Prislin, Michael D. MD; Saultz, John W. MD; Geyman, John P. MD
Few would dispute the benefit that Abraham Flexner's study and subsequent report1 have brought to American medical education. The report resulted in the replacement of a medical education system based largely on apprenticeship or commercially oriented models with a university-centered system, populated by carefully selected students, based on structured coursework, and informed by scholarly inquiry—all of which powerfully improved the quality of medical education. Although less often cited, Flexner's report also led to the widespread dissemination of an integrated clinical teaching, research, and service entity that we recognize today as the academic medical center (AMC). In Flexner's1 words,
The hospital and dispensary which the medical school must provide to obtain these conditions need be large enough to furnish only the fundamental training of the student body in method and to afford the various members of the faculty their own several workshops. Each department needs beds and accompanying facilities enough to care for typical clinical cases for instruction and for such other cases as the teacher himself wants to study under the most favorable conditions.
The dissemination of this integrated model of medical education and clinical care undoubtedly played a critical role in facilitating the establishment of the scientific basis for modern medicine. In turn, the resulting technological advances in diagnosis and therapeutics, as well as the physicians trained in this environment, profoundly shaped the evolution of the contemporary health care economy in the United States.
At the time of Flexner's report, the physician community in the United States almost entirely comprised generalists.2 Although the care these physicians provided often lacked a scientific basis, ongoing relationships between patients and physicians formed the backbone of clinical practice. Today, many observers of U.S. health care believe that relationships between patients and physicians have become badly frayed. These observers believe that health care is too often viewed as a commodity for which return on investment receives more attention than the needs of patients.3 Physicians have become masters of caring for diseases, but they have lost much of the art of caring for patients.4 Physicians today constitute the “workforce”; they are employees who fill therapeutic niches and who strive to achieve “controllable” lifestyles for themselves. In the contemporary educational and practice environments, the generalist disciplines seem to be at grave risk. So, too, may be the health of the people of the United States; a variety of measures indicate that health care quality in the United States—as reflected by indicators such as infant mortality, measures of effective chronic disease management, and overall life expectancy—lags behind that of other nations.5
Although some might assert that the decline in the generalist disciplines represents an evolutionary process propelled by advances in biomedical knowledge and therapeutic technologies, we suggest that the decline may be the consequence of forces, largely unintended, resulting in part from the adoption of Flexner's reforms. In this article we will explore both how these forces stemming from Flexnerian reform of U.S. medical education influenced the proliferation of clinical specialties and how changes in the generalist and specialist distribution of physicians, along with changes in the financing of health care, have impacted the evolution of health care delivery in the United States. We will then elaborate a series of proposals for post-Flexnerian reform designed to restore the vitality of patient-centered care and of the generalist disciplines in U.S. medicine.
Abraham Flexner and the Evolution of the Academic Health Center
Flexner's1 analysis of U.S. medical schools at the beginning of the 20th century found many to be severely wanting.
The school catalogues abound in exaggeration, misstatement, and half-truths. The deans of these institutions occasionally know more about modern advertising than about modern medical teaching. They may be uncertain about the relation of the clinical laboratory to bedside teaching; but they have calculated to a nicety which “medium” brings the largest “return.”
And the response to Flexner's report was rapid and profound. The number of medical schools operating in the United States declined from 160 in 1904 to 85 in 1920. All remaining schools became university based, and all came under tight regulatory scrutiny (initially by the American Medical Association Committee on Medical Education and subsequently by its successor, the Liaison Committee on Medical Education) in terms of their curricula, facilities, and resources, including faculty.
Flexner believed that the primary functions for medical school faculty lie within the realms of teaching and scientific discovery.
Educationally, then, research is required of the medical faculty because only research will keep the teachers in condition. A nonproductive school, conceivably up to date today, would be out of date tomorrow; its dead atmosphere would soon breed a careless and unenlightened dogmatism.1
Yet, two decades after the release of Flexner's report, most medical schools still had limited research programs in place.6 In 1930, Congress enacted legislation transforming the National Hygienic Laboratory into the National Institutes of Health (NIH) and appropriated the first public funds to support biomedical research.7 NIH funding has subsequently grown from an annual allocation of $400,000 in 1938 to more than $23 billion in 2007.8 Much of this funding has been redistributed to U.S. medical schools, funding faculty research (as Flexner advocated) and fueling an almost incomprehensible growth in biomedical research. Perhaps as influential as the absolute amount of funding, though, is how this funding has been prioritized. NIH support has primarily fostered disease-oriented inquiry in the basic human biological and applied clinical sciences. The creation of not only institutes with focused areas of inquiry (e.g., the heart, the blood vessels and lungs, kidney diseases, neurological diseases, and stroke), but also these institutes' related study sections, produced narrowly defined areas of research inquiry. The advances that resulted from this research served to encourage specialization of the clinical disciplines as well.2
Within the clinical realm, Flexner seemed to anticipate that his recommendations could lead to increasingly prominent academic health centers (AHCs) and might also encourage specialization of services.
The clinical teacher should indeed not arbitrarily restrict his experience: he may wisely develop—preferably in close connection with the hospital—a consulting practice, assured thus that his time will not be sacrificed to trivial ailments. On the same basis, other university facilities are at the service of those who require unusually skilful aid; for at all points only good can come of educational contact with unsolved problems—practical or other.1
Nevertheless, clinical faculty practice remained very much a secondary focus of the AHC until the enactment of the Medicare and Medicaid programs in the mid-1960s. Care for the elderly and the underserved had theretofore represented a major element of the social contract between medicine and society at large, and this was particularly true of AHCs. This social contract broadly encompassed the provision of public support for medical education, including the charitable provision of care to needy patients, in exchange for their participation in the education of medical students and residents.6 In 1965, American medical schools had relatively small numbers of clinical faculty, and those faculty members focused primarily on medical education. Clinical practice consisted of limited consultative activities or service on the charity wards. The advent of Medicare and Medicaid allowed direct clinical revenue to be generated by the participation of faculty in the care of such needy patients. Further, Medicare funding, for the first time, provided medical schools with direct public support of their graduate medical education (residency and fellowship) programs.6
A third and perhaps more consequential impact of Medicare occurred in the context of physician reimbursement. Commercial insurance programs first appeared during the 1930s, covering primarily hospital care costs. Early (from the 1930s to the 1950s) approaches of physician compensation were based on “usual and customary physician fees” in which physicians arbitrarily assigned a fee to the services they rendered. Reimbursements determined on the basis of the specific nature of services rendered (relative value units) were first developed in the 1950s, but they were limited in impact. The introduction of Medicare in 1965 brought with it a series of initiatives to rationalize payment for health services on a much broader scale. The net result was the creation of a reimbursement system that favored procedurally oriented disciplines, which then resulted in the highly variable levels of physician reimbursement that occur today.2 In 1974, for example, orthopedic surgeons received nearly twice the annual compensation of general pediatricians and about one and one half times the annual compensation of family physicians and general internists. In 2007, orthopedic surgeons received nearly two and one half times the compensation of pediatricians and about twice the compensation of family physicians and general internists. Orthopedic subspecialists in the areas of joint replacement surgery and spine surgery, which did not even exist in 1974, currently receive about triple the annual compensation of their colleagues in primary care.9,10
The net result in the context of the AHC has been an explosive growth in the size of clinical faculties11 and a corresponding growth in the scope and financial impact of AMC clinical activities. In 1965, federally funded research provided about $350,000,000 to U.S. medical schools, accounting for about 40% of their overall revenue, while patient care and service-related revenue totaled about $49,000,000, accounting for just 6% of overall revenue. By 2007, federal research funding had grown to more than $15 billion, but it now accounted for only about 20% of overall medical school revenue while patient care and service income grew to nearly $36 billion in this period, accounting now for 50% of overall revenue.12 Rather than being dependent for funding, medical schools today are often the primary driver of an economic engine that sustains their parent universities. In a broader context, Anderson and colleagues13 describe the role of the contemporary AHC and its influence on shaping the evolution of contemporary clinical practice as follows:
Academic health centers have shaped the American health care system during most of the twentieth century.... The academic health center, encouraged by federal initiatives, has played major roles in medical innovation and has been the focus of most basic and clinical research in this century. It is the place where most new technologies have been adopted and evaluated, where health care practitioners have been trained to use the most sophisticated equipment and the most innovative medical practices.
Even in his wildest dreams, Flexner could not have imagined these developments. Indeed, the faculty clinical practice model that has developed in American medical schools would likely be abhorrent to Flexner.
But a consulting practice—developed in a professional or commercial, rather than a scientific spirit, may prove quite as fatal to scientific interest as general practice. University hospitals, academic salaries, etc., make the conditions in which clinical medicine may be productively cultivated. They do not create ideals; and without ideals, superabundant and highly paid consultations are perhaps as demoralizing as superabundant, low-priced “calls.”1
The Evolution of American Health Care During the Late 20th Century
The direct delivery of extensive clinical services by AHCs gave medical schools the wherewithal to support the production of physicians who were, in turn, essential in helping sustain the AHCs' clinical programs. Within 15 years after the passage of Medicare (i.e., by the early 1980s), commercial insurance providers also adopted the differential levels of reimbursement for clinical services established through Medicare. As a result, specialty- and subspecialty-based clinical faculty members played increasingly prominent roles in AHCs, and the graduate medical education programs in their disciplines rapidly expanded—as did student interest in these disciplines. A commensurate decline in the number of U.S. students entering graduate training in the generalist disciplines began. This decline clearly affected the primary care disciplines of family medicine, general internal medicine, and general pediatrics, but it also affected student career interest in the generalist tracks of other specialties such as surgery.14,15 Physicians trained during the later part of the 1970s, and subsequently during the 1980s and 1990s, fundamentally reshaped the composition of the U.S. physician workforce and contributed to a literal redefinition of health care in the United States. Paraphrasing Dwight Eisenhower's famous speech describing the military–industrial complex, Arnold Relman,16 writing in 1980, described the emerging for-profit sector in U.S. health care in the following words:
This new “medical–industrial complex” may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and “cream-skimming,” and it may also exercise undue influence on national health policy.
However, during the decades of the 1980s and 1990s, important countervailing forces emerged. First, this period saw the widespread introduction and subsequent evolution of managed care as a method for financing health care. Philosophically based on principles of distributed public health as articulated in the concepts of community-oriented primary care and enabled by federal legislation creating health maintenance organizations, managed care sought to rationalize the delivery of health care services taking into consideration need, costs, and efficacy of services. These programs featured a strong foundation of primary care “case managers.” Costs savings derived from effective care management were supposed to be funneled back into supporting services for members.
Second, the federal government ventured into the arena of health workforce policy through the creation of the Council on Graduate Medical Education (COGME). COGME's charge was to advise Congress and the secretary of health and human resources on matters pertaining to the physician workforce including physician supply and distribution, physician training issues, and the financing of physician training. In its early reports COGME projected an emerging surplus in the total number of physicians, but it also warned of a maldistribution of the workforce in terms of both geographic and specialty mix. Anticipating the preeminence of managed care delivery models, COGME recommended an increase in training positions for generalist specialties, particularly the primary care disciplines.17
Buoyed by an initial enthusiasm surrounding managed care and prominent public advocacy supporting expansion of primary care, this period saw a significant upswing in student interest with respect to careers in the generalist disciplines. However, as managed care matured, and in response to the opportunity to extract substantial levels of wealth from the financing of health care services, the not-for-profit plans, which had previously predominated, were transformed into for-profit, publicly owned corporate entities. Surplus revenues generated by the plan became shareholder dividends, and primary care case management became a device to contain costs by restricting patient access to health care services. Increasing levels of costly administrative oversight further diminished resources available for patient care. Primary care physicians, previously seen as effective case managers, were now vilified by patients and their specialty colleagues alike as “gatekeepers.”18
Perhaps the signature health policy event of the 1990s was the proposal of, and then subsequent failure to adopt, an ambitious health care reform plan during the initial years of the Clinton administration. The Clinton health care plan embraced many managed care principles of primary-care-based case management. Although not opposed to primary care per se, an array of special interest groups including insurers, hospitals, and physician specialty groups resisted the plan's reimbursement structure and cost-control mechanisms, as well its limitations on patient access to specialized services, and thus played a critical role in ensuring that the plan failed to pass.19 In the wake of the Clinton health care reform failure, a number of limited proposals addressing issues of access and quality have subsequently emerged at both the federal and state levels.20 Further, in the 1990s, in terms of workforce policy, COGME, facing conflicting analyses of need, turned its attention to other issues, including a projected physician shortage in most if not all specialties, a need to train additional women and minority physicians, and strategies to improve access to health care services.21
By the end of the 1990s, managed care as a broad set of organizing principles for the delivery of health care was no longer credible. What remained (and remains today) are remnants of case management designed primarily to constrain costs and maximize shareholder benefit.22 Although not exclusive to the primary care disciplines, studies suggest that physicians became progressively more dissatisfied with medical practice throughout the final two decades of the 20th century. Physicians identify managed care, with its attendant productivity and administrative demands as well as its perceived impact on decreasing physician autonomy, as a major source of this dissatisfaction.23
Not surprisingly, student interest in primary care also declined. In 1998, nearly 36% of graduating medical students indicated interest in pursuing a career in primary care. That number declined to 21% in 2002.24 There is evidence that interest in the generalist disciplines among U.S. medical students has decreased even more precipitously during recent years. A survey of medical students graduating in 2007 from 11 U.S. medical schools indicated that only 2% of graduates were pursuing careers in general internal medicine.25 While international medical graduates (IMGs) subsequently fill a large number of internal medicine residency positions not filled by U.S. students during the match, data suggest that IMGs entering internal medicine residencies have a high likelihood of pursuing subspecialty training.26 IMGs also largely fill unfilled positions in family medicine after the match. However, unlike internal medicine, for which the number of positions offered declined by 140 (5%) between 1998 and 2008, the number of family medicine residency positions offered during this same period decreased by 639 (19.3%).27 In contrast, U.S. medical student interest in pediatrics, after a period of decline in the 1980s, increased during the 1990s and has remained fairly steady since that time. This may be strongly related to the increasing number of women entering medical school during the past two decades—as a high level of career interest in pediatrics exists among women medical students. Some research has shown that lifestyle considerations, especially the desire to have a part-time career, are the most significant factors influencing this career decision. A trend toward subspecialization in pediatrics that began in the 1970s reversed in the 1990s. However, the most recent data available suggest that this may be changing, with increasing levels of interest once again in subspecialization.28,29
Osteopathic medical schools also make important contributions to the physician workforce. Differing substantially in philosophy and structure from U.S. MD-degree-granting medical schools, osteopathic medical schools have historically strongly embraced the preparation of physicians for generalist careers. However, during the past two decades, there has been a dramatic growth in undergraduate osteopathic medical education without concomitant growth in osteopathic graduate medical education. The relative scarcity of osteopathic residency positions, combined with a dramatic growth in available Accreditation Council of Graduate Medical Education residency positions, has resulted in a dramatic shift of osteopathic students to MD-degree-granting oriented graduate medical education programs.30 As the number of new osteopathic schools has grown and class sizes of existing schools have expanded, an increased mix of MD and osteopathic students during the third- and fourth-year clinical rotations has occurred.31 One important consequence of this intermixing seems to be that the factors influencing specialty choice among both MD and osteopathic students have now become quite similar.32
The Imperative for Change
Few would disagree that health care in the United States in 2010 includes the most highly scientifically based, technologically sophisticated, and potentially efficacious diagnostic and therapeutic modalities in the history of humankind. Yet, disturbing trends also exist. Both access to services and disparities in quality based on socioeconomic status, race, and geographic location remain problematic for large segments of the U.S. population. Although the United States spends a higher proportion of its gross domestic product on health care than other developed countries do, the health status of its population based on common population-based health indicators lags behind those same countries.33 As the costs of health care continue to increase, so do the numbers of Americans who have no health insurance. Market forces have proven ineffective in regulating expenditures, and efforts at ensuring quality in this context create additional administrative and regulatory burdens which further increase costs.34 The prevailing system is no longer sustainable on either a moral or economic basis.
For much of the 20th century, academic medicine, as previously noted, engaged in a social contract that provided superior care to patients in exchange for their participation in the education of physicians. That social contract has now eroded, and the money culture that dominates the academic health system has led to distortions in medical education and to our present maldistribution of physicians by specialty. Reflecting on the impact of Flexner's reforms, it is ironic that any reform of medical education must now begin with reform of the health care delivery system itself rather than the other way around.
Proponents of a national single-payer program believe that such a program would be the most transformative reform. Such a model could transition the U.S. system toward not-for-profit care, provide a structure to increase compensation to physicians in shortage fields (including primary care, psychiatry, and geriatrics), increase access to care while decreasing bureaucracy and waste, render care more affordable for all Americans through simplified administration and more effective cost containment, and make the U.S. health care system more accountable for its access, quality, value, and equity. Given the current plans under consideration, more incremental proposals for health care reform are the ones that are likely to pass. Analysts agree, however, that whatever system emerges will require a strong foundation of generalist providers to achieve a rational and efficient delivery system.34 Recent experience in Massachusetts has demonstrated that simply providing broad insurance coverage to patients will not adequately address issues of access to care.35 Ensuring access to care also requires having an appropriate distribution of generalist and specialist physicians.36 A strong core of generalist physicians will facilitate a rebalancing of health care delivery with an increased focus on health promotion and primary prevention, provision of improved secondary prevention services through effective chronic disease management, and efficient coordination of diverse specialty services for management of complex problems.34 The physician workforce currently training in U.S. AMCs no longer provides this core, and we believe that this must change.
Although differences in income based on levels of required training and respective levels of practice-related difficulty, stress, or time commitment are not unreasonable, the current system of reimbursement in the United States has led to disproportionately wide differences in physician compensation. Reforming how physicians are compensated in order to narrow this gap is essential to rebuilding primary care. Physician reimbursement patterns in countries that have organized national health delivery systems, such as the United Kingdom, have in fact realized more proportionate levels of compensation.37 Reimbursement reforms will also help to rein in inappropriate and unnecessary services that are overreimbursed in today's system.38
Further, if primary care practice is going to once again capture the imagination of medical students, it must reengineer its prevailing care delivery model.39 Initiatives such as the Future of Family Medicine Project include a detailed outline for practice transformation that involves patient-centered care using a medical home model, improved access to services, team-oriented collaborative care using both physician and nonphysician care providers, and a focus on quality that maximizes the effective use of information technologies and evidence-based medicine.40
A Proposal for a Post-Flexnerian Reform of Medical Education
Flexner identified selection of students, allocation of resources to support medical education, and the structure of the medical school curriculum as the key elements of American medical education in need of reform at the beginning of the 20th century.1 We believe that the time has come for a new set of 21st-century post-Flexnerian reforms in each of these three areas. Such reforms are necessary not only so that new physicians receive the training needed to provide effective patient-centered care and to rebalance the physician workforce but also so that the provision of medical care to all segments of the U.S. population will be possible at an affordable cost. Our suggestions are not necessarily prescriptive. Rather we present them to stimulate dialogue.
U.S. culture celebrates the triumphs of the biomedical enterprise. Mass media influence not only what the public learns about health topics but also how people feel about these topics and how they behave in relation to making consumer choices.41 Beyond influencing trends in utilization of health care services, exposure to the contemporary popular culture of health care may be impacting the decisions of students who choose to apply to medical school and the decisions of medical school admissions committees who review their applications. A U.S. News and World Report approach to judging medical schools that focuses on faculty academic reputation and research expenditures on the one hand, and student Medical College Admission Test scores on the other, may be influencing the types of students who choose to apply to medical school, the types who are successful in gaining admission, and the choices matriculants subsequently make in terms of specialty training. Physician educators and administrators need to be sure that students who might be interested in the generalist disciplines are also among those who are applying to and entering medical school. U.S. medical schools should also be responsible for tracking the subsequent careers of the students they admit and for measuring their graduates' impact on the health of their communities. Solving access issues may be critically linked to having a physician workforce derived from diverse socioeconomic, ethnic, and geographical backgrounds.42 Access to U.S. medical schools is problematic for important segments of society. Seventy-five percent of U.S. medical students come from families whose income is in the upper two quintiles.43 This circumstance impacts students well before they get to medical school: A majority of students entering medical school complete their undergraduate education at a relatively small number of highly selective colleges and universities,44 and students entering these colleges and universities must, in turn, have access during their high school years to enrichment programs such as advanced placement coursework, tutors, and SAT preparation classes—enrichment activities that are often limited to children raised in more affluent communities.
Recent initiatives have proposed refocusing the medical student selection process so that admissions personnel weigh factors beyond proficiency in science courses and performance on standardized tests.45,46 We propose that medical schools adopt such initiatives so that they can foster increased diversity among their student populations from not only racial, ethnic, and cultural perspectives but also in terms of their students' economic and geographic backgrounds. Providing public funding to support all or a largely expanded number of students attending medical school would also likely encourage a much broader range of applicants, thus helping contribute to a more diverse professional community. Creating a service commitment for all physicians at the conclusion of their graduate training that they could fulfill in a wide variety of settings would further improve access to care, particularly in geographically remote areas.47 In addition, medical schools need more effective strategies to shift the emphasis from the subspecialties to primary care generalists. Reexamining the allocation of funding for graduate medical education will likely represent a key piece of this puzzle; additional funding must be provided to support residency training in the primary care specialties.48,49 The following observation of Jeremiah Barondess50 suggests the breadth of this challenge:
Alteration of the structure of the health care system, including the physician workforce mix, can only be informed if the education and training system in medicine joins with the training program accreditation and board certification processes to come at these issues primarily through the lens of patient and population need, rather than the needs of the profession.
In addition to changing admissions policies and reallocating funding, major curricular reforms are also necessary. Although these reforms are yet to be fully defined, several themes are clear. The medical education process should be tied to defined outcomes including both the desired composition of the physician community being trained and objective measures of the quality of care (including both patient satisfaction and desired clinical outcomes) that graduates deliver. In the words of Steven Woolf,
Health is much more than health care. Diseases are mediated by factors outside the clinical setting such as personal behaviors and environmental exposures.51
A new curriculum will need to place greater emphasis on the modern social sciences such as sociology, cultural anthropology, behavioral psychology, and economics, all of which have matured since the time of Flexner's report.52 This reform should help to rebalance medical education from its current excessive focus on disease management to a greater emphasis on population-based health improvement. Disease management has created a preoccupation with technology that has affected physician training. Beyond ensuring technologically oriented competency, medical educators need to develop physicians who are skilled at listening to and talking with patients. Effective communication with patients must be emphasized throughout the education continuum, not merely during the first years of medical school.53 As the costs of care continue to escalate beyond the reach of many Americans, and as physicians prosper from delivering medical care, whether needed or not, ethical issues in medicine multiply by the day. Except for a few leading centers, teaching of and research into ethical issues are largely neglected. Adding a new emphasis to ethics and the physician–patient relationship in the curriculum will help to prepare graduates to better meet the needs of 21st-century medicine. This approach can also help to restore credibility and professionalism, much of which the profession of medicine has lost, as evidenced by the public view that medicine has increasingly become just another self-interest group.54 Edmund Pellegrino55 gives us this perspective and challenge:
Medicine is at heart a moral enterprise and those who practice it are de facto members of a moral community. We can accept or repudiate that fact, but we cannot ignore it or absolve ourselves of the moral consequences of our choice. We are not a guild, business, trade union, or a political party. If the care of the sick is increasingly treated as a commodity, an investment opportunity, a bureaucrat's power trip, or a political trading chip: The profession bears part of the responsibility.
Determining the quality of health care delivery demands that the abilities of those who are providing the services be objectively measured. Similarly, advancement in medical education should move from a system that measures courses completed or time elapsed from novice trainee to independently practicing physician to one that measures competencies attained including knowledge acquisition, development of clinical skills and reasoning abilities, and demonstration of professional behaviors. The current medical education system in the United States defines competency as an attribute of the individual physician, whereas care outcomes depend on the ability of interdisciplinary teams of professionals working together. Medical education today is woefully lacking in effective strategies of teaching such teamwork. Perhaps the time has come to reconsider the traditional disciplinary boundaries and sites of training that define the clinical education of physicians.47,53,56
Modern medicine also demands sophisticated information management skills. Evidence-based practice and the application of information technology are revolutionizing medicine's capacity to measure and improve clinical outcomes. New technologies and procedures often come to the market without adequate evaluation or oversight. Clinical practice guidelines ideally should improve the quality of care, but they are too often biased by special interests.57 Informed by the latest science and information technologies, teachers and learners at all levels with guides to best practices can provide evidence-based medicine across the spectrum of medical care from screening and early diagnosis to treatment and follow-up care. To facilitate development of a robust curriculum in this area, health care providers need a new, science-based federal agency to evaluate and recommend policies for coverage of new technologies and services. Such a “Comparative Effectiveness Institute” needs to be well staffed and funded, be nonpartisan and not-for-profit, maintain a societal perspective, have authority to effect policy, and enjoy full independence from political interference. Other countries have accomplished this objective well, as illustrated by the United Kingdom's National Institute for Health and Clinical Excellence.58
Adding such breadth to an already highly crowded medical school curriculum will necessarily require careful consideration of what faculty can reasonably cover. Achieving a closer and more meaningful integration of elements in the premedical, undergraduate, and graduate medical education curricula will be crucial in this context, as will ensuring that ongoing continuing medical education efforts meaningfully address maintenance of physician competence across the breadth of their professional careers.
We have indeed in America medical practitioners not inferior to the best elsewhere; but there is probably no other country in the world in which there is so great a distance and so fatal a distance between the best, the average, and the worst.1
These words, which Flexner used to describe the status of U.S. physicians at the beginning of the last century, might be aptly applied today to describe the broader status of health care. The United States now faces a health care crisis in which the middle class, together with lower-income people, have great difficulty in gaining access to even basic medical care. The public has lost faith in organized medicine as an answer to this crisis and tends to see physicians as part of the problem—not part of the solution. If the medical profession can put its own interests aside and strongly advocate universal coverage for all Americans, it can reclaim much of its traditional legacy of service. Given the stakes involved for powerful vested interests, reforming health care will be no easy task.59
Once again, health care reform is being actively debated at the national level. The time for the public to engage in this dialogue is now, and we believe that this dialogue should extend broadly to include roles physicians should play and how those roles meet the needs of patients. The academic medicine community must decide how active it wishes to be in this dialogue, and it must also confront important existential questions regarding the continuing contribution of the generalist disciplines to the physician workforce. Some have brought forward cogent arguments supporting the provision of primary care services by nonphysician health care providers.60 Ideally, evolving practice models will allow collaborative primary care practices to develop. However, if instead the result is the loss of the generalist-physician primary care disciplines, the nature of the unique bond between patient and physician epitomized by the Hippocratic tradition will likely also be lost as physicians will increasingly provide only fragmented and episodic technical services to patients. If this occurs, we believe medicine as a professional calling will be severely diminished. Given the aging of the U.S. population and the increasing burden and complexity of chronic disease management, we believe that the health of the American public would also likely suffer from the loss of generalist physicians.61 A window of opportunity now exists to make sure that this outcome does not happen. Just as Abraham Flexner seized the opportunity at the beginning of the 20th century to advocate meaningful reform of medical education, we believe that academic medicine must now play a leading role in a new process of reform.62 Our country's ability to provide affordable, equitable, efficacious, and high-quality care to the American people in the 21st century hangs in the balance.
Other disclosures: Dr. Geyman is a member and past president of Physicians for a National Health Plan, a group that advocates for a single payer health plan.
Ethical approval: Not applicable.
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