There have been recent calls to reform medical education to make the process more patient- and learner-focused. In addition, reformed medical education will be a key component in transforming the nation's system of health care delivery to a system that will value patient-centered care, quality improvement, and resource conservation. The U.S. accreditation bodies also have the expectation that medical schools will engage in continuous improvement to enhance their students' learning environment.
The current economic climate is affecting many aspects of most academic institutions.1 Reduced reimbursement and a declining margin from the medical practice places a strain on institutions that have used practice income to help support educational endeavors. The forecast for even further reductions in Medicare reimbursement clearly portends an era of financial challenges in the support of medical education.
Despite these financial pressures, we must implement measures to improve the medical education that we provide to our students. Through the alignment of medical education with the institutional mission, management strategies grow out of core principles to guide daily operational activity.2 This alignment with the institution's mission and core values can make cost-saving measures more readily accepted by the faculty and students. It is important to stress that cost-containment efforts and improvements in educational processes are not mutually exclusive. We believe, in fact, that we must succeed both in containing costs and in improving the value of the education that we provide to our students.
Medical Education Landscape
The Flexner Report of 1910 recommended that medical education occur in a scientifically rigorous university system rather than in an apprenticeship system of proprietary schools. Medical schools adopted Flexner's recommendation that “a more uniformly arduous and expensive medical education is demanded.” Over the past several years, there have been new calls to reform the traditional, systematized, scientific medical education by reemphasizing the assurance of clinical competency, expanding the focus on the “system” aspects of care delivery, and responding to the health needs of both the larger society and the medical school's local community.3,4 A willingness to reexamine current structures, to seek alignment with institutional priorities and national directions, and to communicate with leaders, faculty, and students is essential.
In this commentary, we emphasize the need to adopt medical education programs that will align with the new models of health care that are likely to emerge from the current reform efforts. We discuss our experiences in order to share our school's efforts in improving medical education while containing costs. From our experience, we concluded that quality improvement in education can proceed even during a time of financial constraints. In fact, the financial constraints may push for even more far-reaching innovations in medical education because of the need to do more with less. Changes that retain the essence of the educational programs while eliminating the excess effort contained in many processes are the changes that are most likely to be effective.
Explicitly involving students in decisions about and in the responsibility for their own education, as well as providing knowledge about the revenues that support their education, is an important philosophical step. Immersing students and faculty in discussions on the reform of the health care system is vital during these financially challenging times. The increased national attention to this important topic and students' eagerness to be part of the country's solution to this issue are important motivations for change.
The economic challenges of the times may help dislodge the inertia that is inherent in large academic institutions and may allow broad and sweeping changes in our schools' curricula and administrations. Furthermore, executive leadership support for these changes is more likely if a careful alignment is ensured between the schools' goals and institutional priorities.
Mayo Medical School as an Example
The implementation of a new curriculum at the Mayo Medical School resulted in a transformation from overlapping, subject-based courses to multidisciplinary, integrated blocks that were designed to achieve specified learning outcomes. The incorporation of outcome-based principles in a six-week, block-based curricular structure led to a patient-oriented, clinically relevant, and highly integrated curriculum in the first and second years of medical school. The new curriculum linked all educational objectives to outcomes and enhanced integration by a focus on forming four longitudinal themes: (1) the scientific foundations of medical practice, (2) clinical experience, (3) improvement in the public's health, and (4) the principles of therapeutics.
The didactic components of the new curriculum provide subject overviews, briefings for the whole class, and small-group discussions led by faculty; individual reading assignments augment the sessions. Clinical experiences are woven throughout these blocks to ensure that students develop history-taking and physical examination skills. Especially in year two, students have patient encounters that are designed to help illustrate and bring to life concepts that the students have covered in the classroom and their readings.
The redesigned curriculum is student-centered and places emphasis on student learning, rather than on teacher pedagogy; it also includes more frequent, broader, and earlier clinical exposure. The new curriculum incorporates independent and team-based learning environments, but the responsibility for learning is primarily placed on the students. Perhaps counterintuitively, the resulting reduction in students' time with faculty actually enhanced the students' learning outcomes. The combination of these various aspects of the curriculum change have been associated with very high levels of student engagement, participation, and satisfaction and have increasingly received faculty endorsement, and few would consider reverting to the old way of doing things.5 The rapid implementation of these changes was enhanced by the chance to examine a successful, block-based curriculum at the University of North Dakota School of Medicine and Health Sciences, which was a most useful model.6
These changes in aggregate have reduced the number of contact hours for faculty with students in several blocks by >30% (from 180 to 120 hours), thus lowering cost. The new methodologies and structures also have allowed students to improve their performance on standardized tests.
Health Reform for the Medically Underserved
An increasing awareness of the social determinants of health necessitates that medical education also consider the other factors determining health, such as prevention, lifestyle, and poverty, rather than focusing only on medical care. Part of our “advanced doctoring” course in year two, which teaches physical examination of patients, was moved to a free clinic sponsored by a local charitable organization. This setting exposes our students to medically underserved populations and community organizations that are dealing with the other social determinants of health and also promoting an expansion of the free care offered to this population. Thus, our students can develop a closer connection to the local community as they work collaboratively with community partners involved in health and health promotion. The medical students not only gain knowledge about programs but also serve as a resource through their engagement in service projects. These projects help community-based organizations achieve their own goals in promoting health and wellness in the communities they serve and also directly involve our students in service to these organizations. These changes have been revenue-neutral but have greatly enhanced the students' learning experience.
Provisos and Conclusion
Mayo Medical School has a different learning environment from many schools. The student body is small—fewer than 200 students in total—and the faculty in Rochester alone consists of more than 1,800 full-time physicians and scientists. These factors have enhanced the school's ability to implement changes that may not be so readily adapted by schools with the more typical structure of a larger student body and a smaller faculty. We are aware that our new processes are only now producing the first graduates, and, thus, long-term data regarding the results of these changes are not yet available. Nevertheless, we have taken to heart the adage “necessity is the mother of invention” and have successfully improved medical education at Mayo during financially challenging times. We encourage others to do likewise.
1 Bach PB. Quality wrapped in volume inside a hospital. Ann Intern Med. 2009;150:729–730.
2 Viggiano TR, Pawlina W, Lindor KD, Olsen KD, Cortese DA. Putting the needs of the patient first: Mayo Clinic's core value, institutional culture, and professionalism covenant. Acad Med. 2007;82:1089–1093.
3 Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner Report. N Engl J Med. 2006;355:1339–1344.
4 Hoover EL. A century after Flexner: The need for reform in medical education from college and medical school through residency training. J Natl Med Assoc. 2005;97:1232–1239.
5 Jelsing EJ, Lachman N, O'Neil AE, Pawlina W. Can a flexible medical curriculum promote student learning and satisfaction? Ann Acad Med Singapore. 2007;36:713–718.
6 Christianson CE, McBride RB, Vari RC, Olson L, Wilson HD. From traditional to patient-centered learning: Curriculum change as an intervention for changing institutional culture and promoting professionalism in undergraduate medical education. Acad Med. 2007;82: 1079–1088.