Sklar, David P. MD; Lee, Robert MS
Two recent issues of Academic Medicine focused on areas of great importance for our health care system and our medical education system. The December 2009 issue focused on quality and safety and their place in the medical education system. The February 2010 issue focused on Flexner's legacy for medical education and considered how current thinking might change Flexner's original model. In this commentary, we propose joining the two themes by considering a medical education curriculum that has high-quality medical care as its desired objective.
Our current medical education system is based on the assumption that students progress from the mastery of basic mechanisms of human structure and function to pathologies of genetic, microbiologic, or environmental origin to treatments based on sound scientific principles.1 For example, the Association of American Medical Colleges Howard Hughes Medical Institute Committee on Scientific Foundations for Future Physicians has recently defined scientific competencies for premedical and medical students.2 However, as concerns have been raised about deficits in students' professionalism, compassion, communication skills, and understanding of broader health systems, additional courses or programs have been added to many curricula. In those programs with problem-based curricula, cases have been adjusted to address these topics. The Accreditation Council for Graduate Medical Education introduced six core competencies in 2002, which included professionalism, communications, practice-based learning, and systems-based learning in addition to traditional medical knowledge and clinical care.3 As various proponents for additions or subtractions from the medical curriculum craft arguments about the importance of one area of knowledge compared with another, it becomes difficult to prioritize the content or skills for inclusion without a clear sense of the destination for the journey of medical education. Methods for altering curricula have generally included the convening of medical education experts and the development of consensus documents.1–3 However, before changing curricula and developing competencies, a clear rationale should be developed about why particular focus areas are included and excluded. At present, to our knowledge, there are no clear, agreed-on objectives that guide these changes. This lack of standardization is particularly worrisome because calls for curricula/competency changes seem to involve adding more and more information while keeping the duration of medical education the same or shortening it even more. The problem facing medical educators has been how to organize and prioritize the vast and expanding medical knowledge base for inclusion in the medical curriculum, especially as social sciences, humanities, and economics compete for inclusion.
In this commentary, we suggest beginning with the end—that is, starting with the desired high-level objective outcome for the medical care system. We suggest that this objective should be the delivery of high-quality medical care. Definitions for high-quality care vary, though. Optimally, a definition of quality could be derived that encompassed a variety of situations. For the purposes of this essay, we will use, as an example, the Institute of Medicine (IOM) definition of quality proposed in the monograph “Crossing the Quality Chasm: A New Health System for the 21st Century.”4 Although quality can be defined in other ways, this particular definition is broad and generally agreed on. It identifies six sub objectives for quality, which can be characterized and measured by attributes (these definitions are standard in the field of decision theory).5 According to the IOM, high-quality care should be safe, timely, effective, efficient, equitable, and patient-centered. For example, in the case of safety, we want to maximize safe care (or minimize unsafe care), and we may measure safety by the reduction of adverse events. Other objectives may be less intuitive (e.g., patient-centered care), but in these cases we can use scales (e.g., 1–10, with 1 being not patient-centered, and 10 being highly patient-centered). Although each objective may not be equally important in all situations, and, in any case, all cannot be achieved equally (i.e., there are trade-offs between the objectives), these objectives may be useful guides for the educational system because they suggest what disciplines and principles might be pertinent to achieving competence in these areas. As we work our way backward from these end points, implications for change and prioritization emerge.
The process of multiattribute decision making, which has been described in various fields,5,6 involves identification of strategic objectives (in this case, maximizing delivery of high-quality care) and then subobjectives and attributes. Trade-offs across the objectives and attributes are estimated, and ultimately, the comparative utility or “worth” of particular curricula (in terms of achieving high-quality care) can be estimated. For curriculum design, this method provides a way to compare various mixes of courses and practical experience, as objectives and attributes can be mapped based on the course content. Development of such an analysis is beyond the scope of this commentary, but examples from other fields demonstrate its potential applicability for curriculum change.5,6 Using the subobjectives of quality identified by the IOM, we can estimate which mixes of academic disciplines (and indeed in which order) would contribute most to training students to provide the highest-quality care.
Figure 1 illustrates, in a high-level sense, how different areas of study might address various objectives of quality. As can be noted, many of the areas of study are not typically included as required topics in most medical education curricula.
For medical care to be safe, defined as care where patients are not harmed by the care that is intended to help them, students would need to understand models of patient safety and medical error, which include cognitive processes of providers in making decisions and the impact of the interface between providers and the system or environment in which they work. Provision of safe care requires a knowledge base and experience in systems design and improvement as well as an understanding of how such factors as fatigue, interruptions, noise, and supervision impact medical knowledge and skills. Although safe medical care requires the acquisition of a comprehensive medical vocabulary, basic sciences, and clinical care, it also requires an understanding of how other factors can influence the outcome of the patient's interaction with the health care system.
For medical care to be timely, defined as care where there are not unnecessary waits and harmful delays are reduced, students would need to recognize their responsibility to participate in decisions about how limited health care resources are allocated so that those problems that are time sensitive would be recognized and treated in a timely manner. Medical care may be divided into acute care, chronic care, elective care, and preventive care. Timeliness is most important in acute care, where certain conditions such as myocardial infarctions, strokes, sepsis, and trauma require smoothly functioning care systems that match a patient's need with appropriate resources. Students would need to be taught the time-sensitive nature of pathologic processes, the scientific basis for interventions, and the design of systems to address these issues. Skills, process and quality improvement, and elimination of waste would provide students background in addressing complex medical systems.
For medical care to be effective, defined as care that is based on sound scientific knowledge, students would need to develop building blocks of basic sciences and develop linkages with clinical care skills and knowledge. They would need to understand how to analyze the latest information with computer and statistical tools such that evidence-based decisions could be made. Basic science education should emphasize the acquisition of the vocabulary of human biologic science necessary to master key principles and concepts, in much the same way that vocabulary for a language is necessary to understand communications of thoughts and ideas.1 Students would continue to master skills with practice, but this practice might occur on simulators as well as on actual patients.
For medical care to be efficient, defined as care that is not wasteful of equipment, supplies, ideas, or energy, students would need to learn how to compare costs and benefits of various treatment options, how to organize medical care so that waste and variation in care were minimized, and how incentives could help to drive the changes needed to maximize efficiency in an expensive health care system. Courses that included information on economics and process engineering and tools to analyze evidence of effectiveness would be needed to prepare students in this area of quality care.
For medical care to be equitable, defined as care that should not vary in quality because of patient characteristics such as ethnicity, poverty, or geographic location, students would need to understand the philosophical and ethical background for the concept of justice and how race, economic disadvantage, and limited resources might impact an equitable distribution of health care. Study of health systems in other countries would provide context for study of this concept in the American health care context.7
For medical care to be patient-centered, defined as care that is respectful and responsive to individual preferences, needs, and values, a student may begin education with a focus on how people understand and communicate their concerns about health, disease, pain, suffering, and death. A basic education in the culture of health, communication, and the uniqueness of the genetics of each individual would be major building blocks to lead to expertise in patient-centered care. Language skills—for example, Spanish—would provide opportunities for direct communication with that portion of the population whose first language is not English. Awareness of the social determinants of health would provide support for productive team efforts with social workers, counselors, and other support systems for patients.
We have proposed a framework that suggests how a high-level objective of high-quality care and its subobjectives and attributes might influence the medical curriculum. Modifications of the definition of quality would impact this model, and comparisons and valuing of the various attributes of quality would likely occur as we consider such factors as acuity, risk, and individual values. However, this conception of medical education from the perspective of the desired end point of quality clinical care may provide a fresh approach to current efforts to reform medical education. We believe this approach also offers the opportunity to approach education in quality care as a foundational element of medical education rather than a peripheral, optional topic. Pronovost and colleagues8 have identified challenges in integrating the concepts of quality and safety into academic medical centers, which include lack of evidence and scientific basis in quality improvement, lack of leadership development, and structural problems for implementation of quality improvement within the organization. By focusing on quality clinical care as the end point of medical education, the current scientific foundation of medical education can be merged with the skills and knowledge needed to achieve quality medical care and create a model of medical education that will prepare our future physicians for the challenges they will face one day as leaders in the health care system. We believe that current competencies (and calls for changes in competencies) could and indeed should be “mapped” to the quality objectives; this effort is likely to be highly instructive as to “what should stay” and “what should go.” Should this approach appear to provide value, next steps could include actual application of multiattribute approaches and modeling to compare and value various curriculum models.
We recognize that a problem with this approach is that we have not shown that adopting a definition of quality to change medical curricula will necessarily improve the quality of care. Although we believe that the quality of care will improve because such changes in the medical school curricula will lead to a better alignment of the clinical and educational missions of academic medical centers, this approach requires empirical evidence of effectiveness. We also recognize that a huge degree of inertia has accumulated with regard to the process of medical education. It will be quite difficult to redesign medical education, even if a framework such as we propose is adopted. However, we maintain that medical education is due for a system redesign. Just as there are insistent and consistent calls for a system redesign in health care delivery in the spirit of quality (as the IOM and many others have called for), medical education is no different. To ask for broadscale system changes in health care delivery without broadscale system changes in medical education is a prescription for failure.