Whitcomb, Michael E. MD
Everyone in the academic medicine community, especially those who design and conduct medical education programs, must recognize that there are serious concerns about the state of medical education in this country. In recent years, several blue-ribbon committees have issued reports that acknowledge the seriousness of the problem. The fact that both the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA) have embarked on initiatives to improve medical education lends weight to the concerns expressed in those reports. Indeed, the AAMC’s Institute for Improving Medical Education, which was established several years ago, already has begun a number of projects targeted to specific problem areas. And the AMA’s Initiative for Transforming Medical Education is now formulating the agenda that the AMA will pursue.
Academic Medicine seeks to contribute to the effort to improve medical education by regularly publishing articles that focus attention on the issues of concern. Also, I sometimes use my monthly column to highlight areas that I believe need special attention. But this issue of the journal is particularly important: every article that appears was carefully selected because of the lessons it holds for improving the education of medical students. The staff and I are already working on another collection about the education of residents, which we hope to publish later this year.
I hope that the dean and key faculty members of every medical school will read and study all the articles in this issue, and then meet to discuss what they have learned that can inform their efforts to better educate their students. Much of the value of these articles is that they describe well-thought-out initiatives that some medical schools have actually carried out to successfully improve their undergraduate medical education programs.
The four articles by Loeser, Stratton, Sierpina, and Watson and their colleagues address issues that relate to the design, conduct, and management of the education program. I suspect that some readers recall, as I do, the days when curriculum committees composed of departmental representatives met to engage in heated discussions about the nature of the education program. The content to be provided in the program and the strategies to be employed in presenting the content were not usually at issue during those discussions. Instead, committees focused their attention largely on the number of hours or weeks devoted respectively to departmentally controlled basic science courses or specialty-specific clerkships. At issue, of course, was the relative importance assigned to the courses offered by the various departments—a determination based to a great extent on the time allocated for each course. I trust that this kind of discussion no longer occurs at any medical school. Everyone in the medical education community should understand by now that in order to offer a coherent, high-quality education program, the design, conduct, and management of the program must be conducted within a framework established and supported by a school’s central administration (the dean’s office). Each of the four articles noted above contains important lessons about how that can be accomplished.
The next three articles—those by Drees, Neville, and Grochowski and their colleagues—describe the structure and organization of the undergraduate medical education programs conducted at the University of Missouri–Kansas City School of Medicine, McMaster University Faculty of Health Sciences, and Duke University School of Medicine. When those programs were implemented over 30 years ago, they were each quite unique, and they remain so today. Over the years, the programs have been subjected periodically both to internal faculty reviews and also to external reviews conducted by the Liaison Committee on Medical Education. There have been no substantive changes in the fundamental design of the programs as a result of those reviews. They have withstood the test of time because of the performance of their students. And therein lies a very important lesson! The success of the three programs demonstrates convincingly that there are other ways to educate medical students besides using a traditional, four-year curriculum structure. Thus, medical schools that decide to improve the education of their students by embarking on a curriculum review process should not feel constrained by that structure as they consider needed changes.
The two articles that follow—by Rackleff and Fishleder and their colleagues—describe the development of alternative instructional approaches by the University of Miami School of Medicine (UM) and by Case Western Reserve University College of Medicine (CWRU). Rackleff and colleagues describe a UM program being established at Florida Atlantic University (FAU). This initiative provides an excellent example of a successful partnership between a private medical school and a public university. When fully implemented later this year, the curriculum at FAU will differ in a number of ways from the one conducted at the main UM campus, including a greater focus on educating students for the care of patients with chronic illness. Fishleder and colleagues discuss the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, a partnership between CWRU and the Cleveland Clinic. The program differs from the standard CWRU program in that it lasts five years and is targeted to students interested in pursuing careers in clinical research. Despite the special emphases of each of the programs, their graduates will receive the same degrees as will students who complete the traditional UM and CWRU programs.
These two programs are good examples of how medical schools can partner with other institutions to develop educational tracks that can serve the special interests of certain students. In one sense, many medical schools already offer certain kinds of special tracks. MD–PhD programs, as well as other kinds of joint-degree programs, can be viewed in this way. But in those cases, the required components of the medical school program are generally identical for all students. The programs conducted by UM and CWRU show that this need not be the case. So, as schools embark on initiatives to improve the education of their students, it makes good sense for them to develop tracks that will serve students with particular interests in medicine. And I also believe that schools should be free to offer those tracks wherever the resources exist to allow them to develop a quality educational experience. By providing students opportunities to gain special insights into aspects of medicine of special interest to them, they might well be influenced to embark on nontraditional careers that will serve important societal needs.
The next three articles—by Ogur, Kanter, and Litzelman and Cottingham and their colleagues—describe approaches being used by the medical schools at Harvard University, the University of Pittsburgh, and Indiana University to provide opportunities for their students to gain a deep appreciation of what it means to be a physician. And the last article in this issue of the journal, by Dobie, sets the stage for addressing what it means to be a physician by using narratives obtained from medical students and residents at the University of Washington School of Medicine to show the importance of helping students and residents enhance their understanding of the responsibilities that doctors have to patients.
Litzelman and Cottingham discuss how Indiana restructured its entire institutional approach for dealing with students to create an environment that supports their professional development. The Cambridge Integrated Clerkship (CIC), a program described by Ogur and colleagues, seeks to accomplish this objective in a very different way. The CIC team restructured the clerkship experiences required in the third year of the Harvard Medical School curriculum so that students would have opportunities to follow some patients over the course of an entire year. By doing so, the students have opportunities to be involved in the care of individual patients in a variety of clinical care venues and can gain a deep appreciation of the profound responsibilities doctors have in providing care for patients over time. The approach adopted at Pittsburgh, described by Kanter, attempts to embed an understanding of the human dimensions of medicine into in-depth, integrated learning experiences that utilize three learning strategies.
My brief comments about the articles appearing this month only hint at the important lessons they contain. Nor do my comments adequately reflect a key lesson that emerges from the entire collection. That is, important advances in medical education have come about because of the willingness of some schools to lead in developing and implementing innovative approaches for educating their students. Given that, medical schools now considering how to improve the education of their students should be encouraged to be innovative in the redesign of their education programs. As in the past, innovation at one school may lead to an improvement in the education of medical students at many more.
Michael E. Whitcomb, MD