WHITCOMB, MICHAEL E. MD
In the early 1980s, the Association of American Medical Colleges embarked on a three-year project designed to develop recommendations for improving the quality of the undergraduate medical education programs provided by the nation's medical schools.1 The Association believed that such a project was indicated, given that the purpose of undergraduate medical education had shifted during the previous decades from one of educating general practitioners to one of providing a general professional education for future specialists.
Those responsible at the time for the design and conduct of the undergraduate medical education programs offered by U.S. medical schools seemed to believe that the general professional education of the physician could be completed in less than four years. The most telling evidence of this was their willingness to allow the fourth year of the medical school curriculum to become an unstructured educational experience consisting almost entirely of elective rotations selected by the students, primarily for the purpose of acquiring residencies in the specialties of their choice. In a provocative paper published in Health Affairs in the late 1980s, Robert Ebert and Eli Ginzburg proposed that the fourth year of medical school be eliminated because the educational experience did not contribute in a coherent way to the general professional education of medical students.
Today, such a proposal would be unthinkable. Instead, the medical education community is on the brink of facing a serious challenge: Can the general professional education of the physician be completed in only four years? How is it possible that circumstances could have changed so much in such a short period of time? A review of the content of recent issues of this journal, including the current issue, provides some insight into the answer to that question.
This month's journal contains a set of papers that address various issues related to education in complementary and alternative medicine (CAM), and other papers devoted to educational programs in a closely-related topic, integrative medicine. This is the fourth thematic set published this year that has focused on an important contemporary issue in medicine that most medical educators believe must be more adequately represented in the medical school curriculum. The topics addressed in those four theme issues (CAM and integrative medicine, cultural competence, end-of-life care, and professionalism) are only a few of the many new topics that medical schools are being challenged to incorporate into their educational programs. Others include medical informatics, population health, quality of care (including medical errors), spirituality, genetics—and the list goes on.
I am sure that most in the medical education community agree that the general professional education of the physician should include adequate coverage of all these topics. In fact, medical school deans and faculties are making efforts to see that this occurs. The incredible number of changes occurring in the curricula of medical schools is evidence of this.
But a note of concern is in order here. Based on my own and others' observations, I believe that many of the curricular changes that have been implemented in recent years provide only token amounts of content related to the topics of interest. I suspect that a systematic analysis of the newly added curriculum content related to any one of the topics listed above would reveal that important elements are not being covered. Consider, for example, the recent paper that documented key deficiencies in the end-of-life care education provided by medical schools in New York.2
The observation that medical schools are having a difficult time providing adequate coverage of these new topics is particularly disconcerting, given that the number of them that will have to be incorporated into the curriculum will certainly continue to increase over time. Because of continued advances in scientific knowledge, the development of new technologies, changes in medical practice patterns, and changes in society's expectations of medicine, such an increase is inevitable.
Some may argue that there is really nothing new about this, because adding new content to the curriculum has always been a challenge, and yet deans and faculties have been successful throughout the years in introducing new topics as they became relevant to the practice of medicine. In the past few decades, schools have added courses in, for example, biomedical ethics and communication skills, have fundamentally reorganized courses in the biomedical sciences to incorporate material on cellular and molecular biology, and have introduced clerkships in family medicine and emergency medicine.
However, because of the sheer number of new topics that need to be incorporated into the general professional education of physicians, and the rapidity with which these topics are appearing, the current challenge is far greater than those in the past. Therefore, the medical education community must face the possibility that the density of the curriculum will not permit any new topics to be introduced in ways that allow them to be covered adequately. I don't think that time is here yet—think of all of the elective time that remains in the fourth year of the curriculum. But the fact that an increasing number of medical schools are beginning to eliminate some of that elective time suggests that the time is rapidly approaching. So what is the medical education community to do?
Needless to say, ignoring the new topics as they arise, or providing only token coverage of them in the curriculum, is not an acceptable solution. The medical education community has a responsibility to provide all new physicians with high-quality general professional education, and it must take that responsibility seriously. One way to ensure that the new topics are adequately covered is to extend the length of the medical school curriculum to five years. The consequences of extending the length of the curriculum are staggering, and it is hard to imagine the development of a consensus that would allow this to happen. Nonetheless, it is worth noting that the medical school curricula in most of the rest of the world are at least five years in length.
There is another option that deserves serious consideration—that is, to restructure the clinical education of medical students so that some of the educational experiences now provided during the course of undergraduate medical education become integrated into the early period of graduate medical education. This action would eliminate some of the redundancy that now occurs in the clinical education of medical students and residents, and would provide time for course work that could adequately cover the new topics. Given the general disconnect that exists between the organization and administration of undergraduate and graduate medical education, major obstacles will have to be overcome to accomplish this.
It is time for the medical education community to begin discussing how to ensure the quality of the general professional education of the physician. Neither of the options outlined above, nor others that may surface over time, can be accomplished easily and within a relatively short period. Accordingly, those discussions must begin sooner rather than later. If our community can not agree on a way to provide all new physicians with high-quality general professional education, the future patients of those new doctors will suffer in the long run. We cannot allow this to happen!
1. Muller S (chairman). Physicians for the twenty-first century: report of the project panel on the general professional education of the physician and college preparation for medicine. J Med Educ. 1984 Nov;59(11 Pt 2).
2. Wood EB, Meekin SA, Fins JJ, Fleishman AR. Enhancing palliative care education in medical school curricula: implementation of the palliative education assessment tool. Acad Med. 2002;77:285–91.