This is the first installment in a three-part series on major changes in medical education. Tomorrow's story will focus on changes to undergraduate medical education at the University.
Around the fifth century B.C., Hippocrates, the father of medicine, said that his discipline should focus on "matters known to the general public," and that any departure from "popular knowledge" was impractical.
Now, more than any other time during the past 50 years, medical education in the United States is undergoing a revolutionary metamorphosis in response to three major factors: market forces, specifically cost containment, are demanding that doctors and hospitals provide high-quality care at lower costs; substantially decreased federal support for graduate medical education is forcing teaching hospitals to restructure the number and distribution of residency slots; and lastly, technological forces, both biomedical and informational, are redrawing the landscape on which traditional curricula have been based.
These factors, among others, have forced medical educators to rethink the organization and content of medical education. In the past year, the Association of American Medical Colleges has formed the Advisory Panel on the Mission and Organization of Medical Schools, as well as the Center for the Assessment and Management of Change in Academic Medicine. And last month, the Pew Health Professions Commission, a private non-profit group based in Washington, D.C., released a report recommending, among other changes, a 20 to 25 percent reduction in medical school enrollments--primarily through the closing of entire medical schools--by 2005 to avert a future glut of 100,000 to 150,000 doctors.
Medical educators at Duke are cognizant of the rapidly changing health-care environment and have made changes to ensure that the University will not be left behind.
"There have been more changes in American health care in the last three years than probably in the last 50 years," said Dr. Ralph Snyderman, chancellor for health affairs and dean of the Medical School. "I hate to use the cliche, `paradigm shift,' but it's a paradigm shift."
Under the previous health-care paradigm, a patient is admitted to a hospital, and a physician carries out tests to amass the greatest amount of information and do everything possible that might be of benefit. That scenario has changed dramatically.
"The new paradigm is cost-effectiveness, following something over time, doing just what is needed and not more, any more, at any given time," Snyderman said. "It's a different way of thinking about health care, and this leads to changes in practice, and how you train for practice, so you maintain the quality."
The primary changes in medical education with which schools are grappling are the need to train medical students in a communit and ambulatory setting, educate medical students in social issues outside the realm of traditional biomedical sciences and disease management, and expose medical students to more primary-care professions. Meanwhile, the market is such that many medical schools are going to be forced to reevaluate their programs, perhaps leading some to merge or shut down altogether.
These changes have been primarily driven by the new paradigm of cost-focused managed care. "We're seeing more and more students go into primary care," said Dr. Dan Blazer, dean of medical education at Duke. "Students are not dumb. They see where the jobs are, and they see very good people are graduating from [certain specialties] and can't get jobs, and so they're going to move away from specialities like that and move into areas where the jobs are at."
As a result, there has been greater competition for primary-care residency slots, and large unfilled spots for certain specialties, such as anesthesiology.
One dilemma for medical schools is how to give students more of a non-science context in which they will be asked to operate. "Every time I hear someone talk about adding another course to the curriculum, particularly at this medical school, I wince," said Dr. Lois Pounds, associate dean of medical education.
But educators at Duke and across the nation agree that students must be exposed to more social issues, such as family violence, child abuse and drug addiction. "Understanding the molecular pathogenesis of disease can't possibly deal with more than 20 to 25 percent of the cases physicians deal with today," Snyderman said.
The AAMC held a conference last spring to discuss how medical schools could incorporate such issues into their curricula. "By and large, there is no coherent educational program in medical schools that introduces and reinforces a broad understanding of family violence and abuse," says a statement issued by AAMC.
The Pew report predicts the closure of as many as half the nation's hospitals, a massive expansion of primary care in ambulatory and community settings, and a surplus of 100,000 to 150,000 physicians as the demand for specialty care shrinks. The report also demands that public health professionals meet the needs of the market driven health-care system, and suggests a fundamental alteration of health professional schools and the ways in which they organize, structure, and frame their educational, research and patient-care programs.
"I congratulate [the Pew commission] for laying out the issue," Snyderman said. "I think it's a valuable report because it focuses on important issues that medical centers and schools need to deal with. The way we have done things in the past will need to change in the future. Some medical schools that are not responding to the needs of the health-care market could go out of commission." He said, however, that the numbers they cite are "very questionable."
Because of the fundamental changes, administrators have been advising students to keep other options in mind.
"I have been recommending for quite some time that anyone thinking about medicine have a Plan B... when the acceptance rate is only 37 percent nationally, I think people do need to look at other options," said Kay Singer, director of the Health Professions Advising Center.
Nevertheless, current medical students caught between the two paradigms are dealing with change as well as can be expected.
"The best that medical schools can do now is to educate students about what's happening and educate them about how to keep up with all the changes," said Seth Kaplan, a third-year medical student who sits on the steering committee that evaluates the Medical School's primary-care program. "For me, I'm not worried about the changes. As long as I do good work and keep learning... as long as I do something I enjoy doing and grow, I'll be fine."
Get The Chronicle straight to your inbox
Signup for our weekly newsletter. Cancel at any time.