To the Editor: Cooke and colleagues (Sept. 28 issue)1 tracethe changes in medical education that have occurred since theFlexner report was issued a century ago and outline the currentchallenges. A recent international Web-based survey of 806 ofthe 2200 members of the Association for Medical Education inEurope (37%) focused on the perceived needs of medical educatorsfrom 76 countries. The United Kingdom and the United Stateshad the highest representation among the responses (24% and10%, respectively). The main challenges in medical educationidentified by the survey respondents were lack of academic recognition(40%), funding (36%), faculty development (24%), time for medicaleducation issues (22%), and institutional support (21%). Inaddition, development in medical education research methods(63%), computer-based training (46%), and course and curriculumevaluation (40%) were identified as high-priority needs. Wethink Flexner would agree that in the current internationalcommunity of practice, the choices we make about the distributionof resources for the development of teachers are fundamentalto the future of medical education and the health of society.
Stewart Mennin, Ph.D. University of New Mexico School of Medicine Albuquerque, NM 87131
Christoph Nikendei, M.D. University of Heidelberg Medical Hospital 69120 Heidelberg, Germany
References
Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med 2006;355:1339-1344. [Free Full Text]
To the Editor: Cooke and colleagues provide a tribute to Flexnerand an informative history of North American medical education.The factors that stress our current system culminate in thequestion "Who will do the teaching?" and the recognition that"a final problem is the financing of medical education."
Persons capable of teaching are compensated by means of severalmechanisms. Laboratory investigators (and a few clinicians)compete for grants, predominantly from a branch of the federalgovernment. Clinicians bill insurance providers (including thegovernment). Clinician-investigators collect funds for participationin trials that are sponsored by pharmaceutical companies, cooperativegroups, or the government.
Despite the creation of "clinician-educator" tracks at somecenters and the stray grant available for educational activity,there is no consistent, realistic mechanism through which teacherscan expect meaningful material compensation. Until such a mechanismis created, we will continue to have a crumbs-off-the-table,trickle-down system for financing education; intensified curriculumrevision will not correct this situation, nor will relianceon the magnanimity of medical school deans. The "will to change"relies on a will to pay; will anyone step forth?
Jonathan D. Schwartz, M.D. Imclone Systems Branchburg, NJ 08876 jonathan.schwartz{at}imclone.com
To the Editor: Cooke et al. succinctly summarize the challengesinvolved in training physicians. However, they do not discussthe elephant in the room. Physician assistants have a 2-yearpostbachelor education program, as compared with a 7-year postbachelorprogram for internists, pediatricians, and family practice specialists.Physician assistants receive much of their training "on thejob," having moved on with their lives and minimized their educationaldebt. In many practice settings, physician assistants and theirnursing counterparts, nurse practitioners, function highly autonomously.Two years or 7 years — what can allopathic and osteopathicmedical education learn from this?
L. Allen Kindman, M.D. Cardiovascular Care of Northern Carolina Oxford, NC 27565 lakindman{at}cc-nc.com
To the Editor: The overview of medical education by Cooke etal. provides considerable insight regarding the inherent difficultiesin changing a complex and evolving medical education curriculum.The article does not mention, however, a critically importantforce that has powerful effects on curricular change: externalregulation. The professional regulatory organizations (the LiaisonCommittee on Medical Education, the Accreditation Council forGraduate Medical Education, the United States Medical LicensingExamination, and the American Board of Medical Specialties)promulgate standards that directly affect educational practices,such as the 80-hour residency workweek and the Step 2 clinicalskills examination of the United States Medical Licensing Examination.Although each regulatory organization is doing an exemplaryjob within its specific sphere, I am concerned that there isno overarching harmonization of their efforts. As a result,the medical education continuum tends to be compartmentalizedand somewhat fragmented. It has been pointed out that "the continuingmultiplicity of bodies and responsibilities prevents optimal,systemwide approaches."1 I think that in our review of the statusof medical education, we must take into consideration the "strongforces" of regulation and how they can best be harnessed collectivelyto implement the needed changes in medical education.
Steven A. Wartman, M.D., Ph.D. Association of Academic Health Centers Washington, DC 20036 swartman{at}acadhlthctrs.org
References
Blue Ridge Academic Health Group. Reforming medical education: urgent priority for the academic health center in the new century. Report 7. Atlanta: Emory University, May 2003.
The authors reply: Huwendiek et al. and Schwartz point out thatmedical teachers lack resources in both the United States andEurope; we could not agree more. Like Huwendiek et al., Americanmedical educators have commented on the denigration of clinician-teachers1and uneven professional development for the teaching role.2We concur entirely with Schwartz that teaching, the originalmission of medical schools, lacks a reliable funding streambecause of the diversion of revenue intended for education toother missions.
Kindman notes that physician assistants receive a dramaticallyshorter education than physicians, even those in generalistdisciplines. The length of physician training, the associateddebt burden, and perhaps the undesirable shifts in career choiceshave led to proposals for shortened training in both internalmedicine3 and general surgery.4 Although physician assistantsprovide excellent care, they function as a member of a physicianassistant–physician team5 and thus have a role that isquite distinct from that of the physician. We concur with Kindman'simplied question: Might medical training be made substantiallymore efficient? One of the sources of inefficiency in medicaltraining has been the compartmentalization of medical educationinto discrete stages with abrupt and often difficult transitionsfrom one stage to the next. This curricular segmentation hasbeen reinforced by the multiplicity of regulatory organizations,each with its own jurisdiction. Until recently, the regulatoryorganizations described ideal educational experiences in termsof process measures — primarily, how long the learnerspent in one setting or another, rather than the outcomes forthe learner. Fortunately, that is beginning to change. We haveno doubt that Abraham Flexner would endorse the vision of ourcorrespondents: a thoughtful educational program, overseen byregulatory organizations working cooperatively to provide coherentoversight across the curriculum, in which the experiences ofthe students and residents would be of high educational value.The linchpin in the system is a cadre of faculty with the motivationand skill to teach well and the salary support to do so.
Molly Cooke, M.D. David M. Irby, Ph.D. University of California, San Francisco San Francisco, CA 94143
Kenneth Ludmerer, M.D. Washington University St. Louis, MO 63130
References
Levinson W, Rubenstein A. Integrating clinician-educators into academic medical centers: challenges and potential solutions. Acad Med 2000;75:906-912. [ISI][Medline]
Houston TK, Ferenchick GS, Clark JM, et al. Faculty development needs. J Gen Intern Med 2004;19:375-379. [CrossRef][ISI][Medline]
Goldman L. Modernizing the paths to certification in internal medicine and its subspecialties. Am J Med 2004;117:133-136. [CrossRef][ISI][Medline]
Kavic SM. Surgical training should be shortened for specialists. Curr Surg 2003;60:475-476. [CrossRef][Medline]
Competencies for the physician assistant profession. JAAPA 2005;18:16-18. [Medline]
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