ACP: 10 major challenges that confront medical education over the next decade

The following is part of a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

ACP: 10 major challenges that confront medical education over the next decadeAt times of calendar transitions, e.g., at the onset of a new year or a new decade, the popular press often takes a broad view in looking retrospectively at the outstanding or defining events and people of the past year or decade. Since we are now at a transition to both a new year and a new decade, I would like to take this opportunity as a medical educator to look forward rather than backward, summarizing what I think are 10 major challenges (in no special order) that confront the continuum of medical education over the next decade.

1. Educating students, residents, and practicing physicians about cost-conscious care. Given the unsustainably high costs of health care, it is critical to educate both current and future physicians about the appropriate and rational use of diagnostic and therapeutic modalities in order to minimize their overuse and misuse.

2. Establishing a culture in medical school and residency programs that fosters trainees to enter fields and practice medicine in areas of greatest societal need, e.g., primary care and care in underserved areas. Besides the need for financial remuneration to attract students and residents, appropriate recognition and prestige must be provided during training to these specialties and areas of practice need.

3. Focusing medical education on wellness and disease prevention. Whereas medical education has traditionally focused on diagnosis and treatment of disease, a high priority must simultaneously be placed upon education relating to maintenance of health and prevention of disease.

4. Establishing the proper balances among experience and education of trainees, number of hours and intensity of resident workload (duty hours), and patient safety. While the public is concerned about safety when being cared for by sleep-deprived residents, this must be balanced against concerns about discontinuity of care associated with patient handoffs, as well as the impact of duty hour restrictions on resident education and clinical experience.

5. Educating medical students and residents in a way that appropriately balances a scientific/pathophysiologic and an evidence-based approach to patient care. The current emphasis on evidence-based care must be integrated with, rather than replace, a firm grounding in the scientific and pathophysiologic principles underlying clinical medicine.

6. Preparing medical students and residents for a team-based, patient-centered approach to patient care. Medicine is increasingly becoming a “team sport,” and physicians must be well-trained to work as both a member and a leader of health care teams designed to provide high quality, patient-centered care.

7. Establishing an educational culture in which trainees and physicians examine their performance and measure patient outcomes, with the ultimate aim of continually improving the quality of care they provide. Measuring and improving quality of care needs to be embedded into the cultures of medical education and patient care; an important step has been the designation of practice-based learning and improvement as one of the required six general competencies for residents.

8. Establishing and developing “core” educational faculty who have the competencies necessary to train and promote the professional development of medical students and residents. Given the pressures on academic faculty for both clinical and research productivity, we must identify, support, and train a cadre of faculty for whom educating, assessing, and guiding the next generation of physicians represent the central component of their academic contributions.

9. Developing a system to support continuing medical education that avoids either the reality or the perception of bias by commercial interests. Given the increasing public concern about bias and conflict of interest resulting from commercial support of continuing medical education, a mechanism must be developed to support the high costs of continuing education that is sustainable and avoids even the perception of bias or conflict of interest.

10. Expansion of financial models to support medical student education with appropriate service paybacks to meet societal health care needs. Expanding opportunities to link tuition support for medical students with an obligation to provide needed health care services simultaneously serves the needs of students and patients, and potentially allows students to choose careers without the worry of oppressive educational debt.

These 10 challenges are daunting in their scope, but they are laudable goals for the medical profession and its educational arm over the next decade.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • http://www.wendyharpham.com Wendy S. Harpham, MD

    Thank you for this post. The training of tomorrow’s physicians is of critical importance. With hope, Wendy

  • ninguem

    How about getting tuition down to earth?

  • amy

    There is an imbalance between the medical school cost inflation and physicians salaries deflation. This is true for all college tuition cost. The high education bubble will burst soon, just wait another 2-3 years.

  • Rezmed09

    The university culture is so down on primary care and so intrinsically intoxicated with high tech, specialty driven medicine that this will be no easy fix.

    “You’re too smart for primary care” will be a tough nut to crack. and there is nothing sexy about being leader of the pack if the pack is a “medical home” and patients still expect to be sent to a specialist at the drop of a hat. These are challenges alright, but is it realistic to try to tackle these problems at the med school level when the incentives haven’t changed?

  • imdoc

    Did you ever notice that other fields have built in “training” regarding these things? It is called the marketplace. Try running any other business and not attend to issues critical to fulfilling needs of those served, and your competitor will. All of the above listed challenges are the result of inability to allow free enterprise to work. Culture doesn’t just get changed by being “taught”. Behaviors change when incentives change. Culture is the observed sum of behavioral patterns. We don’t need new programs which attempt to coerce students to resist existing strong incentives. I do agree medical educators have “challenge” if the goal is to subvert natural human behavior.

  • Primary Care Internist

    I agree wholeheartedly with “imdoc”.

    The ACP (and the AMA) are going about this wrongly – it is IMPOSSIBLE to a) convince med students and residents to go into primary care in the current environment which totally disincentivizes such; and b) convince bright young students to accept a “patient-centric” or “wellness/prevention” model when these are just buzzwords that even I don’t quite get.

    No matter how many focus groups and feel-good presentations about the happy patient who didn’t get sick because a “team” taught them how to control their diabetes, and didn’t just get an rx from an arrogant doctor, people will STILL get sick from their diabetes,e.g.

    Until the incentives are changed, IM and FP (and Peds) are on the death spiral, circling the drain. I think that it has reached the point that even if reimbursements (ie. PAYMENT) doubled tomorrow for primary care, med students would still be running the other way, as current docs are already. Even NPs and PAs are smarter than to do tons of unpaid work and be treated like a dog by patients, insurers, other docs, and even the president (“pediatricians take out tonsils for money” ie. they are criminals who willfully mutilate children for a buck).

    Good luck to patients, especially the elderly multiply-comorbid ie. boomers in the next 5-20yrs. These folks will have tons of HTN, DM, prostate cancer, heart disease, etc., will need lots of meds and someone coordinating all, and nobody will be there to do it. There will, however, be an ever-expanding “team” – a mail-order pharmacist from MEDCO, a NP from each of six subspecialist offices who only narrowly manages her niche, a walgreens pharmacy giving the flu shot and advising patients to “see your doctor” about this or that, visiting nurses advising patients that their doctor should’ve put them on ambien-CR instead of ambien; but NO DOCTOR TO PUT IT ALL TOGETHER.

    And the whole conflict of interest thing. Congress (and the president) are ALL ON THE TAKE. They are all taking money in the 6-figure to 8-figure range from all sorts of shady characters buying their vote. But if a drug rep brings pizza to the office, that is near-criminal??? If docs from a public hospital take a CME course in Hawaii, that is subject to scrutiny???

    I think policymakers and the public alike will get their wish. Everyone in their 30′s and 40′s I know in primary care medicine are like a ticking clock – looking to scrape together just enough for a realistic career change without a major change in lifestyle, then bolting. Everyone in the 50s-60′s are retiring. And everyone older is just thanking their lucky stars they got through the “golden age” of medicine when you could take care of patients first, and the business second.

    The ACP is on the wrong track (again).

  • ninguem

    Indeed.

    “…….a walgreens pharmacy giving the flu shot and advising patients to “see your doctor” about this or that……”

    “This or that” would include complications of the flu shot they just gave. I’ve had a few of those, have you seen it?

  • ninguem

    I’ve done a couple of personal injury reviews where I have specifically recommended a primary care doc, because of the NP/subspecialist office thing, where the patient ends up with the same structure getting imaged multiple times in a year, because the narrowly-focused practices don’t pay attention to that the other doc is doing.

  • Rod

    just seen a patient who saw a endrocrinologist and was told to see her primary for simple constipation. How in the world can we improve care if this is what patients go through. It has to be patient centric not doctor centric. If we need doctors at switch boards to take calls, so be it, maybe that is what some of them need to be doing.