Medical education and training programs generally have been slow to introduce curriculum content that reflects important changes in practice organization and health services delivery. However, impetus for curricular reform is gaining momentum as national organizations endorse new content for both medical school and residency education.
The authors and colleagues at Tufts Managed Care Institute reviewed nine reports by key national organizations to assess their positions on curricular reform in light of changes in practice and the system of care. The reports agree generally on the evolving nature of practice, the need to address these changes during medical school and residency training, and the description of the new curriculum content that they advocate. The authors grouped these reports' specific recommendations under ten curriculum domains: health care system overview; population-based care; quality measurement and improvement; medical management; preventive care; physician-patient communication; ethics; teamwork and collaboration; information management and technology; and practice management. They describe the reports' rationales and cite specific knowledge and skills that these national organizations identify within each domain. This domain-based framework synthesizes and complements the recommendations of these national organizations.
The authors conclude that implementing curricular reform remains a challenge. The information and competencies need to be organized and sequenced for stage of training and specialty, and barriers to change require strategic and operational planning. Having a common nomenclature and framework will facilitate the introduction of new content within schools and programs, across departments, and among institutions nationwide.
Two revolutions have affected medical practice in the United States during the last 15 years: first, the continued explosive growth of biomedical technology for diagnosis and treatment of illness; and second, significant and widespread change in the payment for and organization of health services. Medical education and training programs have maintained a core curricular focus on the diagnosis and treatment of illness, incorporating key advances in biomedical knowledge and technology over time. However, by and large, they have not paid systematic attention to preparing graduates for changes in the practice environment.1-4 This practice context is critical to the professional lives of physicians as well as to their ability to positively affect the health and well-being of patients.
One manifestation of the revolution in the health care environment in the United States is the growth of managed care, characterized by prospective payment and medical management processes. In 1980, after decades of existence, managed care was limited in scope and geography and was restricted primarily to the presence of staff- and group-model health maintenance organizations (HMOs). The great majority of U.S. physicians were untouched by its presence and unfamiliar with its tenets. In contrast, by 1998, approximately 90% of physicians participated in at least one managed care contract; and approximately 85% of patients insured by their employers were enrolled in some form of managed care plan.5,6
Rather than referring to particular insurance plans or arrangements, in this article we use the phrase managed care as an umbrella term to describe a set of general characteristics and trends in today's health care environment. More specifically, we use the term to suggest any environment that
â–ª acknowledges constraints on health care resources and values cost-effective care;
â–ª sees patients not only as individuals but as members of a population to be cared for and, therefore, supports health assessment, patient outreach, and illness-prevention strategies;
â–ª fosters the systematic assessment and improvement of quality indicators for physicians, hospitals, and patient populations; and
â–ª coordinates and delivers care through organized systems.
The leadership of the Tufts Managed Care Institute (TMCI) is especially interested in assessing changes in medical education and training in response to the environmental forces reviewed above. The TMCI was founded in 1995 by Tufts University School of Medicine and Tufts Health Plan with the mission of helping physicians and other health care professionals to practice more comfortably and effectively in the emerging environment through the development and dissemination of relevant educational tools, programs, and curricula. The TMCI's original curriculum framework was derived from interviews with more than 50 practitioners, faculty, medical students, residents, and others, largely within the greater Tufts community.7 At that time, while one could find occasional articles and editorials about medical education and managed care, there was little organized discussion or consensus to guide us at the TMCI regarding the appropriate content for our course materials.
More recently, as a prelude to developing Web-based learning resources about managed care, we (the authors) revisited this curricular framework. This time when we researched the literature, we discovered that, in the years since 1995, several prestigious national medical education organizations and professional societies had published reports and recommendations for curricular reform that address the preparation of physicians for this evolving practice environment; see Table 1 for a list of these reports and the groups that prepared them. In this article we summarize our findings from analyzing those nine reports.
The appearance of these reports is significant for three reasons. First, it demonstrates a growing recognition among physician-educators and leaders that the content of medical education and training must reflect changes in the health care environment and the organization of medical services. Second, the reports are consistent in their characterizations of the environment and the evolving nature of practice. Third, there is significant confluence among the reports in the nature of the new curricular content they recommend.
We being with a brief overview of the reports' assessments of the practice environment. We then present a synthesis of the key content areas they recommend for inclusion in medical education and training programs. We conclude with reflections on the challenges that lie ahead as academic medicine responds to these forces and endeavors to incorporate the new curricular components.