Perhaps my techno-naivety has blinded me! I agree with some of my co-reviewers that the paper is a little gloomy. I agree that big IT systems are expensive, but the potential power of information management seems to make this worthwhile. It would be interesting to read reports from others who have had both negative and positive experiences as we need to develop a balanced view. An interesting article but far too gloomy. The has always been worry and comment about reduction in attention span and yet then moan that young people spend endless time playing games which require significant time spent on mastering the different levels..
Erosion of an acceptable knowledge base - what is an acceptable knowledge base and where should it reside? Is knowledge to be found only within skull and skin? The whole of knowledge since the dawn of civilisation can now be access on your phone. Assessment of this knowledge and its veracity and validity is one of the many new skills we should be teaching students.
Failed TEL initiatives - is this anymore a problem than other failed educational initiatives - i think not. Ghost writing - yes a problem but plagiarism much likely to be picked up now using technology. I could go on. However this piece does set out areas that should form the basis of new research and as such can be applauded particularly if the authors start the ball rolling The use of technology is on today's agenda in medical education and features on lists of trends..
I have recommended this article as it draws our attention to possible problems. I would have liked more details on the issues raised in the table. I like the suggestion that we should publish not only descriptions of successes but also failures. A topic for a future AMEE conference! This short editorial type piece highlights some considerations for medical educators and their institutions before they dive into TEL.
I had hoped that the issues noted in the Table might have been discussed in more detail. I am unsure of the relevance of promoting a conference within this short piece. Some interesting ideas that I would have been keen to have a detailed discussion presented.
I enjoyed reading this article which looks at TEL from an opposite angle. It bodes healthy that we look towards the negative effects of new educational approaches and opposed to constantly promoting the benefits. I would agree with one of my co-reviewers that some of these issues relate to non TEL, but that doesn't mean we should avoid the issues in totality. Given that this an opinion piece, I hope that it promotes deeper discussion into the real pros and cons of TEL.
Although very short, I think this paper is timely. Whilst we can apply and use technology to enhance learning it can also reduce the quality of the learning experience for example death by PowerPoint bullet points or clicky, click, click online learning. Similarly, the lack of robustness and rigour in the published literature around TEL could be applied to many areas of educational research.
There are wider debates going on around the use of technology and the ethics around learner analytics etc. I look forward to seeing a growing discourse around thedarksideofTEL in medical education. Although the paper is rather pessimistic, it does set out to warn about problems with technology in medical education, and so, is necessarily pessimistic.
There are few points, however, that need to be taken into account: Some of the problems referred to in the paper are not restricted to medical education research, and are also currently an inherent part of pure medical research. Lack of reporting of negative results. This is standard in most medical research; in fact, a known weakness of EBM is that negative results are seldom published, both for the reasons advanced in this paper, and for the fact that most medical and scientific journals are loath to publish negative results. This problem is compounded by commercial sponsorships of EBM research.
Again, this is a problem in medical research: Often these are also a result of extremely narrow inclusion criteria in trials. This is a problem not only of medical education research, but of research in general, especially when dealing with human subjects. So, while the authors are right in their concerns, medical researchers might be encouraged to examine the plank in their own eye before looking to the speck in that of the comparatively new field of technology in medical education.
It would have been useful for the researchers to refer to this, as medical research does form an important context for medical education research. On a positive note, the authors have shown a way for some possible solutions. In addition to these, there is another: Again, however, this is something from which medical research could also benefit, so, again, we look to medical research to set the pace in this.
Gamification is the generally positive activity in which principles of games are applied to other situations in order to encourage participation and increase understanding e. Related to this, the authors have rather unfairly lumped the gaming of portfolios to the use of technology in medical education. Portfolios have been around for a long time, and were gamed for a long time before e-portfolios were designed.
If there is a problem with e-portfolios, then the technology is unlikely to be the problem — the technology is merely the storage container. The social and behavioral sciences, on the other hand, must open up new places for themselves rather than evolve from old ones. And the population-based sciences typically would have been housed in schools of public health in those universities that had such schools.
They too must forge a new place in the training of physicians. We must fully understand the confounding variables in discussions of what constitutes the science base in medicine. Status, for example, often is linked to a department's share of curriculum time. Giving up time to make room for other disciplines can be viewed as yielding power and status. There also may be a lack of understanding and communication across disciplines. A useful study would explore ways to promote inter-institutional and inter-disciplinary communication. Case studies of attempts to enhance cross-departmental or cross-institutional understanding of goals, methods, language, and constraints should elucidate productive future directions.
During the course of this planning study, a number of such experiments were identified—Morehouse College undertook to educate basic scientists and clinicians about one another's purposes and needs, for example. Medical education in the U. Within this continuum are private and public institutions, some emphasizing research, others clinical practice, some with an eye toward community needs, others with a more national view.
Ideally, it would be a smooth continuum, with each stage building on earlier ones and taking advantage of the particular combination of strengths and goals individuals bring to their education. Discussions of curricula usually focus on the four years of medical school or the first two years of basic science training , but pre-practice medical education begins in the college years and continues through several years of graduate training. What should be taught, how, and when? Does this vary with the varying goals of medical schools?
How early might the language, approaches, and knowledge base of some disciplines be taught and how long might others be deferred? How might this instruction be integrated so as to optimize use of time and resources, and to make learning most effective? Are scientists, be they in the traditional life sciences, the social and behavioral sciences, or the population-based sciences, conveying only a language and an approach to prepare students for life-long learning, or are they conveying an essential body of facts as well?
The rhetoric on this distinction varies with time and place. Students who enter medical school arrive with diverse academic backgrounds, and they develop a variety of career objectives over the following five to eight years. Some start their medical training after a very strong undergraduate program in the natural sciences in college, while others have a background in the humanities or social sciences with only the required minimum of premedical science courses.
Many students entering medical school have had a strong liberal education while still others suffer from the current problems of American elementary education and have a poorly developed ability to write reasonable English sentences. Most medical students have as their primary objective careers in medical practice; however, a few aim at careers in academic medicine either as clinical investigators or as basic scientists. Individuals who make each of these different career choices play valuable roles in the society and are needed in the profession.
A diverse background of the student body seems desirable both for the medical schools and for the profession as a whole. What constitutes a reasonable minimum background for entrance to medical school and what level of intellectual diversity should be encouraged for premedical students in college? There are certainly some areas of medicine in which it would be important for students to have strong backgrounds in molecular biology and genetics, others for which a strong background in chemistry and biochemistry would be desirable, and still others for which backgrounds in sociology, philosophy, economics, computer science, physics, engineering, or management would be extremely useful.
The present premedical requirements have remained unchanged for many years. Are they all necessary, either because of the substantive material they contain or the information they provide for the medical school admission process? Are there new requirements which should be added to the premedical program, such as statistics and probability, computer programming, ethics, etc.? Should there be a requirement for service in the health care system? What criteria can and should be used in establishing such requirements? Students and other critics generally list two complaints about the basic science instruction in medical school—that its relevance to clinical medicine is obscure and that it is overloaded with esoteric facts of importance only to researchers.
The basic science faculty indicate they are first and foremost conveying a way of thinking and are teaching essential principles which may at times best be illustrated by non-clinical experimental systems, and which can best be understood by in-depth exploration of a research problem. Teaching in the sciences needs to be assessed as to cognitive tasks.
Have the basic scientists articulated for themselves clear goals for their students? Can a cognitive-task approach be used in this setting? Some thought also should be given to the way in which clinical faculty challenge the students to apply their training in science. The responsibility to relate the basic to the clinical is not one sided. Paradoxically, the information explosion may contribute to its own containment.
More knowledge should lead to fundamental understanding so that organization of detail into conceptual frameworks becomes possible. This should ease both teaching and learning. The use of computers, for information management, for teaching, and for problem-solving, undoubtedly will grow in the future. This tool could simplify teaching and learning, but there is the danger that instead the computer technology will be treated as yet another package of information to be learned—adding to the students' burden rather than easing it. In this age of computers in the home, grade school, and summer camp, incoming medical students will bring computer facility to their medical education.
Are their teachers adequately prepared to use the students' facility to greatest advantage? A recurrent question in medical education is the adequacy with which courses at one level build on material provided in previous study. This question arises with respect to the use which the basic science courses make of college preparation and even more critically with respect to the use that clinical training makes of the basic science courses. Several different experimental programs have been introduced to provide closer integration between the clinical and the preclinical training.
However, there is little reliable data as to whether the problem really exists; can and do students make the necessary connections themselves; do faculties know enough of each other's specialty to provide the integration automatically? How much success have the new, more integrated programs really achieved? Better integration of science training programs within and among institutions colleges, medical schools, and teaching hospitals might conserve time, one of the scarcest resources in medical education. Willingness to trust another department or institution to convey relevant bodies of knowledge probably will depend on enhanced communication across territorial barriers.
Until the life scientists, the social-behavioral scientists, the population-based scientists, and the clinical scientists understand and appreciate the contributions of one another's disciplines, mutual dependence and reinforcement will not be apparent in their teaching. Is there a way to allow multiple pathways through medical school? Can the same basic curriculum fill both the role of graduate school training and professional school training? How can the methods, approaches, and excitement of science be taught rigorously to researchers in such a way as to stimulate students intending a career in practice?
What exactly is the role of research in medical education institutions? Should only certain selected schools train our future cadre of clinical investigators? Another aspect of the diversity of the population being educated is the student with advanced training. Do our educational institutions respond adequately to their knowledge and sophistication and build individualized programs for them?
What are the barriers to and supports for such individualization? And do these students devise a career that draws on all facets of their advanced education? For example, what portion of MD-PhDs do not do research, and are there correlates or predictors of particular decisions about research, practice, or doing both? When there were a number of medically underserved segments of our country, and an undersupply of physicians was projected, training programs for a variety of allied health personnel were developed—nurse midwives, nurse practitioners, child health associates, etc.
The advantages of upward and lateral mobility in these profession was noted at that time. There has been some drift of physicians toward traditionally underserved areas, but inner-city and rural dwelling Americans still have limited access to health care Chapters 4 and And concern about rising health care costs continues to loom large.
Thus, there may still be a role for health care personnel with intermediate levels of training. Diverse entry and exit options for health professions education should be considered. How readily may students in related educational programs—schools of medicine, schools of public health, graduate schools of arts and sciences, and schools of nursing, for example— transfer across programs when it seems well-advised? Should there be structured opportunities for transfer after greater experience and maturity have clarified students' knowledge of their own aptitudes and career aspirations?
Can there be multi-tiered programs so that students can exit from the educational system at varying levels of professional responsibilities, and perhaps re-enter in later years? Might there be drop-out points for service in the health care system or to devote full time to research projects, for example, and thus to glean practical experience which also helps clarify aptitudes and career goals?
Concern has been expressed that this country at present does not have a sufficient supply of well-trained physician researchers; the problem seems to be growing. Only a small percentage of medical school students intend to pursue a career in research; furthermore, those with an M. As research funding declines and reports indicate an undersupply of medically trained researchers Chapter 11 , a number of questions related to the significance and importance of research to medical education have arisen. How much research is essential to medical education?
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How large a research faculty is needed to support this essential element? What factors hinder and support the production of medical research personnel? How large a pool of medical researchers does the nation want? Does the existence of research activities in medical schools increase the cost of medical education? Some of the questions have been answered, or partially answered, by existing research. A brief survey of literature revealed the following findings:.
Concern about the impact of loss of research funds is not new. In Van der Klost sounded the alarm, saying,. In the last few years…we have been taught a bitter lesson. Programs that took years to build can be undercut almost overnight…Today we are abruptly confronted with a generation of students who for a variety of reasons …tend to turn away from science as a satisfying and creative life work. The relative handful who retain interest can only view the future support of science as bleak and uncertain. Many students now in training programs supported by the federal government are unsure from month to month how long they will be able to continue.
The alarm bells are ringing even more loudly today, not only for biomedical research but also for the essential research understanding of students in medical school. While there are some who suggest that private industry may fill at least some part of the gap left by the withdrawal of federal funds, doubt is expressed that much help can be expected from that quarter.
Research faculty, unlike clinical faculty, have no major avenue of financial support available to them outside of direct research funding, the bulk of which comes from government sources. The implication is that, if faculty are to be cut, researchers who cannot fully support themselve through research awards are most vulnerable. Estimating the impact on medical education of reduced research funding is complicated by the diffusion of research and research related activities throughout academic health centers. There are full-time and part-time research faculty, full-time and part-time clinical faculty who are involved in research, there are research physicians involved in investigations in hospitals, there are medical students with short-term research fellowships, etc.
At the most obvious level, one might assume that because of federal research cuts faculty and Ph. Because there are fears that the quality of medical education will suffer if there is a diminution of research activity, and apparently no consensus on the level of research involvement necessary to instill the necessary qualities ability to absorb the results of research, understanding of deductive processes, scientific curiosity in students intending to practice clinical medicine, at this time monitoring actions are required to determine how medical schools are reacting to diminishing funds.
Most of the issues outlined here pertain not only to physicians but to a wide range of health professions. For example, in such areas as financing of education, qualities sought by admissions committees, developing curricula, and acquisition of new knowledge through research. Consideration of other health professions is integral to successful analysis and policy development. Effective and cost-conscious division of labor and responsibilities in the care of patients, the management of the health care system, and the education of future professionals in that system require coordination and integration of educational planning.
An HPSL is delinquent if a payment is more than 90 days late. The HPSL delinquency rates, which are determined for each school, ranged up to Some members of the committee suggest that it might be productive to look at foreign medical schools that, at a lower cost than domestic schools, graduate high-quality physicians.
The purpose of this investigation would be to discover how a good physician can be educated less expensively. Bourne, Vice Chancellor of St. George's University School of Medicine in Granada, West Indies, in a letter in Education on September 23, , argues persuasively against assuming that all foreign schools produce inadequately prepared physicians. To support his contention he cites both the clinical preparation given students in his school and their success in various examinations. The close collaboration of medical school based disciplines e. It points to the benefit of lowering barriers to communication across institutional and departmental barriers.
Turn recording back on. National Center for Biotechnology Information , U. Four sets of questions will underlie the future work of the Agenda Group. The targeted studies and their subtopics, in priority order, are listed here. Financial Pressures on Medical Education a. The Cost of Medical Education b. Availability of Financial Assistance c. Impact on Teaching Hospitals and Medical Schools 2. The Changing Role of the Physician a. Desired Qualities in Physicians b. Health Manpower Policy c.
Potential New Roles for Physicians 3. The Cultures of the Medical Education System a. Decision-making in the Medical Education System b. Fostering Teaching, Research, and Service c. The Professionalization Process for the Physician d. The Teaching Hospital e. The Premedical Syndrome 4. The Science Base of Medicine a.
The Science Base of Medicine b. Financial Pressures on Medical Education Medical education today is rebounding from an earlier expansionary era in which increasing the production of health manpower was considered a priority. Relevant to the impact on students are analyses of factors affecting: The Cost of Medical Education Tuitions and fees have increased considerably in the last 20 years Table 2 , Chapter 8 , yet they seldom cover all educational costs to the institution. Availability of Financial Assisistance Policymakers concerned with such matters as the size and composition of the physician labor force, the type of medical care offered to the public, and equity in access to medical education, should be informed thoroughly about the consequences of increased tuition and changes in financial assistance to students.
Impact on Teaching Hospitals and Medical Schools Financial pressures on teaching hospitals may affect clinical education. The Changing Role of the Physician This theme was selected because, although it is not possible to predict with absolute certainty the demands on the medical profession 10 to 20 years from now, it is necessary to prepare for change and develop the ability to deal with change. These studies emerged from committee discussions and background materials, and are presented in order of priority set by the committee: Desired Qualities in Physicians Are there qualities, such as honesty, curiosity, and skepticism, that are required in all those seeking a career in medicine, regardless of whether patient care, research, administration, or some other activity is their major responsibility?
Health Manpower Policy The increasing supply of physicians in respect to other health professionals, modifications in roles of non-physician health care personnel, scientific advances, and changing demographic patterns and burdens of illness, may well lead physicians into new roles. Potential New Roles for Physicians With changing patterns of health and disease and an increasing supply of physicians to interact with a variety of health care providers, the division of labor among health professionals may undergo major shifts.
The Cultures of the Medical Education System Patterns of authority and complexity in medical schools and affiliated universities have changed profoundly in the past three decades. Decision-making in the medical education system. Decision-making in the Medical Education System At each stage of medical education, there are persons or committees with power to include or exclude, to shape, redirect, encourage or discourage the student or physician.
The Professionalization Process of the Physician During the course of their education, physicians-in-training acquire a set of facts, a knowledge of resources, an approach to problem-solving, a set of values and attitudes, and a personal style of interacting with patients and professional colleagues. The Teaching Hospitals For a long time, schools of medicine held a dominant position in the ecological system of health care.
The Premedical Syndrome The premedical syndrome is one adverse outcome of perceptions about the culture of medical school. The Science Base of Medicine During their education, physicians must learn the ways of science as well as a specific body of knowledge. How could the separate components of the educational process be better integrated? The Science Base of Medicine In many areas of practice, the physician must integrate observations and data spanning a range from the submicroscopic level through physiology and individual variation to the ecological environment of the patient.
A Strong Research Establishment Concern has been expressed that this country at present does not have a sufficient supply of well-trained physician researchers; the problem seems to be growing. A brief survey of literature revealed the following findings: A study noted that a 50 percent increase in research essential to education resulted in a 13 percent cost increase, which was usually offset by an equivalent increase in revenues from research.
The research intensity of a medical school does not affect the specialty choice of graduates. Academic health centers have not been able to compensate fully for cuts in federal research funds by attracting funds from other sources. Federal funding affects both the level of and nature of biomedical research. Conclusion Most of the issues outlined here pertain not only to physicians but to a wide range of health professions.
Association of Academic Health Centers. New England Journal of Medicine Costs of Education in the Health Professions. National Academy Press, State responsibilities under the new federalism. Health Affairs 1 2: Medical education in the United States, — Journal of the American Medical Association State Support for Health Professions Education. Government Printing Office, Survey of graduates of a traditionally black college of medicine.
Journal of Medical Education Medical Education Financing Financing. Policy Analyses and Options for the s. The Urban Institute, Problems and Policy Alternatives. College Entrance Examination Board, Economic growth and equal opportunity: Conflicting or complementary goals in higher education. Medical loan rules eased but most schools will have problems. Washington Post , June 6, , p. American Medical Student Association. New developments with financial aid programs , p. Scarcity of residency slots becoming a worry for medical-school graduates.
Medical World News , Aug. Seline, Association of American Medical Colleges. Personal communication to the committee. Lewin, Lewin and Associates, Washington, D. The costs of health professional educations. Association of American Medical Colleges. Personal communication to Dr. Community Oriented Primary Care: New Directions for Health Services Delivery. Report of a conference held March Department of Health and Human Services. More Medical Care, Better Health?
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University of Chicago Press, Priorities in medical education. Perspectives in Biology and Medicine Oelgeschlager, Gunn, and Hain, The New Biology and Medical Education: Merging the Biological, Information, and Cognitive Sciences. Genetic Influences on Responses to the Environment. Revson Foundation, July 10—11, Maternal and Child Health Research. National Academy of Sciences, A Study of the Knowledge and Attitudes of Physicians.
Frontiers of Research in the Biobehavioral Sciences. Report of a Study by a Committee of the Institute of Medicine. Stress and Human Health. Alcoholism, Alcohol Abuse and Related Problems: Committee on Science, Engineering, and Public Policy. Report of the Research Briefing Panel on Neuroscience. The role of psychiatric and behavioral factors in the practice of medicine. American Journal of Psychiatry Prepared for the Commonwealth Fund, April Career mobility in allied health education.
Costs of Education in the Health Professions , p. Prepared for the President's Biomedical Research Panel. Van der Kloot, W. The education of biomedical scientists. The Future of Medical Education. Duke University Press, The Blue Sheet , Feb. PubMed Links to PubMed. Clear Turn Off Turn On. Support Center Support Center. Please review our privacy policy.
Medical practice plans have become an increasingly important source of revenue for medical schools Table 1 , Chapter 8 and have been used to finance expansions in clinical faculty.
Medical Education and Societal Needs: A Planning Report for the Health Professions.
Although the organization of plans differs among schools, all specify the way in which funds generated by faculty members engaged in patient care are distributed to the school or faculty member. Medical practice plans have been in place for over twenty years, but concern with the impact of these arrangements has become acute only recently as the search for revenues to replace shrinking government funds has stimulated a greater emphasis on medical practice plans.
Many members of our committee, noting that faculty appear to be devoting a large proportion of their time to their clinical practices in order to generate increased plan revenue, expressed concern about two observed effects. First, that teaching activities are becoming secondary to clinical practice and, second, that two tiers of faculty are developing—those who can produce revenue and those who cannot. The latter group includes most research faculty, whose positions may be becoming tenuous since their earnings ability is constrained.
Studies have come to differing conclusions as to whether residents represent a loss or gain for teaching hospitals, whether residents should be considered as students, apprentices, or some other status, and whether or how much residents increase the cost of care or decrease productivity in teaching hospitals Chapter Regardless of the outcome of these differences, a number of things are clear. Residents spend the bulk of their time roughly 75 percent in patient care, and are largely again about 75 percent funded by hospitals' general operating revenues. Additional costs include supervision, extra tests and procedures, and space for teaching.
It is unclear whether it is these costs or the severity of patients' illnesses or a combination of these and other factors that result in higher patient care costs in teaching hospitals than in others. In —82, there were a total of 73, residency positions, 94 percent of which were filled. Recent trends have been for the demand to increase at a higher rate than the number of slots offered; first year slots have declined and are particularly problematic.
It is clear that much time and money has been spent developing methodologies for cost estimation in medical and graduate medical education. It seems questionable whether further effort in that direction is the most useful approach today, when concern is directed toward identifying ways of making medical education more cost effective. For, even if we know educational costs, we do not necessarily know how to produce physicians efficiently. This implies that utility should be a prime consideration in selecting research. In short, if medical schools and their affiliated institutions are looking for ways to reduce costs, and making changes in response to economic pressures, research can help by presenting a menu of cost-containing measures for which the effects of reduced expenditures are known.
Educators should then be able to select measures with the most desired, or least undesired, impact. This approach is exemplified by Lewin, who suggests that, since faculty represent the largest single medical school expenditure, studies of faculty costs, through an examination of how faculty spend their time and the revenues they generate, would provide useful information for management, budgeting, and planning.
A logical approach to performing research useful to decision-makers could use as a base the work begun by the Institute of Medicine in the report on the Cost of Education in the Health Professions. Further research to discover gross differences in costs among schools and associated educational differences would indicate possible areas of cost reductions and their expected impact.
This approach moves away from an emphasis on developing complex cost finding methodologies to arrive at finely tuned cost calculations, toward identification of major cost components, such as faculty, and rough cost estimates. Another approach would group medical schools according to selected characteristics, examine major cost differences again avoiding complex cost-finding methodologies in favor of concentrating on major blocks of money , and result in pointers to greater cost effectiveness.
Characteristics that could be examined include size, to discover if economies of scale exist and if there is an optimal size for medical schools; the proportion of each type of specialist produced, to determine differences in the costs of education of different specialists and if it might be more cost effective for some hospitals to reduce the range of specialties offered; the proportion of graduates selecting careers in biomedical research and the level of research activity, to determine if there are economies of scale associated with research and the training of research scientists that could result in more cost effective ways of conducting these activities, and if there are differences in costs between research intensive and more primary care or clinically oriented schools that could suggest the most economical way of educating a majority of physicians.
A number of people have suggested that one approach to finding less costly ways of educating physicians could be to investigate differences in the cost of educating medical and osteopathic doctors and differences in cost in foreign and U. This approach seems dangerous, since many believe that there are major differences in the quality of education offered—for a true cost comparison, an identical, or at least very similar, product is needed.
An initial step toward a study aimed at developing cost effective faculty mix or size is to determine the appropriate variables and measures to be used. A one- or two-day conference of leaders in the different aspects of medical education would be a first move toward conceptualizing such a study, defining its parameters, developing hypotheses, and suggesting appropriate outcome measures. A study should look at the different financial arrangements of practice plans to determine whether some arrangements are more effective than others in structuring incentives that constrain tendencies to allow clinical practices to override teaching to the detriment of educational goals.
Financial factors in the demand for residencies also deserve investigation. Does the level of debt incurred in the first stage of medical education relate to the length of specialty training chosen? This could be studied as part of an inquiry into the impact of debt levels. This theme was selected because, although it is not possible to predict with absolute certainty the demands on the medical profession 10 to 20 years from now, it is necessary to prepare for change and develop the ability to deal with change. There are trends underway both in the health care system and in society at large that are likely to have significant impact Chapters 4 , 6 , Because of the long period required for a physician's training, we must begin to consider the implications of these trends—implications for the role of the physician and appropriate education for that role.
The trends that appear to be significant include demographic changes, particularly the aging of the U. All of these trends can be expected to produce changes in traditional physicians' roles. Some may be merely quantitative—for example, a greater amount of time may be spent with each patient as each physician sees fewer patients. However, there also may be profound qualitative changes in the role of the physician.
For example, with financial resource limitation assuming great importance, the criterion of the greatest benefit to the individual patient may no longer be the dominant basis for decision-making by the physician. A number of study topics integrating the trends enumerated above provide an opportunity to explore in depth the changes in professional education predicated by the changes in professional roles.
These studies emerged from committee discussions and background materials, and are presented in order of priority set by the committee:. The first three will be discussed below. The issue of educating physicians to be researchers will be addressed in study issue 4, the science base of medicine. Are there qualities, such as honesty, curiosity, and skepticism, that are required in all those seeking a career in medicine, regardless of whether patient care, research, administration, or some other activity is their major responsibility?
The findings of this working group should be available in approximately one year and should be a helpful for further work in this field. Other resources that might be used, bearing in mind possible cultural differences, include the experiences and evaluations of the student selection process at, among others, Ben Gurion University of the Negev Center for Health Sciences. This community-oriented primary care school lists nine major characteristics particularly looked for in the interviewing process; these include integrity and a sense of responsibility, as well as community orientation and tolerance of ambiguity Chapter 5 , Appendix D.
Some personal characteristics may be taught after entry into medical school, but others, perhaps, must be well-formed by the inception of the education process. Questions to be addressed include: What are the desired qualities, and how can they be detected in applicants? There are varied and more or less elaborate testing and interview processes in place to screen candidates at several stages of medical education—admission to medical school, appointment to residency slots.
How relevant are these screening procedures; how predictive are they? Can the selection process be validated? Aspects of medical education that reinforce particular personal qualities must be identified. How much malleability exists in young adults with respect to critical personality characteristics?
How can characteristics be influenced? How are messages about desirable and undesirable qualities transmitted? Are the messages correctly perceived? What happens when mixed messages are received? Can critical stages or processes in the education continuum be identified for nurturing desirable and unlearning undesirable qualities? There are reports, for example, that the medical education process dampens enthusiasm for learning. There are systematic efforts to assess factual knowledge, but what are the possibilities for enhancing the use of evaluation of and feedback on more personal aspects of performance by college pre-medical students, by medical students, by residents, and by faculty at all stages of the education process?
Perhaps physicians in practice also should be included in the evaluation and feedback so that it is viewed as an expected part of an effective continuum. Should someone ill-suited to the practice of medicine, but with potential for outstanding performance as a clinical researcher, for example, be admitted to medical school? How can we better understand and shape career decisions? For example, will prospective researchers change their minds and go into practice or vice versa , or should there be ways to restrict career choices based on personal qualities?
Perhaps of greatest importance, how can desired values and attitudes be taught, modeled, and learned? How can appropriate role models be selected for faculty within the cultures of the medical school and clinical teaching settings? A number of innovative medical educational programs have attempted to nurture particular qualities in future physicians. An assessment of the value and success of representative innovative programs is timely Chapter 5.
A review of innovative programs by a study committee would seek to make explicit the goals of the programs, agree on outcome measures, and evaluate the outcomes. Intended and unintended effects, both desirable and undesirable, would have to be determined. Information on decision processes also would be sought—how are decisions made about retention or termination of new programs, who decides, and what factors sway the decision? See Study Issue 3.
The first task will be agreeing on outcome measures by which the effectiveness of the innovations can be assessed. Most difficult of all, and most essential, will be developing consensus around measures of quality in clinical activities.
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A Delphi approach to agreement on such measures might prove fruitful. This could be carried out as a 2-to 3-day workshop. The AAMC 20 has done some exploration of soft measures, which might provide a starting point for the enumeration of measures by the Delphi process. The National Board of Medical Examiners also has developed methodology to assess communication skills 21 as an educational tool, rather than as a certification test. Once having agreed upon outcome measures, it would be possible to compare cohorts of physicians who have followed different pathways through their medical education.
Further topics to be explored by a committee would include the question of transfer of successful innovative programs—what can be transferred, what should be transferred, and how to encourage appropriate transfer without starting a slide toward homogeneity. Nurturance of innovations in the medical education system which seem to address specific societal health needs also should be explored Chapter 5.
Periodic meetings with an international group of medical educators involved in educational activities tied to meeting national health care needs e. These small conferences also might provide a forum at which to inquire into the desirability and feasibility of using our excess health manpower to assist other countries in meeting their health care needs. It has often been suggested that a national service obligation be considered for the youth of our country.
This might coincide with a program of service at home or abroad, as part of medical education. An international forum for discussion would be invaluable in this regard as well. The increasing supply of physicians in respect to other health professionals, modifications in roles of non-physician health care personnel, scientific advances, and changing demographic patterns and burdens of illness, may well lead physicians into new roles.
Although techniques for forecasting manpower requirements have become more sophisticated, improvements have been offset by increasing complexity of the health manpower situation and a rapidly changing health care system. It is necessary to integrate manpower needs across all the professions, including allopathic and osteopathic physicians, nurses and nurse practitioners, dentists, optometrists, podiatrists, psychologists, and social workers.
Connections should be made across the health professions in identifying and resolving manpower-related problems at entry points into the professions. For example, there are a shrinking applicant pool and declining enrollments in dental schools. A decreased demand for dental services, because of families facing financial constraints and lacking insurance coverage, and because of the success of preventive programs, probably account for these trends. A decline in applications to medical school also may be imminent. What kind of cross-over occurs, and how may each profession assure continuing high quality of entrants in the face of these trends?
Ultimately, the long-term requirements for each profession's services must be translated into the number of available training positions residencies in each specialty, for example. Connections must be made between specialty-specific requirements, supply, training positions, entering class size, and immigration laws. Especially challenging will be the development of an acceptable policy for funding medical and graduate medical education in the approaching era in which the economics of the health services system will undergo radical transformation. We note the following important developments Chapters 4 , The supply of health professionals will continue to outgrow the U.
The physician supply will expand by one-third in this decade. The requirements for health professional services cannot be estimated satisfactorily for the s because the determinants are largely unpredictable technological advances and social, economic, and political factors. These changes will be made possible by the marked expansion in health manpower and the progressive move toward contractual medicine.
The marked increase in the number of women physicians in the last decade and their distinct practice patterns as a group must be considered in planning for the future. We believe that a national health manpower policy should be developed to meet these changes Chapter A health manpower policy is critically important for long-range funding of medical and other health profession schools and teaching hospitals, to provide reliable information to high school and college students concerning opportunities in the health professions, and to provide useful information for long-range planning of the health services industry.
Our supply of health researchers also is a crucial component of manpower policy. This will be addressed in study issue 4 , the science base of medicine. Establishment of a national health manpower policy requires a sustained illumination of the issues through data collection and analysis, integration across all health professions, effective participation by both the private sector and governments, and the development of consensus.
We recommend that there be a continuing effort to collect and analyze data, making available biennial profiles of the manpower situation and two- to ten-year forecasts. One function of a national health manpower policy effort would be to create likely scenarios, identify what data are needed to construct the scenarios, and how they can be collected. Scenarios that integrate manpower with demand and need would be particularly instructive.
Medical Education for the Future: Identity, Power and by Alan Bleakley,John Bligh,Julie Browne
Delineation of policies to finance health manpower would have profound effects on a number of factors in education, such as faculty behavior, flexibility of approach, etc. The available evidence supports the hypothesis that the demand for medical education, as measured by the number of students applying to medical school, is directly related to the economic returns from the investment. However, this concept is based on aggregate numbers and relatively old data. It would be useful to develop and estimate models of individual choice in order to improve our understanding of the influence of socioeconomic characteristics, and family and educational background, as well as economic costs and returns.
A scenario that allowed market forces to operate on an open admissions policy to medical schools might be useful to create and analyze. Research on physicians' specialty choice has suggested that prospective earnings play a negligible role. However, a recent study calls these findings into question on the basis that their estimates of future earnings may have been biased Chapter 9.
This issue needs to be investigated further with more recent data, building on advances in modeling individual choice behavior, to give us a better understanding of the extent to which financial pressures will affect future specialty distribution of physicians. In addition, it will be desirable to consider the data in the context of a number of broad socio-economic-political issues, such as: What are the special needs of certain populations—blacks and Hispanics, the urban and rural poor, and the elderly? What are the comparative benefits of present high and low patterns of utilization? How can the reimbursement system or other mechanisms be used to bring demand for medical services in line with need?
What is the outcome of health services as measured in socially relevant terms, i. What are the appropriate roles for government? It should be emphasized that while a national policy is desirable, one body does not control it, because ours is a decentralized system. State-controlled institutions constitute 60 percent of the nation's medical schools.
States will have to determine their health manpower needs, the distribution of existing providers by location and specialty, the inflow and outflow of health professionals, and the return rates on funds for health professions training. State legislatures, facing increased budgetary pressures, will want guidance on future levels of medical and other health professional school enrollments.
They will be greatly assisted by having available national data for purposes of comparison, and for projections about possible migration of physicians. Specialty societies also will want to compare their assessments with national statistics. The American Board of Medical Specialties recently released the statement: Directed toward fact-finding and dissemination of information, this study should be primarily the responsibility of the private sector with the collaboration and assistance of the federal government.
Two crucial concerns to be kept in mind in the fiscalization of manpower policies, however, are that quality of education needs to be systematically maintained and that policies based on the belief that more doctors mean higher health care costs, which we cannot afford, may be detrimental to the health of the population. Professional schools, by their formal and informal programs of instruction, can influence the individual career decisions which in aggregate give our national manpower supply its detailed shape and characteristics.
The development and successful implementation of a national health manpower policy—for practitioners as well as for researchers, academicians, and administrators—requires that a broad constituency be involved from the outset. This will include medical schools, other health professions schools, and professional organizations, as well as state and federal governments. A health manpower policy can only be implemented successfully through broad consensus, developed by all sectors that have a role to play. With changing patterns of health and disease and an increasing supply of physicians to interact with a variety of health care providers, the division of labor among health professionals may undergo major shifts.
Two areas in which shifts might occur and therefore should be studied so that changes are made for improved patient care are related to delivery of patients' health education and of primary care. According to Lewis Thomas, medicine first focused on diagnosis. There was insufficient knowledge to do anything about the conditions that were described, but the prognosis and description of diseases, once identified, could be accomplished.
The second phase of medicine was that of therapeutics. This coincided with the tremendously expanding science base and the Flexnerian revolution, but also resulted in an increase of distance, both physical and psychological, of the patient from the physician. We are entering into a third stage, that of health promotion, health maintenance, and disease prevention.
Traditionally, the conceptual role of the physician has been illness-related rather than health-oriented. Behavioral responsibilities have been a traditional component of the nursing role—pain management, patient education, and family counseling. Should physicians take on more of a role and be trained as health educators? Should education about lifestyle and health be done person to person; and by whom? Should efforts be directed to a population via mass communication? What combinations of approaches are likely to be effective?
Regardless of alternative practices, or first contacts with other health professionals, will a role remain for physicians in rendering advice on health-related behaviors or for validating advice of other professionals? Physicians are as effective as others in inducing changes in health-related behaviors, but is the cost too high? Decisions about reimbursement for preventive services will undoubtedly influence the speed and direction in which the medical profession moves with respect to health education.
A public policy analysis, to identify the health professionals who will provide the requisite services with the optimal combination of availability, effectiveness, and cost, is recommended. This analysis would include critical assessment of such issues as prestige, educational competence, the costs and benefits of training, the aptitudes of those selected to be trained, and the willingness of the different health professions to take on the role of health educator.
An important question for the future, related also to health manpower policies, is who should deliver primary care? In the s, in the wake of the proclaimed shortage of providers of primary care, a variety of non-physician providers were educated. Some studies indicate that non-physician health professionals, independently, can provide quality primary care, but many questions remain about the division of labor, supervision, and patient choice.
The role of the non-physician practitioners in counseling, health education, and patient advocacy services also is of interest. The numbers of primary care physicians continue to grow; will they expand their traditional roles into those of other professionals? What will be the impacts of such trends on health manpower and on quality and costs of care?
Patterns of authority and complexity in medical schools and affiliated universities have changed profoundly in the past three decades. Changing patterns of financing and the changing allocation of faculty time to teaching, practice, administration, and research demand a careful tracking and evaluation in the years ahead. We need to understand how the component parts of the educational system shape the practitioner, the health care system, the researcher, the teacher, and the administrator.
A better understanding of the cultures of the medical education system will enable us to learn where decisions necessary for implementation of change are made or blocked, where and how improvements can be made and sound recommendations implemented to influence the development of future physicians to meet future health care needs. Decisions to start or terminate innovations in the education process as a whole, in introducing and establishing new fields Chapter 5 , 6 or eliminating those that have outlived their usefulness, would benefit from an appreciation of the social organization and functioning of the medical education system.
As social organizations, medical schools and teaching hospitals have distinctive characteristics, patterns of authority and power, and expectations of behavior. There are at least three cultures within medicine—primary care physicians, technically-oriented subspecialists, and those concerned with public health. The students, faculties, and institutions of the medical education system also can each be thought of as a culture which shapes the expectations, attitudes, and practices of the physicians in this country.
The way in which faculty define the purposes of medical education and priorities within it, formally and informally, provides a set of influential messages to students that eventually impinge on medical practice. Some of this influence is intended and explicit and viewed as part of the professionalization process. But at other times, individuals are acting on false perceptions or are being influenced inadvertently. The student culture, for example, develops its own style, ideas, and preferences. It also is important to understand the sub-culture of resident physicians.
They spend more time with students than any clinical faculty, and the education system depends on them, yet they have no control over the system. There are major differences in the cultures of medical schools and schools for educating health professionals that physicians must interact with. An example is the difference between schools of medicine and of public health in reference to income, way of life, and political view. In general, physicians are wealthier, more conservative politically, and resist government intervention, but public health professionals' culture includes acceptance of lower personal income and a close working relationship with government.
A closer study of the cultures in the health field could facilitate mutual understanding, better collaborative relationships, and insights as to where changes are needed and how to bring them about. Of critical importance is an understanding of responsibilities and ethical duties various health professionals should have and how to make these consistent with the relevant cultures. The following study topics are presented in order of the priorities that emerged from the committee's discussions based in part on the background papers in Part III of this report. At each stage of medical education, there are persons or committees with power to include or exclude, to shape, redirect, encourage or discourage the student or physician.
Three crucial points are that 1 we are very uncertain about the criteria that should govern admissions decisions Chapter 7 ; 2 performance evaluation during the education process generally is weak when it comes to anything other than objective measurement of science knowledge; and 3 many leverage points are not used or are used poorly in the very circumstances that faculty should exert more control—that is, during the clinical professionalization process clerkship and residency. Why are faculty powers sometimes not exercised to exclude clearly undesirable persons; how could they be used positively to include and encourage persons who would be good physicians?
These questions go beyond the culture of the faculty to the culture of the institutions in which training takes place. What are the best ways of initiating and implementing constructive change? What are the internal forces, including sources of power and decision-making processes, and the external forces shaping education-related decisions?
What are the organizational attributes of schools recognized as the most successful in reaching an explicit goal? How can educational values be protected in the face of conflicting priorities and responsibilities such as the fiscal health of a teaching hospital? These questions relate to the desired personal characteristics for medicine and their selection discussed earlier in this chapter.
Our concern is in having a medical education system evolve toward a flexible and adaptable one that prepares physicians to meet society's health care needs equitably and ethically, and that is able to reset priorities as these needs evolve. Among those involved are federal and state governments, state lobby groups, foundations, and public interest groups, all of whose leverage derives from funding for teaching, research, clinical care, through scholarships, loan programs, research grants, capitation, reimbursement for care, and the like.
Participants from the health care system include professional societies and organizations, insurance firms, practicing physicians, and other health professionals. The consumers of care—the patients— also have a role. To gain an understanding of the cultures of the medical education system, studies of the norms and values of medical education and the forces that maintain them should be done, covering the system from pre-medicine to practice circumstances and norms.
For example, a study is recommended of the hierarchical value structure of the medical education system in selected schools. The study would include identification of factors in addition to dollars that contribute to power and prestige in the schools and clinical settings; the position of the health institutions within the university structure where applicable and the influences of the university on the medical education power structure; the relationships of curriculum time and place to power and prestige Chapter 6. One format would employ a social scientist and a health professional, working as a team, to conduct site visits and interviews with key people in medical schools and hospitals selected to be representative of a genre e.
An analytical summary of the decision-making hierarchy of medical education establishments could then be used to identify levers for change within the institutions and the kinds of outside pressures that have major impact on them. Case studies that reflect some of the cultural dimensions of medical education also would be instructive.
For example, a study of committees on promotion could examine the processes of appointment, organizational structure, modes of work, and decision-making. Studies of the introduction and long term adjustment of fringe disciplines or fields within the established power structure in specific schools would be useful to other schools considering similar changes Chapter 6. Examples for case studies are: The role of research in medical schools and academic health centers has grown strong since World War II.
Only more recently have practice plans grown in importance. Laboratory basic science research and clinical faculty lead in prestige and rewards. The growth and strength of the biomedical research effort has had significant influence on medical school organization, power hierarchy, curriculum, priorities, and student selection. Funds for research, directly and indirectly, supported medical schools. In many schools, research became the primary component of the culture, with population-based social and behavioral research in secondary positions, if present at all. In some institutions this led to such distortions as medical education and teaching becoming by-products rather than primary goals of the schools.
The fruits of biomedical research have provided scientifically based improvements in health care, but at some cost to the process of education for the practice of humanistic medicine. How can a proper balance be attained among teaching, service, and research when teaching is underfinanced? How can quality and productivity be assessed for non-researchers? What are the equivalents of scholarly publications for teachers or clinicians? Medical school and teaching hospital faculty are operating in a system that usually gives low priority and few rewards for teaching, except for personal rewards that come from students themselves.
Furthermore, a faculty member's identity is likely to be aligned with a department, rather than with the school, hospital, or university. In such an environment, how might rewards be structured and communications enhanced to promote educational values? During the course of this planning study, we heard anecdotal evidence of experiments in rewarding teaching, and in helping clinicians, behavioral scientists, and biomedical scientists become better role models for students and understand one another's needs, advantages, constraints, and contributions.
Do these efforts help the institution build a balanced and integrated education for their students? Preliminary data from Case Western Reserve indicate that their graduates are knowledgeable about behavioral impacts on health, use their knowledge in practice, and are comfortable with communicating and relating to patients as people. There is a growing awareness of fraud in biomedical research which makes it imperative that we grapple with the problems of research data fabrication and the inadequacy of our traditional supervisory approaches in preventing deceptions.
The essence of scientific inquiry is respect for truthful pursuit of knowledge irrespective of outcome. Recently publicized cases establish that what has been assumed inviolate is not, and that our methods of education require prompt re-examination if the values of science are to be preserved. The environment for the education of both clinicians and researchers will otherwise not be conducive to building the integrity both require. Little research has been done since the s and early s on how medical schools work as social organizations, or on student or faculty attitudes to the educational experience.
In addition, experiments in faculty, education and sharing of views are called for, both within and across schools.