Whither Medical Education in the United States?

“It was the best of times, it was the worst of times.” This famous first sentence from Charles Dickens' A Tale of Two Cities could describe the current state of medical education in this country. The tension between the expanding roster of successful innovations in medical education and the increasing demands and challenges faced by medical educators is captured nicely by a provocative article in this issue of the Journal by Irby and Wilkerson.¹

These authors describe 5 “environmental trends”—a mix of societal, economic, scientific, technologic, and educational forces—that have impacted medical education in the past decade. Two of the environmental trends they describe, demands for increased clinical productivity by medical faculty and greater accountability for their teaching, have resulted from forces outside medical schools. One, the necessity for new multidisciplinary approaches to biomedical knowledge, has been spurred by work within academic medical centers. Another, the need to respond to the changing health care needs of a diverse population, stems from both external and internal forces. Whether external or intrinsic to medical education, though, these four trends have challenged medical educators to balance new requirements with available resources. The fifth trend, the introduction of new methods of problem-solving and case-based instruction, supported by the diffusion of new educational technologies, has created new opportunities for learning in medicine.

Irby and Wilkerson suggest that the conjunction of external demands, changing paradigms in the biomedical and clinical sciences, and advances in the science of learning have stimulated innovation in medical education to an extent not seen since the beginning of the last century. They provide a catalog of recent projects, more in undergraduate medical school curricula than in graduate or continuing medical education. Their useful overview helps to illuminate the landscape of innovations in medical education and should provide focus and inspiration to medical educators struggling with environmental forces.

As the authors acknowledge, their essay is not a systematic survey of innovations in medical education or a critical assessment of the projects they cite. Nor are the environmental trends they describe derived from an empirical or consensus process. Two of the trends, multidisciplinary approaches to medicine and shifting views of health and disease, seem less clearly drawn than the others. In relation to these two trends, we would put even greater emphasis on the profusion of new areas of knowledge and skills common to all disciplines (communication, informatics, evidence-based medicine and clinical decision making, population and systems-based practice, legal and ethical issues, pain management, end-of-life care, and genomics would be just a short list), and on the challenges of how to incorporate them into undergraduate, graduate, and continuing medical education. We also note that perhaps the greatest challenge to increased accountability in medical education, the recent imposition of limits on duty hours for graduate trainees, is not mentioned, perhaps because we have yet to see successful educational responses.

The trends proposed by Irby and Wilkerson and the innovative projects they describe should be of particular interest to general internists. Faculty in departments of medicine play a predominant role in the education of medical students, residents, and faculty.^2,3 General internal medicine and its academic divisions are inherently multidisciplinary, and have played a leading role in advancing new approaches to clinical education and clinical care. The Journal of General Internal Medicine has recognized and supported this with its Innovations in Medical Education section and its plans for a medical education supplement.^4,5 The Society of General Internal Medicine (SGIM) recently launched the Clinician-Educator Initiative to support its members in their educational roles.⁵ General internal medicine faculty thus will be compelled to consider the following conundrums.

Irby and Wilkerson suggest that the “outburst of creativity and innovation” in medical education is a response to adversity and that “organizations rarely change when … resources are expanding.” We would suggest that while adversity may stimulate change and innovation, so may opportunity and the availability of resources. This is exemplified by the tremendous advances in medical knowledge and care during the past century in response to peer-reviewed competition and the generous funding of biomedical and clinical research by the federal government and others. On a more modest level, peer-reviewed competition and federal funding through Title VII grants from the Health Resources and Services Administration (HRSA) of the U.S. Public Health Service have stimulated advances in medical education in primary care residency training and faculty development. Unfortunately, funding for research and development in medical education is a very small fraction of what is available for research and development in biomedical and clinical research. Most federal funding for medical education in the United States is funneled through Medicare, and goes to support under-reimbursed and inefficient care rather than research and development.⁶

It is unclear to us to what degree creativity and innovation have been greater in medical education during the past decade than previously. Substantive advances in the teaching of communication skills to physicians, for example, began in the 1970s, stimulated by a combination of societal pressures, HRSA grants, the resurgence of generalist physician groups, and the support of professional organizations such as SGIM, the Society of Teachers of Family Medicine, the Ambulatory Pediatric Association, and the Academy on Physician and Patient (originally a task force of SGIM).

It is also unclear to what degree the innovations Irby and Wilkerson describe are widespread. Although some innovations, such as the use of new educational methods (e.g., standardized patients) may have been implemented widely, others have not. For example, in a recent national survey, only 39% of teaching hospitals had any ongoing faculty development activities in educational skills for their department of medicine faculty, and a minority of faculty in these institutions had been trained.⁷

Perhaps there is a contemporary lesson in the remarkable reformation that occurred in medical education at the beginning of the 20^th century.⁸ Stimulated by advances in medical science and medical education that occurred at a relatively small proportion of medical schools, a combination of factors led to the widespread adoption of scientific research as the basis for medical knowledge and practice, clinical training for physicians, and standards for training and licensure. These factors included leadership from within and outside the medical profession, publicity (most notably the Flexner Report), professional and government standards, and new sources of funding.

Reforms needed today include direct funding for medical education, widespread adoption of evidence-based methods of education,⁹ appropriate criteria and recognition for educational excellence and scholarship, and the training of all physicians in important core competencies.¹⁰ While Irby and Wilkerson suggest that both creativity and innovation may be born from adversity, they also note that current reforms may represent “merely inadequate adaptations to overwhelming environmental forces.” Such forces were shaped to society's benefit at the turn of the previous century, but required a multifaceted approach. We propose that medical faculty and institutional leaders not only need to adapt locally to existing environmental trends, but should also lead^11,12 and advocate broadly for institutional and societal changes, e.g., in the funding, regulations, and processes that support educational development, research, and reform in this country. We believe that both approaches will be essential in determining whether medical education in this country continues to be vibrant and innovative, or withers.