More on Medical Education Reform

Whitcomb, Michael E. MD

From the Editor

The Articles and Research Reports (hereafter “articles”) in this month’s journal document some of the scholarly work being carried out to improve the education of medical students. The articles cover a wide range of topics: preclerkship education, enhancing education in ambulatory care settings, the use of technology to foster learning in clinical settings, the role of faculty in teaching clinical skills, and improving the ways important contemporary issues are presented in the curriculum. Each article provides information that deans and faculty members will find useful as they seek to address specific educational concerns or achieve specific educational objectives in their own institutions.

Five of the articles provide information about one of the most important challenges facing the medical education community—the need to offer more opportunities for medical students and residents to gain experience caring for the kinds of patients they are likely to encounter on entering practice. Given the changes occurring in the demographics of the population, steps must be taken to ensure that students and residents gain adequate experience caring for an ethnically diverse and aging population, many of whom are afflicted with chronic diseases. And because of changes that have occurred in the organization, financing, and delivery of medical care, those experiences will have to take place in ambulatory settings outside the academic medical center, since that is where those patients are currently receiving most of their care. If this does not occur, I fear that new doctors will not be prepared to provide high-quality care on entering practice for the simple reason that they will not have had the experience needed to do so. So what can we learn from the articles?

Satterfield et al. and Pham et al. provide insights into issues that schools must address if they are to better prepare their students to interact with the patient populations of concern. Satterfield and his colleagues describe how they were able to integrate content from the social and behavioral sciences into the preclerkship curriculum at the University of California, San Francisco (UCSF), School of Medicine. Their work is significant, because the social and behavioral sciences inform our understanding of how to care for those vulnerable populations. Pham et al. reveal the magnitude of the challenge medical schools face in attempting to integrate into the curriculum content relevant to the diagnosis and management of patients with chronic diseases. They document that clerkship directors—individuals with key responsibilities for the clinical education of medical students—do not necessarily agree on the importance of topics relevant to the care of patients with chronic diseases, and even those topics they deem important are not necessarily covered during their clerkships. Now, if students do not have opportunities to learn such material during their clinical education experiences, when will they learn it?

Two other articles by UCSF authors (Irby et al. and Aagard et al.) and another article by Carney et al. begin to fill in some of the gaps in our understanding of how to provide effective educational experiences in ambulatory care settings. The UCSF authors describe two facets of a particular approach for improving teaching in ambulatory care settings, an approach that takes into account the constraints those settings place on the time available for student-patient-teacher interaction. Carney et al. document another aspect of teaching in ambulatory settings that must be understood-that the kinds of patients encountered and, thus, the learning that can occur, vary from one setting to another.

As noted above, the authors who contributed to this month’s issue tell us a great deal about the commitment deans and faculties are making to improve the education of medical students at a time when academic medicine’s institutions are facing a number of serious challenges. But as I pointed out last month, reform of graduate medical education (GME) is arguably the greatest challenge the academic medicine community faces. Given that, it is worth noting that only one of the articles appearing this month addresses a topic related to the education of residents.

To appreciate the significance of this observation, one has to understand how the editorial staff creates the theme issues (like this month’s) that we have been publishing for the past few years. Many believe we solicit the articles that appear in those issues, and, in fact, we occasionally do. The October 2003 issue, which is devoted entirely to the teaching of humanities in medicine, is such an example, and others are in the works. But we create most of the theme issues by aggregating spontaneously submitted papers covering related topics. That is the way the current issue was created. The fact that only a single paper in this issue addresses a topic related specifically to the education of residents reflects a trend: we receive relatively few papers addressing issues related to the educational dimensions of GME.

There may be a very simple explanation for this: those who conduct scholarly work on those issues may choose not to publish the results of their efforts in Academic Medicine. Clearly, articles describing efforts to improve educational aspects of GME do appear in other journals, usually journals that are focused on a specific clinical discipline. This is not surprising, since GME programs are specialty oriented. But as I scan the content of the specialty journals, I am not impressed that a large number of GME-education-related articles are appearing in those journals. I think the answer lies elsewhere.

I believe the relative lack of papers addressing GME issues can be explained in part by the lack of an institutional locus for GME-related scholarship within academic medical centers. Over the years, resources supporting faculty efforts to conduct medical education research and other kinds of educational scholarship have been based in medical schools, largely in offices or departments of medical education. I believe this explains why most of the medical education scholarship has focused on issues related to the education of medical students. If I am correct, then an increase in the quantity of GME-related educational scholarship will require the institutions that sponsor GME programs to establish an institutional locus for that work. This could be accomplished quite easily in major academic medical centers simply by ensuring that those interested in conducting scholarly work on GME-related issues are able to gain access to the resources already available in their associated medical schools and are able to participate fully in the evolving medical education academies, centers, and institutes. Since almost two thirds of the medical schools serve as institutional sponsors for GME programs, this approach could have a significant impact in the near term.

I know that many GME program directors and members of the clinical faculty involved in GME are developing and implementing important innovations in residents’ education. Regardless of the strategies that may be adopted to facilitate the conduct of GME-related scholarship, those who are conducting this important work should be aware that we are anxious to publish high-quality articles describing significant innovations in GME. I hope this comment will encourage those conducting GME-related scholarship to prepare manuscripts describing their work and to send them to us for consideration for publication in Academic Medicine. The entire academic medicine community would benefit.

Michael E. Whitcomb, MD


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Academic Medicine
Web-Based Learning in Residents’ Continuity Clinics: A Randomized, Controlled Trial
Cook, DA; Dupras, DM; Thompson, WG; Pankratz, VS
Academic Medicine, 80(1): 90-97.

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