The U.S. must aggressively reform the way it trains its physicians if they are to competently provide care to meet the mandates, hopes, and expectations of health reform, according to a report from The Carnegie Foundation for the Advancement of Teaching.
"It's generally recognized that our healthcare system is not functioning well," explains one of the report's three authors, Molly Cooke, MD, an HIV specialist at the University of California San Francisco and a member of the National Board of Medical Examiners, which oversees the licensing of American physicians.
One reason, she says, is that this country's new doctors don't get the training they should that teaches them to work with an integrated team.
"If you talk to any of the integrated health systems, you will hear that it takes them a year or two to take a very bright graduate from a very good residency program and convert that person into somebody who is functional in and engaged with the system. Right now, they can't function effectively as a member of a team," Cooke says.
What that means is summed up in the 320 pages of the report, "Educating Physicians: A Call for Reform of Medical School and Residency." The document was compiled on the basis of interviews with 10 faculty members, the dean, the education-related associate deans and the CEO, at each of 14 community, academic, and non-university teaching hospitals in 11 urban and rural states. They included Cambridge Hospital in MA, University of North Dakota, the Mayo Medical School in Rochester MN.
For example, in the report's summary, Cooke and colleagues wrote "clinical education is overly focused on inpatient clinical experience, supervised by clinical faculty who have less and less time to teach and who have ceded much of their teaching responsibilities to residents, and (who are) situated in hospitals with marginal capacity to support their teaching mission."
Also, the authors found "poor connections between formal knowledge and experiential learning and inadequate attention to patient populations, systems of healthcare delivery, and effectiveness."
Students don't have enough opportunity to work with patients over time and "observe the course of illness and recovery," and medical training is "inflexible, excessively long and not learner centered," the report said.
The Association of American Medical Colleges (AAMC) and the American Medical Association (AMA) did not respond immediately yesterday to requests for comment about the report.
The report calls for indirect and direct medical education funding from the Centers for Medicare and Medicaid Services to be realigned to support "infrastructure, innovation, and research in medical education."
"Everyone is doing what they believe to be good and useful, and so people don't appreciate it when it's suggested that perhaps the activity of a particular organization isn't as good and useful as it might be," Cooke says.
Cooke and her UCSF co-authors, David Irby, vice dean for education and Bridget O'Brien, assistant professor in UCSF's Office of Medical Education, recommend seven radical policy changes. They include:
1. Revising pre-medical course requirements and readmission processes to ensure socio-economic and racial-ethnic diversity of medical training.
2. Accrediting, certifying and licensing agencies work together to coordinate standards and resolve jurisdictional conflicts.
3. CEOs of teaching hospitals and directors of residency programs align patient care and clinical education to improve educational programs.
4. Medical school deans and teaching hospital CEOS should provide financial support, mentoring, faculty development, and recognition of academic advancement.
5. Medical school deans and teaching hospital CEOs should make funding for medical education transparent and fair.
6. The AAMC, AMA, Accreditation Council for Graduate Medical Education (ACGME), medical specialty societies, and medical schools advocate for sustained private, federal and state funding commitments to support innovation, infrastructure and research in medical education.
7. The above organizations should collaborate on developing a medical workforce policy to create interventions that address the cost of medical education, length of training and practice viability to ensure the nation has enough of and the right specialties of physicians.
The report also sums up four goals for medical education.
1. In the model of what medical education should be, a blueprint designed by Abraham Flexner 100 years ago, two years of basic science instruction is followed by two years of clinical experience. Today, medical education should instead standardize learning outcomes and general competencies, but provide options for individualizing the learning process for students and residents, such as offering the possibility of fast tracking within and across research, policymaking, education, to reflect "the broad role" played by today's doctors.
2. Students and residents need to understand and prepare to integrate the diverse roles they are expected to play to "educate, advocate, innovate, investigate and manage teams" while they "constantly integrate all aspects of their knowledge, skills and values." To do this, students should be provided with earlier clinical immersion, and residents should be more intensely exposed to the sciences underlying their practices.
3. Medical schools should engage physicians-in-training to be inquisitive, interested in discovery, and systems innovation.
4. More attention should be focused on developing physicians' professional values, communication, and interpersonal skills as well as ethical and legal understanding, aspirational goals, accountability, humanism, and altruism.
The report seems to push for training that empowers physicians to be more advocacy-oriented, "to change the policies that affect the design and delivery of U.S. medical education."
And, the report goes in to some detail about preparing doctors to avoid burnout and depression.