In my April editorial, I discussed articles appearing in that month's issue of the journal that described community-based educational experiences. My goal was to emphasize the importance of exposing students and residents to the concept of civic professionalism and better preparing them to fulfill their professional responsibilities to the communities where they will live and practice.
In this editorial, I continue that discussion by arguing that if physicians are to meet their professional responsibilities to their communities, they must better understand the various ways that health care is organized, financed, and delivered in this country, and be more aware of the critical health policy issues facing legislators and other policymakers. Although I made this point in my February 2004 editorial,1 it deserves to be repeated.
One of the research reports appearing in this month's journal provides insight into the current state of teaching this material in U.S. medical schools. Specifically, Agrawal and his colleagues report a survey of a small sample of first-year and fourth-year medical students to assess their knowledge of central issues in this country's health care system. Their findings are not very surprising. Many of the students had significant gaps in their understanding of the U.S health care system. However, they felt that an understanding of health policy issues is important for physicians, and believed that such issues did not receive sufficient attention in the medical school curriculum.
These findings generally confirm those of other studies that have documented deficiencies in the understanding students and residents have about an array of health policy issues. And they are certainly in keeping with the results of an informal survey the Association of American Medical Colleges (AAMC) conducted to gain insight into how adequately health policy issues are presented in the medical school curriculum. That survey indicated that while some schools have attempted to provide some relevant content at various points in their curricula, a surprising number admit to having no formal approach to teaching students about health policy issues, and those that do generally offer the material during the second year.
Schools face two major challenges to providing meaningful instruction about the country's health care system and the health policy issues now facing legislators and others at both the state and federal levels: Who will teach the material, and how will it be integrated into the curriculum? In their article in this month's issue, Quraishi and colleagues describe how this challenge is currently being addressed at one medical school. Note that the educational program they describe is an elective for first- and second-year medical students, and that guest lecturers provide most of the formal didactic presentations. In my experience, this is not an unusual situation. The authors discuss the challenges they face in attempting to integrate the course content into the curriculum so that all students would have an opportunity to benefit.
So what can be done to improve the teaching of this type of material in medical schools?
First and foremost, the leaders of our medical schools must make a commitment to ensure that their students receive appropriate exposure to the organization and financing of the U.S. health care system and to the key health policy issues the country faces. If the leaders of an institution are not committed to this goal, it is highly unlikely that it will be implemented, for the simple reason that additional institutional resources will be needed to make it occur. Why is this? Because most medical schools are not organized in ways that provide an academic home for an individual or individuals who are qualified to teach the material and interested in doing so. Given the traditional departmental organization of medical schools, which department is likely to commit resources to support faculty interested in health policy? It is true that there are schools that have special health policy programs (centers or institutes) or that have departments that view health policy analysis as a legitimate part of their academic mission, but these are few and far between. As a result, the typical medical school will have to reach out to other academic units of the university to supply faculty who are willing to teach the material to medical students, and the school will have to provide support for those faculty.
Second, the faculty and staff most directly responsible for the management of the medical school curriculum (the associate dean and members of the curriculum committee) must be willing to see to it that appropriate material is integrated into the curriculum, and integrated in a way that will make its meaning most apparent to students. As a general rule, this particular goal is not likely to be achieved by limiting exposure to the material to selected periods of time in the students’ second year. Medical students are always striving to understand the relevance of the material being presented to them. In that regard, doesn't it make more sense to integrate the material into the last two years of the curriculum, when students are actually involved in patient care? For example, aren't students more likely to gain an understanding of the Medicaid and Medicare programs if they learn the provisions of those programs while being involved in the care of program beneficiaries? I believe, based on my own experience of having taught the material in several medical schools, that students are much more likely to gain an appreciation of a program's benefits when they see how those benefits apply to actual patients they are helping to care for. But even more important, students will see the limits of those benefits and how those limits affect the lives of those who depend on the programs for access to needed care.
So let me repeat what I said in my February 2004 editorial: I hope deans and faculties will seriously consider how they might best expose students to the important health policy issues facing the country, and then take steps to see that appropriate material is integrated into their schools’ curricula. I similarly challenge those responsible for the design and conduct of graduate medical education programs. If we, as medical educators, really believe in the principles of professionalism embedded in the Physician Charter2 I discussed last month, then we must do a much better job in seeing to it that medical students and residents understand and value those principles.
Michael E. Whitcomb, MD
1 Whitcomb ME. Future doctors should learn about our country's health care system. Acad Med. 2004;79:105–6.
2 ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine Foundation. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243–6.