University of Miami Miller School of Medicine
Medical Education: Past, Present and Future
Thank you very much, Dean Fogel, for that wonderful introduction. As Bernie mentioned, we have known each other since I was a medical student and he was a young faculty member back in the mid 1960s, so you can understand we have shared a lot of common experiences, including the wonderful privilege it is to serve as Senior Vice President and Dean of our Medical School. As I move on to my next position I hope I can be as gracious, supportive, and helpful to our next Dean as Dr. Fogel has been with me, and that whatever contribution I have made or will make to our School of Medicine might be favorably compared with what Dr. Fogel has done for nearly 50 years.
It is a singular honor for me to have been selected to give this year’s Gross Lecture. I want to acknowledge the presence of the late Mrs. Gross’ two daughters, Mrs. Carol Clarkson of Fort Lauderdale, and Mrs. Patricia Bergman of San Jose, California, and Mrs. Gross’ companion of many years, Mr. Lou Compton. Thank you very much for being here, thank you for your support of our School of Medicine, and particularly for your family’s support of our library. Mrs. Carol Clarkson is actually joined by two other Mrs. Clarksons – my mother, Jean, and my wife, Diana.
I also want to acknowledge the presence of several other former Gross Lecturers, Dr. Henry King Stanford, President Emeritus of the University of Miami and the University of Georgia, Dr. Bernard Fogel, Dr. Carl Eisdorfer, and Mr. Henry Lemkau. I am also delighted that former UM President Tad Foote and Mrs. Edith Reiss are with us today.
As I began to consider the topic for the Gross Lecture, the evolution of medical education in this country came to mind as it has been almost 100 years since there was a major transformation in medical education in the United States, and as we have entered the 21 st century, the challenges for medical education are different, but the need for continuous improvement in medical education has never been more important. To be sure medical education improved throughout the entirety of the 20 th century, but as we shall review, the issues have changed as expectations have increased
At the end of the 19 th century in North America there were three pathways to become a physician. The first of these was an apprenticeship where a young person would work with a practicing physician to learn the skills and practices and ultimately be afforded the privilege of practicing medicine. A second method was through for-profit or proprietary schools run by practicing physicians, some with and some without affiliations with larger institutions. There was no formal admissions process; the main criterion for admission to these proprietary schools was an ability to pay the tuition. Local physicians lectured on subjects such as Anatomy, Medical Jurisprudence, Surgery and Obstetrics. The third method was a university system which actually started in the 18 th century. The University of Pennsylvania opened in 1765, King’s College, later to become Columbia, in 1767, and Harvard in 1782. Johns Hopkins was the first university to build a hospital for clinical training, which opened in 1893. There was no standard admissions process, the criteria for acceptance were variable, and there was no standardized curriculum. (1)
There was growing concern about an overproduction of poorly qualified physicians, and in response the American Medical Association (AMA) created the Council on Medical Education in 1904. (2) In 1908 the AMA directed that a survey be conducted of medical education for the purpose of promoting change and encouraging acceptance of the AMA’s “ideal” medical curriculum. This Council on Medical Education contacted the Carnegie Foundation for the Advancement of Teaching to conduct the survey, and the Carnegie Foundation chose Abraham Flexner, a noted educational theorist and former high school principal, to lead the research. Flexner visited all 155 American and Canadian schools over an 18-month period, and in 1910 issued his report, which was 363 pages in length. Among its conclusions: “The interests of the general public have been so generally lost sight of in this matter that the public has in large measure forgot that it has any interests to protect. And yet in no other way does education more closely touch the individual than in the quality of medical training which the institutions of the country provide.” Flexner noted the lack of a standardized admission process, lack of standardized curriculum, and the great variation in quality reflected in the results of the apprentice and proprietary medical school system. Only 16 of 155 schools required two years of college for admission, and many schools ignored their own admission requirements, resulting in 25 years of overproduction of ill-trained medical practitioners. As a result of his report, a large number of schools either closed or merged with others, so that by 1927 there were 71 medical schools in the United States. The proprietary medical schools and the apprentice system had largely disappeared. American medical education at that point closely resembled the German model blending bioscience and clinical training.
A couple of other important events occurred in the early 20 th century. The National Confederation of State and Medical Licensing Boards, established in 1891, and the American Confederation of Reciprocating Examining and Licensing Boards, established in 1902, merged in 1912 to form the Federation of State Medical Boards. Specialty certifying Boards began to appear, the first of which was the American Board of Ophthalmology, established in 1916. As noted in the history of the American Board of Ophthalmology written by Frederick C. Cordes and C. Wilbur Rucker and reported in the American Journal of Ophthalmology in 1962: “The American Board of Ophthalmology was created for the purpose of improving the quality of ophthalmologic practice through elevation of the educational standards required of those who sought to practice this specialty. It was formed by ophthalmologists of vision and courage who were distressed during the early years of the century by the inadequate training received by many of their confreres.” Gradually other specialties responded in a similar way, such that today there are 24 Boards, 18 of which have certificates of subspecialty certification. The purpose of these Boards was to assure the public that a certified specialist had met certain criteria in the specialty area. In 1927 a system for accrediting postgraduate training through specialty Boards had begun. Several decades later this system became the Accrediting Committee for Graduate Medical Education (ACGME). In 1942 the American Medical Association and the Association of American Medical Colleges jointly formed the Liaison Committee for Medical Education, the purpose of which was to accredit North American medical schools.
Therefore, in the decades following the Flexner Report, the LCME was formed to accredit medical schools, the system for accrediting postgraduate training was put in place through the specialty Boards, and the Federation of State Medical Boards came into existence. The purpose of the LCME and the ACGME was to establish criteria for accreditation of undergraduate and graduate medical education, primarily to protect students and improve the quality of medical education. The Federation of State Medical Boards and the specialty Boards were formed for the purpose of protecting the public and assuring that those licensed to practice medicine and certified in a specialty of medicine had met certain standards.
Two major changes in undergraduate medical education occurred through most of the 20 th century. The first was an organ system based instruction program to replace instruction in anatomy, physiology, pathology and other subjects presented independently, leaving the learner to assimilate and integrate the information across the various disciplines. There were two primary impacts of this organ based curriculum: It presented information to the learner in a more practical manner, and the control of the curriculum shifted from individual departments to a school-wide curriculum committee to select not only the content, but the most appropriate instructors.
A second major change that occurred during the 20 th century was a shift to problem based learning, better known as PBL. PBL was introduced in Canada about 25 years ago, and is present in almost all North American medical schools today. The principle of PBL is that small student groups develop problem solving skills using patient cases designed to have learners use the knowledge they develop in the context of solving a patient problem. The process maximizes active learning, and the emphasis is on how students learn rather than what information is presented. In addition, medical educators began to gain status as full-time faculty members, with emphasis on teaching and research, and not just clinical care.
In the not-too-distant past, it was expected that a medical student could master the information necessary to practice medicine during medical school and in the post-graduate training program. There has been a shift from what was termed “Continuing Medical Education” to “Life Long Learning.” At a recent conference of the Association of American Medical Colleges, Dr. Molly Broad, Chancellor of the University of North Carolina System, focused on the need for life long learning in the context of the literal explosion of information. (3) She estimated that information doubled between 1900 and 1950. It doubled again between 1950 and 1975, again between 1975 and 1990, and again between 1990 and 2000. She suggested that by the year 2012, information will be doubling every twelve days. The idea that a physician can master and retain all the information required to practice medicine today is not only impractical, it is impossible.
The curriculum for undergraduate medical education, as recommended by the Flexner report, was six years. Following an introductory year of physics, chemistry and biology, the first two years were strictly basic science with little patient contact in Years 1 and 2, with Years 3 and 4 patient care through rotations in medicine, surgery, pediatrics and OB/GYN. The sixth year was a year of supervised practice in a hospital, the internship. At the halfway point of the first decade of the 21 st century, it is interesting to note that the length of the undergraduate medical curriculum has not changed. The term “preclinical” applies to the first two years where there is an emphasis on basic science. However, patient contact actually begins almost immediately in all medical schools. The third and fourth years are primarily clinical with required rotations in Year 3 and Year 4 almost completely elective. Our curriculum contains a review of basic science in the fourth year. Numerous medical specialties and subspecialties developed during the 20 th century. It is not possible to participate in rotations in all specialties, but the elective year allows a student to concentrate on a specialty or subspecialty if he or she so desires. For instance, a rotation in ophthalmology is not a required course in most medical schools. Some of us believe that is a major shortcoming.
At the turn of the 20 th century concerns in healthcare addressed a lack of admission standards and a poorly structured medical curriculum resulting in a large number of unqualified physicians. The implementation of the recommendations of the Flexner report as well as the development of oversight organizations served to standardize the medical curriculum and assure the public that those practicing medicine had met a certain minimum standard of education and training.
As any educator will tell you, changing a curriculum is not a simple task. Our Faculty Council looked at our curriculum in the mid 1990s, and it was determined that the curriculum needed more than fine tuning -- indeed, it needed to experience a transformation. We brought in two wonderful consultants, Dr. Dan Federman of Harvard and Dr. Ian Hart from the University of Ottawa, Canada. Dr. Hart commented that changing a curriculum was like moving a cemetery, one body at a time. We actually had two different task forces, the first which described the guiding principles for improving our educational program, and the second to design an implementation strategy and timeline for the curriculum revision. Dr. Laurence Gardner, who chairs the National Board of Medical Examiners and is our Chairman of Medicine, and Dr. Mark O’Connell, our Senior Associate Dean for Medical Education, co-chaired the implementation plan, and along with other faculty, but most specifically Dr. Karl Magleby and Dr. Andy Taylor, helped design the implementation process. The process which began in 1996 actually was implemented in 2001.
Let me briefly describe the undergraduate medical experience today. The emphasis on course integration continues with interdisciplinary groups of faculty who provide instruction in organ-based systems. This provides an atmosphere where learning is occurring within the context of the application of knowledge and is therefore more easily applied and retained. Such course integration is a horizontally oriented approach to undergraduate medical education. At the same time, there is a longitudinal or vertical integration of themes that were not previously included within the medical curriculum. These include topics such as quality improvement, professionalism, ethics, end of life care, complementary and alternative medicine, and systems based care. At the UM Miller School of Medicine, some of these themes are also addressed beyond the classroom through academic societies, which include students from all four classes.
As we noted at the beginning, the primary concern for medical education at the beginning of the 20 th century was the number of unqualified physicians practicing medicine due to a lack of standardized admission criteria and a standardized curriculum that assured that all practitioners met certain minimum qualifications. Medicine advanced in remarkable ways on virtually every front during the 20 th century, allowing physicians and other healthcare providers to address conditions previously felt untreatable and leading, for many, to improvement in the length and quality of life. At the turn of the 21 st century, our primary concern is with medical errors, communication and the rapidly increasing cost of healthcare. In 2000 the Institute of Medicine issued a report entitled: “To Err is Human.” (4) This report estimated that between 44,000 and 98,000 Americans die each year from preventable medical errors. Medical errors are killing more people per year in America than breast cancer, AIDS or motor vehicle accidents. In a recent study, it was estimated that 80 percent of errors were initiated by miscommunication, including miscommunication between physicians, misinformation in medical records, mishandling of patient requests and messages, inaccessible records, mislabeled specimens, misfiled or missing charts, and inadequate reminder systems. (5)
We all acknowledge that errors occur. What is a reasonable error rate? Let’s assume we apply a standard of 99.9 percent error free activity to some everyday activities. In aviation that would mean 84 unsafe landings every day, and a major plane crash every 3 days. In the post office there would be 16,000 mail items lost every hour, and in banking, 37,000 bank transaction errors per hour. Such experiences would be totally unacceptable, indicating that the error rate for these activities is far better than 99.9 percent. Yet medical error rates are no where near the 99.9 percent standard.
Let’s look at how aviation addressed safety concerns. A 1979 workshop sponsored by NASA took place following research into the causes of air transport accidents. (6) The research identified human error in the majority of air crashes as failure of interpersonal communication, decision making and leadership. The term “Cockpit Resource Management” was applied to the process of training crews to reduce pilot errors by making better use of human resources on the flight deck. Part of the process of reducing aviation errors was to shift from the cockpit to “crew” resource management, shifting responsibility from pilots to the entire team of people involved in a flight. Topics such as team building, briefing strategies, situation awareness and stress management were addressed. The fundamental principle of crew resource management is that error is ubiquitous and inevitable. Crew resource management is viewed as a set of error countermeasures with three levels of defense. First, avoidance of errors; second, trapping of incipient errors or near misses before they are committed; and third, mitigating the consequences of those errors that do occur. In aviation, error management begins with the understanding and communication of the fact that errors do occur and there should be a non-punitive approach to error.
Another aviation approach to error management is joint training of cabin and cockpit crews with the fundamental understanding that anyone on the crew may register a concern and keep the flight on the ground. Pilots are team leaders but not dictators. Recall, from your own experience, that on any given flight it is possible that none of the individuals who make up the crew have worked with each other previously. Yet the team training and individual competencies allow a successful completion of the flight. There also was recognition that individual stressors, such as fatigue and family issues, impact performance.
Now, let’s return to the Institute of Medicine Report. Several recommendations emerged. First and foremost, it was recommended that “All healthcare professionals should be educated to deliver patient centered care as members of an interdisciplinary team, emphasizing evidence based practice, quality improvement approaches and informatics.” To achieve these goals, the Institute of Medicine recommends several competencies be assured for all physicians:
These recommendations have been modified slightly by the accrediting organizations -- the LCME, the AGME and the American Board of Medical Specialists -- to create standards in six competencies including patient care, medical knowledge, practice based learning and improvement in interpersonal and communications skills, professionalism and systems based practice. While there is universal acceptance of these competencies, in principle, some such as professionalism and communication do not lend themselves well to standard methods of evaluation
Summarized more briefly, the primary goals for 21 st century medical education fall into three main areas:
As in aviation, the communication is critical. A major problem for each of us today is that when more than one doctor is involved in a patient’s care, it is possible and even likely that no one physician is aware of exactly what the another physician is doing, or sometimes even that another is involved. The consequences range from inconvenience to possibly critical or even fatal errors. Each time we see a new healthcare provider we must retell our medical history. Not only is this redundant, it can introduce error and imprecision, ensuring that no two copies of a personal medical record will be exactly alike, and in an emergency, delay and a lack of information can be crucial, in fact, deadly. One of the most common complaints that we receive in the Dean’s office is the lack of clear understanding on the part of a patient or a family of the overview in a complex medical situation. Even with our very best physicians involved, it’s not clear that the groups of physicians providing care sit down to develop an overview of care. Reliance on handwritten records which are easily misread, particularly prescriptions, can result in potentially life-threatening mistakes. In the age of the internet, this shortcoming is unacceptable.
The recommended competencies have been incorporated into the undergraduate medical curriculum as longitudinal themes and are addressed during all four years of medical education. In post-graduate training or graduate medical education, the six competencies are part of an ongoing evaluation, and each program must demonstrate what the trainees have learned, not what they have been taught. In addition, work hours have been limited in an attempt to reduce stress and fatigue and to improve performance. The specialty Boards under the direction of the American Board of Medical Specialties are requiring that these competencies be demonstrated in order to maintain Board certification, and all Boards have a maintenance of competency process which includes a review of practice, cognitive knowledge, and a demonstration of competence.
Interprofessional education and training models are not yet established, but the importance of interprofessional learning experiences is understood. We are participating with a group of approximately 20 other medical schools in a quality improvement program to address the need for nurses, physicians, pharmacists, social workers and healthcare administrators to learn together. There are certain obvious areas where participation in shared learning can improve communication among healthcare providers -- courses such as the introduction of the patient, medical ethics and system based practice.
As an aside, everyone is aware of the national medical malpractice crisis. This is a particularly difficult problem in South Florida and has been a major problem for our School of Medicine. Dr. Dennis S. O’Leary, the President of the Joint Commission on Accreditation of Health Care Organizations, the agency that accredits hospitals, notes that the vast majority of untoward events occur in hospitals, and roughly 88 percent are the result of system errors, while only about 12 percent are actually attributable to individuals. (7) The application of a process similar to aviation’s crew resource management with teams of healthcare providers within hospitals, led by physicians but with team training and communication, can provide an opportunity to reduce errors. Some of this is already happening and includes steps such as a time out before starting a surgical procedure to discuss the patient, the procedure and the potential pitfalls
Students at the University of Miami Miller School of Medicine have for several years been evaluated through the use of an Objective Structured Clinical Examination, or an OSCE. In this setting actor/patients are interviewed and examined by medical students with a faculty member present. At the conclusion of the session the student is evaluated, both by the faculty observer and the patient. The focus is not only that the symptoms and findings have been addressed, but that interpersonal skills and communication skills of the student are appropriate and empathetic, and that the patient is treated with respect and concern. In addition, our students have a four-year experience with a cardiac simulator developed by Dr. Michael Gordon, known as “ Harvey.” Harvey is a computerized mannequin that has been programmed to manifest specific symptoms of heart disease and objective findings that can be elicited through appropriate examination techniques. In addition, the computer software permits increasing degrees of difficulty to allow a student to progress through a maturation process as he/she learns more about cardiovascular disease.
The evaluation of competence is facilitated in areas where direct observation is possible. This is the case for both medical students and graduate medical education where students work with faculty on a day-to-day basis. However, the demonstration of competence is more challenging when we begin to talk about the evaluation of the practicing physician. Here again, I think we can learn from the aviation model. Pilots are subjected to simulation testing and training on a regular basis. The simulation places the pilot into realistic circumstances and tests his/her ability to make adjustments to maintain the safety of the aircraft and the passengers. Similarly, medical simulators have been developed, particularly in anesthesia and for some of the interventional techniques. These simulators allow the same kind of testing for procedural competence of physicians. At present the University of Miami Miller School of Medicine has an anesthesia simulator, endoscopic simulation with virtual reality for examinations such as colonoscopy, in addition to Dr. Gordon’s “ Harvey” and other initiatives developed at the Center for Research in Medical Education.
The aims of simulation include education and training as well as performance assessment. Participants can be individuals or teams, such as an ICU team, a ward team, or a physician’s office team. In fact, simulation could and should apply to all aspects of healthcare. The technology includes the use of mannequins, a web based program on a computer screen and virtual reality. While simulation techniques can help to evaluate someone’s competence to perform a procedure, they can also be used to enhance teamwork. As an example, simulators can be programmed based on the findings of an MRI prior to an interventional cardiology case and permit the team to perform the procedure using virtual reality based on the MRI, with the difficulties encountered on the simulator before attempting to perform the procedure on the patient. It is clear such practice can only serve to enhance the ultimate outcome for the patient.
Four years ago during the recruitment of Dr. David Lubarsky as Chairman of our Department of Anesthesiology, he proposed the creation of a Center for Patient Safety which both Ira Clark, the CEO of the Public Health Trust, and I endorsed wholeheartedly. The University and the Public Health Trust agreed to invest $10 million in this initiative. Our Center for Patient Safety, under the direction of Dr. David Birnbach, employs medical simulation training, systems engineering and human factors, research and education. Some of the current simulation projects include a patient safety workshop for all incoming interns, resident training for the anesthesiology residency program, code blue training for internal medicine residents and critical care nurses, simulation for medical students, post-operative simulation for residents in internal medicine, critical events simulation for surgical hospital nurses and others.
Our Patient Safety Center was funded by the State of Florida as part of the Florida Patient Safety Corporation to coordinate patient safety education research statewide. It has also been funded in near-miss reporting systems for the State of Florida.
An oft used phrase in medical education used to be “See one, Do one, Teach one.” This is the method through which clinical medicine was taught for decades. This is no longer an acceptable method for teaching or learning, and is certainly not in the best interest of patient centered care. It is my hope that in the next decade we will expand on our Patient Safety Center to have a fully functional patient simulation center that will be available for our medical students, the physicians in our training programs and the practicing physicians in our community. Demonstration of competency is already a requirement for graduation from medical school and for the successful completion of training programs. It will soon be a requirement for continued licensure and Board certification. In addition, we must work to improve interprofessional education and communication among all healthcare workers, and among all people involved in the healthcare system.
While healthcare by nature is more complicated than aviation, we can learn from both the use of simulation and improved communication. It is no longer acceptable that the physician has the final word. Our training must address the role of physicians as leaders acknowledging the competence and importance of every team member involved in the delivery of care.
We are on the right track, but here are some thoughts on Future Steps for Medical Education:
These systems can best be developed in an academic medical center where medical students, house officers and physicians in training can learn the system and adapt to its use. The patients’ interface with this connected system of healthcare information could be with a smart card which contains all our healthcare information and is updated regularly as needed.
In conclusion, the successes of medical education in the 20 th century have been nothing short of phenomenal. The treatments developed to alleviate suffering and improve the quality of life and function are mind boggling, but we cannot be satisfied with our success and must strive to reduce error. The challenge today is to continuously improve healthcare by reducing error through effective communication, maintaining and improving competence, while recognizing that complex healthcare problems can be best approached and managed most safely through effective interpersonal teamwork.
Thank you for your attention and for this wonderful honor from the University of Miami Miller School of Medicine.
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