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Perspective: Competency-Based Medical Education: A Defense Against the Four Horsemen of the Medical Education Apocalypse

Albanese, Mark MA, PhD; Mejicano, George MEd, MD; Gruppen, Larry MA, PhD

doi: 10.1097/ACM.0b013e31818c6638
Medical Education Reform

Medical education is facing a convergence of challenges that the authors characterize as the four horsemen of the medical education apocalypse: teaching patient shortages, teacher shortages, conflicting systems, and financial problems. Rapidly expanding class sizes and new medical schools are coming online as medical student access to teaching patients is becoming increasingly difficult because of the decreasing length and increasing intensity of hospital stays, concerns about patient safety, patients who are stressed for time, teaching physician shortages and needs for increasing productivity from those who remain, and increasing emphasis on translational research. Further, medical education is facing reductions in funding from all sources, just as it is mounting its first major expansion in 40 years. The authors contend that medical education is on the verge of crisis and that little outside assistance is forthcoming. If medical education is to avoid a catastrophic decline, it will need to take steps to reinvent itself and make optimum use of all available resources. Curriculum materials developed nationally, increased reliance on simulation and standardized patient experiences, and adoption of quality-control methods such as competency-based education are suggested as ways to keep medical education vital in an environment that is increasingly preoccupied with fending off the four horsemen. The authors conclude with a call for a national dialogue about how the medical education community can address the problems represented by the four horsemen, and they offer some potential ways to maintain the vitality of medical education in the face of such overwhelming problems.

Dr. Albanese is professor, Departments of Population Health Sciences and Educational Leadership and Policy Analysis, University of Wisconsin School of Medicine and Public Health and School of Education, Madison, Wisconsin.

Dr. Mejicano is associate dean for continuing and professional education and interim division chair, Infectious Diseases, Department of Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Dr. Gruppen is Josiah Macy, Jr., Professor of Medical Education, and chair, Department of Medical Education, University of Michigan Medical School, Ann Arbor, Michigan.

Correspondence should be addressed to Dr. Albanese, University of Wisconsin–Madison, School of Medicine and Public Health, 10 Walnut Street, 1007C WARF, Madison, WI 53726-2397; telephone: (608) 263-4714; fax: (608) 263-2820; e-mail: (

© 2008 Association of American Medical Colleges