Whitcomb, Michael E. MD
Twenty-five years ago, the Association of American Medical Colleges (AAMC) convened a panel of distinguished educators to review how those aspiring to careers in medicine were being prepared for the study of medicine and how those gaining admission to medical schools were being educated and readied for their careers as doctors. The Panel on the General Professional Education of the Physician and College Preparation for Medicine (“the GPEP panel”) issued its report in 1984.1 In the introduction to the report, the panel's chairman stated: “The Panel asserts that changes are needed now to anticipate the circumstances that are beginning to alter the practice of medicine and that today's medical students will confront in the future. The Panel judges that the present system of general professional education for medicine will become increasingly inadequate unless it is revised.”
That statement is as true today as it was when it was written over 20 years ago. In saying that, I don't mean to suggest that the medical education community failed to respond to the recommendations set forth by the panel. Quite the contrary! The organization of the medical school curriculum and the strategies employed to enhance students' learning have changed dramatically over the ensuing years, particularly during the past decade. But the simple fact is that changes continually occur in medical care—both changes in the organization and financing of care and also in medicine itself—and, as a result, in society's expectations of medicine. This means that the medical education community has an ongoing responsibility to review how physicians are being educated and to modify the educational process whenever necessary to ensure that doctors are being adequately prepared to carry out the tasks of medicine.
Nevertheless, it is important to note that some of the issues raised by the GPEP panel in its report have not been fully addressed. In its final report, the panel suggested that medical schools need more curriculum content drawn from the social sciences, behavioral sciences, medical humanities, and bioethics. Regarding that recommendation, it is interesting that the panel was criticized by two quite divergent groups of the medical education community. One group said that the recommendation indicated that the panel believed that the emphasis placed on the science of medicine in the education of doctors was no longer appropriate.2 The other group criticized the panel for not being more definitive about the need to increase the content drawn from the nonbiomedical disciplines.3 The tension that existed between those two camps in the mid-1980s persists today.
In a recent article, Ezekial Emmanuel, MD, a member of the Department of Clinical Bioethics at the Clinical Center of the National Institutes of Health, argues that in selecting students for admission, medical schools continue to place too much emphasis on how the students performed as undergraduates in math and science courses and on how they performed on the biological and physical sciences components of the Medical College Admission Test (MCAT).4 He believes, based partly on personal experience, that much of the science that aspiring medical students are required to learn has very little to do with how physicians carry out the tasks of medicine. And he notes that despite a growing appreciation that content drawn from the social sciences, behavioral sciences, medical humanities, and bioethics does have relevance for the way doctors care for patients, medical schools do not require potential applicants to have studied those subjects as undergraduates.
His critique of the “college preparation for medicine” carries over in a similar manner to the “general professional education of the physician” provided by medical schools. He believes that medical schools need to create a better balance between the content drawn from the biological sciences, on the one hand, and from the social sciences, behavioral sciences, medical humanities, and bioethics, on the other. And he argues that the changes he proposes are needed to improve the quality of the health care provided to the American public. His argument is based on the proposition that the education of doctors should be focused primarily on preparing them to carry out the tasks of medicine, and that requiring students to take courses that are not relevant to that goal serves no purpose.
Those who read this column regularly know that I agree with him.5 I think the current requirements for admission to medical school would make sense if there were any evidence that mastering the facts presented in the required math and science courses contributed to a physician's ability to practice medicine. But the data that are available show that physicians use very little, if any, of the scientific information they are required to learn, both as undergraduates and as medical students, in making decisions about how to care for patients. Furthermore, I think that medical school deans and faculties do understand that content drawn from the physical and biological sciences has been overemphasized in the medical school curriculum. Why do I say this? Quite simply, because the amount of time now devoted to presenting this material in the curriculum is significantly less than it was even a decade ago. It is also clear that content drawn from the other disciplines is now being more prominently represented in the curricula of many schools.
But focusing on the balance that exists in the medical school curriculum between content drawn from these various disciplines misses the important question that needs to be addressed: What is the purpose of the undergraduate medical education program, or, to use the GPEP terminology, the general professional education of the physician? If we were clear about that, we would be in a better position to clarify how aspiring physicians should be prepared for the study of medicine. This brings me to a point I made in this column one year ago,6 which is that the medical education community should strive to answer a very fundamental question: What does it mean to be a physician?
Having given a great deal of thought to that question during the past year, I recognize that it is not easy to come up with an answer that is concise and exactly on point. The primary reason is that physicians serve many different roles. Although the majority are full-time clinicians, others serve primarily as investigators, as teachers, or as administrators within academic institutions or health care delivery systems. As a result, it is difficult to identify a single core attribute that is common to all physicians. But there must be something about the essence of what physicians do that defines for the public what it means to be a physician. In other words, being a physician must go beyond simply possessing an MD degree. And I suspect that to members of the public, the essence of what it means to be a physician is derived from the public's perspective on the doctor–patient relationship.
To understand that perspective, we need to be clear about why individuals seek a doctor's care. Kathryn Montgomery, PhD, director of the Medical Humanities and Bioethics Program at the Northwestern Feinberg School of Medicine, states this pretty clearly: “Patients come to physicians for recognition of their predicament, identification of their malady, and action on their behalf. They want some idea of what lies in store as a consequence of both diagnosis and treatment.”7 So I suggest that serving the needs of patients defines what it means to be a physician. If that is the case, shouldn't the purpose of the undergraduate medical education program be to teach students how to care for patients?
Montgomery goes a bit deeper in addressing that point. She argues that because of the vagueness of how patients with a variety of afflictions present to the physician, and because what needs to be done for them is often uncertain, one of the goals of medical education must be to ensure that physicians develop good clinical judgment. In other words, medical education must ensure that physicians have the ability to reason properly in deciding how to care for an individual patient. And to be able to do that during their professional careers, medical students must learn that the best care for a particular patient can only be determined by understanding that the patient is a distinct person whose care must be shaped by the specifics of his or her individual life circumstances. Therein resides the essence of what it really means to be a physician! And to ensure that doctors are educated and prepared for that purpose, medical schools need to think seriously about how students are selected for the study of medicine and about how students are oriented to the tasks of medicine while they are in medical school. I think this is exactly the point that Emmanuel is making in his critique of the current requirements for admission to medical school and of the nature of the medical school curriculum.4
If the goal of undergraduate medical education is to educate and prepare students to be physicians (not just to possess an MD degree), we must make some fundamental changes in how we select students for medical school and how we educate them once they have been admitted. Our goal in the admission process should be to identify explicitly the personal attributes and intellectual ability that will allow an individual to become a good physician—that is, a person with the ability to interact with patients in a way that is not only medically informed but also caring. And while those we select are studying medicine, we should spend much more time than we do now teaching them how to truly care for patients. In short, the design and conduct of the undergraduate medical education program has to be informed by an understanding of what it means to be a physician.
In closing, I want to make an important point that is highly relevant to this goal: Medical schools have not placed sufficient importance on the teaching of clinical reasoning as a distinct clinical skill. Most important, very few students ever have the opportunity to see, firsthand, clinical reasoning in action. Or, to put it another way, to see what it means to be a physician. How might that occur? By having students observe a skilled clinician during a patient encounter in which the clinician explains to the students what she or he is thinking as the clinician goes about taking a medical history and conducting a physical examination, explaining the reasons why she or he would choose to pursue a particular course of action. During the past few decades, we have placed great emphasis on having clinical faculty observe students in the limited patient encounters that occur during standardized patient exercises. It is distressing to note that during the same period, we have almost totally eliminated opportunities for students to observe the faculty engaging in clinical reasoning. There really is something amiss here!
Michael E. Whitcomb, MD
1 Muller S. 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).
2 COD-CAS Working Group. Commentary on the report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine. J Med Educ. 1986;61:347–352.
3 White KL. The Task of Medicine: Dialogue at Wickenburg. Menlo Park, CA: The Henry J. Kaiser Family Foundation, 1988.
4 Emmanuel E. Changing the pre-med requirements and the medical curriculum: time for a second Flexner Report. JAMA. 2006;296:1128–1131.
5 Whitcomb ME. The teaching of basic sciences in medical schools. Acad Med. 2006;81:413–414.
6 Whitcomb ME. What does it mean to be a physician? Acad Med. 2005;80:1077–1078.
7 Montgomery K. How Doctors Think: Clinical Judgment and the Practice of Medicine. New York: Oxford University Press, 2006.