Whitcomb, Michael E. MD
In last month's editorial, I indicated that I had asked the editorial board to consider whether the journal should play a greater role in helping current and future leaders of academic medicine gain a better understanding of some of the important challenges facing academic health centers. Since the board and I agreed that the journal should take on that role, Academic Medicine will begin in the near future to publish more articles (Viewpoints, Articles, and Research Reports) that address those challenges. In the hopes of stimulating potential authors to submit such manuscripts, I will outline in a future editorial some of the important institutional issues that the editorial board and I believe should be addressed in articles appearing in the journal.
To illustrate the kind of issue that deserves attention in the journal, I will comment in this editorial on what I believe to be one of the most important challenges facing medical schools and teaching hospitals.
To begin, I call attention to two major reports on academic health centers (AHCs) that provide an important context for the decision to focus more of the journal's attention on major institutional issues. In 2003, The Commonwealth Fund Task Force on Academic Health Centers issued a report that summarized the results of its work over the previous seven years.1 And in the same year, the Committee on the Roles of Academic Health Centers in the 21st Century—a committee convened by the Institute of Medicine (IOM)—published its own report.2 In weighing the importance of the conclusions and recommendations appearing in the reports, readers should recognize that both panels were composed of leaders in academic medicine—individuals who understand clearly from first-hand experience the nature of the issues being faced by AHCs.
I'm surprised at how little attention the reports seem to have received. I suspect that they were read and discussed within the various organizations that represent either AHCs or the individual institutions that make up AHCs (medical schools, teaching hospitals, and other health professions schools). But I don't recall that any of those organizations, or others that represent various elements of the academic medicine community, issued detailed responses that set forth strategies for how the academic community should respond to the issues the panels identified, or that challenged the reports' conclusions and recommendations.
Because Academic Medicine serves the interests of both medical educators and institutional leaders, I think it is appropriate for the journal to focus attention on these reports, since both place special emphasis on how important it is for AHCs to meet the critical challenges facing their education mission. The IOM Committee was perfectly clear about this:
The committee believes that among all of the AHC roles, education will require the greatest changes in the coming decade …. We regard education as one of the primary mechanisms for initiating a cultural shift toward an emphasis on the needs of patients and populations and a focus on improving health, using the best of science and the best of caring.
And in keeping with this view, The Commonwealth Fund Task Force called on the institutions to assume more direct responsibility for the quality of the educational programs they sponsor.
With that in mind, let me comment on what is clearly one of the major challenges that AHCs must meet successfully if they are to fulfill their education mission—that is, how can medical schools and teaching hospitals ensure in today's health care environment that medical students and residents have opportunities to learn how to provide high-quality medical care?
To appreciate the magnitude of this challenge, readers must recognize that students and residents cannot learn clinical medicine adequately unless they participate on a regular basis and in a developmentally appropriate manner in structured apprenticeship experiences that allow them to observe master clinicians interacting with and providing care to patients. And for those experiences to be most effective, the patients involved must have conditions that are relevant to the learners' stage of education and training. And for that to occur, the encounters must take place in the clinical venues where those patients are currently seeking care.
Now, many of those responsible for the clinical education of medical students recognize that assigning students to teams caring for patients on the inpatient services of major teaching hospitals—the traditional approach that has dominated the teaching of clinical medicine for decades—is no longer the best way to promote students' learning of clinical medicine. The reality is that the kinds of patients admitted to those services, the increasingly specialized nature of the services, the dynamics of care provided on the services, and the composition of the teams to which the students are attached have all changed dramatically in recent decades. These changes have had a major and often negative effect on students' ability to learn clinical medicine. Among other things, students generally do not encounter (in sufficient numbers, or at all) the kinds of patients they should for optimal learning, and their role as members of the inpatient team has become increasingly marginalized. The end result is that students assigned to those teams are no longer having a meaningful apprenticeship experience. Recognizing this, medical schools are assigning an increasing number of their students to clerkship experiences based in other clinical settings where the types and mix of patients are more appropriate for their stage of learning.
The situation is more complex when it comes to the education of residents. First, the changes that have occurred in major teaching hospitals affect some specialties more than others. Second, because residents are further along in their training, they are more likely to benefit educationally from some of the encounters they experience in hospital settings. Nevertheless, residency program directors in some specialties are facing major challenges as they attempt to ensure the quality of their residents' educational experiences. And in turn, the approaches that may have to be adopted to address those challenges present particular difficulties for the medical schools and teaching hospitals that are the institutional sponsors of those programs.
For example, let us consider the current situation facing internal medicine. I think many would agree that internal medicine residencies have been profoundly affected by the changes that have occurred on the inpatient services of major teaching hospitals. Many in the internal medicine community recognize the growing challenge that internists face in caring for patients afflicted with one or more chronic diseases. As a result, they believe that the amount of time internal medicine residents should spend in ambulatory care and other clinical settings should be substantially increased. At issue is not whether there are important lessons to be learned by participating in the care of patients hospitalized on the medicine services of major teaching hospitals. The issue is whether those experiences are adequate to allow residents to learn what an internist, regardless of whether the individual practices general internal medicine or one of the subspecialties, needs to know to provide high-quality care in the 21st century.
My purpose in focusing on internal medicine is not to enter the debate on how internal medicine residency programs should be redesigned—that debate is fully under way within that internal medicine community. Instead, I am using the internal medicine situation to make an important point. A redesign process that results in some residents' being transferred from the inpatient services of teaching hospitals to other clinical venues—an approach recommended by many—will clearly have an effect on the institutions that sponsor the programs. In particular, teaching hospitals—the institutions that finance the programs—will face a daunting challenge in developing acceptable arrangements for continued funding of the programs. And reaching agreement with clinical faculty on how the services that residents now provide on inpatient services will be provided in the future is likely to present an even greater challenge.
Be that as it may, those who hold leadership roles in medical schools and teaching hospitals must meet the challenges noted above if the clinical education of future physicians is to prepare them adequately to provide high-quality care to the patients that seek their help. To do so, they must play an active role in the design of the clinical education experiences that students and residents will need in ambulatory care settings and other clinical care venues. They must be involved in determining how the quality of those educational experiences will be documented, and how they will be managed and financed. In addition, they need to spend time thinking about how the clinical education experiences available on the inpatient services of teaching hospitals might be redesigned to increase their educational value for students and residents. And they will also have to determine how other educational strategies—such as the use of virtual patients and other simulation exercises—can complement what students and residents can learn from their involvement in the care of real patients.
In my view, the readers of Academic Medicine and the academic medicine community at large will benefit if the journal publishes articles that provide insight into how those objectives can be achieved or that describe how some institutions have begun to address these important challenges. Readers should recognize that this is a “Call for Papers” on that topic, something we will frequently do for other institutional topics in the months ahead.
Michael E. Whitcomb, MD
1Envisioning the Future of Academic Health Centers. Final Report of The Commonwealth Fund Task Force on Academic Health Centers. New York: The Commonwealth Fund, 2003.
2Academic Health Centers: Leading Change in the 21st Century. Committee on the Roles of Academic Health Centers in the 21st Century. Washington, DC: Institute of Medicine, 2003.