Whitcomb, Michael E. MD
In late 1981, the AAMC charged a blue-ribbon panel (the Panel on the General Professional Education of the Physician and College Preparation for Medicine)
to assess the current approaches to the general professional education of the physician and college preparation for medicine and to develop recommendations and strategies to improve the effectiveness of instructional programs for the promotion of learning and the personal development of each medical student.1
The document they produced in 1984, the “GPEP Report,” was important for a number of reasons. But most important was that it stated clearly that medical schools are responsible for ensuring that all physicians, regardless of their individual specialties, possess certain knowledge and skills and share certain attitudes and values. In this way, the panel made clear that the primary purpose of the educational program leading to the MD degree is not to prepare doctors for the practice of medicine, but rather to provide them a general professional education in medicine.
In one sense, the panel was not breaking new ground. Medical school graduates had recognized for decades prior to the GREP Report that they needed to acquire knowledge and skills not learned in medical school before entering practice. Thus, at the time, all graduates who planned to enter practice were taking at least three additional years of training in the form of internships and residency programs. Despite this, many outside observers, and even some within the academic medicine community, continue even today to equate the medical school experience with preparation for practice. Think of how often one hears individuals concerned about some aspect of medical practice ask why medical schools are not doing a better job educating students about the issues that concern them. Since the MD degree is granted at the time of graduation from medical school, I can understand why some members of the public may be confused about this. But I really don’t understand why this thinking continues to permeate reports issued by committees and task forces composed largely of individuals from the academic medicine community. And why is it that state medical boards continue to grant an unrestricted license for the practice of medicine to graduates of U.S. medical schools after they have completed only one additional year of postgraduate training?
By making it clear that the primary purpose of a medical school’s educational program is to provide students a general professional education, the GPEP Panel hoped to stimulate broad discussions among medical school and college faculties and their disciplinary societies about their philosophies and approaches to medical education and college preparation for medicine. But the fact remains that more than 20 years after the GPEP Report was issued, that objective has not been fully realized. Many medical school faculty members continue to act as though the primary purpose of the medical school experience is to prepare medical students for residency training. Indeed, those responsible for such training often argue that medical schools should do a better job preparing their graduates for their residencies but, sadly, they hardly ever complain about the adequacy of the general professional education schools are providing. While it is important for schools to prepare their students to meet the patient care responsibilities they will assume as residents (the GPEP Panel acknowledged this), it is more important that everyone understand that that is not the primary purpose of the medical school’s educational program. Having visited many medical schools to participate in curriculum reform initiatives, I am convinced that confusion about this among the faculty, particularly the clinical faculty, makes it difficult for schools to implement changes needed in the design and conduct of their educational programs.
So I think the GPEP Panel’s main message deserves to be restated: the purpose of the medical school’s educational program is first and foremost to provide students with a general professional education. Because of the changes that have occurred in recent years in the ways medical care is organized, financed, and delivered—and of particular importance, because of changes in society’s expectations of medicine—it is even more important to emphasize this point now than it was when the GPEP Report was issued. And in keeping with that, it is critical that the medical education community engage in a serious debate about how the program should be designed and conducted to provide a general professional education in medicine.
The two Viewpoint pieces that appear in this month’s journal should help to bring some focus to the debate. In their essay, Cooper and Tauber raise issues about the responsibilities that physicians have when they are providing care to individual patients. I seriously doubt that anyone would take exception to the points they make. Solyom comes at the issue from a very different perspective. His concern is not just that students begin to acquire the knowledge, skills, and attitudes needed to provide high-quality care to individual patients. He is equally concerned about whether the educational program is imbuing students with an understanding that as members of the medical profession they have responsibilities to the society at large, including being advocates for those who do not have equal access to the care they need. Once again, I would be surprised if anyone would take exception to his message. At issue, of course, is how the educational program should be designed and conducted to make certain that students are able to acquire at a foundational level the attributes that these authors believe are essential to being a physician.
In last month’s editorial,2 I stated that the redesign of the clinical education of medical students is one of the most important challenges facing the medical education community. The issues raised in this month’s Viewpoint pieces are embedded in that challenge, because they really have to do with learning what it means to care for patients, both those who have access to medical care and those who do not. Students need to learn about the challenges involved and about their responsibility to meet those challenges when they are involved in clinical education experiences, not simply by being exposed to relevant content during the preclinical phase of the curriculum. The opportunities for students to learn these critically important aspects of what it means to care for patients are readily available, but such learning requires that students be exposed to patients in a wide range of clinical care settings. The challenge that schools face is to ensure that students have opportunities to encounter patients in those settings and that the clinical faculty supervising those encounters address those fundamental and defining aspects of what it means to be a physician.
And what about the other element of the charge made to the GPEP Panel? How should college students be prepared for the study of medicine? Some suggest that a broad liberal arts education, rather than one that is largely focused on science, would better prepare potential medical students for some of the critical challenges they will face as future physicians. But it is worth noting that neither students nor the general public appear to share an appreciation of the value of a liberal arts education. The Association of American Colleges and Universities (AACU) has recently embarked on a campaign to expand the public’s understanding of the value of such an education. Some of the AACU’s concerns are relevant to both college preparation for medicine and the education of medical students: lack of appreciation of the importance of values and ethics, cultural diversity, global awareness, and civic responsibility. Much of this resonates with the concerns expressed by Sullivan in his recent book about the state of professional education in this country.3
So the medical education community faces a formidable challenge: What content and what experiences should be included in the educational program leading to the MD degree to ensure that students are indeed receiving a general professional education in medicine? Because members of the community bring a variety of perspectives to this issue, it will be difficult to achieve a consensus on those issues. Given that, I think it would be useful to agree on the following governing principle before beginning to debate the organization and structure of the curriculum: the educational program should be designed and conducted in ways that will ensure that medical students learn what it means to be a physician. Medical school graduates will ultimately learn how to practice medicine during their residencies and will continue to do so throughout their professional careers. But before they embark on those phases of the medical education continuum, they must understand and internalize what it means to be a physician.
So as the members of the medical education community begins to debate how the educational program should be designed and conducted to better provide the general professional education in medicine that the GPEP Report recommends, I think they should first answer the question: What does it mean to be a physician?
Michael E. Whitcomb, MD
1 Muller S (chair). 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;59 (11 Pt 2):1–208.
2 Whitcomb ME. More about the journal’s new direction. Acad Med. 2005;80:971–72.
3 Sullivan W. Work and Integrity: The Crisis and Promise of Professionalism in America. San Francisco: Jossey-Bass, 2005.