Medical Education and Training
Medical Education and Training – How Did We Arrive at the Current State?
Historically, our patients have always expected and deserved competent healthcare providers. Right or wrong they have put their faith in their “healers” from ancient times to the present. This is especially true of their physicians. What guarantees that competence and that their trust is well placed? What is the foundation and process for attaining competence? Moreover, what method establishes mastery of a specific competency? These are all questions under review in the context of the current methods of general medical education. Change is coming.
There is a mandate underway that medical professionals shift our educational model at the medical school level from that established in the early nineteen hundreds in response to the Flexner Report (1) to a curriculum of competency based education and training. The American Medical Association supports and has provided seed funding for this movement toward competency based medical education (CBME). (2) This current change initiative continues the tradition of the AMA’s dedication to our patients’ well-being; this call for radical change coming over 100 years after the AMA establishing the Council on Medical Education in 1904 in an equally radical response to the Flexner Report.
The Flexner “model” of medical education, generally established as the required standard in the early 1900’s, became part of an unwritten social contract that moved the practice of medicine from a craft, in a trade/guild construct, to a profession (3). This attempt to standardize medical education was born in an era of a largely disorganized and haphazard state of formal education with essentially no reliable evidence (truly zero by even today’s Level 2 or even 3 standards of reliability) with regard to how to execute effective medical decision-making and treatment. Still, these Flexner inspired curriculum renovations and educational standards represented a good faith effort to begin to hold the medical profession accountable for a reasonable educational foundation of those who choose represent themselves as professionals competent to diagnose and treat patients. There has been steady improvement in the century since the Flexner Report, and the guidance and oversight that has grown out of the CME, but that progress fails to meet the current complexity of the practice or medicine as well as might be possible (4).
We currently practice in an era of enormous, virtually daily, advances in our knowledge base, diagnostic tools (including modern imaging) and treatment options; this extraordinary evidence base can now be reasonably consolidated and relied upon to begin to consistently inform the practice of medicine as well as the content of medical education and training. There are also parallel, even more rapidly evolving, developments of IT systems that provide an infrastructure for rapid sharing of evidence-based information. The evolving IT tools provide a backbone for whatever guidance of practice or education we might wish to share with one another; not necessarily as a robotic practice of medicine or method of education but one that is much better informed, updated and disseminated more efficiently than ever possible in the past. Dr. Lawrence Weed anticipated this in the 1960’s with his revelations related to the “Problem Based Medical Record”; another bit of revolutionary thinking coming about 60 years after that of the Flexner Report (5). Fortunately Dr. Weed’s insights were recognized by the editor of the New England Journal of Medicine where his concepts were reviewed in 1968 resulting in the recognition of their importance soon after their birth by leaders in medical education (6-9). These IT tools, anticipated by Dr. Weed, are now available as living and breathing modern guides and “textbooks”. Reliable electronic information resources are, in some ways, a natural evolution of the old Merck Manual and similar guides to clinical practice; those works while heavily dog-eared in the past, are now largely relegated to the shelf and history. The need to update and modernize medical education and PGME and the IT infrastructure to support that effort are parts of the necessary revolution that are here and spreading rapidly if not cohesively. The missing pieces are a comprehensive CBE curriculum and the evaluation rubrics necessary to fairly and properly assess mastery/competency of the specific competencies that make up the spectrum of a particular physician’s practice.
The Flexner “model of medical education” was established long ago in medical schools and currently remains the base methodology. However, the postgraduate method of training, in both general and specialized medicine, remains essentially in the model of apprenticeship type education. This adherence to the old model leaves post graduate training method fundamentally in a craft/trade/guild construct, albeit much improved and codified, while its graduate trainees emerge as respected, and trusted, competent professionals. This is manifest in the typical internship and residency model, now solely referred to as residency training, which has been in place since the early 1900’s. While there has been some refinement of the training standards in approved programs, a comprehensive, detailed written curriculum and pathway to assuring competency really does not exist. Some might dispute this premise but for the most part it is a reasonably correct assertion; if not there would not be a call from the AMA to move to CBME; the need for this in post graduate medical education (PGME) is a corollary to that effort, admitted or not. This call must also include a similar message to move us from our historical approach PGME to one aligned with the extraordinary complexity of a modern practice of medicine. Recent advances in PGME include the definition of broad “Competencies” that must be adhered to as general professional standards; an excellent start (4). Those competencies; however, do not specifically represent skill sets that must be mastered. An extension of the desire to produce a curriculum is the more recent development of the concept of residency “Milestones” (4). Still, there is no specific, comprehensive curriculum or lesson plan or definition of the behavioral objectives that compose the individual skills that must be mastered in a specific clinical scenario/competency. This must change radically. The time has come for CBME to be the educational method of choice for PGME as well as basic medical school education. This will be a natural extension of the process that began in 1904 with the Flexner Report and the formation of the CME. We are “all in” for this change.
1-Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (PDF), Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, p. 346, OCLC 9795002,
2- AMA.org- Education-Creating the Modern Medical School.
3-Starr, Paul (1982). The Social Transformation of American Medicine. Basic Books. pp. 514 pages. ISBN 0-465-07935-0.)
5-Weed, L. L. (1964-06-01). “MEDICAL RECORDS, PATIENT CARE, AND MEDICAL EDUCATION”. Irish Journal of Medical Science. 462: 271–282. doi:10.1007/BF02945791. ISSN 1863-4362. PMID 14160426.
6-Weed, L. L. (1968-03-14). “Medical records that guide and teach”. The New England Journal of Medicine. 278 (11): 593–600. doi:10.1056/NEJM196803142781105. ISSN 0028-4793. PMID 5637758.
7-Weed, L. L. (1968-03-21). “Medical records that guide and teach”. The New England Journal of Medicine. 278 (12): 652–657 concl. doi:10.1056/NEJM196803212781204. ISSN 0028-4793. PMID 5637250.
8-Weed LL. Medical records, medical education, and patient care: the Problem-Oriented Medical Record as a basic tool. 1970. Cleveland (OH): Press of Case Western Reserve University.
9-Jacobs L. Interview with Lawrence Weed, MD—the father of the problem-oriented medical record looks ahead [editorial]. Perm J 2009 Summer;13(3):84–9.