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Medical Education Reform: Is It Time for a Modern Flexner Report?

Whitcomb, Michael E., MD

doi: 10.1097/ACM.0b013e31802be06e
From the Editor

The New England Journal of Medicine (NEJM) is probably the most prestigious and influential of all medical journals. Throughout the years, the journal has published primarily research reports describing the results of cutting-edge translational and clinical research studies, reviews summarizing how advances in medicine have affected the understanding of certain clinical conditions, and articles focused on current health policy issues. This past September the journal announced publication of a series of articles dealing with contemporary issues in medical education1 and published the first article in the series.2

Having been a regular reader of the NEJM throughout my career, I can state that the publication of the medical education series is a remarkable departure from the journal’s traditional practice. While the journal has published over the years an occasional article focusing on some aspect of medical education, I can’t recall that it ever published such a series. That being the case, I think the academic medicine community, particularly those responsible at the national level for the nature of the country’s medical education system, should stop and take note. And in doing so, they should ask themselves an important question: Why would the NEJM decide to devote highly valuable space in its pages to articles addressing medical education issues?

I can only speculate on the answer. I have known for some time that the series was being planned, but I didn’t seek out Jeffrey M. Drazen, MD, the journal’s editor, or other members of the editorial staff to gain insight into why they made the decision to depart from the journal’s standard publication policies. Even if my speculation (see below) is not exactly on target, there is at the very least an implicit message embedded in the NEJM’s decision that is worth reflecting on.

I surmise that the editorial staff is publishing the series because they understand that the approaches now being used to educate doctors across the medical education continuum must be reformed. And given that insight, they have decided that their journal should use its prestige and influence to focus the attention of thought leaders, many from outside the profession—business leaders, government officials, patient advocates, and others concerned about the cost and quality of U.S. medical care—on the seriousness of the issue. If I am right, and I hope I am, I very much applaud them for doing so.

I believe strongly, based on a great deal of personal experience, that the kinds of reforms that are needed to improve the education of doctors are unlikely to come about unless influential individuals outside the profession make it clear to leaders within the profession that this must happen. Why do I say this? Quite simply because recent calls for major reforms have as yet had no impact on the leadership of a number of the professional organizations that must take the lead in making the reforms possible!

Please understand that I am not referring to how the members of the medical education community have responded to the need to make changes in the design and conduct of the educational programs they are responsible for. For the most part, they have responded in very responsible ways to numerous calls to modify their programs to better prepare their learners (medical students and residents) for the challenges they will face in their careers. I am referring instead to the apparent unwillingness of professional organizations that have control over some aspects of the “medical education system” to change certain policies and procedures that affect how the system functions. And by failing to do so, they have impeded adoption of the kinds of fundamental changes needed to improve how U.S. doctors are being educated. There is nothing new about this observation!

For example, in July 2004, the Association of American Medical Colleges (AAMC) issued a report prepared by the Ad Hoc Committee of Deans, which had been convened to create a vision for the country’s medical education system. In its report, the committee stated that

the shortcomings that exist in the ways doctors are educated must be remedied if the quality of medical care provided in this country is to improve. Achieving this goal presents a major challenge, since many of the shortcomings that must be addressed are deeply entrenched in the tradition and culture of the institutions and organizations that compose the medical education system.3

This observation reinforced a position set forth the year before by the Blue Ridge Academic Health Group, whose members are leaders in academic medicine:

The multipolarity of responsibility and authority for health professional education must itself be addressed. The existing regulatory framework is too unwieldy and must be streamlined and consolidated.4

Despite the clear, apt, and timely statements made by those groups, nothing of substance has happened. So what needs to be done to make the responsible organizations take action?

Well, I don’t think there is any merit in creating another body of academic medicine’s leaders to address once again the issues of concern. The simple fact seems to be that the leaders of the professional organizations that could change the nature of the medical education system in this country are more concerned about the views of their constituents than they are with positions emanating from a group of medical school deans or other leaders in the trenches of academic medicine. Unfortunately, many of their constituents have little understanding of the current situation or have a vested interest in maintaining the status quo.

Thus, I believe the current situation calls for the establishment of a group of individuals from outside the academic medicine community who, by virtue of the positions they hold in society, can gain the attention of the leaders of the professional organizations and spur them to action. I suggest that a prominent foundation establish a commission to study and report on the state of medical education in this country, with a particular focus on how well the medical education system is serving the interests of patients. And to avoid having the process captured by the professional organizations that are at fault for not making needed changes, the commission should be composed of leaders in business, government, and other entities concerned about the future of medical care in this country. In other words, they should create a commission somewhat akin to the Citizens Commission on Graduate Medical Education, established by the American Medical Association in the early 1960s. The report5 issued by that commission—“the Millis Report”—had a real impact on a number of issues embedded in the country’s medical education system at that time. At issue, of course, is who will lead? Will any foundation take on this challenge, or will one of the major professional organizations commission such a body to conduct the review?

I hope that the series being published by the NEJM will help make this proposal a reality. I am pretty sure that future patients, if they really understood the nature of the challenge at hand, would join me in applauding the NEJM for its decision to place a spotlight on medical education.

Michael E. Whitcomb, MD

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1 Cox M, Irby DM. A new series on medical education. N Engl J Med. 2006;355:1375–1376.
2 Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 110 years after the Flexner Report. N Engl J Med. 2006;355:1339–1344.
3 Report of the Ad Hoc Committee of Deans. Educating Doctors to Provide High Quality Medical Care. A Vision for Medical Education in the United States. Washington, DC: Association of American Medical Colleges; 2004.
4 The Blue Ridge Academic Health Group. Reforming Medical Education: Urgent Priority for Academic Health Centers in the New Century. Atlanta, Ga: The Robert W. Woodruff Health Sciences Center; 2003.
5 Millis JS (chair). The Report of the Citizens Commission on Graduate Medical Education. The Graduate Education of Physicians. Chicago, Ill: American Medical Association; 1966.
© 2007 Association of American Medical Colleges