Surveying the Road Ahead for American Medical SchoolsLarry Gruppen | Chair of Medical Education at the School of Medicine, University of Michigan
Medical education confronts many of the same challenges as other sectors of higher education, including affordability, access, and questions about its efficacy. However, as a domain that incorporates a high level of social accountability, technical sophistication, trust and prestige, it also faces a number of special challenges.
Each of the 141 allopathic and 30 osteopathic medical schools in the US is seeking ways to address these challenges, which creates a very dynamic and innovative educational environment. The research findings from medical education are too often segregated from those of higher education, but there is much for each domain to learn from each other.
One of the major challenges in medical education is the growing adoption of competency-based education (CBE) models. Unlike traditional higher education—in which CBE is proposed as a means for expanding access and increasing affordability—CBE in medicine is proposed primarily as a means of ensuring that the targeted skills and capabilities (competence) are actually present in graduates. CBE in medicine has resulted in enormous investments in assessment technologies for key knowledge and performance outcomes. Individualized learning plans are also becoming a routine aspect of medical education. Perhaps most significantly, there is a growing recognition that traditional time-based models may not be adequate for the diversity of competencies required in medicine. As a result, some programs are experimenting with time-flexible models that allow graduation when (and only when) competence is demonstrated.
A longstanding challenge for medical education is the tension between viewing medical education as a public vs. a private good. Arguably, health care is viewed increasingly as a “right” that is supported to some degree by federal and state government. This public investment in health care logically impinges on the education of medical practitioners. However, there is still considerable ambivalence about the role of public finance of education that seems to benefit the individual learner with a well-paying career while also providing benefit to society. Although there is a significant level of public investment in graduate medical education (residents and fellows), undergraduate medical education is largely the responsibility of the learner and the result is a huge level of debt, often of multiple hundreds of thousands of dollars. This debt load influences the specialties that graduates pursue and directly limits the number of physicians willing to pursue lower-paying specialties, such as primary care and geriatrics. Public policy efforts to address a looming physician shortage (actually, more of a maldistribution) will need to address this tension.
Ever since the emergence of scientific medicine, the exponential growth of medical knowledge has been a perennial source of concern for medical educators. Overloaded medical school curricula place considerable stress on learners and on the faculty who design curricula that seek to maintain “work-life balance” for learners. Medical education administrators struggle to balance competing demands for time and attention from basic science and clinical departments who guard their special area of knowledge. The overload phenomenon, while not new by any means, has taken on greater urgency with the integration of information technologies into medical education and practice. Not only is a vast amount of information available, but this information is changing rapidly. It has become clear that information management is becoming as important a skill for clinicians as learning basic knowledge and skills.
Having to learn information management skills is just one example of a fourth major challenge to medical education. This is the expansion of related skills and educational goals beyond biomedical knowledge and basic patient care. Many are advocating for additional training of physicians in medical ethics, informatics, inter-professional and team collaboration skills, advanced communications, international medicine, patient advocacy, and many more. Each of these reflects a relevant aspect of medical care, but finding ways to add these topics to an already overloaded curriculum requires setting explicit priorities among mutually desirable options. Selecting and pursuing these alternatives is one way medical schools distinguish themselves from each other, but they also become areas of competition among faculty advocates within most medical schools.
Perhaps the greatest challenge is the rapid and dramatic change in the U.S. health care landscape. Advances in treatment and biomedical science alter what needs to be learned, but more profoundly, seismic changes in the organization of health care, its delivery, and financing alter how medicine is practiced. Today’s physicians practice in a very different environment from that of their predecessors and today’s learners will practice in yet another environment. The challenge for medical education is to prepare learners for the future rather than for the present. Predicting and preparing for the future is, of course, a very hazardous and uncertain process, but there is broad agreement that NOT doing so is hardly an option. One theme that has emerged out of this turmoil is the renewed recognition that learning does not and cannot end with a physician’s formal education. Continuing professional development, often tailored to the clinical environment in which a physician working, is emerging as a major focus for health care institutions and even licensing boards.
These challenges (and many others) have led to a considerable growth in the number of physicians who are seeking advanced training in education. More and more medical school faculty recognize that content expertise is not enough for providing high-quality education and many medical schools are supporting faculty in acquiring further educational skills and knowledge. These faculty join with many education experts and researchers to explore innovative solutions and evaluate their impact on future physicians and their practice.