Guide to Medical Education in the Teaching Hospital - 5th Edition

By Association for Hospital Medical Eduation

This fifth edition of the Guide to Medical Education in the Teaching Hospital provides an overview of topics across the medical education continuum that impact hospital medical education. With 43 chapters, the Guide is both a primer for the day-to-day challenges of delivering quality medical education and meeting accreditation standards, and an

• Language: English
• Publisher: Association for Hospital Medical Eduation
• Release date: Jan 11, 2019
• ISBN: 9780578429328

Book preview

CHAPTER

1

The Making of a Physician in the 21st Century: The Education Continuum

Ellen M. Cosgrove, MD

Ellen M. Cosgrove, MD, is Vice Dean, Academic Affairs and Education, University of Nevada, Las Vegas School of Medicine, 1001 Shadow Lane, Las Vegas, NV 89106; [e-mail]

What do we want our doctors to be? All human societies face the problem of diagnosing and treating illness, but not all healers are doctors or professionals. We will all be patients at some point. For the very fortunate, this will be limited to encounters for wellness, prevention, and major physiologic events such as the birth of a child. For many, it will be a mix of these plus acute care visits for limited episodes of illness. For others, the chronic diseases take their toll and result in many more experiences of being a patient. For some with severe chronic illness, becoming a patient becomes a condition of life. For some, truly tragic events such as major trauma, a cancer diagnosis, or a life-threatening disease results in an intense and often frightening patient experience. At these times, what do we want our doctors to be? Certainly, we expect our doctors will have expert knowledge and skills. But we expect much more than expertise. We expect doctors to be caring, compassionate, understanding, team players. As a society, we expect even more than that. We expect doctors to put their patients’ interests above their own self-interest.

MEDICINE AS A PROFESSION

Four characteristics give Medicine special status as a learned profession: a specialized body of knowledge; relative self-regulation in practice; altruistic service to individuals and society; and the responsibility for maintaining and expanding the knowledge and skills needed to practice.¹ This social contract gives medical faculties the power to accept and train students and test them in the way they see fit, and it gives society the power to trust physicians with their care.² What we expect of the medical profession has shaped medical education in the past century.

Abraham Flexner addressed the first of the four attributes of medicine as a profession: the specialized body of knowledge, the issue of physician expertise. His selection of the Hopkins model as the basis for accreditation assured that American medical education would have a firm foundation in the biomedical sciences. In so doing, he raised the quality of medical education and medical practice; he also set the stage for what became a defining paradox of medical education in the second half of the 20th century. The paradox is that doctors must simultaneously balance a reductionist, scientific view of illness with a constructivist, patient-centered approach. George Engel was an early pioneer in enlarging the definition of expertise with the biopsychosocial model which recognized the importance of factors beyond biology in the patient’s experience of illness and healing. Closely aligned with the incorporation of psychosocial factors was the growth in recognition of the importance of communication skills for physicians. Thus the stage was set for the changes in medical education in the latter half of the 20th Century. Physical diagnosis courses transformed from skills training in examination techniques to include formal training in communication and then transformed again to ‘doctoring’ courses that include substantial self-reflection.

Applying cognitive science of how people learn and change led to adoption of student-centered approaches such as problem-based learning in undergraduate medical education, deliberate practice approaches in graduate medical education, and the movement toward practice-based learning for interprofessional teams in continuing medical education.

PROFESSIONALISM

Answering this question, What do we want our doctors to be? is at the heart of what has come to be called Professional Formation, a term used in the religious realm to describe the deliberate process of education and experiences through which a lay person grows and changes to develop the identity of a clergyperson. Using the vocabulary of Formation acknowledges with Frederic Hafferty that, Medicine is a moral community, the practice of medicine a moral undertaking, and professionalism a moral commitment.³ The importance of the commitment of the medical profession and medical education across the continuum to professionalism cannot be overstated. Along with a foundation of knowledge, medicine as a profession must transmit the values to the next generation of doctors and must nourish and sustain these values over a lifetime of professional practice.⁴ A good doctor does the right thing, at the right time, for the right reasons—even when nobody is watching. But this is not a static achievement. Professionalism must be fostered and developed. Once developed, it must be actively maintained. Both experience and reflection are required to achieve and maintain the highest level of professionalism.

Reflection is a key skill and an important theme in the literature of professionalism. Becoming self-aware enhances one’s own professionalism as well as that of the students at every level. Noting that self-reflection is a skill that faculty must model, Jack Coulehan observed that the essence of professionalism is really about change and growth throughout physicians’ professional lives.⁵ When faculty acknowledge competing interests and values and thoughtfully consider alternative courses of action with their students and residents, they teach a more powerful lesson in professionalism. In particular, such reflection with learners helps in the analysis of those difficult, real-world decisions where values clash and there is no easy ‘right’ answer. Faculty can help trainees to incorporate an analysis of the context of the situation as well as an analysis of their own behavior into self-assessment.

COMPETENCIES

But what of medical education in the 21st Century? How will we answer the question, What do we want our doctors to be? The new millennium began with the transformative paradigm shift in graduate medical education accreditation from process to outcomes measured by competencies. David Leach led the Accreditation Council for Graduate Medical Education through the period of defining, adopting, and disseminating the Six General Competencies for physicians: medical knowledge; patient care; communication skills; professionalism; practice-based learning and improvement; and systems-based care. These same competencies were adopted by the American Board of Medical Specialties. They have come to serve as the foundation for planning curriculum and assessment across the continuum. Advantages of this approach include the focus on the learner - not teacher/syllabus, the possibility for innovation and flexibility in curriculum, and more integrative thinking. These advantages are just starting to be appreciated and developed in the second decade of the 21st Century. The power of the competencies to individualize assessment is being developed with the milestones approach in Graduate Medical Education. Over time, use of the milestones has the potential to foster a much more individualized approach to residency training.⁶ Similarly, a competencies approach is being widely adopted in undergraduate medical education. Innovative medical schools are developing more flexible curricula and giving students the ability to individualize their educational program as long as they demonstrate that they achieve the competencies. The work now underway to define, adopt, and disseminate a set of Entrustable Professional Activities which medical schools will certify that all their graduating medical students possess has the potential to transform the transition from medical school to residency.

FUTURE DIRECTIONS

And what are the implications for medical education in the shifting paradigms in health care itself? The integrated health system model is highly cost-sensitive. Of necessity, it has more ambulatory focus and attention to chronic care. This will necessitate a shift to new models of medical education that are genuinely longitudinal and much more community-based, with continuity of patients, curriculum, teachers and sites.⁷ The emphasis on continuity highlights the importance of relationships. Relationships are the heart of the practice of medicine and medical education across the continuum. The doctor-patient relationship, the doctor-student relationship, and team relationships are important. There is an increasing understanding that these individual relationships are but one part of a larger picture which recognizes the role of physicians individually and collectively through institutions such as medical schools to the communities they serve. This perspective is the Symbiosis model of medical education,⁸ which recognizes that during their clinical training the learners’ relationships with their patients, their clinical teachers, their program, and the community are key. Studies to date demonstrate that medical students are fundamentally changed by experiencing longitudinal integrated clerkships. Many emerge transformed at a very human and personal level; this transformation is recognized and valued by their clinical supervisors.⁹

We in medicine must be accountable to our patients, our communities, and society at large not only for our student and resident outcomes, but also for our own outcomes as we grow and change as professionals throughout a lifetime of practicing medicine and a lifetime of teaching medicine. Through our answer to the question, What do we want our doctors to be? we just may find the answer to the question, What do we want our society to be?¹⁰

REFERENCES

1. Gruen RL, Arya J, Cosgrove E, et al. Professionalism in surgery. J Am Coll Surg. 2003; 197(4): 605-8.

2. Cruess R, Creuss S, Johnston SE. Professionalism and medicine’s social contract. Bone Joint Surg Am. 2000;82: 1189-94.

3. Hafferty F. Professionalism - the next wave. NEJM. 2006; 355.

4. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.

5. Coulehan J. Today’s professionalism: engaging the mind but not the heart. Acad Med. 2005;80: 892-898.

6. Nasca TJ, Weiss KB, Bagian JP, Brigham TP. The accreditation system after the next accreditation system. Acad Med. 2014;89(1): 27-9.

7. Hirsh D, Ogur B, Thibault G, Cox M. New models of clinical clerkships: continuity as an organizing principle for medical education reform. NEJM. 2007;256: 858-66.

8. Prideaux D, Worley P, Bligh J. Symbiosis: a new model for medical education. Clin Teach. 2007;4: 209-212.

9. Hirsh D, Walters L, Poncelet AN. Better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships. Med Teach. 2012;34(7): 548-54.

10. Hirsh D, Worley P. Better learning, better doctors, better community: how transforming clinical education can help repair society. Med Educ. 2013;47(9): 942-9.

CHAPTER

2

Academic Medicine and the Physician Workforce

Joanne M. Conroy, MD

Cori E. Ast, MHSA

Darrell G. Kirch, MD

Joanne M. Conroy, MD, is Chief Executive Officer, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805; [phone]; [e-mail]

Cori Ast, MHSA, is Senior Director, Executive Activities, Association of American Medical Colleges, 655 K Street, NW, Suite 100, Washington, DC 20001; [phone]; [e-mail]

Darrell G. Kirch, MD, is President and CEO, Association of American Medical Colleges, 655 K Street, NW, Suite 100, Washington, DC 20001; [phone]; [e-mail]

In 2016, the United States was home to 145 medical schools and more than 1,100 teaching hospitals. These institutions are home to more than 148,000 faculty who train more than 83,000 medical students and 115,000 resident physicians each year.¹ Collectively, these institutions and individuals comprise academic medicine in America and are united in their efforts to carry out the missions of education, research, patient care, and community service. Though each institution is different in organizational design and approach, each remains steadfast in its commitment to educating the next generation of physicians and biomedical scientists, enhancing biomedical knowledge to discover life-saving treatments and cures, and providing patient-centered, cutting-edge care.²

With health care reform taking center stage in the United States, academic medicine faces a growing urgency to prepare future physicians for the changing and, in some cases, undefined needs of a diverse society.³-⁵ Increasingly, policymakers and the public are looking to academic medicine to lead in shaping a health care system that responds to changing demographics, continues to provide high-quality care, and educates health providers for a lifetime of continuous learning focused on patient-centered care, quality improvement, chronic condition management, and coordination of care across settings.⁶ These stakeholders also expect that new doctors will be working within a system that emphasizes disease prevention and efficient resource management rather than focuses primarily on acute illness.⁷

The push for academic medicine to take the lead in transforming the health system is not new. In fact, academic medicine has risen to the challenge in previous eras. Nearly a century ago, when both the quality and consistency of the American medical education experience came under sharp public criticism, medical schools made dramatic changes in undergraduate medical education (UME) in response to the recommendations made in the landmark Flexner Report (Medical Education in the United States and Canada).⁸ Fifty years later, when the turbulent 1960s saw an expansion in scientific knowledge and a need to significantly increase the physician workforce, academic medicine answered with the Coggeshall Report (Planning for Medical Progress Through Education).⁹ This report led to a new focus on health services delivery, contributed to the standardization of graduate medical education (GME), and accelerated the pace of health system change.

When compared with the drivers for change in the early and mid-twentieth century, the forces at work today are largely external (i.e., involving financing, emerging public health needs, and workforce planning) rather than internal (i.e., the result of critical self-evaluation within academic medicine).¹⁰,¹¹ Today, there is a clear and resounding call for academic medicine to demonstrate how it is preparing a physician workforce for a health care future that is only beginning to be defined. Now, as then, academic medicine is ready to respond to public concerns and address the tough questions it faces, as exemplified by the community’s willingness to leverage its valuable health care expertise and limited resources.¹²

This chapter examines academic medicine’s ability to embrace these challenges and utilize innovation as a source of continuing improvement. We present a discussion of key changes in medical education and training over the last 120 years, with particular emphasis on how those changes strengthen the physician workforce. The chapter concludes by identifying barriers to accelerating the pace of change and highlights opportunities for continued improvement.

EMBRACING CHALLENGE IN THE EARLY TWENTIETH CENTURY

At the dawn of the twentieth century, there were 170 medical schools in the United States and Canada; by 1935, only 87 M.D.-granting institutions remained.¹³,¹⁴ In the intervening years, academic medicine addressed longstanding issues of quality, standardization, and resources, while it concurrently aligned medical school curricula with the substantial advancements being made in the sciences. These changes were critical to establishing and maintaining the credibility of the physician workforce.¹⁵

In the early 1900s, the medical profession and medical education enjoyed great autonomy, operating with little or no oversight. During this time, educator Abraham Flexner conducted an exhaustive analysis (sponsored by the Carnegie Foundation for the Advancement of Teaching) of the state of U.S. medical education. The Flexner Report revealed that medical school infrastructure was not standardized, with many facilities justly described as wretched and filthy, and lacking faculty and/or adequate clinical material. The report recommended that physician training be improved by adherence to scientific methods and the affiliation of medical schools with universities.⁸

Within three decades of the report’s issuance, more than half of the medical schools ceased to exist because of failure to meet the standards of both the Council on Medical Education of the American Medical Association and the Association of American Medical Colleges (AAMC), the two bodies that inspected medical schools in the post-Flexner era.¹⁶,¹⁷ By 1935, the vast majority of the 87 surviving M.D.-granting institutions were associated with a university.¹⁴ The medical education community, by taking these dramatic actions, had demonstrated clear acknowledgement of public concern. It also had shown a willingness to embrace the role of medical education in creating and maintaining a high-quality physician workforce by reducing the tremendous variability in the expertise of medical school graduates and improving the quality of the education they received.

MID-CENTURY AND THE COGGESHALL REPORT

While the Flexner Report’s impact was far reaching, medical education and the medical profession itself faced a new set of challenges as America neared the half-century mark. The Great Depression magnified the usual challenges of providing health care and generated new public health concerns because many patients lacked ability to access and/or pay for the rapid introduction of new technologies and medications. These challenges encouraged a radical transformation in the U.S. health care system—the proliferation of acute care facilities (spurred by the 1946 Hospital Survey and Construction Act, known as Hill-Burton, Pub. L. 79-725), coupled with the introduction of new payment mechanisms (e.g., insurance products and employer-based offerings) to support the cost of hospital care. An explosion of clinical applications was made possible by biomedical research. This was matched by increased access to tertiary care, which resulted in improved quality of life and longevity.

Consequently, public expectation and demand for physician services began to exceed the physician workforce supply and require appropriate mechanisms for payment. As hospitals began to more aggressively manage the critically ill around-the-clock and the profession recognized the future increase in demand for specialty care, hospital-based internships and residencies were born to support the effort, and the foundation to support GME was laid.¹⁸

In order to investigate and document the ability of U.S. medical education to meet these challenges, the AAMC enlisted the expertise of Lowell T. Coggeshall, M.D., to survey academic medicine, which was, as identified by J.D. Howell, seen as devoid of influence and failing to lead the public debate on national health policy.¹⁹ The resulting Coggeshall Report identified 12 important trends in health care, and described the role that academic medicine (as led by the AAMC) should play. In the report, Coggeshall advocated that medical education should pay increased attention to the needs of the public and improve the delivery of health care services. He also recommended that medical education be a coherent continuum that included residency training. In less than two decades, the number of residency programs within accredited teaching hospitals associated with medical schools increased significantly; from less than half in 1965, to more than 90 percent in 1980.²⁰ Coggeshall also recognized early on that the team approach to medical care was a paradigm for the future. In its entirety, the Coggeshall Report highlighted the role academic medicine should play in addressing public and professional concerns.⁹

EMBRACING CHALLENGE TODAY

Academic medicine continues to assess its own capacity to meet rapidly changing health care needs.²¹ During the last half of the twentieth century, a new set of factors has converged to test academic medicine, including the emergence of new medical specialties and an explosion in growth of related industries, such as pharmaceuticals and medical devices. Health care itself has become both a large employer and an industry driven by a payment model based upon reimbursement for units of care and procedures. This particular change, in turn, has meant the emergence of health care as a business; one that now represents more than 17 percent of national gross domestic product.²² Health care’s enormous growth also spurred the growth of academic medical centers (AMCs). From 1960 to 2011, as the U.S. population increased by 72 percent, the number of full-time clinical faculty increased by 1,500 percent.²³ Given this unprecedented growth, AMCs have become not only large institutions that provide critical services to their communities, but also major employers in their regions.²⁴

Against this backdrop of change, academic medicine has been quietly, but deliberately, evolving medical education and practice. As academic medicine has been responding to changes in its external environment, it has been undergoing profound culture change,²⁵ focusing not only on what students learn, but the more interactive process of how they learn (instead of what they are taught). Further, in a world focused on the business of medicine, academic medicine has worked continually to preserve its commitment to professionalism. One of the key tools academic medicine is employing to shape the behavior and practices of physicians is through the identification and implementation of competencies essential to health professional training.²⁶ In 2004, the Accreditation Council for Graduate Medical Education (ACGME) introduced six core competencies, which serve to ensure that students are better prepared to be life-long learners in an environment that is undergoing rapid change.²⁷

Additionally, as patient care has migrated from in-hospital to ambulatory settings,²⁸ medical education has mirrored this trend by training increasing numbers of students and residents at alternate sites. Further, in response to the increased national focus on the prevention of medical errors, educators have integrated patient safety and quality education into the core competencies for undergraduate and graduate educational experiences.²⁹

Other factors related to academic medicine’s research mission also have led to a dramatic change in medical practice. These factors include the evolving nature of molecular research, the development of new drugs and devices, genomics, and the often symbiotic, but potentially conflicted, relationship between academic medicine and industry.³⁰-³² Together, these factors have engendered a transformation in medical school department structures (i.e., how basic and clinical sciences are aligned to educate and deliver care), as well as a change in how, where, and when medical educators teach students and residents in basic and translational biomedical science.

Today, academic medicine continues to struggle with how to financially support an educational and research enterprise that is no longer self-sustaining (i.e., without additional internal cross-subsidy or external support). In an age when the medical profession must be concerned with diminishing resources, the overall impact of this dynamic is substantial and far-reaching. Large cross-subsidization from the clinical enterprise is being calculated and questioned. Many institutions are experiencing dramatic and painful metamorphoses of their organizations, and are struggling to meet their mission.³³ Collectively, these also present challenges for the physician workforce of today and the one of the future.

EXAMINING THE PHYSICIAN WORKFORCE

In 2013, more than 829,000 licensed physicians practiced in the United States, of which 89 percent reported patient care as their major professional activity.³⁴ Females made up about 33 percent of active physicians, and 42.2 percent of active physicians were ages 55 or older.³⁴ Each year, approximately 27,000 join their ranks by entering their first year of residency.³⁵ Unfortunately, the current training rate of physicians in the United States will not be enough to meet health care demand in the future.

In the coming decades, the American population is projected to expand, diversify, and age.³⁶ The Affordable Care Act has increased access for millions to affordable health insurance, and with it, the expectation of access to affordable health care. Collectively, these factors contribute to a groundswell in demand that will be impossible to meet with the current physician supply pipeline, which is stymied further as more physicians retire.³⁷ The current nationwide physician shortage is projected to become more acute, with the AAMC estimating that the U.S. could be short more than 100,000 physicians in the coming years.³⁸

GROWING GRADUATE MEDICAL EDUCATION TO MEET DEMAND

Though academic medicine is working diligently to mitigate physician shortages and enhance quality with transformations in care delivery, including ensuring that all members of the health care team are performing functions at the top of their license, it is too early to know if such transformation will offset the new demand.³⁹ The number of students enrolled in undergraduate medical education per capita has increased significantly, but the number of students enrolled in graduate medical education per capita has remained essentially flat.⁴⁰ The United States will need to train more resident physicians to meet demand, but increasing the number of residency positions has proven extremely difficult, in large part to a cap on federally-funded residency positions enacted by Congress in 1997 by the Balanced Budget Act.⁴¹

Graduate medical education is a critical component to training highly skilled physicians, but it also comes at a significant cost. Though the financing of GME is extremely complex, current estimates for the direct costs of the United States’ graduate medical education (such as stipends for trainees, faculty supervisors, equipment, and salaries for administrative staff) are more than $16 billion annually. Medicare is the largest single financial supporter of GME, providing an amount of about $3 billion annually. Medicare financing partially offsets the federal government’s share of training costs, as well as supports the additional costs of teaching hospitals, which often disproportionately provide high-acuity services, such as burn units and neonatal intensive care units, that are essential to the health of communities. For example, teaching hospital members of the AAMC, which make up only 5 percent of all U.S. hospitals, provided 37 percent of all charity care in fiscal year 2012. Without additional financing, there is little incentive for academic health centers to bear the full expense of additional residency trainees, so the challenges to expanding the number of physicians in the United States will persist.⁴²

CULTIVATING A SKILLED PHYSICIAN WORKFORCE

The United States physician workforce is both a question of quantity—will there be enough physicians?—and quality—will they be effective? Academic medicine accepts its role in leading on both fronts. Institutions are working diligently to ensure physician trainees are equipped today to practice in tomorrow’s health care environment. These efforts begin prior to admission and extend well into physician practice.

Increasingly, the medical education community has recognized that cultivating a skilled physician workforce begins with ensuring that those who begin the training have the full range of abilities to become proficient physicians.⁴³ There is growing consensus that being a good doctor is about more than scientific knowledge—it requires an understanding of people. Because test scores alone do not show which aspirants have the ability to live the humanistic qualities of medicine, many medical schools are adopting a holistic review approach to their admissions.⁴⁴ Holistic review encourages admissions officers and institutions to use a wide range of tools to identify students who have the attributes, experiences, and cognitive abilities to become outstanding humanistic physicians and leaders in their field. These efforts are being further complemented by a redesigned MCAT exam, which, beginning in 2015, includes a section on social and behavioral health, as well as questions that examine the problem-solving and knowledge application abilities of aspirants.⁴⁵

Preparing the physicians of the future means helping students apply their knowledge to improve patient care. To achieve this, training is increasingly being conducted as part of an interprofessional, collaborative approach.⁴⁶ An increasing number of AMCs are implementing programs that effectively use a team-based philosophy, and are doing so in a variety of ways: from outpatient clinics that use the medical home model⁴⁷ to inpatient settings with coordinated intensive care unit teams. For all the professions serving on these teams, educational programs and assessment tools have been revised to reward not just knowing the answer, but also knowing how or where to find the answer.

Further, because scientific knowledge is growing exponentially⁴⁸ and learning is continually evolving, medical education must instill in doctors the principle that learning and self-improvement are continuous processes throughout an entire medical career. Whether training professionals who engage almost exclusively in research, those who primarily translate medical discoveries to the bedside, those who will have the combined roles of care providers and educators, those who are exclusively clinicians, or those who become health care administrators, academic medicine must build the educational infrastructure that helps all students continuously improve their performance.

This principle is being reflected in curricular changes and in the implementation of innovative learning approaches. For example, students must demonstrate the ability to self-evaluate their own practice patterns and make meaningful changes in their practice; to investigate and evaluate their own interaction with patients; to appraise and assimilate scientific evidence; and to improve clinical outcomes and the overall quality of care they provide to patients. With regard to the core competency of communication and interpersonal skills (taught explicitly at nearly every medical school), students learn to view matters through the patient’s eyes and consider the familial, lifestyle, socio-economic, and other factors that may influence patient behavior and/or effect care. As outlined by the ACGME, students are required to demonstrate that they can deliver patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.²⁷

Additionally, courses in cultural diversity are helping students appreciate how cultural differences may affect patient care. With less than 45 years until the projected U.S. population flips, when minority populations become the majority,⁴⁹ cultural competence is an increasingly important factor in the doctor-patient relationship. Additionally, many undergraduate and graduate medical education programs teach students and residents how to involve a patient’s family as part of the care team (e.g., obtaining informed consent from a family member). Most important, students are required to demonstrate professionalism, ethical and respectful behavior, and skills for effective communication.

Beyond the continual pursuit of knowledge and the ability to effectively communicate with patients, it is essential that physicians have knowledge of systems-based practice and be able to demonstrate the responsible use of resources in the larger context of health care. Being a doctor today requires the ability to interact with health care systems. In this evolving competency domain, students must learn how to work in a complex health care environment with attention to the value equation in which cost, quality, access, and the patient experience are all interconnected. In a truly patient-centric model, it is the patient who ultimately determines whether the care provided has been valuable.⁵⁰

HAS ACADEMIC MEDICINE DONE ENOUGH?

Despite a rich history of accomplishments, many challenges remain for medical education and academic medicine. As observed by Swick: The leaders of academic medicine must continue to engage in a dialogue with the broader academic community, the government, the public, and the health care industry.⁵¹ This dialogue, explained Swick, should emphasize three elements: (1) managing change rather than resisting it … (2) making academic medicine’s case with many constituencies, such as the health care industry, government, and the public; and (3) fostering professionalism by increasing medical schools’ emphasis on this task, by ensuring that schools keep an appropriate balance between the science and the art of medicine, and by having faculty model appropriate professional values for their students.⁵¹ Academic medicine has made tremendous progress in each of the areas defined by Swick. Moreover, it continues to undergo transformative change by responding to emerging issues such as continuing disparities in care,⁵² variations in the costs of care,⁵³ and escalating health care spending.⁵⁴

Another set of challenges relates to quality and patient safety, as identified by organizations such as the Institute of Medicine.⁵⁵,⁵⁶ As in Flexner’s time, the speed at which initiatives have been adopted by organizations to address these issues has been variable. Some attribute this variability, in part, to the financial exigencies of teaching hospitals, which have led to greater focus on clinical productivity to the detriment of the educational enterprise.⁴¹ However, such a focus is unsustainable in the long run. To be successful, as Snyderman and Williams argued, academic medical centers cannot simply focus on improving the management of the clinical services provided, but also must change the ways in which they provide clinical care.⁵⁷

Clearly, more remains for academic medicine to do in preparing a skilled physician workforce for an uncertain future. Payers are demanding that medical education be redirected toward a system-based care philosophy where the value equation of cost, quality, and access is imperative.⁵⁸-⁶⁰ Variability in quality, coupled with an unsustainable rise in health care costs, has led to greater calls for accountability regarding both medical education and clinical care.⁶¹ Further, the nation continues to struggle under the burden of ongoing racial and ethnic disparities in health status and health care access, combined with rapidly growing ranks of patients with chronic illness and disability.³⁶,⁶²

Despite significant progress and forward momentum over the last two decades, public pressure necessitates asking whether the improvements academic medicine has made to date are adequate. Some believe that society’s needs, as well as economic and political pressures, demand a reevaluation of the current educational process along the same lines as the Flexner and Coggeshall reports. But is it a total overhaul of medical education that is needed, or should academic medicine instead focus on accelerating, and making more visible, those changes already underway?

MOVING FORWARD

Though there is debate over the extent to which medical education should change, there is broad consensus within the medical community about what medical education and training must accomplish. These imperatives include: (1) responding to developments in a health care system growing increasingly more complex; (2) aligning with society’s needs and expectations; and (3) preparing students for a lifetime of continuous learning and development in anticipation of a future that is as exciting as it is uncertain.

At the same time, and on a broader scale, there is public and political recognition that health care remains inaccessible for many Americans, be that due to prohibitive costs,⁶³ sociocultural factors,⁵² or inability to find a physician within their region.⁶⁴ Fortunately, the transformations resulting from the Affordable Care Act are increasing access, but challenges still remain. It is here that academic medicine’s critical role in supporting and encouraging transformation—and preparing future physicians to do the same—becomes especially important.

Yet even as academic medicine strives to address these systemic issues, another question looms large. How rapidly can the nation be expected to introduce and/or adjust to changes to a system of medical education and care delivery that, though imperfect, provides health care to millions of Americans? Of necessity, a successful, sustainable change process entails a series of phases that require considerable time and effort.⁶⁵ Flexner’s report resulted in recommendations that were implemented over 20 years; Coggeshall’s required 15 years to take shape. Academic medicine’s challenge will be to rapidly and effectively leverage the current sense of national urgency and to help craft a powerful vision for the future of health care, while promoting, communicating, and then anchoring the emerging changes in its culture.

SUMMARY

Many reports state interesting facts. Others stimulate change. Precious few do both, while providing a remarkably accurate window into the future.⁶⁶ The Flexner and Coggeshall reports belong to that rare breed of documents that engender transformational change.

Many factors have again converged to challenge medical education, and once again academic medicine is at a crossroads that calls for medical education to demonstrate a resilience and responsiveness to the demands of the present and future.

However, unlike the previous eras described above, when major change in medical education addressed largely internal matters, today the nation is calling upon academic medicine to lead on national policy matters. Our nation is in the midst of the most widespread transformation of its health care system since the creation of Medicare. Academic medicine is embracing today’s challenges and is shaping efforts to address issues of cost, quality, and access by training physicians today to practice in tomorrow’s health care environment.⁶ In so doing, academic medicine continues to meet the needs of future medical practice and lead the nation into a new era of health care.

REFERENCES

1. Association of American Medical Colleges. AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers. Washington, DC: AAMC; 2014.

2. Association of American Medical Colleges. Handbook of Academic Medicine: How Medical Schools and Teaching Hospitals Work. Washington, DC: AAMC; 2013.

3. Medicare Payment Advisory Committee, Washington, DC; Transcript of public meeting. April 8-9, 2009: 244-247.

4. Iglehart JK. Diversity dynamics—challenges to a representative U.S. medical workforce. N Engl J Med. 2014;371(16): 1471-1474.

5. U.S. Department of Health and Human Services. Pipeline programs to improve racial and ethnic diversity in the health professions: An inventory of federal programs, assessment of evaluation approaches, and critical review of the research literature. Washington, DC: Department of Health and Human Services; 2009.

6. Association of American Medical Colleges. Advancing the Academic Health System for the Future: A Report from the AAMC Advisory Panel on Health Care. Washington, DC: AAMC; 2014.

7. Schroeder SA. We can do better—improving the health of the American people. N Engl J Med. 2007;357: 1221-1228.

8. Flexner A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Boston, MA: Updyke; 1910. In: The Carnegie Foundation for the Advancement of Teaching Bulletin No. 4.

9. Coggeshall, LT. Planning for medical progress through education. JAMA. 1966;197(11):909-912.

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CHAPTER

3

Management of Medical Student Rotations

Mindy Houng, MD, FACP

Sunil Sapru, MD, FACP

Mindy Houng, MD, FACP, is Clinical Assistant Professor of Medicine, Rutgers - New Jersey Medical School, Newark, NJ and Associate Professor of Medicine, St. George’s University School of Medicine, Grenada; [e-mail].

Sunil Sapru, MD, FACP, is Program Director, Department of Medicine, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingston, NJ 07039 and Clinical Assistant Professor of Medicine, Rutgers, New Jersey Medical School, Newark, NJ and Professor of Medicine, St. George’s University School of Medicine, Grenada; [e-mail],.

In the past, medical students spent the first 2 years of their education in the classroom and moved on to the hospital for clinical training in their third and fourth years. Recently, however, exposing students to the clinical setting earlier in their medical education has become the norm. Teaching hospitals frequently have to accommodate medical students with various levels of clinical experience, which can be both exciting and challenging for the professionals coordinating medical education.

Students must acquire a wide range of knowledge during the clinical portion of medical school. In addition, they need to perfect communication skills and develop an understanding of professionalism. The clerkship must provide the educational foundation, clinical experience, career exposure, and role modeling to give students the tools they need to develop their own identities in an ever-changing profession. This chapter provides a guide to effective management of medical students in the teaching hospital setting.

TYPES OF ROTATIONS FOR MEDICAL STUDENTS

First and Second Year Medical Student Rotations

In many cases, medical students are sent to the hospital to develop such skills as obtaining histories and performing physical examinations. These rotations expose students to residents and the hospital environment, and provide face-to-face experience with patients. Students are observed performing a history and physical and receive direct feedback for reflection. Patient contact is often supplemented with basic skills presented in formal classroom-style seminars and lectures.

Third Year Clerkships

The goal of third year clerkships or rotations is to provide students with broad clinical exposure to the major medical and surgical specialties. Traditionally, clerkships in internal medicine and surgery have been 12 weeks in duration. Students usually spend 6 weeks in other specialties such as obstetrics/gynecology, pediatrics, psychiatry, family medicine, and neurology, but the exact number and duration of the clerkships vary among medical schools. During the clerkship, students rotate through a variety of inpatient units and/or outpatient services within the specialty. During the surgery clerkship, for example, students may work in an inpatient general surgery unit, surgical intensive care unit, trauma unit, general surgery clinic, and/or ambulatory surgery center.

Students are assigned patients and are treated as an integral part of the team. They perform a comprehensive history and physical under supervision of the senior residents and faculty. They participate in work rounds with the medical or surgical team, providing clinical information and discussing management options. In this venue, students work on gathering and communicating data in a clear and organized fashion. They are encouraged to read about a patient’s illness and to research evidence-based evaluation and treatment options; this gives them the opportunity to use the medical literature and computer-based educational tools to reinforce the clinical picture they observe first-hand.

The core rotation can also be a time when the involved faculty can help the students familiarize themselves with the evolving system of health care delivery, the changes in the healthcare system, and the impact of these changes on the practice of medicine. Concepts of patient safety, quality improvement, and proper utilization of healthcare resources should also be emphasized during the third year clerkships.

Fourth Year Sub-internships or Audition Rotations

The goal of the sub-internship is to provide in-depth experience in a specific field with greater patient care responsibilities. The sub-internship also may be called an audition rotation, because students often complete rotations in the specialty and at institutions where they would like to attend residency training. Usually, the rotation is 4 weeks in duration. Common sub-internships include internal medicine, general surgery, obstetrics/gynecology, and pediatrics, but may include rotations in the intensive care units (e.g., surgical, medical, or pediatric) or other disciplines.

Electives

Electives are usually 2 or 4 week rotations in any field of medicine available at the medical center or at outpatient facilities/practices. Although not required by the medical school, these rotations offer a chance to gain experience in certain fields that students may or may not have received during the required rotations. These rotations also provide additional experience in subspecialty fields of career interest.

Selectives

These are rotations that are not part of the third year clerkships, but are required by the medical school. Examples include neurology and ambulatory medicine.

SOURCE OF STUDENTS

While most university hospitals have close ties with one associated medical school, a community hospital may be linked to more than one. Several schools may supply students on any given rotation, requiring coordination of educational requirements and schedules.

The medical center or hospital often has a department of medical education headed by a director of medical education (DME) to oversee the educational requirements of medical students. The DME should ensure that every rotation adequately meets the requirements of each medical school. Some medical schools prefer that their students’ curricula and rotations be kept separate, while others welcome exposure to students from different schools. Formal affiliation agreements, which spell out the roles and expectations of both the medical school and community hospital, are usually required before students begin any rotations. Often the agreements allow involved community hospital physicians to obtain voluntary faculty appointments at the medical school as an incentive for affiliation.

American medical schools that offer the MD degree must be accredited by the Liaison Committee on Medical Education (LCME), and schools that offer the DO degree are accredited by the American Osteopathic Association (AOA). International medical schools have neither accreditation.

Medical schools in the Caribbean and Latin America frequently send their students to the United States for clinical rotations. The state board of medical examiners determines if an international medical school can send its students to a hospital in that state. The board then decides which hospitals have the resources to accommodate students and how many students will be allowed. The DME should be wellversed in state regulations regarding international medical students.

COORDINATION OF ROTATIONS

In coordinating rotations, the hospital DME frequently works in concert with a medical student coordinator (MSC). One or more MSCs may be required depending on the number of students and rotations offered by the hospital. The DME and the MSC are usually responsible for the following:

• Scheduling the rotations

• Ensuring the correct number of students in each rotation

• Coordinating schedules of the medical schools sending students

• Coordinating schedules with each departmental faculty or clerkship coordinator

• Providing housing or housing information to students

• Ensuring compliance with state medical board regulations regarding international medical students (international medical schools allowed to send students and number of students allowed)

• Providing students with access to call rooms, meals, and parking

• Providing access to online and hospital-based educational resources (e.g., library access) as well as hospital and ambulatory electronic health record systems.

In focusing on education, medical educators can overlook other basic needs of students. The academic stress of medical school is often compounded by learning to adjust to call schedules, communicating with residents and attendings, and juggling rigorous schedules of inpatient responsibilities. Addressing such concerns as the use of call rooms, travel, and meal costs can minimize the social adjustment that accompanies the transition to hospital and clinical medicine.

Clerkship Director

In addition to the central DME, a clerkship director (CD) in each department is required to oversee the educational process. The CD is responsible for coordinating students’ orientation to the rotation (in hospital and/or clinic), including setting expectations and goals and ensuring that the goals provided by the medical school are communicated to the students. The curriculum is usually developed and regularly updated by the CD. The CD ensures that educational content and quality is level-appropriate for first through fourth year students. The rotations also should fulfill the educational requirements established by the medical school. Another responsibility of the CD is to ensure that the students are properly supervised and evaluated and receive appropriate feedback designed to improve their clinical abilities. Either the CD or another assigned faculty member must have periodic meetings with the students (e.g., mid-rotation and after final exams). The end-of-rotation examination (oral, written, and/or practical) may be the responsibility of the CD or other faculty at the medical school.

Faculty

Teaching the medical students can be done in a variety of settings, including hospital units, outpatient offices, clinics, hospice centers, nursing homes, dialysis centers, surgicenters, or patient homes.

Clinical educators may include full-time faculty as well as voluntary staff. In addition, students may benefit from working with nurses, physical therapists, social workers, and other allied health professionals. Interns and residents are invaluable in providing personal and practical clinical education for students and should view this duty as an essential part of their own educational process. Evidence shows that medical students frequently perceive residents as their primary educators.

Because residents often have more direct contact with students than the faculty, efforts are increasingly focused on educating residents to be more effective teachers. Residency programs present seminars on ‘teaching the teacher’ to improve the instructional skills of residents and ultimately enhance the experience of medical students.¹ Therefore, residents have a significant impact on the education of medical students.

The graduate medical education (GME) department can honor residents who display exemplary skills in teaching medical students with an award distinguishing them from their peers. This award can carry special merit if it is bestowed by students and can act as an incentive for residents to be recognized by students and the faculty.

EVALUATING MEDICAL STUDENTS

An essential part of medical student education is evaluating performance and providing regular, constructive feedback. According to guidelines published by the Association of American Medical Colleges (AAMC), the objective of medical schools is to allow future physicians to acquire the knowledge, skills, and attitudes that are needed for medical practice.² In evaluating the effectiveness of a rotation, faculty must objectively demonstrate that those goals are being met.

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified 6 General Competencies that should be used to evaluate the proficiency of current medical residents. In 2013, the ACGME further expanded these 6 General Competencies into 22 Sub-Competencies to provide ‘more explicit and transparent expectations of performance, facilitate better feedback and professional development, and to support better self-directed assessment and learning for evaluation of medical residents’ as a part of the Milestones Evaluation Project.³ The 6 core General Competencies can also be used to evaluate medical students during their rotations. These are: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism; and systems-based practice.

Students should be evaluated frequently and by various tools. In addition to written evaluations, other evaluation tools may include:

• Direct observation of clinical skills at the bedside

• Standardized patients (professional patients) to evaluate clinical skills

• Objective structured clinical examinations

• Case-based oral examinations

• Evaluation of professionalism and bedside manner by patients and hospital staff

• Formal patient write-ups

• Computer-assisted assessment

• Group sessions to discuss patients

• Written essay or multiple-choice examinations

• Portfolios

As part of the evaluation process, it is important to give students regular feedback. Formal mid-rotation and end-of-rotation feedback is required by the LCME. Ideally, this is done soon after the evaluations and should include direct and practical pointers.

There should be a concerted effort to provide feedback on the students’ level of professionalism. The AAMC has published guidelines to help the CD objectively evaluate student professionalism. It is important to stress to students, preferably during the orientation period, that professionalism is as essential to a career in medicine as basic science and clinical knowledge.

It is helpful for students to maintain a patient log, to be submitted at the completion of the clerkship, that records their clinical experience. The mid-clerkship evaluation and final evaluation can be documented on the log to ensure that the student receives structured feedback.

The Clerkship Directors in Internal Medicine (CDIM) group has published guidelines for the development of effective evaluation and feedback tools as outlined below:⁴

• Train evaluators at least annually in ongoing faculty and resident development sessions.

• Specify educational objectives and criteria to determine when an objective is met, and work with teachers to develop methods to assess teacher and student performance.

• Use a number of evaluators and frequently deploy evaluation forms over the course of the clerkship to improve the reliability of data. Use formal evaluation and feedback sessions to better evaluate and counsel all students.

• In ambulatory settings, where interactions are predominately with 1 preceptor, design a system that uses numbers of patient-based encounters as the unit of assessment.

• Use the AAMC framework of 7 basic categories (specific clinical skills, interpersonal skills, clinical judgment and problem-solving, fund and application of knowledge, professional characteristics, personal characteristics, and use of the medical literature) to develop structured evaluation forms, and use behavioral descriptions for each stage in the rating scheme to improve reliability of results.

• Increase interaction between students and evaluating faculty and residents to enhance opportunities of direct observation of specific objective criteria and to improve the instrument validity.

• Mandate that evaluation forms be completed on time.

EVALUATING THE EFFECTIVENESS OF ROTATIONS

The most important reflection of a successful educational program is the success of its students. Objective documentation of student evaluations is an important measure of the effectiveness of a rotation.

In addition, student input is essential in maintaining and improving the quality of educational programs. Educators should actively seek student feedback about the rotation. This feedback must then be disseminated to the DME, site directors, individual faculty members, and the medical school. Frequently, anonymous evaluations distributed by the medical school provide a candid view of the students’ experience during the rotation.

Student evaluations can be made available on-line, especially if the students are visiting from an international medical school and attend multiple community medical centers for different rotations. To ensure that students provide feedback, the clerkship evaluation can be part of the exit process when a student completes a particular clerkship.

Reviewing end-of-rotation written and oral exams for areas with consistently poor performance may help identify areas of weakness within the rotation. These subject areas may be poorly taught or students may lack exposure to them entirely. Finally, objective measures, such as the United States Medical Licensing Examination (USMLE) scores, may be used as an indirect measure of the effectiveness of the educational process.

REFERENCES

1. Spencer J. Learning and teaching in the clinical environment. BMJ. 2004;326: 591-594.

2. Association of American Medical Colleges. The AAMC Project on the Clinical Education of Medical Students. August 27, 2010.

3. Accreditation Council for Graduate Medical Education. www.acgme.org. Accessed November 14, 2014.

4. Appel J, Friedman E, Fazio S, Kimmel J, Whelan A. Educational assessment guidelines: a Clerkship Directors in Internal Medicine commentary. Am J Med. August 2002;113: 172-179.

RESOURCES

Morgenstern, B, ed. Guidebook for Clerkship Directors. 4th ed. Washington, DC: Alliance for Clinical Education; 2012.

The Handbook of Academic Medicine: How Medical Schools and Teaching Hospitals Work. Washington, DC: American Association of Medical Colleges; 2009.

www.aamc.org. The AAMC website has information that may be helpful to the DME, including educational requirements of medical schools, surveys revealing average time spent in each specialty by medical students, and publications about academic medical institutions.

www.acgme.org. The ACGME accredits all allopathic postgraduate training programs in the United States. This website contains extensive information on core competencies, milestone reporting, and the implementation of these evaluation tools.

www.im.org. The Alliance for Academic Internal Medicine (AAIM), the nation’s largest academically focused specialty organization, consists of the Association of Professors of Medicine (APM), the Association of Program Directors in Internal Medicine (APDIM), the Association of Specialty Professors (ASP), the CDIM, and the Administrators of Internal Medicine (AIM). Although focused on internal medicine, the CDIM section has many helpful resources for professionals who coordinate medical student education.

CHAPTER

4

The Next Accreditation System and the Future of Graduate Medical Education Accreditation

Ingrid Philibert, PhD, MBA

Thomas J. Nasca, MD, MACP

Ingrid Philibert, PhD, MBA, is Senior Vice President, Field Activities at the Accreditation Council for Graduate Medical Education (ACGME), 401 North Michigan Avenue, Suite 2000, Chicago, IL, 60611; [e-mail]

Thomas J. Nasca, MD, MACP, is Chief Executive Officer at the Accreditation Council for Graduate Medical Education (ACGME), 401 North Michigan Avenue, Suite 2000, Chicago, IL, 60611; [e-mail]

SELF-REGULATION AND THE MEDICAL PROFESSION

In the United States, professional self-regulation for physicians is carried out through private organizations that are critically important to maintaining the profession as a public trust.¹ Accreditation of medical education is an important component of this,