Reforming Medical Education
Medical education in the United States, both undergraduate (medical school) and graduate (residency programs) produce highly skilled physicians who excel in practice, teaching, and research. Yet, medical education is in need of reform. Many of the practices and norms date back to more than a century ago – to the Flexner Report, published in 1910 – and have not been updated to meet the demands of modern medicine and society. A few of the most obvious challenges:
Selecting students: Medical school admissions are unfair and select many of the wrong students. Although greater attention has been placed on choosing medical students from diverse backgrounds, students from poor families remain vastly underrepresented. When students from poorer families are recruited, they often struggle due to their level of preparation and lack the resources (financial and otherwise) to support their ongoing education. Talented students are denied admission while lesser ones are accepted. Factors that are critical to gaining admission to medical school are often ones not important for mastering the medical sciences or being a successful physician.
Educating students: Much of the basic science curriculum (both the premedical requirements and preclinical medical school curriculum) is irrelevant to the majority of practicing physicians. At the same time, fields such as statistics, epidemiology, and decision making, critical to the practicing doctor, are underrepresented in the education of physicians.
Promotion and dismissal: Assessment throughout the continuum of medical education is not done well. Students and residents are seldom assessed doing the tasks for which they are being trained. The traditional standardized tests of knowledge, which are themselves flawed, are being abandoned or their importance decreased. Institutions struggle to dismiss or remove the tiny proportion of students who are not suited for medicine. Problematic residents are often passed forward. At the same time, highly talented residents are kept on the same timetable as average ones.
Education vs free labor: While the goal of medical education is to educate the physicians, at times
residents are used as cheap labor. Research years are added to boost the call pool. The final year of medical school is often an expensive vacation. Education could be made more efficient, training better doctors faster.
We asked physicians involved in medical education to comment on these issues (or on others they thought were important). We limited them to 600 words. No author saw another author’s comments prior to posting. Here are the first three. Others will follow in the coming weeks. We hope to post more in the coming weeks. If you would like to add your voice to the conversation, please reach out.
The first proposal comes from Adam Cifu, MD.
Before offering a proposal, I’ll briefly lay out my biases and the observations which underlie it.
· A liberal arts education is valuable physicians (and humans) and should not be sacrificed for medical training.
· The primacy of basic science education (both philosophically and chronologically) undermines clinical reasoning and leads to medical reversal. (See Chapter 14: Ending Medical Reversal).
· Medical school (and the preparation for medicine school) is too expensive. Thus, our current medical students vastly overrepresent the richest of our society.
· Many students are already teaching themselves the basic sciences during medical school (“home schooling”) using commercial products, rather than learning from the curriculum of their home medical school.
· Medical education reform needs to begin during the undergraduate years. The present requirements include coursework of little use to most practicing doctors. (Choose any school on this page).
A proposal:
1) Undergraduate requirement are reduced to include only biochemistry (and undergraduate prerequisites for this course) and data science.
2) The AAMC will produce a free, massive open online course that prepares students for a 3-year medical school degree program. Any student that completes this course, and passes a comprehensive exam, with a high passing standard, will be eligible to apply to medical school. This free exam, produced by the AAMC, will replace the MCAT and USMLE step I. We will call it “The Preclinical Medical Assessment Exam” or PcMAE.
3) Medical schools will accept applicants from the pool of students who have passed the PcMAE during the previous 3 years. The passing score will be high enough to assure that all applicants have the requisite mastery of the medical basic sciences. In addition to a bachelor’s degree and a passing score on the PcMAE, medical schools will base their admission decisions on qualities they see as important to their mission. Is the institution dedicated to training clinicians, academics, researchers...?
4) Medical school will be 3 years. There may be some preclinical work, depending on individual schools’ curricular decisions, but the majority of the curriculum will be dedicated to closely mentored clinical experience and deliberate practice. Without a need to dedicate resources to preclinical education, faculty time will be freed up for clinical mentorship.
5) After the core clinical rotations, there will be specialized basic science experiences. Budding surgeons might do advanced anatomical dissection, future internists and pediatricians might take decision making courses or advanced pharmacology, next generation plastic surgeons would could enrol in wealth management courses (joking...).
6) The Liasson Committee for Medical Education (LCME) would retain the responsibility for accrediting schools but they would not make recommendations regarding curricular elements. Greater variability among medical schools would promote curricular innovation.
7) Assessment within medical school would be pass/fail until the final year. At this time students would be assessed within their field of choice, doing the actual tasks of medicine. Residencies would judge students based on these grades and their Clinical Medical Assessment Exam (CMEA) score.
Impact:
In this system, Students would be free to pursue their interests as undergraduates. Medical school applicants in this system would likely choose to pursue medical school a bit later, helping to assure a better fit with the career. Financial barriers to entering medical school would be lowered and a shortened medical school would be less expensive. Medical schools would have more varied curricula, allowing students to choose the schools that best match their interests and career goals. Schools would provide a generalist education while offering more time to complete coursework useful to a student’s future specialty.
The second proposal comes from D. Rani Nandiwada MD, MSed. Dr. Nandiwada is an Associate Professor of Clinical Medicine from the University of Pennsylvania Perelman School of Medicine in the Division of General Internal Medicine. She is the Program Director of the Primary Care Residency Program, Director of the Medical Education and Leadership track for the Internal Medicine Residency Program and course directs medical student curricula focusing on health system science. Her teaching interests are in teaching to teach, health systems science, and coaching from good to great.
Recently, assessment strategies in undergraduate and graduate medical education have used standardized tools to ensure at least minimal competency among our youngest physicians. This form of assessment promotes a culture of perfection and a fixed mindset that highlights the extremes but overlooks the 90% of students and trainees who are doing fine.
It is important to ensure there is minimal competence and to seek out our struggling learners to give them support. However, only a minority of our learner’s struggle. Once minimal competency is met, we have only limited educational strategies (and faculty development to support these strategies) to coach learners toward excellence. We are fortunate that many students are smart enough and work hard enough to become competent physicians with minimal intervention. But should we not be striving for more than competence?
Our current assessment strategies, which is often comprised of short, isolated activities, creates an environment where a student who starts at a lower level than his or her peers is evaluated as lessor even if he or she grows to an equal level of success. We judge students at intervals in clerkships with evaluators who have different assessment skills and limited training in coaching students to their level. If medical school was truly interested in cultivating excellence and encouraging students to achieve a growth mindset, we would coach medical students as we do athletes. There would be deliberate practice, critical and continuous feedback, and reflection to ensure improvement beyond minimal competency. Students would become master adaptive learners constantly assessing themselves and looking to faculty for areas in which to grow. These aggressively-coached learners would be a stark contrast to out presently constantly-assessed students who fear feedback and attempt to hide their areas of weakness lest their weaknesses may make them seem inferior to their peers. In an environment of intensive coaching, we would identify struggling learners organically rather than having to hunt for those who hide their needs.
Coaching to excellence rather than assessing for attainment of minimal competency challenges our medical education culture in many ways. First, there is the assumption that coaching is is expensive. This assumption is true for struggling learners. For successful else, coaching is just a different way of interacting -- focusing on goals and action plans without the costs that come with remediation. Second, such a change would create challenges for program directors. During recruitment, how does one distinguish which candidates are truly a good fit for your program. If moving to an educational system focused on coaching means abandoning traditional grades (which currently have limited ability to meaningfully distinguish one learner from another), we would need to create a new dossier for applications to residency. This dossier would outline strengths, areas for growth, and ability to incorporate feedback. Educators could also look to the evaluate the more complex skills that are part of being a physician. How talented are students in realms such as leadership, the incorporation of social determinants of health into care, systems thinking, interprofessional interactions, teamwork, and growth mindset. It would even be important judge students differently depending on their career goals. Students focused on future clinical work would need to be evaluated and trained differently than those considering a career in research. Same for students whose careers will be focused on medical vs. surgical specialties or inpatient vs. outpatient. Educators would need to tailor skills training and areas of assessment to career trajectory.
Finally, a proposal from Vinay Prasad, MD, MPH.
Medical Education is highly suboptimal. We squander years, teach basic science esoterica, and do an awful job at preparing doctors to be critical readers of medical science. What makes it unbearable is that each year there is nearly no substantive effort to improve. We make superficial changes—step 1 is now pass fail—but don’t address the root of the problem—step 1 assesses largely useless content knowledge. I say this to acknowledge that there is no way to fix all the problems of medical education in 600 words, but here I will make 2 suggestions.
Content suggestion
The content of medical education needs complete revision. Memorizing the isoforms of RNA polymerase or the Kreb cycle is a fools’ errand. I have prescribed both FDA approved isocitrate dehydrogenase inhibitors many times, and drawing out the cycle is not necessary to do this appropriately. Meanwhile, we face a crisis of poor reading of the medical literature. Doctors do not know when randomized trials are feasible, practical or necessary. Doctors believe that mannequin mask studies can inform year-over-year public policy. Doctors don’t understand what a p-value is, or a power calculation. They have no sense for how to interpret subgroups or how to think about multiplicity. These latter skills are necessary every single day in clinical medicine as we apply the latest studies to the people in front of us, yet they are poorly taught, if at all.
When it comes to content, we need a group of thoughtful, practicing doctors with methods experience to re-design the curriculum based around day-to-day medical decision making. Twelve years ago, when I was still a young man, I wrote this proposal: Beyond storytelling in medicine: an encounter-based curriculum; I still think that roadmap is correct. (Link)
Process suggestion
My process suggestion would be for medical education to be competency based and not time based. Not all trainees grow at the same rate. Some core knowledge, assessed via standardized exam, is necessary to master. But students should be able to decide when they wish to take these tests, and having passed them, advance to the next level. Instead of tying the star students to the weakest ones, we should allow people to move at their own pace. Some great doctors might need a few extra years to master the basics, and others might move fast initially, but slow later. Education should permit learners to grow at their own pace.
Students who get stuck, repeatedly, might wish to drop out of medical school, and perhaps their tuition debt can be partially waived to make this more feasible. Moreover, given that there are roughly 10,000 more residency spots than medical school spots in the US, this proposal could also coincide with a widespread expansion of enrollment. Each year many talented young people in America are denied the chance to develop into a doctor. My proposal would give more people a chance, and also permit more people to drop out (also a need in medical education).
In conclusion, the two greatest threats I see in medical education is that the content trains doctors to overly rely on reductionism, and not empiricism, and the process wastes the time of the talented, and promotes many who are not ready. My solutions are to re-engineer content, and have more flexibility in advancement.
 | A guest post by
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I am a tenured full professor and have been teaching/practicing for decades. While I would not disagree that updates to curricula and approach are always meritorious (more on that below) I respectfully disagree with major tenets here.
1. I have seldom, going back decades, seen underfinanced students excluded because they "could not afford" medical school. We were among the first schools (in the 1970s) to specifically recruit from HBCUs to make sure that we were not missing students who could otherwise be potentially great physicians but could not pay (I made some of those visits myself). Every school of my acquaintance has plenty of scholarships, loans and grants for those who have trouble paying. Some even cover all tuition for all students. This is just a distractor and often a trope to obscure other matters.
2. As other commentors have noted, there is a social engineering component introduced into medical education over the last five years that is substantially deprecating the quality of applicants and, almost certainly, the quality of the physicians we are putting out. Primarily selecting students by their demographics, how many hours of pushing wheelchairs they did, and their social justice warrior scores and compliance almost guarantees bad physicians. Across the medical schools with which I am involved (either directly or tangentially) student essays and interviews often dwell on how they want to use medicine to cure the world's social ills, rather than taking care of patients. The idea that medicine is fundamentally an interaction between patients and their physicians seems completely foreign to where they want to go. Few want to be the "best doctor providing the best care" they can be as their primary motivation. Rather it seems a well-paid stepping stone to more social justice warrior-ing and this pattern continues through their medical school tenure.
3. Because we are accepting less qualified students, we have all been forced (word deliberately chosen) to remove all of the measurement tools that we used to, at least, note who was learning and how well. So no more grades (might make someone in the class sad and/or demonstrate that some are better than others), no more scores on USMLE Part I...the list of watering down the validation of learning is long and getting longer. The LCME and their effort to change medical education to something barely related to medicine is a major driver of this. The authors above suggest that we should use "coaching to excellence" which returns to the pre-Flexner days of hocus-pocus completely subjective evaluation of students. I am not even going to go down that rat hole. Of course we should coach our students to excellence, but that is in a very, very different category than measuring excellence. I think all of us that went through medical school can remember attendings that loved us no matter how badly we screwed up and those that hated us no matter how good we were. Part of life, but a bad predicate to being our measurement standard.
4. There is a substantial difference between being a physician and being an NP/PA that the authors seem to mostly ignore. Not to take anything away from the support practitioners, but they already get the education mostly being advocated here -- focus on signs and symptoms and quick diagnoses/cures without much focus on the whys and wherefores. There is an important place for this kind of approach -- but it is not for physicians. I am a hematologist and when I lecture about megaloblastic anemia and its many twists and turns I spend considerable time with concepts from biochemistry, microbiology, histology and pathology. I could not possibly include this information de novo in my lectures -- if not grounded in all these areas, the relevant content would not be taught.
One could still become a check off the boxes kind of provider (coached to excellence in checking off boxes, I suppose). That is not the physician's role. SOMEONE needs to be able to understand what they are seeing beyond signs and symptoms. By discarding all of this, you deprecate the physician's role to that of Epic slave...just like many other health care workers.
5. There is no question that even with the above there is too little time spent on learning to be inquisitive and to question everything. The blind acceptance of the AAPs disastrously wrong diktats in support of the governments disastrously wrong diktats vis-à-vis Covid underscores this well, to the greater detriment of thousands of children. The recent passage of the California law that delicenses physicians who disagree with the government diktats ("Oh, they are experts."...BS) and have the temerity to tell their patients that they do is a further example of how obsequious and unquestioning the general physician population has become. If one is not primarily interested in caring for their patients but rather in supporting whatever party is leading in your social justice warrioring irrespective of their patient-immolating diktats (about which Vinay has written often) then patients suffer. In my opinion this is always wrong. Teaching physicians how to read literature and to question what they read should be high on the hit parade as a prerequisite for graduation. Requiring biostatistics and understanding scientific literature should be a preadmission requirement to medical school. You can be sure that the colleges would jump to offer this if required.
6. The idea of having competence-based progression through school is sound; some do learn faster/better than others. I have also seen the flip side of this -- students who were still there taking resources literally seven years later, still failing to meet the minimum standards. And no one should get out of school after six months because they can memorize things quickly. So this needs some deep thinking to do effectively.
Medical education is inherently difficult and is supposed to be -- one is taking others' lives into one's hands and there are few greater responsibilities. Flexner started the move toward making the selection of those for this profession more objective and more based on understanding health and health care, patient by patient. Recent deprecations of this are not good for the profession or, more importantly, for patients.
There are large numbers of current medical school graduates that I would not let care for me. Enough said.
As a non academic surgeon who works internationally in a developing country medical education should include nutrition and public health. It’s construct should be system based where students learn about let’s say: the GI system from anatomy, histology, pathology, pharmacology and to prevention. We put way too much emphasis on illness and disease treatment and not enough on disease prevention.
I hope physicians who are not working in academic institutions weigh in here.