Following in Flexner’s Footsteps
MODERN PROBLEMS IN MEDICAL EDUCATION
Today’s medical training is riddled with problems not addressed in the Flexner Report because they were not concerns early 20th century medical education. The inflexibility of modern medical education is one of the major issues faced by medical students today along with the unnecessarily long duration of training which is not learner-centered. In these years of training, students do not have sufficient contact with their supervising faculty members who have become so busy that they are forced to hand off the majority of their teaching duties to residents.
Similar to the problems faced in the later part of the 20th century, “the pace and commercial nature of health care impede inculcation of the fundamental values of the profession.” (Cooke, Irby, and O’Brien)
As schools began experimenting with new curricula, dual degree programs were established both combining undergraduate with graduate degrees as well as one graduate degree with another.
The combination programs that include undergraduate degrees are usually designed to eliminate one year from the time spent earning degrees. This fast track to professional education accepts students with outstanding high school performances who demonstrate a serious interest pursuing such challenging curricula. Colleges and universities across the country offer these programs including Boston University School of Medicine’s seven year Liberal Arts and Medical Education Program and eight year Engineering/Medical Integrated Curriculum for BU Engineering Sophomores and the George Washington University School of Medicine and Health Sciences’ seven year BA/MD Program which allows students to complete a bachelor’s degree in the discipline of their choice in three years before beginning their medical education which is specialized to follow the “track” they choose. Other programs are geared toward residents of the state in which the school is located like the University of Nevada School of Medicine where a seven year BS/MD Accelerated Early Admission Program for Nevada Residents is offered. Some programs are not designed to cut out a year spent in school. Brown University Warren Alpert School of Medicine offers an eight year Program in Liberal Medical Education, Mount Sinai School of Medicine has an eight year Humanities/Medicine Early Acceptance Program, and theUniversity of Southern California Keck School of Medicine offers an eight year BA/MD Program. These programs which follow the traditional eight year timeline still allow accepted students entrance into medical school without the completion of the traditional application process including the report of MCAT scores.
Medical schools themselves have also revamped their curricula to offer more flexibility and personalization to their students. Abandoning the traditional set up designed by Flexner over 100 years ago, an increasing number of schools have redesigned their curricula in the hopes of better accommodating the modern medical student and of creating a more efficient system. Putting into simple words the goals of today’s medical education, theColumbia University Medical Center has a description on their website stating “the College of Physicians and Surgeons is guided by the principle that medical education is university education.”
At the Perelman School of Medicine at the University of Pennsylvania, the goal of added flexibility was to make it possible for students to pursue dual degree opportunities (MD/PhD, MD/Master’s). The modules put in place afford students the option of added research time, time to take nonmedical classes, and time to spend on clinical work- a solution to the concern that research has over taken clinical training and other academic pursuits.
At the Duke University School of Medicine, they have compressed the traditional four years into three with the goal being to “encourage and entice students to pursue any of a wide range of careers.” Students at Duke spend their first year studying core basic sciences, their second year on core clinical clerkships, their third year on what is called “scholarly investigation” or biomedically related research, and their fourth year doing elective rotations which are designed to expose students to potential career paths. This allows students to gain early exposure to the different types of medicine and helps them to make educated decisions about their chosen career paths later on and also alleviates the concern that modern medical education is too drawn out over a four year period before residency.
The University of Michigan Medical School took an early interest in curriculum reform and has recently changed their curriculum to allow medical students access to patients as early as their first semester in an effort to get students out of the lab and into hospitals. Students also have access to a clinical simulation center where technology allows for experience without posing a risk to patients. Early access to patients and the availability of a simulation center refocus medical education on clinical skills. Also in line with this approach is perhaps one of the points most deviant from Flexner’s model – at Michigan, research is an option and not a requirement, the school offers a first rate research facility but does not require its medical students to do research.
Finally, the University of North Carolina Medical School is a prime example of a refocus on the humanistic objectives of medical education. The competency objectives for graduation include medical knowledge, patient care/clinical skills, intrapersonal and communication skills, professionalism, and managing the health populations. With the belief that mastering benchmarks within these categories will lead to the development of a well-rounded and well-qualified physician, UNC has implemented a curriculum that allows students to meet such requirements and measure their progress along the way.
Other schools nationwide have implemented similar curricula looking to reform medical education and make it more fitting in today’s society. The pioneers of curriculum reform are being followed by other schools using their example and personalizing it further to fit the missions of their individual schools. As we move forward in this era of reform we can expect to see a greater divergence from the standard curricula to more creative and individualized programs of study. It is up to students to identify what they themselves find important about a curriculum and what about various curricula will best allow them to pursue their desired medical careers.
IDENTIFYING GOALS FOR MEDICAL EDUCATION TODAY
In 2010, 100 years after the Flexner Report was published, the Carnegie Foundation for the Advancement of Teaching published another text calling for medical education reform. “Educating Physicians: A Call for Reform of Medical School and Residency,” by Molly Cooke, David M. Irby, and Bridget C. O’Brien, defines the problems and goals of today like its predecessor, the Flexner Report, did a century ago.
Questions to Ask:
- How can we improve medical education?
- Can we produce competent and compassionate physicians more efficiently and effectively?
- How can we reorganize medical education to produce physicians who are able to achieve better health care outcomes for the American people?
Four Goals for Medical Education:
- Standardization of learning outcomes and individualization of the learning process
- Integration of formal knowledge and clinical experience
- Development of habits of inquiry and innovation
- Focus on professional identity formation
THE REFOCUS OF MEDICAL EDUCATION ON CLINICAL SKILLS
While it is unreasonable to expect to perform complex procedures as a medical student, there is great value in early exposure to clinical experiences. Students should be regularly active in clinical work that is compatible with their skill level. To facilitate the development of clinical skills without increasing the risk of treating real patients, many institutions have adopted simulation centers where students have the opportunity to practice their skills in real life scenarios without the chance of making a life threatening mistake. Advancing technology has dramatically improved these clinical skill centers. With these centers and with more feedback from clinical teachers it is easier to make the transition from learning clinical skills to putting them into practice while also enhancing student experiences and patient safety. There is a gradual increase in exposure to patients throughout one’s medical education; if this process begins earlier even with a smaller step, it is likely that clinical skills will be better developed and that students will reach their clinical potential.
DUAL DEGREE OPPORTUNITIES
Combined MD/PhD programs are designed to allow students interested in becoming research physicians to pursue course work and degrees in both medicine and an additional area of interest simultaneously. These additional areas in which student choose to do research are usually connected to human biology and disease which play into their futures as research physicians. Research physicians often spend the majority of their time doing research but are also involved in patient care. Many of the graduates from MD/PhD programs go on to have careers as faculty members in medical schools, universities, or other research institutions. Special financing opportunities are often available for dual degree programs. These opportunities include the availability of stipends and tuition waivers for accepted students.
Although national institutionalization of MD/PhD programs began in the 1970’s, unique opportunities exist within each program. Most programs follow a six to eight year plan where the first two years are devoted to the preclinical part of medical education. The next two to three years are usually spent doing research in a field of the student’s choice. The final two years of the program then make up of the clinical part of medical education. Upon the completion of this course of study students are recognized as both medical doctors and doctors of philosophy.
MD/MPH programs may be the dual degree program with fastest growing popularity, designed to train students to be both practicing physicians and public health leaders. Students in these programs graduate with a medical degree and a master’s in public health. Pursuing an MPH during medical education often means taking a year off before or after the first year of clinical rotations to study at a School of Public Health. This may be at the same university or at a nearby institution. The timing of this break in medical education is determined by the fact that many schools do not accept dual degree applications from pre-clinical medical students. Some students choose to complete their medical education before earning a degree in public health. In that scenario, completing the MPH requirements can be part of residency training or a fellowship program.
There are a wide variety of opportunities available when it comes to dual medical degree programs. At the Vanderbilt University School of Medicine collaboration between the medical school and other graduate programs including the Law School, the Graduate School, the Owens School of Management, and the Divinity School. These collaborations provide students with the option of combining their medical pursuits with another area of interest to further individualize their learning experience, a trend evident throughout modern medical education and its reform.
OSTEOPATHIC VS. ALLOPATHIC MEDICINE: WHAT IS THE DIFFERENCE?
To become physicians, students have two options: become a Doctor of Medicine (MD) or become a Doctor of Osteopathic Medicine (DO). MD schools are accredited by the Liaison Committee on Graduate Medical Education (LCME) while DO schools are accredited by the American Osteopathic Association (AOA). Despite a historical stigma against osteopathic medicine, today graduates of both programs are licensed in all states and students in both schools complete a required residency program. MD’s practice what is known as allopathic medicine and make up the majority of physicians today; however, the number of DO’s is rapidly expanding. Modern osteopathic training is very similar to MD programs but with the addition of Osteopathic Manipulative Medicine (OMM), a type of manual therapy. Additionally, osteopathic physicians are typically taught to think holistically and are trained in osteopathic manipulative treatment (OMT); this may be why a greater percentage of DO’s than MD’s pursue careers in primary care medicine. In recent years however, the trend for osteopathic physicians has been to perform less OMT and to prescribe other, allopathic treatments. The number of osteopathic schools in the United States is growing as the perceived differences between allopathic and osteopathic physicians continue to narrow.
THE HUMANISTIC OBJECTIVES OF MEDICAL EDUCATION
Medical education should prepare students for life as professionals. Professions differ from other careers in that there is a tradition of morality and of the protection of public well-being that is transpired with the practice of specialized skills. In medicine specifically, there are codes of ethics dating back to the days ofHippocrates and the ancient Greeks. There is the idea of professionalism as a catch-all term for virtues like duty, honor, integrity, accountability, and respect. It is only fitting that students studying to enter a professional field be exposed to these kinds of expectations and not only the science of medicine. Lessons in professionalism and medical ethics will help provide the grounding needed to make the complicated decisions they face later on as physicians and should be integrated throughout medical education. Students should also develop strong skills in communication and teamwork to become respected physicians.