical Education System”
The ultimate goal of medical
education is to ensure that students
can be transformed into the most
effective deliverers of patient care
that is possible…
Medical education seems to be in a
perpetual state of unrest. From the early
1900s to the present, more than a score of
reports….have criticized medical education
for emphasizing scientific knowledge over
biologic understanding, clinical reasoning,
practical skill, and the development of
character, compassion, and integrity.
Cooke, Irby, Sullivan, and Ludmerer, NEJM, 2006
History of Medical Education
The Flexner Report (1906)
“new” vision of medical education
•
Medical schools within the academic frame
of the university
•
Faculty work in laboratories in proximity to
modern, academic clinical teaching facilities
•
Faculty to provide students with a thorough
grounding in the science and practice of
medicine in a rigorous environment of
scholarship and discovery
The Flexner Report
• Students must learn by doing, must
develop habits of scientific thinking and
critical inquiry, and must be able to apply
the scientific method to clinical problem
solving. [ “competency”]
• Tough medical school admission
requirements
“INTELLECTUAL
•Physics
•Chemistry
•Biology
FOUNDATION
OF MODERN
MEDICINE.”
Calls for Revision and
Reform of Medical Education
Rappleye Report (1932)
Medical Education. Final Report
of the Commission on Medical Education (AAMC)
• Develop learning objectives
• Institutional and clinical clerkship
• Go beyond knowledge acquisition and include
“behavioral” elements and to emphasize
fundamental clinical skills
• Relate student performance assessment to the
stated learning objectives
• Create sound habits and methods of
independent study to equip students for
lifelong learning and reflection
GPEP: General Professional Education of the
Physician and College Preparation for
Medicine (AAMC) 1984
• Charge
• Develop strategies for improving the
general professional education of the
physician
• Agreement on the knowledge and skills
that all physicians should possess to
practice medicine in the 21st century
• Debate the personal qualities, values and
attitudes that those pursuing careers in
medicine should possess
GPEP: General Professional Education of the
Physician and College Preparation for
Medicine (AAMC) 1984
• Final Report
• All physicians should possess a common
foundation of knowledge, skills, attitudes
and values
• Recommended that each medical school
faculty specify the attributes appropriate
for students graduating from its school
• Adopt learning objectives for the
curriculum consistent with those
attributes
Assessing Change in Medical
Education: The Road to
Implementation
(ACME-TRI Report, AAMC 1992)
• Charge
• Determine how schools responded to the
GPEP Panel recommendations
• Findings
• Few medical schools had delineated a
comprehensive set of learning objectives for
.
the medical
student education program
Priorities of Medical Schools
the Past 50 years
Priorities of Medical Schools
• Increase in clinical practice
• Increase in grants and research
• Decrease emphasis on teaching and
education
Changes in Organization and
Orientation of the Basic Sciences
New Basic Science Departments
U.S. Medical Schools, 1980-2004
•
•
•
•
•
•
•
•
Neuroscience
Genetics
Immunology
Biomedical Engineering
Community and Public Health Sciences
Cancer Biology
Comparative Medicine
Health Evaluation Sciences
• Humanities
Settings for Medical
Education Have Changed
Primarily situated in a university
health care delivery system
(where faculty are expected to teach
from the hospital wards)
“New Curricula”
Constantly Being Designed
New Curricula for Medical
Student Education (2000-2007)
• Biomedical Ethics
• Human Genetics
• Evidence Based
Medicine
• Disease Prevention
• Health Promotion
•
•
•
•
Population Health
Communication Skills
Cultural Sensitivity
The Business of
Medicine
• Patient-Centered/
Family-Centered Care
If the “tattered social contract between
medicine and society is to be repaired,”
we believe it is incumbent on the
profession to develop and field test
new models of medical education.
The reform of medical education
will surely benefit from
broad-based debate.
NEJM: Series on Medical Education 2006
Malcolm Cox, MD, and David M. Irby, PhD
Quest for the
Ideal Medical System
Ideal System

Create Diverse Workforce
 Attract
and successfully educate a diverse
group of learners

Produce practitioners that provide high
quality health care
Humanistic approach to medicine
 Patient-centered approach to medical care


Ensure that doctors provide culturally
sensitive and appropriate care, and listen
and communicate effectively
Ideal System
• Ensure learners’ demonstrate they have
acquired the learning objectives set forth
• Conduct rigorous assessment of learners’
abilities
• formative assessment
• summative assessment
• Base licensure and specialty certification on
physicians’ demonstrated ability to
provide high quality medical care to
patients
CHALLENGES IN MEDICAL
EDUCATION
• Ensuring the adequacy of the overall
physician workforce
• Keeping the distribution of generalist and
specialist physicians fairly even
• Securing a uniform distribution of
physicians in the country
• Increasing the racial and ethnic diversity
among medical students
• Aligning the curriculum with the needs
and expectations of the public
Challenges
…”major challenge facing medical
education in the United States is the
erosion of the clinical environment,
the loss of clinical revenues and all its
attendant consequences, including
pressures for increased faculty
productivity in an environment that is
increasingly managed”
Philip O Ozuah
BMC Medical Education 2002
Initiative to
Transform Medical
Education (ITME)
The Problem
• There is a critical need to improve
the quality of the physician training
process in order to improve patient
safety and care.
• To improve patient safety and care,
medical education must be realigned
with recent changes in the health care
system.
Phase 1: Identification of
strengths and gaps in
physician preparation
Strengths in physician
preparation
• Physicians are knowledgeable and
technically proficient
• especially for acute disease, but less so
for chronic conditions
• Physicians wish to do what is best
for their patients
• strong commitment by the physician to
the care of his/her individual patients
• Patients respect physicians as
credible sources of information
Gaps in physician
preparation
Physicians are NOT currently prepared to:
•
•
•
•
•
•
•
Self-evaluate
Assess the quality of their own practices
Be social advocates
Provide effective patient care
Be “team players”
Communicate effectively
Convey uncertainty to patients
Physicians are NOT currently able to:
• Make mid-career changes (specialty/practice)
Phase 2: Solutions to
address the 11 gaps in the
preparation of physicians
ITME: Recommendations
for change in the medical
education system
Recommendations
• Change admission process
• Applicant qualities:
• Lifelong learning
• Team orientation
• Service orientation
• Course requirements:
• Humanities
• Social Sciences
• Economics
• Create alternatives to the current sequence
of the medical education continuum
Recommendations
New Curriculum
• Develop integrated curriculum
• Humanism, Ethics, Professionalism
• Basic and Clinical Sciences
• Develop core competencies
• Teamwork and Communication
• Information acquisition
• Self-assessment
• Professionalism
• Community service
Recommendations
• Introduce new methods of evaluation
appropriate to assess the core
competencies
• Ensure that faculty are prepared to teach
• Ensure tangible values and rewards for
participation in education
• Support enhanced funding for medical
education research, planning and delivery
across the continuum
What’s Missing from the
Ideal Medical System?
JAMA 2004
Why Don’t
Professors Profess?
• Lack of adequate reimbursement for
teaching
• Requirements for the attending
physician to personally perform patient
care services
• Malpractice liability involved in the care
clinical faculty provide
• Decreased likelihood of promotion
Tribulations and Rewards of Academic
Medicine — Where Does Teaching Fit?
Jerome P. Kassirer, MD NEJM 334:184-185, 1996
“….teaching has been the Cinderella of
academic medicine. As a stepchild, it has
garnered little respect in comparison with
that accorded its sister tasks of research
and patient care. “
Where Does Teaching Fit?
NEJM 334:184-185, 1996
• Most faculty members continue to be
enthusiastic about teaching
• Many have taken courses designed to
improve their teaching skills
• New curriculums stimulate excitement
• New courses in problem-solving and
decision-making promise to better
prepare students
Where Does Teaching Fit?
Rewards of Academic Medicine
• Prestige of professorial appointments
• Opportunity to interact with bright students,
house officers, and colleagues
• Exposure to the most challenging clinical
problems
• Involvement in important research
• Recognition for one’s expertise, scientific
achievements and leadership abilities
Our challenge:
Light a fire in our colleagues
… what it takes for professors to
be motivated to profess. Our members (i.e.,
YOU) must pass on to the next generation the
organized body of Ob-Gyn knowledge if the
profession is to be preserved. Hence, for the
profession to survive and flourish, the
professors of Ob-Gyn must profess!
How to light a fire?
One way is to become
Gung Ho !!!!!
“Gung Ho” is:
1. Chinese for “working together”
2. Slogan of WWII marine raider division
3. Term describing boundless
enthusiasm, energy and dedication
applied to a task
4. Recent business book by Blanchard
and Bowles
5. All the above
Gung Ho!
Three Principles
Spirit of the Squirrel
Way of the Beaver
Gift of the Goose
Gung Ho by Blanchard and Bowles
Spirit of the Squirrel
Worthwhile Work
• Knowing we make the world a better
place
• Everyone works toward a shared goal
• Values guide all plans, decisions and
actions
Way of the Beaver
In control of achieving
the goal
• Playing field with clearly marked
territory
• Thoughts, feelings, needs and dreams
are respected, listened to and acted
upon
• Able, but challenged
Gift of the Goose
Cheering each other on
• Active or passive congratulations must
be TRUE
• Timely
• Responsive
• Unconditional
• Enthusiastic
• No score, no game and cheer the
progress
Are we (you) Gung Ho?
Can you take that spirit back
to your colleagues?
… education is “not the
filling of a pail, but the
lighting of a fire.”
William Butler Yeats