Physician Education for a Changing Health Care EnvironmentDivision of General Medicine Brigham & Women’s Hospital Boston, Massachusetts Carl J. Getto, M.D. Dean and Provost Southern

M A R C H 1 9 9 9

Physician Educationfor a Changing Health

Care Environment

COUNCIL ON GRADUATE MEDICAL EDUCATION

Thirteenth Report

COUNCIL ON GRADUATE MEDICAL EDUCATION

Thirteenth Report

Physician Education for aChanging Health CareEnvironment

March 1999

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESHealth Resources and Services Administration

iiTHIRTEENTH REPORT OF COGME

The views expressed in this document are solely those of theCouncil on Graduate Medical Education and do not

necessarily represent the views of theHealth Resources and Services Administration

nor the U.S. Government.

iiiTHIRTEENTH REPORT OF COGME

TTTTTable oable oable oable oable of Contentf Contentf Contentf Contentf Contentsssss

List of Tables and Figures ................................................................................................... iv

The Council on Graduate Medical Education ................................................................. v

Contributions ........................................................................................................................ x

Executive Summary ............................................................................................................. xiPurpose .................................................................................................................................................... xi

Listing of Findings and Recommendations (I – VIII) ............................................................................. xi

Background .......................................................................................................................... 1The Changing Practice of Medicine .......................................................................................................... 1

Evolving Curricula in Medical Education ................................................................................................. 2Changing the Environment of Clinical Education .................................................................................... 3

Medical Education Programs for a Changing Environment ........................................... 7I. Understanding the System in Which Health Care is Delivered ...................................................... 8

II. Establishing Practical and Relevant Teaching Sites ........................................................................ 9

III. Developing Community Clinician Teachers .................................................................................. 13IV. Revising the Curriculum Content and Learning Process ............................................................... 15

V. Reinforcing Communication Skills ................................................................................................ 18

VI. Assuring Quality and Accountability in Physician Education ....................................................... 20VII. Financing the Evolution of Graduate Medical Education ............................................................. 24

VIII. Sustaining Quality and Vitality in Medical Education .................................................................. 26

References ............................................................................................................................. 29

Selected Internet Resources ................................................................................................ 35

ivTHIRTEENTH REPORT OF COGME

LIST OF TABLES AND FIGURES

Table 1: Sample of Context & Evaluator Effect Upon Outcome Indicators ................................. 22Table 2: Examples of Educational Components and Possible Assesment Stategies ..................... 23

Figure 1: Similarities Between Three Integrated Evaluation Systems ........................................... 21

vTHIRTEENTH REPORT OF COGME

The Council on Graduate Medical Education(COGME) was authorized by Congress in1986 to provide an ongoing assessment of

physician workforce trends, training issues and fi-nancing policies, and to recommend appropriateFederal and private sector efforts to address identi-fied needs. The legislation calls for COGME to ad-vise and make recommendations to the Secretaryof the Department of Health and Human Services(DHHS), the Senate Committee on Labor and Hu-man Resources, and the House of RepresentativesCommittee on Commerce. The Health ProfessionsEducation Partnerships Act of 1998 reauthorizedthe Council through September 30, 2002.

The legislation specifies 17 members for theCouncil. Appointed individuals are to include rep-resentatives of practicing primary care physicians,national and specialty physician organizations, in-ternational medical graduates, medical student andhouse staff associations, schools of medicine andosteopathy, public and private teaching hospitals,health insurers, business, and labor. Federal repre-sentation includes the Assistant Secretary forHealth, DHHS; the Administrator of the Health CareFinancing Administration, DHHS; and the ChiefMedical Director of the Veterans Administration.

Charge to the CouncilThe charge to COGME is broader than the name

would imply. Title VII of the Public Health ServiceAct, as amended, requires COGME to provide ad-vice and recommendations to the Secretary andCongress on the following issues:

1. The supply and distribution of physicians inthe United States.

2. Current and future shortages or excesses ofphysicians in medical and surgical specialtiesand subspecialties.

3. Issues relating to international medical schoolgraduates.

4. Appropriate Federal policies with respect to thematters specified in items 1-3, including poli-cies concerning changes in the financing ofundergraduate and graduate medical education(GME) programs and changes in the types ofmedical education training in GME programs.

5. Appropriate efforts to be carried out by hospi-tals, schools of medicine, schools of osteopa-

The Council on GrThe Council on GrThe Council on GrThe Council on GrThe Council on Graduate Medical Educationaduate Medical Educationaduate Medical Educationaduate Medical Educationaduate Medical Education

thy, and accrediting bodies with respect to thematters specified in items 1-3, including ef-forts for changes in undergraduate and GMEprograms.

6. Deficiencies and needs for improvements indata bases concerning the supply and distri-bution of, and postgraduate training programsfor, physicians in the United States and stepsthat should be taken to eliminate those defi-ciencies.

In addition, the Council is to encourage enti-ties providing graduate medical education to con-duct activities to voluntarily achieve the recommen-dations of the Council specified in item 5.

COGME ReportsSince its establishment, COGME has submit-

ted the following reports to the DHHS Secretaryand Congress:

• First Report of the Council (1988)

• Second Report: The Financial Status of Teach-ing Hospitals and the Underrepresentation ofMinorities in Medicine (1990)

• Scholar in Residence Report: Reform in Medi-cal Education and Medical Education in theAmbulatory Setting (1991)

• Third Report: Improving Access to HealthCare Through Physician Workforce Reform:Directions for the 21st Century (1992)

• Fourth Report: Recommendations to ImproveAccess to Health Care Through PhysicianWorkforce Reform (1994)

• Fifth Report: Women and Medicine (1995)

• Sixth Report: Managed Health Care: Implica-tions for the Physician Workforce and Medi-cal Education (1995)

• Seventh Report: Physician Workforce Fund-ing Recommendations for Department ofHealth and Human Services’ Programs (1995)

• Report to Congress: Process by Which Inter-national Graduates Are Licensed to Practicein the United States (1995)

• Eighth Report: Patient Care Physician Supplyand Requirements: Testing COGMERecommendations (1996)

viTHIRTEENTH REPORT OF COGME

• Ninth Report: Graduate Medical EducationConsortia: Changing the Governance ofGraduate Medical Education to Achieve Phy-sician Workforce Objectives (1997)

• Tenth Report: Physician Distribution andHealth Care Challenges in Rural andInner-City Areas (1998)

• Eleventh Report: International Medical Gradu-ates, The Physician Workforce and GME Pay-ment Reform (1998)

• Twelfth Report: Minorities in Medicine (1998)

COGME Resource Papers• Preparing Learners for Practice in a Managed

Care Environment (1997)

• International Medical Graduates: Immigra-tion Law and Policy and the U.S. PhysicianWorkforce (1998)

viiTHIRTEENTH REPORT OF COGME

Members, Council on Graduate Medical Education

ChairDavid N. Sundwall, M.D.PresidentAmerican Clinical Laboratory AssociationWashington, D.C.

Vice ChairLawrence U. Haspel, D.O.Senior Vice-PresidentMetropolitan Chicago Health Care CouncilChicago, Illinois

Paul W. Ambrose, M.D.ResidentDartmouth Family Practice ProgramConcord, New Hampshire

Macaran A. Baird, M.D., M.S.P.H.Associate Medical Director for Primary CareHealthPartnersBloomington, Minnesota

Regina M. Benjamin, M.D., M.B.A.Family PracticeBayou La Batre, Alabama

JudyAnn Bigby, M.D.Division of General MedicineBrigham & Women’s HospitalBoston, Massachusetts

F. Marian Bishop, Ph.D., M.S.P.H.Professor and Chairman EmeritusDepartment of Family and Preventive MedicineUniversity of Utah School of MedicineSalt Lake City, Utah

Jo Ivey Boufford, M.D.DeanRobert F. Wagner Graduate School of Public

Service, New York UniversityNew York, New York

Sergio A. Bustamante, M.D.Neonatology Associates LimitedPhoenix, Arizona

Richard D. Cordova, M.B.A.Senior Vice PresidentEast Bay Service Area ManagerKaiser Permanente Health PlanOakland, California

Ezra C. Davidson, Jr., M.D.ProfessorDepartment of Obstetrics & GynecologyKing/Drew Medical CenterLos Angeles, California

Carl J. Getto, M.D.Dean and ProvostSouthern Illinois University School of MedicineSpringfield, Illinois

Kylanne GreenSenior ConsultantCoopers and LybrandWashington, D.C.

Ann KempskiAssistant Director Health PolicyAmerican Federation of State, County and

Municipal EmployeesWashington, D.C.

Designee of the Assistant Secretary for HealthNicole Lurie, M.D., M.S.P.H.Principal Deputy Assistant Secretary for HealthU.S. Department of Health and Human ServicesWashington, D.C.

Designee of the Health Care FinancingAdministration

Tzvi M. HefterDirectorDivision of Acute CareCenter for Health Plans and ProvidersHealth Care Financing AdministrationBaltimore, Maryland

Designee of the Department of Veterans AffairsDavid P. Stevens, M.D.Chief Academic Affiliations OfficerDepartment of Veterans AffairsWashington, D.C.

Statutory Members

David Satcher, M.D.Assistant Secretary for Health and Surgeon

GeneralDepartment of Health and Human ServicesWashington, D.C.

viiiTHIRTEENTH REPORT OF COGME

Nancy-Ann Min DeParleAdministratorHealth Care Financing AdministrationDepartment of Health and Human ServicesBaltimore, Maryland

Kenneth Kizer, M.D., M.P.H.Undersecretary for HealthVeterans Health AdministrationDepartment of Veterans AffairsWashington, D.C.

Former Members Contributing to theReportRobert Knouss, M.D.DirectorOffice of Emergency PreparednessHealth Resources and Services AdministrationRockville, Maryland

Barbara WynnFormer DirectorPlan and Provider Purchasing Policy GroupCenter for Health Plans and ProvidersHealth Care Financing AdministrationBaltimore, Maryland

Physician Competencies in aChanging Health Care EnvironmentWork Group Members and Staff

COGME MEMBERS

Macaran A. Baird, M.D., M.S.P.H.Work Group ChairAssociate Medical Director for Primary CareHealthPartnersBloomington, Minnesota

Paul W. Ambrose, M.D.ResidentDartmouth Family Practice ProgramConcord, New Hampshire

JudyAnn Bigby, M.D.Division of General MedicineBrigham & Women’s HospitalBoston, Massachusetts

Carl J. Getto, M.D.Dean and ProvostSouthern Illinois University School of MedicineSpringfield, Illinois

Kylanne GreenSenior ConsultantCoopers and LybrandWashington, D.C.

David P. Stevens, M.D.Chief Academic Affiliations OfficerDepartment of Veterans AffairsWashington, D.C.

OTHER MEMBERS

Marc L. Rivo, M.D., M.P.H.Southern Florida Regional Medical DirectorAvMed Health Plan, Inc.Miami, Florida

Jeannette M. Shorey, M.D.DirectorPrimary Care Residency ProgramHarvard Pilgrim Health CareBoston, Massachusetts

STAFF

Helen K. Lotsikas, M.A.Staff Liaison

COGME StaffCarol Bazell, M.D., M.P.H.Acting DirectorDivision of Medicine

Stanford M. Bastacky, D.M.D., M.H.S.A.Acting Executive SecretaryChief, Special Projects and Data Analysis BranchDivision of Medicine

F. Lawrence Clare, M.D., M.P.H.Deputy Executive SecretaryDeputy Chief, Special Projects and Data Analysis

BranchDivision of Medicine

P. Hannah Davis, M.S.Staff LiaisonGraduate Medical Education Financing and

PolicyMinorities in Medicine Issues

C. Howard Davis, Ph.D.Staff LiaisonMedical Credentialing and International Medical

Graduate Issues

ixTHIRTEENTH REPORT OF COGME

Jerald M. KatzoffStaff LiaisonGraduate Medical Education Financing and

PolicyPhysician Workforce Issues

Helen K. Lotsikas, M.A.Staff LiaisonPhysician Competencies in a Changing Health

Care EnvironmentManaged Care Issues

John Rodak, M.S. (Hyg.), M.S.(H.S.A.)Staff LiaisonGeographic Distribution Issues

Eva M. StoneCommittee Management Assistant

Velma ProctorSecretary

xTHIRTEENTH REPORT OF COGME

CONTRIBUTIONS

The Council gratefully acknowledges MacaranA. Baird, M.D., M.S.P.H., Chair, COGME WorkGroup on Physician Competencies in a ChangingHealth Care Environment for his leadership in thepreparation of this report. The Council also wishesto acknowledge the valued assistance of Peter G.Coggan, M.D., MSEd., and William D. Grant, Ed.D.who prepared the basis of this report; and Anne D.Walling, M.D., for her valuable and expert assis-tance. The Council wishes to acknowledge the valu-able insights and comments Daniel Eubank, M.D.,Linda A. Headrick, M.D., Alice M. Litwinowicz,

M.A., and Gordon T. Moore, M.D. providedthroughout the development of this report. TheCouncil is deeply indebted to the over forty orga-nizations and individuals that responded to its re-quest for comment on the draft report. These com-ments and critiques helped greatly to enhance theCouncil’s final report. The Council is grateful to HelenK. Lotsikas, M.A., of the Division of Medicine, forher orchestration of the report’s preparation, and to F.Lawrence Clare, M.D., M.P.H., and Stanford M.Bastacky, D.M.D., M.H.S.A., of the Division of Medi-cine for their guidance, insight and expert advice.

xiTHIRTEENTH REPORT OF COGME

ExExExExExecutivecutivecutivecutivecutive Summarye Summarye Summarye Summarye Summary

financing, the benefits and limitations oftypical health plans, and the characteris-tics of the systems in which health caremay be delivered.

• The curricula of medical schools and resi-dency training programs should includeclinical learning experiences in the set-tings of each of the components of an in-tegrated health care delivery system

• Medical schools and residency trainingprograms should provide opportunitiesfor medical students and residents to learnthe contribution of other health profes-sionals to the care of their patients andaugment opportunities for learners to par-ticipate in a team approach to patientcare.

• Educational programs for medical stu-dents and residents should address thecare of the individual patient in the con-text of the population or community ofwhich the patient is a member.

II.II.II.II.II. ESTESTESTESTESTABLISHING PRAABLISHING PRAABLISHING PRAABLISHING PRAABLISHING PRACCCCCTICTICTICTICTICALALALALALAND RELEVAND RELEVAND RELEVAND RELEVAND RELEVANT TEAANT TEAANT TEAANT TEAANT TEACHING SITESCHING SITESCHING SITESCHING SITESCHING SITES

FINDING 2 (page 9): There will be an accel-eration in the development of new modelsof medical education that reflect moreclosely the practice of medicine within evolv-ing health systems.

Recommendations:

• Clinical education should occur in settingsthat are representative of the environmentin which graduates will eventually prac-tice. Medical schools and residency train-ing programs should develop or acquireclinical teaching sites that offer the bestlearning opportunities and the higheststandards of clinical practice. Partner-ships with integrated delivery systems,health plans and other organizationsshould be developed as one strategy to ac-complish this.

• Medical educators should exploit the po-tential of distance learning technology todeliver educational programs in which

PURPOSEPURPOSEPURPOSEPURPOSEPURPOSEThis report is intended to clarify the need for,

and to stimulate the further development of, freshapproaches to the professional education of physi-cians for contemporary and future medical prac-tice. It presents an analysis of the issues influenc-ing the preparation of physicians and recommendschanges in teaching programs. Unlike previousCOGME reports which have focused on primarycare, the recommendations in this report apply topreparation for many medical specialties. In par-ticular, the importance of clinical education in thecommunity is no longer limited to the primary carespecialties. In many specialties, the communityoffers unique educational opportunities that arecomplementary to those of the academic healthcenter or teaching hospital. The comprehensivepreparation of all modern physicians requires ex-perience in both traditional and community settings.

This report advocates the development of high-quality, community-based clinical teaching oppor-tunities and a faculty incorporating communityclinician teachers. It calls for expansion and enhance-ment of educational relationships with the commu-nity and a redefinition of the role of conventionalmedical school and residency program faculty. Inaddition, the report emphasizes the role of rigor-ous evaluation systems to assure consistent qualityand guide the steady evolution of educational sys-tems. Finally, the report addresses strategies to fundand sustain the recommended changes.

The findings and associated recommendationsforming the core of the report are listed below:

I.I.I.I.I. UNDERSTUNDERSTUNDERSTUNDERSTUNDERSTANDING THE SANDING THE SANDING THE SANDING THE SANDING THE SYSTEMYSTEMYSTEMYSTEMYSTEMIN WHICH HEALIN WHICH HEALIN WHICH HEALIN WHICH HEALIN WHICH HEALTH CTH CTH CTH CTH CARE ISARE ISARE ISARE ISARE ISDELIVEREDDELIVEREDDELIVEREDDELIVEREDDELIVERED

FINDING 1 (page 8): Physicians increasinglydeliver health care to defined populations ofpatients in the context of integrated delivery sys-tems or health plans. An improved understand-ing of the characteristics of the populationsserved and the attributes of the delivery systemsis fundamental to effective medical practice.

Recommendations:

• Medical students and residents shouldlearn the basic principles of health care

xiiTHIRTEENTH REPORT OF COGME

instruction and evaluation are of a con-sistent and high standard across multiplesettings in the community.

III.III.III.III.III. DEVELDEVELDEVELDEVELDEVELOPING COMMUNITYOPING COMMUNITYOPING COMMUNITYOPING COMMUNITYOPING COMMUNITYCLINICIAN TEACLINICIAN TEACLINICIAN TEACLINICIAN TEACLINICIAN TEACHERSCHERSCHERSCHERSCHERS

FINDING 3 (page 13): The selection and sup-port of clinician teachers in the communitywill become a fundamental priority of medi-cal schools and residency training programs.The current roles of faculty members basedat conventional teaching institutions will besignificantly changed by expanded conceptsof medical education and more inclusivedefinitions of faculty membership.

Recommendations:

• Medical schools and residency trainingprograms should recruit and supportcommunity clinician teachers. Facultymembers at community teaching sitesshould be selected for the quality of theirmedical practice and the excellence oftheir teaching. They should be paid andotherwise rewarded for their educationalactivities. Teaching institutions shoulddevelop mechanisms to involve commu-nity faculty in the design and operationof educational programs.

• Medical school and residency facultyshould complement their skills as teach-ers of students and residents with compe-tencies in faculty development and themanagement of educational programs inthe community.

• Residency training programs should takethe lead in the development of rigorouspractice-based models of graduate medi-cal education in which individual or lim-ited numbers of residents are assigned tophysicians in community teaching prac-tices.

IVIVIVIVIV..... REVISING THE CURRICULREVISING THE CURRICULREVISING THE CURRICULREVISING THE CURRICULREVISING THE CURRICULUMUMUMUMUMCONTENT AND LEARNINGCONTENT AND LEARNINGCONTENT AND LEARNINGCONTENT AND LEARNINGCONTENT AND LEARNINGPROCESSPROCESSPROCESSPROCESSPROCESS

FINDING 4 (page 15): The transformation ofthe health care environment created bychanging demographics, mechanisms ofhealth care financing, and a focus on pre-vention and wellness, has a profound effect

on the practice of medicine. Reflecting thesechanges in educational programs that pre-pare medical students and residents for theirfuture roles requires innovative strategiesand new resources.

Recommendations:

• Medical schools and residency trainingprograms should fundamentally revise thepreparation of their graduates to reflectthe changing practice environment whilesustaining the quality of current teachingprograms. They should emphasize disci-plines that are basic to contemporarymedical practice such as epidemiologyand population-based care, health carepolicy and systems, disease prevention andwellness, and computer information skills.

• To effectively serve patients in the newhealth care systems, educational programsmust prepare physicians in ethical deci-sion-making and advanced communica-tion skills, including patient advocacy,conflict resolution, and teamwork.

• Medical schools and residency trainingprograms should accelerate the incorpo-ration of advanced educational conceptsand techniques such as distance learning,standardized patients, and psychometricsin order to enhance the quality and con-sistency of educational programs.

VVVVV..... REINFORCINGREINFORCINGREINFORCINGREINFORCINGREINFORCINGCOMMUNICCOMMUNICCOMMUNICCOMMUNICCOMMUNICAAAAATION SKILLTION SKILLTION SKILLTION SKILLTION SKILLSSSSS

FINDING 5 (page 18): An increasingly diversepatient population and a changing healthcare environment magnify the need for ef-fective communication by physicians.

Recommendations:

• Instruction in and assessment of commu-nication skills, particularly related to themedical history, should be strengthenedand expanded to ensure an emphasisequal to other major courses and topics.

• The development and augmentation ofcommunication skills with patients includ-ing those from differing cultural back-grounds, and with colleagues, administra-tors, and others should be continuedthroughout medical school and residencytraining.

xiiiTHIRTEENTH REPORT OF COGME

• Physicians should be prepared in a broadrange of communications skills appropri-ate for use with individuals and groupsand utilizing a diversity of media. An em-phasis should be provided on continuallyupdating skills to adapt to rapidly-evolv-ing circumstances and technology

VI. ASSURING QUVI. ASSURING QUVI. ASSURING QUVI. ASSURING QUVI. ASSURING QUALITY ANDALITY ANDALITY ANDALITY ANDALITY ANDAAAAACCOUNTCCOUNTCCOUNTCCOUNTCCOUNTABILITY IN PHYSICIANABILITY IN PHYSICIANABILITY IN PHYSICIANABILITY IN PHYSICIANABILITY IN PHYSICIANEDUCEDUCEDUCEDUCEDUCAAAAATIONTIONTIONTIONTION

FINDING 6 (page 20): The assurance of con-sistent quality in medical education will be-come increasingly critical as clinical teach-ing outside the traditional hospital settingexpands and as teaching strategies becomemore diverse. Methods designed to assessperformance evaluation at multiple sites andassure the longitudinal development ofknowledge, skills, and attitudes are becom-ing increasingly important.

Recommendations:

• Medical educators should continuouslyassess both short-term and longitudinaloutcomes in the learner, the teacher, andthe program.

• Assessment techniques must be selected toprovide reliable and valid measurementof educational outcomes across a varietyof teaching environments.

• Academic health centers, educational pro-grams, and accrediting agencies shouldcontinue to develop monitoring and as-sessment approaches that meet the needsof different constituencies.

VII.VII.VII.VII.VII. FINANCING THE EVFINANCING THE EVFINANCING THE EVFINANCING THE EVFINANCING THE EVOLOLOLOLOLUTIONUTIONUTIONUTIONUTIONOF GRADUOF GRADUOF GRADUOF GRADUOF GRADUAAAAATE MEDICTE MEDICTE MEDICTE MEDICTE MEDICALALALALALEDUCEDUCEDUCEDUCEDUCAAAAATIONTIONTIONTIONTION

FINDING 7 (page 24): The system of fundinggraduate medical education through teach-ing hospitals has inherent limitations anddisincentives that inhibit the development ofambulatory experiences and community-based educational programs. There is still noconsensus on how to appropriately fund andexpand the curriculum to reach into commu-nity settings.

Recommendations:

• A stable reliable source of funding forgraduate medical education is essential.While it is appropriate to assume that theFederal government through the Medicareprogram will continue to support gradu-ate medical education, COGME endorsesefforts to ensure that all payors, includ-ing the Federal government, support anequitable share of medical education costs.

• Medical schools, teaching hospitals andmajor stakeholders should prepare to fi-nance physician education programs thatincorporate the changes recommended inthis report. Most of the funds to supportthese changes will require shifting exist-ing internal resources within the academicenterprise.

• Funding for residency programs mustprovide the flexibility to meet the educa-tional needs of residents. Program fund-ing should be structured to enable resi-dents to attain the knowledge, skills,attitudes and values that will meet boththe profession’s goals and communityneeds.

• The value of graduate medical educationto the sponsoring institution should bedetermined through a candid and explicitassessment of its financial, educational,and service contribution to the achieve-ment of the institution’s mission.

VIII.VIII.VIII.VIII.VIII. SUSTSUSTSUSTSUSTSUSTAINING QUAINING QUAINING QUAINING QUAINING QUALITY ANDALITY ANDALITY ANDALITY ANDALITY ANDVITVITVITVITVITALITY IN ALITY IN ALITY IN ALITY IN ALITY IN MEDICMEDICMEDICMEDICMEDICALALALALALEDUCEDUCEDUCEDUCEDUCAAAAATIONTIONTIONTIONTION

FINDING 8 (page 26): Creating and sustain-ing the educational changes required to re-spond to the changing medical environmentwill continue to be a challenge given thepressures of the medical marketplace andthe complex missions of medical schools,academic medical centers and other teach-ing hospitals.

Recommendations:

• Medical schools, residency training pro-grams, and teaching hospitals must bal-ance their competing roles and reaffirmtheir educational mission. They shouldembrace the task of meeting societal needthrough the education of their graduates.

xivTHIRTEENTH REPORT OF COGME

• The standards for accreditation and finan-cial support of residency programs shouldbe revised to encourage and facilitate new

curriculum content, and opportunities toacquire additional knowledge, skills, atti-tudes and values.

1THIRTEENTH REPORT OF COGME

BackBackBackBackBackgrgrgrgrgroundoundoundoundound

and growth of various forms of managed care isprojected to continue (Rivo, Mays, Katzoff, Kindig,1995). As recently stated by this Council, more thantwo thirds of the population could be participantsin managed care by the end of the century and it ispossible that current medical students may neverexperience a fee-for-service practice (COGME Re-source Paper, 1997).

Most pre-payment models are based on the con-cepts of “managed care”. This term applies to aheterogeneous and rapidly-evolving group of or-ganizations providing diverse health care programs,which share the common attribute of linking thefinancing and delivery of health care (Iglehart,1992). A common feature is that selected healthprofessionals and organizations furnish an estab-lished set of services to a defined population for apredetermined cost, in a system with significant uti-lization and quality control mechanisms. Managedcare organizations encompass a spectrum fromhighly-capitated staff model systems that own fa-cilities and employ physicians, to organizations thatcontract with independent physicians, hospitals, andother agencies for specific services.

Recent trends have modified the original mod-els of managed care and have favored plans thatoffer greater flexibility. The number of staff-modelHMOs has shown a steady decline from 66 in 1989to 46 in 1996, whereas the number of network-model HMOs and Independent Practice Associa-tions (IPAs) has continued to rise. Approximatelytwo-thirds of current HMOs are IPAs (ManagedCare Digest Series, 1997). The parameters set bythe core features (specified services and providers,defined population, predetermined costs, and utili-zation and quality control mechanisms) are likelyto endure even in the rapidly-changing health caremarket. Further evolution of managed care modelswill depend not only on the desires of patients andhealth care professionals, but also on the interestsof employers, legislators, and investors. Arrange-ments in which physicians’ incomes are linked totheir ability to provide cost-effective care will prob-ably persist, but patient satisfaction and other non-traditional measures of the quality of physicianservices are likely to become integral to the calcu-lation of physician rewards. Similarly, future com-petition between plans may not be based exclusivelyon costs but include concepts from the “service sec-tor” such as quality, value, service, and patient sat-isfaction. (O’Connor, Solberg, Baird, 1998). The

THE CHANGING PRATHE CHANGING PRATHE CHANGING PRATHE CHANGING PRATHE CHANGING PRACCCCCTICE OFTICE OFTICE OFTICE OFTICE OFMEDICINEMEDICINEMEDICINEMEDICINEMEDICINE

The practice of medicine has been transformedin the last decade and the pace of change shows nosigns of lessening. This transformation reflects ad-aptation both to the burgeoning scientific and tech-nical abilities of medicine and to dramatic devel-opments in demographic, social, political, andcultural aspects of health. Rapid progress in re-search and technology continues to expand thepower of medical treatment, redefine fundamentalunderstandings and practices, and raise expectationsof the medical system. Simultaneously, a more di-verse and sophisticated society is questioning whatconstitutes “health” and how we value its acquisi-tion and maintenance. These complex interactionshave many important dimensions, but organiza-tional and financial influences have proved particu-larly pervasive. The public now expects depend-able professional expertise from physicians andother members of the health care team in systemsthat are comfortable, affordable, and accessible.

Within the physician encounter itself, the com-bination of “high tech and high touch” is increas-ingly valued. Physicians are expected to appreci-ate the patient perspective, communicate effectively,and to maintain an uncompromising mastery of ap-propriate scientific and clinical advances. Physi-cians are held accountable for their services to anextent not previously imagined. This accountabil-ity goes beyond the outcomes of technical aspectsof care to include service-oriented dimensions suchas communication and patient satisfaction. Ac-countability for costs and the necessity to demon-strate value in patient care activities are now al-most universal.

Financial factors play a significant and com-plex role in the changing practice of medicine. Pro-found changes have occurred in the methods usedto finance health care. Pre-payment and managedcare models have become firmly established and inmany areas have replaced fee-for-service as thedominant financial models. In 1996, over 77 mil-lion Americans were enrolled in one form of man-aged care, Health Maintenance Organizations(HMOs), and the “HMO penetration” was reportedto range from nearly 60% in Delaware to under twopercent in Mississippi with a U.S. average of 29%(Managed Care Digest Series, 1997). Enrollmentin HMOs rose by 14.4% between 1995 and 1996


emphasis on primary care and ambulatory serviceswith a concomitant reduction in the rate and dura-tion of hospital admissions is unlikely to disappeareven in a rapidly-changing and unpredictable envi-ronment. Conversely, the emphasis on healthscreening, preventive services, and wellness of in-dividuals and communities (COGME ResourcePaper, 1997) may be challenged as patient switch-ing between plans negates the long-term financialincentive to avoid future illness.

Although the eventual outcomes of market andother forces are hard to predict, cost containmentwill clearly continue to be a feature of health caredelivery systems. It also appears certain that mostphysicians in the future will interact with some formof managed care. The relationships between physi-cians and managed care organizations or similarorganizations are likely to cover a spectrum fromphysicians in the role of employees to contractualor more distant relationships.

EVEVEVEVEVOLOLOLOLOLVING CURRICULA INVING CURRICULA INVING CURRICULA INVING CURRICULA INVING CURRICULA INMEDICMEDICMEDICMEDICMEDICAL EDUCAL EDUCAL EDUCAL EDUCAL EDUCAAAAATIONTIONTIONTIONTION

Changes in medical practice have profoundimplications for physician education. In 1995, thePew Commission called on educational institutionsto lead rather than react to changes in the healthcare system:

“There exists an overwhelming need for newemphases in health professions education toaddress the emerging and evolving health caresystem . . . educational institutions must leadthe change process, and indeed in so doingboth help developing practitioners form thevalues that define their profession and rein-terpret those values as the configurations anddemands of the health care system change.”

Innovative and creative programs are requiredto ensure that the preparation of physicians for therealities of future practice is based upon knowledge,skills, attitudes, and behaviors that reflect the high-est professional standards and traditions.

Medical education reform has been proposedand documented in several reports published dur-ing the past two decades. Each report has advocatedspecific changes and acknowledged the complexi-ties and difficulties of continuously updating medi-cal education, particularly the long time scale ofseven-ten years to acquire professional qualifica-tions. The importance of volunteer faculty was onlyone element stressed in the comprehensive “FutureDirections for Medical Education” report by theAmerican Medical Association (AMA) in 1982. The1984 report of the Association of American Medi-

cal Colleges (AAMC) on the “General ProfessionalEducation of the Physician: Physicians for the 21st

Century” (GPEP) also addressed the need for revi-sion of the content and process of medical educa-tion, and drew particular attention to the relation-ship between the numbers, specialties, and skillsof physicians trained and the projected needs of thepopulation. The challenge of preparing physiciansfor lifelong practice during times of exponentialscientific advances was one of several themes intwo reports sponsored by the Macy Foundation(1983 and 1988). In spite of considerable study andactivity, the comprehensive review, “AssessingChange in Medical Education: the Road to Imple-mentation” (ACME-TRI) concluded that by 1990,medical schools had responded unevenly to the callfor educational change and the overall pace ofchange had been slow. The ACME-TRI report iden-tified major barriers to change and suggested strat-egies by which both medical schools and relatedorganizations could improve medical education.

Recent years have seen considerable changesin the content of curricula for medical students andresidents and substantial innovations in the meth-ods used in medical education. Two recurrentthemes of particular relevance to this report havebeen the importance of “align(ing) the content ofmedical education programs with evolving societalneeds, practice patterns, and scientific develop-ments” (MSOP:Report II, 1998); and an increas-ing appreciation of the role of measurable learningobjectives to guide the design, content, and con-duct of educational programs (Kassebaum, EaglenCutler,1997). The ambitious Medical Schools Ob-jectives Project (MSOP) of the Association ofAmerican Medical Colleges (AAMC) aims to de-velop a national consensus on the attributes of medi-cal graduates and to articulate these attributes aslearning objectives applicable to curricula in indi-vidual medical schools (MSOP Report I, 1998). Inthe more diverse area of graduate medical educa-tion, accreditation and review processes have in-creasingly stressed attainment of measurable learn-ing objectives and documentation of competencies.

Both ACME-TRI (1992) and the Pew HealthProfessions Commission (1995) emphasized thataddressing the problems in medical education re-quired profound institutional change. The PewCommission stated:

“Changing health professions educationto meet today’s challenges, however, will re-quire health professions educators to do morethan add courses on health care delivery, or-ganization, and finance, and establish clini-cal training experiences in managed care set-tings. It will also require them to articulate


and demonstrate institutional missions andvalues that are in concert both with thenation’s health care needs and health caresystems directions; fundamentally reformcore curriculum; develop new political andeconomic partnerships; focus on the needs ofcommunities; and strengthen the tools neededto effect some institutional change.”

To fulfill their mandate to prepare physiciansfor practice, medical education institutions, there-fore, must implement extensive changes which gobeyond the expected continual updating of curricu-lar content to reflect the exponential expansion ofknowledge in the disciplines and sciences pertinentto medical practice. This alone is a daunting task.It is now recognized that fundamental changes inthe organization of medical education are requiredto adequately prepare physicians for modern prac-tice. For many reasons, most U.S. medical schoolsand residency programs have revised mission state-ments, undergone strategic planning exercises, and/or undertaken organizational re-structuring duringthe last decade - and expect to continue such proc-esses. The reaffirmation of education as the “corebusiness and unique function” (Cohen, 1997) oftraining programs and the development of strate-gies to ensure its success are essential amid the tur-moil and competing demands of the healthcare en-vironment.

Finally, in addition to the curricular and orga-nizational dimensions noted above, medical studentand resident programs are undergoing an “educa-tional revolution”. Nationwide, traditional curriculaand teaching methods are being replaced by pro-grams based on adult learning principles. These arecharacterized by more intense small group learn-ing and stringent evaluation based on a demonstra-tion of competencies. Teaching faculty find them-selves in a process of “re-engineering” complexsystems of curriculum design, delivery, and evalu-ation while at the same time meeting the expecta-tion to lead, or keep abreast of, the scientific devel-opments in their individual disciplines. The revisionof educational programs is an exciting challenge,but it is also demanding and exhausting to facultymembers who are struggling to maintain researchprograms and preserve clinical income.

CHANGING THE ENVIRONMENTCHANGING THE ENVIRONMENTCHANGING THE ENVIRONMENTCHANGING THE ENVIRONMENTCHANGING THE ENVIRONMENTOF CLINICOF CLINICOF CLINICOF CLINICOF CLINICAL EDUCAL EDUCAL EDUCAL EDUCAL EDUCAAAAATIONTIONTIONTIONTION

The educational reforms outlined above expandthe combination and synergy of didactic and expe-riential learning in medical education. The system,especially at the residency level, requires extensiveparticipation in patient care. The changing prac-

tice of medicine profoundly affects the patient-based resources for the education of future physi-cians and determines the optimal environment inwhich education should take place. For many func-tional, organizational, and cultural reasons, man-aged care systems and traditional academic train-ing sites have been described as “structurallyincompatible” (Fox, Wasserman, 1993).

Teaching institutions have traditionally drawnon large patient bases to provide a rich environ-ment for education and the integration of didacticmaterial with clinical experience. These patientbases were sustained by factors such as traditionalreferral patterns, unique availability of services,reputation/excellence of patient care, location, orpatient choice (including lack of alternatives or “nochoice”). With the transformation of the health caremarket, particularly the introduction of capitatedprograms offering discounted services and choiceof provider, both privately-insured and publicly-funded patients have chosen to seek care elsewhere.Conversely patients who lack financial resourcesor those with limited reimbursement for services,frequently rely on teaching institutions. These cen-ters also provide high-intensity specialist servicesthat are needed by the community but are relativelyunprofitable to other hospitals or clinics. Medicalstudents and residents are likely, therefore, to en-counter smaller and less diverse patient populations.Residency patient populations are increasinglyskewed towards the indigent (Bethea, Singh, Pobst,1996) or patients with unique health needs onlytreated at a teaching hospital. Conversely, teachinginstitutions are less and less likely to serve the pa-tient populations representative of those belongingto managed care and other evolving health systems.The shifts in patient populations pose significantproblems for teaching institutions seeking to ful-fill their mandates and missions to prepare physi-cians appropriately for future practice. As summa-rized by Schroeder in 1987:

“As an unintended result of powerful soci-etal changes in the organization and deliveryof medical care, the old model of education ina hospital-based system has been made lessappropriate as the exclusive site for clinicaleducation.”

The challenges to the educational mission areobviously significant, but the changes in patientpopulations and related factors are so pervasive andof such a magnitude that they impact the structureand financial viability of teaching institutions. Asteaching institutions lose certain patient groups andattract those rejected by other systems, the long-standing societal responsibilities for patient care ofthe most vulnerable patients jeopardize the financial


support for educational and other missions. The“historically mutually beneficial relationship”(Houpt, Goode, Anderson et al, 1997) between theclinical, teaching, and research missions is hard tomaintain and, in the current climate, these threemissions are often at odds with one another andeconomic realities. Declining patient bases in ahighly competitive and cost conscious marketplaceplace even the most prestigious institutions in jeop-ardy. The economic advantage of hospitals with noteaching mission has been documented for over adecade (Cameron, 1985) and was recently estimatedto be as high as 35% per admission even with ad-justment for case-mix (Blumenthal, Meyer, 1996).In ambulatory care, physicians in the community,many of whom have been trained at nearby teach-ing hospitals, provide many of the same services atlower cost than their academic counterparts.

Teaching institutions are being fundamentallyaltered by the revolutionary changes occurring inhealth care markets. Paradoxically, the forces thathave shaped the current health care climate havealso been those that have most hindered responsesby education programs (Vanselow, Karalewski1986). The health care industry, by creating a morecompetitive marketplace, has had an adverse im-pact on the clinical revenue of academic medicalcenters and faculty practice plans. Declining clini-cal revenues have, in their turn, reduced the re-sources available to subsidize research and teach-ing (Jones, Sanderson, 1996). As a consequence,physician faculty have found it necessary to devotemore time to clinical activities and correspondinglyless time to teaching and research. During this sametime period, financial support from other sourcessuch as State funding, tuition, endowments and re-search grants has not significantly increased formost teaching institutions (Jones, Ganem, Wiliams,Krakower, 1998). Although new funding for re-search has been generated in some institutionsthrough relationships with industrial partners(Blumenthal, 1996), there is evidence that high lev-els of industrial support are associated with reducedacademic activity (Blumenthal, Campbell, Causino,Louis, 1996). In the face of such severe economicstrictures, the capacity to devote resources to edu-cational programs has been questioned (Fogelman,Goode, Behrens et al 1996/Houpt, Goode, Andersonet al 1997), and the ability to provide quality inundergraduate and graduate programs may be com-promised (Rivo, Mays, Katzoff, Kindig, 1995). Al-though there is substantial variation between insti-tutions, all studies verify the continued dependenceof medical schools on faculty-generated revenueand the current constraints on academic and otherenterprises due to adverse market forces (Jones,Ganem, Williams, Krakower, 1998).

Faced with substantial educational challengesand decreasing and/or inappropriate resources todevelop programs, teaching institutions haveadopted a variety of strategies to preserve patientbases for education and other endeavors (Fogelmanet al, 1996). A new appreciation of the potential ofvolunteer faculty and community-based locationsto complement the experiences available in teach-ing hospitals is a common theme in the recent lit-erature (Fogeleman et al, 1996/Houpt et al, 1997).This trend has also enhanced interest in distancelearning and methods to make didactic curricularelements “portable” for use by learners at commu-nity sites. Several programs have been developedwhich provide examples of successful partnershipsbetween medical schools and managed care orga-nizations for the purpose of educating medical stu-dents and residents (Stevens, Leach, Warden,Cherniak, 1996/ Moore, Inui, Ludden,Schoenbaum, 1994). A study in 1996 estimated thatabout 85% of medical schools potentially exposedstudents to some form of managed care during re-quired clinical experiences and that 16% of schoolsrequired experiences in staff/group model HMOs.(Veloski, Barzansky, Nash et al, 1996). This coun-cil in its Sixth Report (1995) recommended thatundergraduate and GME programs expand their in-volvement with managed care organizations.

Although teaching institutions are developingnew models of clinical care internally and buildingnew partnerships for education, current learners andtheir teachers are caught in the transition from tra-ditional to new models. The gap between the pro-grams that prepare learners and the realities of thenew medical practice environment does not appearto be closing. Four factors seem to be confoundingattempts to close this gap:

• The pace of change in the practice environ-ment;

• The lag between the introduction of changesin educational programs and their impacton the practice of medicine (due to the 7-10year span of training);

• The rate of response of medical schools andresidency training programs to necessarycurriculum change; and

• The lack of available resources to supportneeded change.

Reference has already been made to the firsttwo factors. The others reflect the interplay of or-ganizational and financial disadvantages underwhich most teaching institutions operate. Teach-ing institutions are complex and inflexible businessoperations (Fox, Wasserman, 1993/Houpt et al,


1997/Fogelman et al, 1996) that often seek to ful-fill their missions under legislative, social, and po-litical constraints which hamper their ability to re-spond to change (Allcorn, Winship, 1996). Whilethey have an obligation to acknowledge and sup-port their unique educational mission (Cohen,1997), the leadership and faculties of medicalschools are significantly hampered in so doing byfinancial systems in which distinct budgets for edu-cation are rarely identified.

Uncertainty about the attributable costs of edu-cation makes forecasting appropriate budgets forchange almost impossible (Watson, 1997). Addi-tional funding through Federal programs or fromprivate foundations could assist in initiating newteaching programs but the long-term viability ofeducational activities depends on sustained inter-nal fiscal support. In the current climate, it is hardto argue for an increase in funding from tuition, orfrom State or Federal sources. In graduate medicaleducation, the role of managed care organizationsand other potential employers of resident physiciansin providing funding remain controversial (Gold,1996). A redistribution of existing resources, par-ticularly for graduate medical education which iscurrently strongly linked to hospital service, hasbeen advocated (Kassirer, 1996). Although this is asignificant step, widespread curricular reform isunlikely unless educational budgets are developed,funds are generated or reallocated, and systems areestablished to monitor financial and other “busi-ness” aspects of medical education.

This is no small agenda for teaching institu-tions that are under increasing economic pressureon many fronts and may feel abandoned by the com-munities and populations they have traditionally

served. It is equally daunting to faculty who areexperiencing escalating conflicts in their roles inteaching, research, administration, and clinical care.Support may be forthcoming from public and otherstakeholders. In particular, licensing and accredi-tation bodies may need to review their requirementsand add those that promote the acquisition of newclinical knowledge and skills needed for 21st cen-tury medical practice (Rivo, Mays, Katzoff, Kindig,1995). They may also need to exert pressure forgreater clarity and accountability in medical edu-cation.

There is a pressing need for physicians whoseeducation has prepared them to practice in the newhealthcare environment. The decade-long lag be-tween the introduction of new educational programsand their impact on the practice of medicine in thecommunity gives rise to a sense of urgency in thisreport. In keeping with the scope and pace ofchange, fundamental and extensive changes inmedical education are recommended; however, itmust be stressed that such changes are in the tradi-tion of U.S. medical education. Teaching institu-tions have been in the vanguard of major trends inthe medical sciences and practice for over a cen-tury (Krauss, Smith, 1997/Pardes, 1997) and right-fully claim the intellectual leadership in preparingfuture physicians. When confronted with changein the past, they have coped and emerged as stronginstitutions. Their ability to do so will be repeat-edly tested (Griner, Blumenthal, 1998). This reportemphasizes the magnitude of the change posed bythe tumultuous health care market and establisheskey issues in how changes should be implementedand sustained if the population is to be appropri-ately served by its physicians.



• Ethics and the management of dual respon-sibilities and conflicts of interest

• Patient-provider relationships and commu-nications

• Leadership, teamwork, and organizationalchange

• Quality measurement and improvement

• Systems based care

• Medical informatics and the obtaining, as-sessment, and use of medical information

• Teaching managed care

In this report, the Council focuses on strategiesfor the integration of this content into medical train-ing programs. Of the nine domains, two have beenselected for special consideration. An understand-ing of the system in which the physician is provid-ing care, and the ability to communicate effectivelywith patients, colleagues, and others are critical intoday’s medical practice and underpin the full de-velopment of the other domains.

The sections that follow contain eight findingsand their associated recommendations that are thecore of this report. They are grouped as follows:

I. UNDERSTANDING THE SYSTEM IN

WHICH HEALTH CARE IS DELIVERED

II. ESTABLISHING PRACTICAL AND REL-EVANT TEACHING SITES

III. DEVELOPING COMMUNITY CLINICIAN

TEACHERS

IV. REVISING THE CURRICULUM CONTENT

AND LEARNING PROCESS

V. REINFORCING COMMUNICATION SKILLS

VI. ASSURING QUALITY AND ACCOUNTABIL-ITY IN PHYSICIAN EDUCATION

VII. FINANCING THE EVOLUTION OF GRADU-ATE MEDICAL EDUCATION

VIII. SUSTAINING QUALITY AND VITALITY IN

MEDICAL EDUCATION.

While the findings and recommendations in thisreport focus on graduate medical education,COGME found it difficult, if not impossible, touncouple medical student and resident education.We have chosen not to address the issue of fellowship

Medical Education PrMedical Education PrMedical Education PrMedical Education PrMedical Education Progrogrogrogrograms fams fams fams fams for a Changing Enviror a Changing Enviror a Changing Enviror a Changing Enviror a Changing Environmentonmentonmentonmentonment

The international reputation for excellence ofAmerican medicine is, in no small part, dueto the quality of its educational programs.

This report does not challenge the tradition of qual-ity in graduate medical education but seeks tostrengthen it. The report argues for enhancementof existing programs through the inclusion of newprogram content, proposes dramatic changes in thefaculty structure and roles, and advocates fresh ap-proaches to clinical education. Excellence in thecore disciplines of medicine will always be requiredand the basic scientific method is more importantthan ever in improving the quality of the nation’shealth. Nevertheless, new content must be inte-grated into our teaching programs and new teach-ing methods and settings must be explored in orderto maintain the vigorous traditions of Americanmedical education and its insistence on excellence.Adding to an already saturated curriculum is a dif-ficult task requiring the prioritization and integra-tion of both current and new material. Simply add-ing to educational mandates and responsibilities hasalways been unsatisfactory and may no longer bepossible. This report advocates the reorganizationand modification of current educational programsand the exploration of new strategies for medicaleducation. It has as its objective, the developmentof programs that effectively prepare physicians formedical practice in the changing environment.These programs must meet or exceed current stand-ards of educational excellence as they prepare resi-dents to practice in the more systematic, quality-focused health systems of the future (Stevens,1997).

Much of the curricular content of such programshas already been defined in the literature. As earlyas 1991, the Pew Health Professions Commissionpublished a set of 17 competencies for the futurehealth care practitioner (Shugars, O’Neil, Bader,1991). Two comprehensive recent reviews(COGME 1997 Resource Paper “Preparing Learn-ers for Practice in a Managed Care Environment”,and Meyer, Potter, Gary, 1997) have developed corecurricular domains that physicians need to masterin order to function effectively in new practice en-vironments, particularly managed care practice.These domains include:

• Health systems financing, economics, orga-nization, and delivery

• Practice of evidence-based, epidemiologi-cally-sound medicine


education directly, although the recommendationsof the report should be extended to include fellow-ships. Currently the educational linkages betweenmedical school and GME are tenuous. There is lim-ited consensus on what aspects of the educationalexperience should be focused at the different stagesof the process and little planned attempt tosynergize learning or avoid unhelpful duplicationduring the long period of training. Medical educa-tion should be viewed as a continuum from pre-medical education, through medical school, resi-dency and fellowship training, and into medicalpractice and continuing medical education. Thecurrent artificial division of physician educationinto disconnected phases has contributed to someof the problems identified here. The lack of conti-nuity is manifest at all stages of the training proc-ess—between (and even within) courses duringmedical school, in the transition to residency, and inestablishing and maintaining lifelong practice.

The fragmentation of the educational processhas magnified the mismatch between the educationof physicians and the demands of practice. A sur-vey based on the 1991Pew Commission competen-cies found that only 31% of practicing physiciansreported adequate training to consider cost impli-cations of patient care, 17% felt prepared to workin managed care settings, and 14% reported beingwell-prepared for increased scrutiny of practicestandards (Finocchio, Bailiff, Grant, O’Neill, 1995).

This report is intended to clarify the need for,and to stimulate the development of, fresh ap-proaches to the professional education of physiciansfor contemporary and future medical practice. Itpresents an analysis of the issues influencing thepreparation of physicians and recommends changesin teaching programs. Unlike previous COGMEreports which have focused on primary care, therecommendations in this report apply to prepara-tion for many medical specialties. In particular, theimportance of clinical education in the communityis no longer limited to the primary care specialties.In many specialties, the community offers uniqueeducational opportunities that are complementaryto those of the academic health center or teachinghospital. The comprehensive preparation of allmodern physicians requires experience in both tra-ditional and community settings.

This report advocates the development of high-quality, community-based clinical teaching oppor-tunities and a faculty incorporating community cli-nician teachers. It calls for expansion andenhancement of educational relationships with thecommunity and a redefinition of the roles of con-ventional medical school and residency programfaculty. In addition, the report emphasizes the role

of rigorous evaluation systems to assure consistentquality and guide the steady evolution of educa-tional systems. Finally, the report addresses strate-gies to fund and sustain the recommended changes.

I.I.I.I.I. UNDERSTUNDERSTUNDERSTUNDERSTUNDERSTANDING THE SANDING THE SANDING THE SANDING THE SANDING THE SYSTEMYSTEMYSTEMYSTEMYSTEMIN WHICH HEALIN WHICH HEALIN WHICH HEALIN WHICH HEALIN WHICH HEALTH CTH CTH CTH CTH CARE ISARE ISARE ISARE ISARE ISDELIVEREDDELIVEREDDELIVEREDDELIVEREDDELIVERED

FINDING 1. Physicians increasingly deliverhealth care to defined populations of patientsin the context of integrated delivery systemsor health plans. An improved understandingof the characteristics of the populationsserved and the attributes of the delivery sys-tems is fundamental to effective medicalpractice.

Many patients now receive health care as partof a system that involves physicians, other healthprofessionals, hospitals, community resources, anda health plan. The resources available to patientsthrough a health plan or an integrated health caredelivery system are often comprehensive; cost-ef-fective care is, however, a major theme in almostall health care delivery systems and health insur-ance plans. Restrictions are usually placed on whenand how plan-funded services can be used. Con-trolling and monitoring access to services is fre-quently the role of the plan medical director. Al-though this role may be perceived as adversarial tocolleagues involved in direct patient care, medicaldirectors are physicians with expertise in the healthplan and can be invaluable consultants assistingphysicians in providing high-quality, cost-effectivecare specific to patients’ needs.

Effective medical practice within a health caresystem requires communication skills (see SectionV), effective teamwork built on a clear understand-ing of the roles and capabilities of other health pro-fessionals, and constructive use of the plan’s re-sources and management systems. In order toprovide the highest quality care and to be advo-cates for their patients, physicians must thoroughlyunderstand the benefits and limitations of each planand the characteristics of the system in which careis delivered.

Many residency programs have taken steps toprovide experience in health care financing, prac-tice management, and managed care practice. Resi-dency programs established within HMOs and othermanaged care organizations are relatively uncom-mon but most residents interact with patients whoare members of pre-paid plans in residency clinics/hospitals or during elective experiences. Managedcare Medicaid programs are being introduced in a


number of States, and may provide residents withan opportunity to care for capitated patients in thehospital and outpatient clinic. In spite of these de-velopments, both residency graduates and the man-aged care organizations that they join, currentlyrecognize the lack of understanding of the systemin which they provide healthcare as a barrier toimmediate effectiveness (Gold, 1996). In this andseveral other key areas, executives of managed careorganizations have called for far-reaching changesin residency curricula to better prepare graduatesfor practice (Jacobs, Mott, 1987/Meyer, Potter,Gary, 1997). A recent survey of Internal Medicineresidents concluded that exposure to managed careduring residency training influences attitudes to-wards acceptance of managed care and careerchoices towards generalism (Nelson, Matthews,Patrizio, Cooney, 1998).

Appropriate preparation in systems of healthcare delivery goes beyond learning about policies,procedures and organizational structure. Physiciansmust learn how to optimize the different systemsfor the benefit of their patients and their own senseof professional satisfaction. With the advent ofmanaged care, the relationship between physiciansand their patients has changed. Under the fee-for-service system, open-ended contracts with healthinsurers permitted physicians to make patient man-agement decisions that were not influenced by theconsiderations commonly found in managed careprograms. Today, many physicians provide care forpanels of patients who subscribe to a myriad of dif-ferent plans, each with different benefits, restric-tions, and operational systems. Physicians are of-ten placed in the uncomfortable role of explainingto patients, who may be employees of the samecompany or even members of the same family, whythey are not entitled to the same benefits as otherpatients with the same health status. Conversely,the population-based approach of health plans pro-vides opportunities to enhance the quality of careby providing physicians with data on the charac-teristics of the patient population, the medical prob-lems that are more likely to occur in its members,and collaboration in health promotion/disease pre-vention measures such as screening.

In common with other topics and skills de-scribed in this report, learning about the system inwhich physicians practice is best accomplishedthrough a combination of theoretical studies andpractical experiences. Intensive short didacticcourses on aspects of managed care may have lim-ited long-term educational impact on residents(Lazarus, Foulke, Bell et al, 1998). The emphasison experiential learning in residency training sup-ports the direct involvement of residents both in

patient care and in processes such as quality assur-ance and utilization review that are integral to man-aged care organizations. Similarly, experientiallearning provides opportunities to work with otherhealth professionals to learn about their training andcapabilities, and their role in the clinical team. Thecontent and format of educational programs to en-hance understanding of health care systems mustbe made specific to the stage of medical education,tempered by the predominant form(s) of local healthcare systems. This may range from general over-views for first year medical students to details ofcredentialing and contracting which are of greatsignificance to senior residents. At all levels of train-ing, the requirement to provide optimal patient carein the context of the system must be paramount.

Recommendations:

• Medical students and residents shouldlearn the basic principles of health carefinancing, the benefits and limitations oftypical health plans, and the characteris-tics of the systems in which health caremay be delivered.

• The curricula of medical schools and resi-dency training programs should includeclinical learning experiences in the settingof each of the components of an integratedhealth care delivery system

• Medical schools and residency trainingprograms should provide opportunitiesfor medical students and residents to learnthe contribution of other health profes-sionals to the care of their patients, andaugment opportunities for learners to par-ticipate in a team approach to patientcare.

• Educational programs for medical stu-dents and residents should address thecare of the individual patient in the con-text of the population or community ofwhich the patient is a member.

II.II.II.II.II. ESTESTESTESTESTABLISHING PRAABLISHING PRAABLISHING PRAABLISHING PRAABLISHING PRACCCCCTICTICTICTICTICALALALALALAND RELEVAND RELEVAND RELEVAND RELEVAND RELEVANT TEAANT TEAANT TEAANT TEAANT TEACHING SITESCHING SITESCHING SITESCHING SITESCHING SITES

FINDING 2. There will be an acceleration inthe development of new models of medicaleducation that reflect more closely the prac-tice of medicine within evolving health sys-tems.

Academic health centers (AHCs) and teachinghospitals provide excellent training sites for many


aspects of medical education. Indeed for certainaspects of clinical learning, the classical AHC isthe only environment which brings together theexpertise, selected patients, and the equipment andother resources necessary for education. It is, how-ever, very difficult in the AHC environment to ex-pose students and residents to the patient mix, clini-cal situations, pace and time issues, practicemanagement concerns, interdisciplinary collabora-tion, and physician role models which are preva-lent in the community. (Schroeder, 1988) Withoutsuch exposure, learners are handicapped in devel-oping the skills, knowledge and attitudes neededfor future practice. It is therefore incumbent ontraining programs to include appropriate “non-tra-ditional” experiences that complement the AHC andteaching hospital components to provide a compre-hensive clinical education. In developing this com-prehensive approach, consideration must also begiven to ensuring patient populations which appro-priately represent the community diversity in char-acteristics such as ethnic origin, socioeconomic sta-tus, age, and gender. (Residency training in somespecialties such as pediatrics, geriatrics, and obstet-rics/gynecology should strive for diversity withintheir scope of practice.)

The national trend in medical education is to-wards the attainment of generalist competencies bythe time of graduation from medical school. Theseobjectives are not well served by the specialty-skewed environment of a classic AHC. Many, if notmost, medical schools have acknowledged this bycreating generalist and other ambulatory experi-ences within the AHC and developing new oppor-tunities away from the AHC for medical studentsand residents (Cope, Sherman, Robbins, 1996/Carlton, Weston, 1997). They have accepted theorganizational and other challenges of the ambula-tory setting for resident education, recognizing thatthe unique opportunities of the environment requirenew models of graduate education (Wartman,O’Sullivan, Cyr 1992). A variety of strategies havebeen used to establish a presence in the commu-nity (Urbina, Hickey, McHarney-Brown et al, 1994/Fogleman et al 1996). Some of these strategiesoriginated in, or were influenced by, a need to se-cure patient populations to support the clinical en-terprise of the academic health center. In these cases,the operational systems of the clinics may not ex-plicitly facilitate education, but all community ac-tivity should be seriously considered for its poten-tial role in the education of students and residents.

The established method of experiential learn-ing in GME works particularly well when it closelyparallels future practice settings. The selection ofappropriate settings for learning is therefore criti-

cal. Such settings are more likely to be found in thecommunity than in the academic medical center(Hayashi, Hayden, Yager, Gauze, 1989/Cope et al,1996/Perkoff, 1986/Parenti, Moldow, 1995). Asmedical education has always depended on immers-ing the learner in the work environment as a mem-ber of a team dedicated to patient care, the com-mitment on the part of community sites toparticipate in the education of medical students andresidents is considerable. A quality educationalexperience demands the investment of time andresources by community physicians and staff towork with medical school and residency faculty inthe development, implementation, and evaluationof learning experiences. Community sites are part-ners and stakeholders in an educational processrather than simply locations of an educational ac-tivity (Tallia, Micek-Galinat, Formica, 1996). Thecharacteristics of a quality community teaching siteinclude:

• The practice of the highest possible qualityof medicine in an environment that is rel-evant to current daily practice;

• The presence of expert clinician teacherswho are practicing the highest possible qual-ity of medicine;

• The availability of experiences that are ap-propriate to the stage of training of thelearners and enable them to achieve educa-tional objectives of the curriculum; and

• The presence of clinicians who are preparedto devote the time and attention to the learn-ing experience for students and residents.

Of central concern in community settings is theneed to provide medical education that is of highquality and appropriate to the future practice of thelearner. Each location in which education is con-ducted requires individualized preparation, devel-opment, and monitoring to fully exploit its educa-tional potential (Lemon, Greer, Siegel, 1994/Crump, Chambers, Bolt, 1996). The importance ofthese steps and the resources needed to carry themout have been underestimated by many involved inmedical education (Ricer, Filak, David, 1998). Tra-ditionally, medical schools and residency programshave made relatively informal arrangements for stu-dents and residents at community sites, often basedon relationships with program graduates and thewillingness of community physicians to volunteer.A comprehensive assessment of the quality andscope of the medical practice or the ability of thephysicians and other staff to teach is rarely con-ducted. The increasing significance of community-based education has led to more formal agreementsand, in some locations, the development of


educational consortia to bring together entities forclinical teaching. Although the costs are enormous,some institutions have provided new learning en-vironments by direct acquisition or developmentof AHC-owned clinical facilities in the community.

The introduction of learners into any commu-nity site requires careful consideration of strategiesto anticipate and minimize any negative effectswhile optimizing the positive aspects of participa-tion in teaching. The principal concerns are usu-ally the slowing of patient flow with its subsequenteffect on clinical income, and perceptions that pa-tients dislike learners participating in clinical en-counters. Studies indicate that the time required toteach while seeing patients in a private office var-ies enormously depending principally on the edu-cational stage of the learner and characteristics ofthe teacher (Vinson, Padden, Devera-Sales, 1996/Ricer,Van Horne, Filak, 1997). Although it appearsintuitive, time spent teaching may not directlyequate to diminished clinical revenue. The few stud-ies which have attempted to detect changes in pro-ductivity and other financial outcomes due to teach-ing have given mixed results (Kearl, Mainous, 1993/Garg, Boero, Christiansen, Booher, 1991/McKee,Steiner-Grossman, Burton, Mulvihill, 1998/Fields,Toffler, Bledsoe, 1994/ Heath, Beatty, 1998). It ap-pears that experienced teachers in ambulatory clin-ics have devised strategies to maintain clinical pro-ductivity and income through a combination ofspecific teaching techniques and use of “privatetime” such as during meal breaks or after hours fordirect interaction with learners. Much of the re-search has concerned medical students. Althoughestimates of $6,000-$18,000 per year have beenmade of the cost of training a resident in commu-nity sites (Zweifler, Rodnick, 1998), a widespreadbelief exists that graduate medical education is a“break even” or potential financially positive ac-tivity, very dependent on the seniority of the resi-dent (Rosborough, 1998/Gold, 1996). The financ-ing of resident education in the community isextremely complex (Burg, Kelly, Zervanos 1994)and certainly merits further study (Xakellis, Gjerde,1995/Bordage, Burack, Irby, Stritter, 1998).

The perception that patients will not accept theactive participation of students or residents in theircare is relatively common but generally inaccurate(Tamblyn 1994/O’Malley, Omori, Landry, et al,1997). The majority of patients are positive aboutthe involvement of learners, particularly when des-ignation as a teaching site is seen as an indicator ofhigh quality practice. Although some patients donot want to be seen by learners and others wanttime alone with their physician, many are comfort-able participants in clinical teaching when simple

courtesy is extended. The opportunity to declinethe involvement of students and residents must al-ways be offered (Simons, Imboden, Martel, 1995/Magrane, Gannon, Miller, 1994/ O’Flynn, Spencer,Jones, 1997). Improved patient satisfaction has beencited as an incentive for HMOs to participate inmeical education (Kitz, Larsen, 1997).

Learners also require preparation in order tomaximize their education in community sites. Thestudent or resident who has learned to function ef-fectively in the AHC may find the transition to acommunity site stressful and disorienting. Theymay fear isolation from other learners and may berequired to travel considerable distances from home.Community placements usually require learners totake greater responsibility for their own studying,to act professionally in a situation where the pri-mary purpose is patient care, interact with staff andother health professionals, and have a very differ-ent relationship with teachers than previously. Ex-perience in a community site may be a powerfulcounter to the “hidden curriculum” or institutionalacculturation often cited as a negative influence onthe professional development of physicians(Hafferty, 1998). Learning in a community officemay be different in style (Epstein, Cole, Gawinski,et al, 1998) as well as clinical content (Gjerde, Levy,Xalellis, 1998) from the experience in a residencyor medical school clinic. Even didactic aspects oflearning may be different such as use of distancelearning modalities and an emphasis on personalstudy and completion of projects as opposed to at-tending lectures and working with other learners.Clear expectations should be set out during the ori-entation to the program both at the medical schoolor residency program and “on site.” High levels ofadministrative support and coordination are re-quired to optimize the learning opportunities ofcommunity sites even for residents.

The importance of clinical education in thecommunity is not limited to the primary care spe-cialties. In many aspects of surgery, obstetrics andgynecology, psychiatry and other specialties, thecommunity provides educational opportunities thatare complementary to those of the academic healthcenter. Community sites offer experiences that areboth practical and relevant to the educational needsof the student or resident. This does not imply thatall clinical learning should be moved into the com-munity, but in many instances community sites pro-vide essential experiences that are not available inthe clinics of AHCs. The comprehensive trainingof modern physicians for all specialties requiresexperience in both AHCs and community sites.

The content and relative proportion of experi-ences gained in different environments during the


educational process must be decided by each insti-tution, but the educational value of community ex-periences can no longer be questioned. Learnerswho are placed in such environments are reportedto have equivalent results on formal testing whencompared to students educated more convention-ally (Fincher, Case, Ripkey, Swanson, 1997/Irby,1995/Steiner, Cook, Smith, Curtis, 1998). They arealso reported to have greater confidence in aspectsof communication and patient assessment as wellas a tendency to greater self-reliance in study hab-its (Irby, 1995). Medical education must enable stu-dents and residents to learn in multiple and diversesituations, including the wards, operating rooms,clinics and laboratories of the classical AHC; butto provide a well-balanced spectrum of learningexperiences, the proportion of time spent in com-munity sites such as private offices, managed carefacilities, public clinics, community agencies, andcommunity hospitals should, in almost all cases,be increased.

Several successful community-teaching pro-grams have already been developed. The WWAMIprogram at the University of Washington is an ex-ample of a teaching program incorporating selectedteaching practices distributed across five States(Washington, Wyoming, Alaska, Montana andIdaho) that offer community-based clinical learn-ing opportunities for students and residents. Sev-eral of the teaching practices that participate in theWWAMI program have done so for 20 years ormore. Similar programs exist at the University ofMinnesota, Marshall and West Virginia Universi-ties, the University of Kansas-Wichita, and the StateUniversity of New York, Syracuse.

More recently, the Health Resources and Serv-ices Administration has funded a five-year projectentitled “Undergraduate Medical Education for the21st Century (UME-21): A Demonstration of Cur-riculum Innovations to Keep Pace with a ChangingHealth Care Environment.” The goal of this projectis to demonstrate that medical schools, in partner-ship with managed care and other organizations andinstitutions, can provide educational opportunitiesto better prepare graduates to practice high quality,population-based, cost-effective medicine (Wood,1998). In addition, under the aegis of Partnershipsfor Quality Education (PQE), a three year initia-tive funded by The Pew Charitable Trusts, 66partnerships between academic health centers andmanaged care organizations are developing resi-dency training experiences in managed care settings(PQE, 1998; personal communication, Gordon T.Moore, 1998). The partnership between teachinginstitutions and managed care organizations is per-ceived to be mutually beneficial providing educational

experiences to the medical school and offering themanaged care partner a role in the education of stu-dents and residents who may become future staffphysicians—but the interactions are complex. Byone estimate over half of Internal Medicine resi-dency programs place residents in private physi-cians’ offices for at least a portion of training andthis proportion is increasing rapidly (Swing,Vasilias, 1997). Over 90% of medical schools usecommunity preceptors, predominately family phy-sicians teaching third and fourth year students, butincreasingly in diverse roles and throughout thecurriculum (Fields, Usatine, Stearns, Toffler,Vinson, 1998).

Medical schools, residency programs, and theiraccrediting organizations are rightfully concernedabout quality and consistency of clinical experi-ences for medical students and residents acrossmultiple sites in the community. Careful site selec-tion, faculty development, and rigorous evaluationwith feedback are essential. These, and the impor-tance of an adequate time placement, well-plannedto ensure continuity and substantial patient contact,have recently been reviewed (Irby, 1995). Distancelearning technology (discussed later in this report)and other methods have been developed to enablethe didactic aspects of the curriculum to be deliv-ered consistently to learners and community clini-cians. This concept has been extended to all aspectsof education as “the Virtual Clinical Campus”(Friedman, 1996). Less dramatically, the new em-phases on performance assessment of learners andevaluation of educational programs provide moni-toring and quality enhancement techniques whichenable medical educators to explore the opportuni-ties of unconventional sites with confidence thatexcellence is not being compromised. Indeed it hasbeen stated that community-based experiences havebeen more thoroughly evaluated than any other as-pect of medical education.

Recommendations:

• Clinical education should occur in settingsthat are representative of the environmentin which graduates will eventually prac-tice. Medical schools and residency train-ing programs should develop or acquireclinical teaching sites that offer the bestlearning opportunities and the higheststandards of clinical practice. Partner-ships with integrated delivery systems,health plans and other organizationsshould be developed as one strategy toaccomplish this.

• Medical educators should exploit the po-tential of distance learning technology to


deliver educational programs in which in-struction and evaluation are of a consis-tent and high standard to multiple settingsin the community.

III.III.III.III.III. DEVELDEVELDEVELDEVELDEVELOPING COMMUNITYOPING COMMUNITYOPING COMMUNITYOPING COMMUNITYOPING COMMUNITYCLINICIAN TEACLINICIAN TEACLINICIAN TEACLINICIAN TEACLINICIAN TEACHERSCHERSCHERSCHERSCHERS

FINDING 3: The selection and support of cli-nician teachers in the community will be-come a fundamental priority of medicalschools and residency training programs.The current roles of faculty members basedat conventional teaching institutions will besignificantly changed by expanded conceptsof medical education and more inclusive defi-nitions of faculty membership.

The importance of the teacher has been over-shadowed recently in medical education by a focuson curricular content. In clinical environments thebest teachers are expert clinicians who teach byexample and model the professional characteristicsthat students and residents should emulate (Irby,1995). In the process of teaching, they provide fac-tual information and demonstrate technical skills,but above all, they share the clinical problem-solv-ing, integration, and communication skills essen-tial to patient care. Faculty at AHCs and teachinghospitals are often superb clinical teachers who havelimited contact with students and residents becauseof competing demands on their time from research,administration and service commitments. In thesesituations, residents are commonly given the re-sponsibility for much of the clinical teaching ofstudents. Residents lack the breadth of experienceto be satisfactory role models for learners and areoften pre-occupied with the demands of in-patientcare. Conversely, although busy in patient care, thedaily activities of community physicians are fo-cused on the factors already identified as essentialto prepare future physicians. Highly effective cli-nician teachers and excellent role models for stu-dents and residents should therefore be soughtamong community physicians. This report advo-cates the mobilization of community faculty to anextent not previously attempted both in numbersand in the strength of the relationship with medicalschools and residency programs.

Who should be selected for this teaching role?They must be, first and foremost, experts in theirfield who practice in environments that are repre-sentative of their specialties. They must be physi-cians who, by the evaluation of their peers and othercriteria, are identified as the best clinicians in thecommunity. Although not necessarily trained as

educators, they should have a passion for the roleand be willing to participate in faculty developmentactivities. Community teachers should be involvedin both the medical and wider community so learn-ers may experience the realities of daily medicalpractice and the lifestyle of a community physi-cian. This implies that the community teachershould be willing to share personal experiences,attitudes and other insights with learners creating avery different level of teacher-learner relationshipthan usually exists in medical education. Above all,they must be willing partners with faculty based atthe teaching institution and other community teach-ers in a dynamic educational system that is respon-sive to changes in the practice of medicine and com-mitted to the optimal preparation of futurephysicians.

Community physicians who currently volunteerto teach often have a limited understanding of theobjectives of the learning experience for studentsor residents and the criteria used to evaluate theperformance of learners and teachers. This mayoccur because of geographic distance from themedical school or residency program, limited con-tact with program coordinators, or a lack of involve-ment in program development. Simply recruitingcommunity physicians to teach is not sufficient.Course directors must understand the abilities ofeach community teacher and the extent to whichthose match curricular requirements. Each poten-tial teacher possesses a range of knowledge, skills,and attitudes determined by factors such as the na-ture of the medical practice and the interests andaptitude of the individual physician. Where gapsoccur in the teacher’s experience or skills, or thereis a mismatch with curricular objectives, supple-mentary experiences must be found for learners and/or opportunities provided for teachers to developor refine skills (Skeff, Bowen, Irby, 1997). Arrange-ments must be made to continuously monitor andimprove teaching effectiveness over time (Schuster,Haggerty, 1994/ DeWitt, Goldberg, Roberts, 1993).It is anticipated that students and residents in thefuture will work with multiple community teach-ers. Ensuring a comprehensive range of experiencesfor learners will become a major role for courseand residency program directors. Extremely goodcommunication among members of a diverse fac-ulty team will be essential (Reynolds, Giardino,Onady, Sieigler, 1994).

All educators must be prepared for and sup-ported in their teaching roles. For community prac-titioners, teaching skills development is a crucialactivity (Skeff, Stratos, Mygdal et al, 1997). Theteaching skills necessary to function in the ambu-latory environment are different from those needed


in the in-patient setting but techniques to maximizethe educational value of brief teaching encountershave been described for both students and residents(McGee, Irby,1997/Ferenchick, Simpson,Blackman et al, 1997/Neber,Gordon, Meyer,Stevens, 1992/ Lesky, Borkan, 1989). Well-de-signed faculty development programs can assistfaculty to master the different components of theteaching role. Faculty development must, however,be built on assessment of the needs of individualteachers. Aspects such as evaluation and providingfeedback to learners are often particularly troublingto community teachers because of the very intimaterelationship with learners. Significant, continuousinvestment in faculty development is essential toensure that the quality of teaching in the commu-nity meets acceptable standards (Quirk, DeWit,Lasser et al, 1998).

The insistence on quality and an ability to mea-sure it distinguish the community teachers advo-cated in this report from those of the pre-Flexnerianera. Medical education during that era was justifi-ably criticized for its variability in quality and lackof academic rigor. Many students of medicine wereapprenticed to physicians who were themselvespoorly and unscientifically trained and were inap-propriate role models. Since then the term “appren-ticeship” has acquired a pejorative connotation inmedicine and education outside the AHC or teach-ing hospital has been regarded as of dubious qual-ity. It is time to challenge these beliefs and advo-cate a return to significant community-basededucation to complement the in-patient emphasisof the AHC. Sophisticated systems to credentialphysicians based on clinical performance are nowavailable (Nash, Markson, Howell, Hildreth, 1993)and the assessment of teaching skills has becomemore refined and standardized. Such techniquesprovide medical schools and residency training pro-grams with the ability to select and maintain com-munity faculty who are experts in their clinicalfields and offer the best in clinical teaching. Newinsights in medical education support the confi-dence of many educators that community basedfaculty can provide the best of classical “appren-ticeship” and “mentoring” approaches. Individualresidents or medical students can be assigned forhigh quality clinical experiences and for a majorproportion of their clinical education to clinician-teachers in community practices (Verby, 1988,1991). With scrupulous attention to the attainmentof defined standards of teaching and learning, theapprenticeship holds renewed promise as a viable,practical, and rigorous educational experience.

For community physicians to play their full rolein clinical teaching, they must be appropriately pre-

pared, rewarded, and sustained. This implies a de-gree of commitment and support from the medicalschool and residency-training program that is cur-rently provided in only a few locations. In order torecognize the value and ensure accountability forthe quality of their teaching activities, communityclinician teachers should be paid and otherwise re-warded. The time has passed when altruism andenthusiasm alone can be the foundation of a largecomponent of professional education. The role thatcommunity clinician teachers will fill in the edu-cation of physicians is too important to be assumedby volunteers. Community teachers must be directlyrewarded (Fields, Usatine, Stearns, Toffler, Vinson,1998). The system of rewards must be clear andrelated to measures of commitment and quality. Thespecific form of rewards should be determined byeach institution, incorporating input from the com-munity teachers themselves as to what constitutesappropriate “value” in recognition of their effortsand achievements (Bell, Frey, 1998/Gray, Fine,1997/ Fulkerson, Wang-Cheng, 1997). At a mini-mum, the reward system should incorporate:

• Direct payments;

• “In kind” benefits such as continuing medi-cal education credits and access to univer-sity facilities and services;

• Appreciation and recognition functions;

• Participation in a promotion process thatrecognizes teaching, service and scholar-ship; and

• Ability to participate in the on-goingdevlopment of educational programs

The later is proposed in full appreciation of itsimplications for traditional teaching institutions.Since community teachers will be responsible fora significant portion of the clinical teaching mis-sion of the medical school or residency program,they should understand the mission and participatein its development, implementation, and evolution.Their contributions should be sought and valued.Conversely, sustaining educational standards andenthusiasm will be enhanced if community-basedteachers perceive themselves to provide more than“clinical material”. The required degree of qualitycontrol and commitment can be achieved onlythrough true collaboration (Lemon, Yonke, Roe,Foley, 1995).

New levels of partnership with the teaching in-stitutions should extend to academic promotionsystems. A recent survey revealed that even in cli-nician-educator academic tracks, the number ofpublications remained an influential determinantof promotion (Beasley, 1997). While classical


scholarly work should not be discouraged, academicpromotional policies should be developed to accom-modate clinician teachers, including those basedin the community. The criteria for academic pro-motion for such faculty should be based on theirachievements in their specific roles and measurescholarship in broadly-defined terms appropriate tothese responsibilities (Boyer, 1990).

The creation of a cadre of community clinicianteachers will substantially change the role of full-time medical school and residency program faculty.While they will remain committed to the directteaching of medical students and residents, propor-tionately greater amounts of time and effort arelikely to be required for program design, evaluation,management, and development. Traditional facultymembers based at the AHCs and residency trainingprograms are likely to require more sophisticatedskills in the design, management and evaluation ofeducational programs, as well as in leadership, com-munication and other attributes in order to lead in-creasingly complex educational systems. The cri-teria for academic promotion for such facultyshould reflect achievements and scholarship appro-priate to these responsibilities. More sophisticatedand reliable measures of “service” as well as edu-cational aspects of the faculty role will be neededin order to ensure that those faculty members whodevote their careers to education are not disadvan-taged in academic promotion and incentive pay-ment/ reward systems.

In addition to physician faculty, medical schoolsand residency programs need to consider appropri-ate roles for professionals from educational back-grounds and the enhanced personnel and organiza-tional systems required to support a network ofcommunity-based faculty integrated with thosebased at traditional sites. To assure that educationalstandards are met, evaluation criteria are consis-tently applied, and teaching performance is con-tinuously evaluated and rewarded in complex suc-cessful systems will require moving beyond thetraditional reliance on one or two dedicated fac-ulty members and a course secretary.

Recommendations:

• Medical schools and residency trainingprograms should recruit and supportcommunity clinician teachers. Facultymembers at community teaching sitesshould be selected for the quality of theirmedical practice and the excellence oftheir teaching. They should be paid andotherwise rewarded for their educationalactivities. Teaching institutions should

develop mechanisms to involve commu-nity faculty in the design and operationof educational programs.

• Medical school and residency facultyshould complement their skills as teach-ers of students and residents with compe-tencies in faculty development and themanagement of educational programs inthe community.

• Residency training programs should takethe lead in the development of rigorouspractice-based models of graduate medi-cal education in which individual or lim-ited numbers of residents are assigned tophysicians in community teaching prac-tices.

IVIVIVIVIV..... REVISING THE CURRICULREVISING THE CURRICULREVISING THE CURRICULREVISING THE CURRICULREVISING THE CURRICULUMUMUMUMUMCONTENT AND LEARNINGCONTENT AND LEARNINGCONTENT AND LEARNINGCONTENT AND LEARNINGCONTENT AND LEARNINGPROCESSPROCESSPROCESSPROCESSPROCESS

FINDING 4: The transformation of the healthcare environment created by changing de-mographics, mechanisms of health care fi-nancing, and a focus on prevention andwellness, has a profound effect on the prac-tice of medicine. Reflecting these changesin educational programs that prepare medi-cal students and residents for their futureroles requires innovative strategies and newresources.

The transformation of health care has createdopportunities and challenges for medical educators(Cohen, 1995). Recent changes in medical prac-tice have stimulated the introduction of new topicsand the expansion of existing components in thecurriculum, particularly in areas such as ethics,evidence-based medicine, cost-effectiveness, nutri-tion, wellness and disease prevention. The chang-ing demographics of the population have also cre-ated a need for a greater level of cross-culturalawareness among the graduates of residency train-ing programs. Fundamental understandings of theobjectives of residency preparation (STFM TaskForce on training residents for the future, 1986/Burke, Baron, Lemon et al, 1994/ Noble, Bithoney,MacDonald et al, 1994) have been revisited andupdated due to the extent and pace of recentchanges, particularly the impact of managed care.

The content that should be added to the cur-riculum of medical schools and graduate trainingprograms because of managed care is summarizedin the nine domains found on page 7 of this report.


They incorporate most of the topics and skills to befound in other managed care curriculum descrip-tions. Differences between recommendations forcurricula may reflect problems in the scope anddefinition of terms as well as controversies over therelative priorities of topics. For example, “the prac-tice of evidence-based medicine and population-based medicine” (Greenlick, 1992) are frequentlyrecommended for addition to the curriculum butcould be implied from the nine domains listed.Similar statements could be made concerning “thepractice of cost effective health care, the applica-tion of principles of community medicine and pub-lic health to medical practice, and an understand-ing of the system in which health care is delivered.”Precise definitions of terms, and uncertaintyconcerning appropriate learning strategies are par-ticular issues for other recommended topics suchas “teamwork skills,” “quality measurement,” and“patient advocacy.” The nine domains previouslylisted provide a reasonable basis for comprehen-sive preparation for modern practice. Although thechanging practice of medicine requires that educa-tors continually adapt the specific content of train-ing programs, the concepts encompassed by thesenine domains are likely to endure and becomeincreasingly pervasive in medical education andpractice.

Curricular components that address these do-mains have been introduced in many training pro-grams. While some educators advocate integrationof the new material into standard curricular designsand others have called for dramatic changes inmedical education, the involvement of communitysites features in almost all proposals for the educa-tion of future physicians.

The development of community teaching sitesoffers opportunities to present curricular materialin “real world” settings using a range of formats.Besides organizational complexity, the greatestconcerns have been those of quality and consis-tency. In particular, the extension of teaching intothe community setting requires creative approachesto deliver curricula to residents who are dispersedamong multiple community sites. Distance learn-ing technology offers a potential solution (Spann,1998/ Lewis, Bredfeldt, Strode, D’Arezzo, 1998).Medical schools and residency training programsare exploiting the Internet and other technologiesfor communication and educational purposes. Inaddition to administrative functions (such as post-ing schedules or routine communication) many usetechnology to conduct learning sessions, providelearners with exercises and resources, or conductexaminations. Telemedicine can be used in clinicalas well as didactic instruction (Crump, Pfeil, 1995/

Crump, Tesson, Montero, 1997). These uses of tech-nology in education, administration, and commu-nication are well-established at many teaching in-stitutions to support “on campus” activities andextension to community sites is increasing. A re-cent paper describes the application of a compre-hensive “intranet” system to enhance communica-tion, administration, education, and other aspectsof GME across multiple sites (Zucker, White, Fabri,Khonsari, 1998). The widespread use of technol-ogy will only fulfill its potential in education if allparticipants are comfortable with the necessarytechnology as well as proficient in its use. Supportservices have to accommodate “cultural” as wellas technological issues (Friedman, Corn, Krumreyet al, 1998).

Major changes in educational programs cannotbe recommended without establishing mechanismsto monitor effectiveness and ensure consistent qual-ity over place and time (Tallia, Micek-Galinat,Formica, 1996). As mentioned in previous sections,the teaching and testing of knowledge and skills ofresidents medicine has undergone enormous changein the last decade (Gray,1996). In addition to ad-vances in educational psychometrics (particularlythe more effective use of examination formats), theuse of standardized patients to simulate patient en-counters and multiple-station skills tests, representsignificant advances in the teaching and testing ofclinical competencies. Several medical schools haveparticipated in consortia to develop standardizedpatient training programs, and to share scripts andother materials. Rating scales and scoring systemshave been developed, tested and validated to theextent that the National Board of Medical Examin-ers is planning to adopt this methodology, whichhas already been used in licensing in Canada(Reznick, Blackmore, Dauphinee et al, 1996). TheCanadian and other studies demonstrate conclu-sively that it can be used effectively for teachingand/or testing at multiple sites. It is, therefore, apowerful addition to the ability to standardize teach-ing and evaluation at community sites.

Distance learning technology, standardized pa-tients, clinical skills testing techniques and othereducational advances are changing the way in whichstudents and residents are educated and evaluated.These methodologies have the potential to revolu-tionize medical education since they offer the op-portunity for students to learn and test at their ownpace and in locations that more closely meet theireducational needs. They offer the ability to createa curriculum that is “portable” and adaptable to theindividual student and the unique educational en-vironment; but one whose quality is monitoredclosely by program faculty, and whose outcome is


validated by the achievement of defined competen-cies. When integrated with appropriate faculty de-velopment, distance learning technology and stand-ardized skills testing techniques permit facultymembers to teach and evaluate learners as neverbefore. The improvements in quality and consis-tency over time and place and between instructors,enable community teaching to be regarded as a trueextension of, and complementary to, the programsoffered at the teaching hospital. The unique learn-ing opportunities of community sites can be inte-grated into the curriculum without jeopardizingeducational quality.

Many medical schools and residency programshave already responded to calls for change in theeducation of students and residents. New topics andtechniques have been introduced but few, if any,programs have taken a comprehensive approach.Constrained resources have been a factor. Indeed,many of the curriculum changes in medical educa-tion have been initiated through grants and con-tracts from Federal agencies and private foundationssuch as the Robert Wood Johnson Foundation, thePew Charitable Trusts, the Kellogg Foundation, theMacy Foundation and the Culpepper Foundation.Examples include the Robert Wood Johnson “Gen-eralist Initiative,” the Bureau of Health Professionsadministration of Title VII programs (Politzer,1997), and the “Interdisciplinary Generalist Clerk-ship” project (Wartman, Davis, Wilson et al, 1998).Without the availability of resources such as these,much less might have been accomplished.

In spite of these initiatives and changes, sev-eral recent reports have pointed out the discrepancybetween the education of physicians and the knowl-edge, skills and attitudes required for successfulpractice (Finocchio, Bailiff, Grant, O’Neil, 1995).Graduates of residency training programs in theU.S. have been critical of their preparation for medi-cal practice in the community, particularly in areassuch as practice management, and the care of spe-cific chronic conditions in community settings(Cantor, Baker, Huges, 1993). The health care in-dustry has been equally critical of medical educa-tion (Gumbiner/Gold, 1996). Managed care orga-nizations have identified shortcomings amongnewly-hired physicians, particularly in communi-cation skills and the practice of cost-effective medi-cine. They advocate a much greater emphasis onprimary care in the education of all physicians andare critical of the high proportion of graduates whoselect subspecialist careers.

As stated above, proposals for topics to be in-cluded in a curriculum which appropriately preparesgraduates for managed care practice have been pub-lished. Much less has been published concerning

how these topics should be integrated into the cur-ricula of medical schools and residency trainingprograms. Some of the elements of a managed carecurriculum may already be present in the offeringsof many medical schools and residency trainingprograms. In such cases, coordination and integra-tion of existing components are required to appro-priately prepare graduates for practice. It is likely,however, that many institutions require extensivecurriculum revision (of both content and format)in order to enable their graduates to achieve thecompetencies identified as essential for practice incontemporary and future environments. Again, thisreport emphasizes the need for access to a compre-hensive range of traditional and non-traditional sitesfor medical education and the integration of didac-tic and practical experience in order to prepare acompetent physician. Medical school and residencytraining program faculties should evaluate and re-vise current curricula to ensure that these topics areintroduced at the appropriate time in the educationof medical students and residents, and that they aregiven emphasis and reinforcement throughout theprogram. Many aspects of these domains can bestbe learned in non-AHC settings. Indeed, some top-ics can only be effectively taught and role-mod-eled in community practices or specific sites suchas public health agencies or the administrative of-fices of health care delivery systems. As previouslystated, a comprehensive medical education increas-ingly requires experience in a range of non-tradi-tional learning environments. Some of these sitesmay not directly provide patient care and examplesalready exist of student and residency rotations inadministrative offices of managed care organiza-tions or public health officers.

It is anticipated that institutions will continueto develop different strategies to fulfill their man-dates to appropriately educate physicians for fu-ture practice. The evolving significance of commu-nity sites is such a consistent and powerful themethat all educational models are expected to incor-porate community experiences and in some insti-tutions, such experiences could account for substan-tial portions of the curriculum. The expanded roleof community-based education is likely to enhanceother developments such as electronic and othernon-traditional teaching methods, competency-based curricula, and standardization of testing andevaluation. The patient populations and clinicalexperiences provided by community sites are alsolikely to further accelerate changes in curricularcontent towards those domains identified as cru-cial to future practice environments. Within thesedomains, communication skills (Section V.) andunderstanding of health care delivery systems (Sec-tion I.) are perceived to be of particular significance.


Recommendations:

• Medical schools and residency trainingprograms should fundamentally revise thepreparation of their graduates to reflectthe changing practice environment whilesustaining the quality of current teachingprograms. They should emphasize disci-plines that are basic to contemporarymedical practice such as epidemiologyand population-based care, health carepolicy and systems, disease prevention andwellness, and computer information skills.

• Educational programs must prepare phy-sicians in ethical decision-making and ad-vanced communication skills, includingpatient advocacy, conflict resolution, andteamwork to effectively serve patients inthe new health care systems.

• Medical schools and residency trainingprograms should accelerate the incorpo-ration of advanced educational conceptsand techniques such as distance learning,standardized patients, and psychometricsin order to enhance the quality and con-sistency of educational programs.

VVVVV..... REINFORCINGREINFORCINGREINFORCINGREINFORCINGREINFORCINGCOMMUNICCOMMUNICCOMMUNICCOMMUNICCOMMUNICAAAAATION SKILLTION SKILLTION SKILLTION SKILLTION SKILLSSSSS

FINDING 5. An increasingly diverse patientpopulation and a changing health care envi-ronment magnify the need for effective com-munication by physicians.

Communication is a crucial factor in modernmedical practice. In emerging health systems, threeareas of enhanced importance have been identifiedi.e. clinician-patient, clinician-clinician, and clini-cian-community (Tresolini, Pew-Fetzer Task Force,1994) and the complexity of each area developed(Inui, 1996).

Communication with patients involves muchmore than taking a medical history or conducting aclinical interview. It concerns communicating anunderstanding of lifestyle, health and illness withthe patient and others and the integration of socio-cultural factors into practice (Bolman, 1995). Ef-fective communication not only enhances accuracyof diagnosis and treatment but also builds produc-tive therapeutic relationships, encourages patientcompliance and self-care, and enhances patient sat-isfaction with the physician (Kaplan, Siegel, Madill,Epstein, 1997/Marvel, Doherty, Weiner, 1998). Inparticular, residents must be skilled in many aspects

of communication in order to effectively serve pa-tients of diverse cultural and ethnic backgrounds.Effective clinical communication with such patientsgoes far beyond language comprehension (STFMTask Force, 1986/ Lurie, Yergan, 1990). Curriculahave been developed to assist programs to ensurethat all residents master the general principles ofcommunication and cultural competency (Like,Steiner, Rubel, 1996). Mastery of general principlesis stressed as the increasingly diverse U.S. popula-tion makes it unlikely that any one physician willdevelop true cultural competence for all of the pa-tients he/she encounters (Zweifler, Gonzalez, 1998).The study of literature in medical education has alsobeen advocated as a powerful means to enhancecultural competency and improve communicationskills (Hunter, Charon, Coulehan, 1995).

Most understandings of physician-patient com-munication are based on physicians controllingmedical knowledge and dominating therapeuticdecisions. A recent development concerns commu-nication with patients who are increasingly sophis-ticated “consumers” of health care and may haveunparalleled access to medical information throughelectronic systems. The dangers of indiscriminatehealth information and recommendations, particu-larly on the World Wide Web are well recognized(Silberg, Llundberg, Musacchio, 1997) and recom-mendations have been made on using “informationtherapy” as a positive force in patient care (Bader,Braude, 1998). At a minimum, residents shouldknow if their patients’ usual sources of informationand influence include electronic systems.

As medical practice is increasingly based onteamwork between individuals trained in differenthealth professions as well as between physiciansin different specialties, unambiguous and appropri-ate communication between colleagues is also as-suming greater significance. In this area, too, elec-tronic systems are beginning to be used in what wasexclusively a verbal or written system with its ownconventions (Bergus, Sinift, Randall, Rosenthall,1998). Aspects of communication between col-leagues include the understanding of team dynam-ics, and the facilitation of contributions by othersas well as the articulate presentation of individualcontributions (Inui, 1996). Certain systems of healthcare may place particular strains on specific rela-tionships such as the consultation/referral relation-ship between generalist and subspecialist physi-cians, and the relationship between the physicianproviding direct patient care and one with respon-sibility for utilization review. The physician’s roleas a patient advocate adds a further dimension tocommunication skills. Effective interaction with themedical director of a managed care organization, a


hospital administrator, or with a community healthcare agency, requires skills that are rarely addressedin the educational process. Advocacy and conflictresolution become critical skills (Noble, Bethany,Macdonald et al, 1994) and, in parallel with them,medical ethics and resource allocation assume muchmore important roles.

Enhanced clinician-community interaction isvalued by integrated health systems both to pro-mote the concept of a member or patient commu-nity as defined by membership of the organization,and to affect major community health issues (Inui,1996/Greenlick, 1992). The study of wellness andpreventive medicine, population-based medicine,and community health advocated by many propo-nents of curriculum change imply an enhanced rolein the future for physicians as educators of the com-munities and populations that they serve. If thisresponsibility is to be effectively carried out, addi-tional skills will be required to communicate tolarge groups, including effective use of television,radio and other communication media. Physicianswill also need to acquire the ability to interact ef-fectively in a leadership role with health care ad-ministrators, politicians, and other community lead-ers.

Preparation of residents in communication mustincorporate the use of multiple formats, technolo-gies, and media. As already mentioned, communi-cation in the era of the computer takes on new di-mensions. The use of electronic communication hasbecome a standard in many institutions among phy-sicians in practice in the community. Some patientsalready use this method to communicate with theirphysicians, and physicians are using it to commu-nicate with colleagues, health plans and hospitals.The legal and ethical implications of this revolu-tion, particularly regarding confidentiality, remainproblematic. Another feature of communication isaccess to professional information. Most hospitalmedical libraries and many physician offices nowhave access to the medical literature searching ca-pabilities of the World Wide Web. The use of thistechnology is expanding exponentially as both phy-sicians and their patients grow to understand thepower of immediate availability of almost unlim-ited information. Many medical schools have in-troduced courses on medical informatics and otheraspects of the technological revolution in commu-nications. Equally important, but not always linkedto such courses, is the growing curricular interestin Evidence Based Medicine (EBM). Most EBMcourses stress the evaluation of medical informa-tion and provide practical assistance in distillingrelevant and useful clinical information from theoverwhelming volume of medical literature. With-

out a grounding in EBM, residents are poorly pre-pared to evaluate new and existing information orto understand and use clinical pathways, guidelines,or recommendations for patient care.

Another critical aspect of communication for-mats concerns clinical documentation. Experimen-tation with the electronic medical record is con-tinuing in many locations. The prospect of a medicalrecord that could be almost instantly available atany location is no longer a figment of the imagina-tion. Within a few years, this technological advancewill be in widespread use, and will raise issues suchas confidentiality to new levels.

In all dimensions, verbal and written commu-nication will continue to be essential skills forphysicians. Comments from the health care indus-try, and from the human resources departments ofcompanies purchasing health care plans for theiremployees indicate that poor physician/patientcommunication skills are one of the most trouble-some and recurring problems that they face today(Gumbiner, 1994). The Medical School ObjectivesProject (AAMC/MSOP Report I, 1998) drew atten-tion to multiple aspects of communication as es-sential competencies for graduating physicians andprepared a detailed monograph on medicalinformatics and aspects of community responsibili-ties (AAMC/MSOP Report II, 1998). In recent yearsthere have been renewed efforts in the teaching,refinement and evaluation of communication skills(MSOP, 1998/Kaplan, 1997) and standardized pa-tients are frequently used for both teaching and as-sessment of skills. Communication and related top-ics have been prominent in recent reforms ofpreclinical education (Curry, Makoul, 1998) but lesshas been published concerning their integration intosubsequent training, or the retention/influence ofsuch preclinical courses on residents’ behaviors.Good progress has been made but much remains tobe accomplished. The continuing complaints ofconsumers of health care are difficult to ignore andare likely to increase as changing population de-mographics bring physicians into contact with in-creasingly diverse patient populations.

Progress in the teaching of communicationskills is an encouraging trend. However, such in-struction frequently ends as medical students be-gin their first intensive clinical experiences and isrevisited infrequently, if at all, during the remain-der of medical school and residency training. Con-tinuous reinforcement of communication skills, inevery current and future modality, is neededthroughout all four years of medical school, for theduration of residency training and into the settingof medical practice. The most advanced evidence


of commitment to communications skills as inte-gral to the practice of quality medicine would in-volve the establishment of competency-based cur-ricula with rigorous testing mechanisms to verifymastery of specified skills.

Recommendations:

• Instruction in and assessment of commu-nication skills, particularly related to themedical history, should be strengthenedand expanded to ensure an emphasisequal to other major courses and topics.

• The development and augmentation ofcommunication skills with patients, in-cluding those from differing culturalbackgrounds, and with colleagues, admin-istrators, and others should be continuedthroughout medical school and residencytraining.

• Physicians should be prepared in a broadrange of communications skills appropri-ate for use with individuals and groupsand utilizing a diversity of media. An em-phasis should be provided on continuallyupdating skills to adapt to rapidly-evolv-ing circumstances and technology.

VI.VI.VI.VI.VI. ASSURING QUASSURING QUASSURING QUASSURING QUASSURING QUALITY ANDALITY ANDALITY ANDALITY ANDALITY ANDAAAAACCOUNTCCOUNTCCOUNTCCOUNTCCOUNTABILITY IN PHYSICIANABILITY IN PHYSICIANABILITY IN PHYSICIANABILITY IN PHYSICIANABILITY IN PHYSICIANEDUCEDUCEDUCEDUCEDUCAAAAATIONTIONTIONTIONTION

FINDING 6: The assurance of consistent qual-ity in medical education will become increas-ingly critical as clinical teaching outside thetraditional hospital setting expands and asteaching strategies become more diverse.Methods designed to assess performanceevaluation at multiple sites and assure thelongitudinal development of knowledge,skills, and attitudes are becoming increas-ingly important.

The necessity of achieving and sustaining thehighest standards of physician education is the ba-sis of this report and underlies each recommenda-tion. The nature of medical education requires thatquality must not only be achieved but that its im-mediate and long-term impacts must be documentedand demonstrated to various constituencies, bothinternally and outside traditional medical educa-tion circles. Establishing education in non-tradi-tional settings results in particular pressures to dem-onstrate both quality and credibility. As early as1986, the AAMC concluded that continued societalsupport for medical education depends on systems

which fulfill society’s expectations in the produc-tion of skilled and qualified physicians and pro-vide evidence that this is the case. Specifically, thereport (AAMC 1986) notes:

• The medical education community shouldcontinue to monitor the quality of its resi-dency training and provide assurances thatgraduates of its residency programs areadequately prepared for practice.

• The institutions receiving funding shouldrecognize their obligations to train the typesof physicians needed by society.

• These institutions also must recognize theirobligation to operate the training programsin a cost-effective manner.

In recent years, the documentation of abilities,frequently in terms of demonstrable competenciesin specific skills and mastery of cognitive knowl-edge, has become pervasive in medical practice.Examples include requirements to regularly re-es-tablish specialty status (“re-certification”),credentialing processes mandated by various orga-nizations, and the extensive review systems im-posed to grant staff privileges by hospitals andmedical centers. Clearly physicians face increas-ing requirements to achieve and document specificattributes of their knowledge and clinical practices.Medical schools and residency programs must pre-pare learners for the expanding role of evaluationand accountability in the practice of medicine. In-corporating such systems in the clinical and edu-cational programs of medical schools and residencyprograms has both intrinsic and educational value.

Medical educators have to demonstrate thequality of their outcomes to at least three constitu-encies i.e. the learners, the sponsoring institution,and society at large. Medical learners should beconfident that what they are taught will providethem the knowledge, skills, and other resources tomeet their current and future responsibilities andaspirations. Faculty and institutions require continu-ous evaluative data to monitor and improve all as-pects of programs, including their value in termsof educational gain for resources invested. Mem-bers of society at large are entitled to evidence thatthe educational programs they are supporting willappropriately prepare physicians for the needs ofthe community. The various constituencies havediffering informational needs. As educational pro-grams become more diverse and community set-tings more extensively utilized, the process of evalu-ation becomes increasingly complex (Glassick,Huber, Maeroff, 1997).

Conventional evaluation systems resemble theclassical clinical method that proceeds in a logical


sequence to select the most probable diagnosis oreffective course of action from data and continu-ally re-evaluates findings in order to make the op-timal decisions. In these apparently linear and logi-cal systems, it is relatively easy to establishbenchmarks for education and establish processesfor evaluation of learning. The environment of mod-ern medicine, however, is moving at a rapid pace,opening new and sometimes unpredicted variationsof the classical model. To exploit the environmentfully, future physicians must develop life-longlearning skills and have a high tolerance for changeand ambiguity (Hunter, Charon, Coulehan, 1995/Bundner, 1962). Physicians must be prepared formuch less predictable models of practice. Estab-lishing benchmarks for quality in these new prac-tice environments is challenging and controversial.In turn, strategies to evaluate educational programsmust address the complexities that are encounteredin a wide variety of practice models. Even if thetechnical issues of developing appropriate learn-ing benchmarks and process of educational evalu-ation can be resolved, problems of objectivity re-main. In the new educational models the traditionalteacher-student relationship becomes more of anapprenticeship experience, thus potentially compro-mising objectivity in evaluation by both learner andinstructor.

In newer systems of medical education, multi-modal approaches are needed to demonstrateprogress toward mastery of appropriate competen-cies. While some academic centers could modifyexisting strong assessment programs to meet newchallenges in acquiring and reporting performanceevidence, other centers need to develop entirely newsystems. All teaching institutions require continu-

ous evaluation systems capable of operating in com-plex, changing situations to ensure that learners arereceiving the optimal educational experience andthat this experience is of consistent quality acrosstime and location. Several examples exist, particu-larly in predoctoral education, of institutions withrobust educational objectives and/or specific com-petency statements that form the basis for the de-velopment of educational programs, allow for docu-mentation of learning experiences, and provideguidance in the development of outcome indica-tors. Of particular importance to residency educa-tion is the selection of integrated evaluation sys-tems based on educational goals that reflect thecompetencies required in the new practice environ-ments and the on-going refinement of educationalprograms to ensure that education remains focusedand relevant

One such integrated approach, the ShewhartCycle, incorporates four critical components i.e.plan, do, check, and act (see figure 1) into an evalu-ation-improvement feedback system. The first com-ponent, developing the “plan”, concerns the iden-tification of the problem, appropriate audiences,optimal outcome indicators and initial strategy. Theimplementation phase (“do”) refers to the perform-ance of the selected strategy. “Check” involves thecomparison of the achieved and expected outcomeswith a strong emphasis on identifying areas for pro-gram improvement. The fourth step (“act”) refersto incorporation of improvements to raise the stand-ards of the entire process. Although often illustratedas a static cycle, the process is best conceptualized asa spiral with each stage driven by commitment to learn-ing from experience in order to achieve a truly con-tinuous system of improvement. The similarities

FIGURE 1Similarities Between Three Integrated Evaluation Systems

PLAN

ACT

DO

CHECK

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SHEWHART CYCLE COMPETENCY-BASEDEDUCATIONAL SYSTEM

EDUCATIONALOBJECTIVES

▼▼▼▼▼

EDUCATIONALPROGRAM(PROCESS)

COMPETENCIES(OUTCOMES)

▲▲▲▲ ▲

TESTING(EVALUATION)

▲▲ ▲▲▲

▲▲▲▲▲

CLASSICAL APPROACH TOPATIENT CARE

DATA(H&P, lab, etc.)

▼▼▼▼▼

OPTIMALMANAGEMENT

PROBABLEDIAGNOSIS

▲▲▲▲ ▲

TESTING(EVALUATION)

▲▲ ▲▲▲

▲▲▲▲▲


between the Shewhart Cycle, the classical approachto patient care, and the competency-based educa-tional system are illustrated in Figure 1.

From the learner’s perspective, testing (“check”or “evaluation”) provides verification that compe-tencies are met, insights as to how educational ob-jectives could be re-formulated to achieve higherlevels of performance, and (in the case of a dis-crepancy between expected outcomes and thoseachieved) guidance as to remediation. For the edu-cator, the approach enlightens each stage of theprocess:

– do the specific objectives collectively achievethe program goals?

– what competencies/outcomes most effec-tively assess attainment of objectives?

– which programs/processes most effectivelyand efficiently achieve objectives?

– is the evaluation valid, repeatable, efficient?

– what does the evaluation reveal about poten-tial improvement of the system?

Evaluation methods are needed that benefitlearners and educators directly (and other constitu-encies indirectly) by providing data-driven valida-tion and guidance for improvement. For learners,validation reports can potentially be used both im-mediately and on graduation as evidence for

credentialing. Learners can also use the system toidentify areas of weakness, plan more effectivestudy programs, and improve selection ofcoursework. For educators, the data validating pro-gram quality can be invaluable in both internal andexternal program review and accreditation. The in-creasingly precise documentation of potential forprogram improvement can also be used to articu-late the need for resources and plan logical pro-gram development.

Clearly, no single approach to the assurance ofeducational quality can be used across all programsfor all purposes. Successful models are character-ized by well-defined intentional outcomes, struc-tured unambiguous data collection processes,means for identifying discrepancies between cur-rent and intended status, and feedback loop sys-tems. As the educational program moves into thecommunity and the experience is re-defined to takeadvantage of the local environment, the complexi-ties of measurement within the educational processbecome apparent. Collection of progress and proc-ess data should be unambiguous and equivalent atdifferent sites. Data gathered in one site should beable to be interpreted in the same manner as datagathered from another site. It should be possible tocombine data from several sites with confidencethat such compilations will accurately portray sys-tem-wide perspectives. Systems should be designedto identify and assess discrepancies between cur-rent and intended status as a prerequisite to identi-fying barriers to success. Finally, intentional feed-back loops should be in place to ensure the constantflow of information needed to continuously improvethe system. In fulfilling all these criteria for effec-tiveness, the system must also be efficient. Over-zealous collection of low-utility data results in sys-tems that are too costly and complex to be usefuland threatens credibility.

A variety of models for the specification oflearning objectives exist (Katz, Fulop, 1978/ Patel,Evans, Groen, 1989/ Lipkin, 1989/ Price, Mitchell,1993). Choice of the outcome indicator(s) is highlydependent on the context and the evaluator. Forexample, the educational objective “The learner willconduct an appropriate initial medical history”could be assessed by several different parameters,as noted in Table 1.

Those approaches that are ultimately the mosteffective are characterized by:

– excellence in selection of objectives and out-come measures

– systems that enable continuous interplay be-tween all components of the cycle

– unambiguous focus on quality improvement

TABLE 1Sample of Context & Evaluator Effect

Upon Outcome Indicators

Educational Objective: “The learner will conduct anappropriate initial medical history.”

Potential Outcome Indicators

Are all components of an appropriatehistory included and recorded in asystematic fashion?

Does the physician ask me all thequestions I believe are important tounderstand my condition?

Based upon the billing sheet, are theappropriate components of the medicalhistory appropriately recorded?

Can the subsequent diagnosis andtreatment plan be supported by themedical history?

Context/evaluator

Faculty assessing a juniormedical student

Patient responding to asatisfaction survey

Faculty evaluating a resident

Billing Agent/payer


Voytovich, Rippey, and Mathews (1986) furtherelaborated the above criteria for effective educa-tional evaluative/development systems as:

– Clearly defined objectives delineate the con-tent of the curriculum and provide theframework for specification of the learningexperiences;

– Public statements of objectives permit bothteachers and learners to understand andagree upon the intent of the curriculum;

– Evaluation methods can be directly linkedto the objectives to be attained;

– Information from evaluation efforts are pro-vided to both teachers and learners in a

timely enough fashion and sufficient detailto allow for improvement in subsequent per-formance; and

– Unambiguous data are used as the basis foralterations of the curriculum should therebe shown to be failures across various learn-ers or sites.

A variety of evaluation strategies are availableto assess the educational process and its variouscomponents. The multiple models generally fall intotwo major groups (Scriven, 1967). The Formativemode is designed for on-going processes that haveas their explicit intent to identify and effect change.The Summative mode is undertaken at the conclu-sion of a process and is used to determine if thespecific objectives and/or standards have beenachieved. The emphasis on feedback even in thevalidating summative models makes them oppor-tunities for learning and growth of the curriculum.The selection of an individual strategy may be in-fluenced by many factors including the environ-ment, stage of evolution of the curriculum, degreeof precision required, or availability of resources.Although increasing emphasis is being placed onobjective and scientifically-measurable evaluationtechniques, the nature of medicine will continue torequire some role for subjective evaluations. Evenin the traditionally “subjective” areas such as feed-back from students, peers, patients, and others, in-sights from education and other disciplines are lead-ing to greater quantification, reliability andreproducibility of data. Examples of educationalcomponents and possible assessment strategies areillustrated in Table 2 (Glaser, 1963).

Evaluation is an essential and rapidly-develop-ing component of medical education. Systematicscientific evaluation is fundamental to the changesadvocated in order to prepare physicians for cur-rent and future practice environments. Much hasbeen achieved, particularly in the adaptation tomedical education of concepts and practices frombusiness and education. Overall, however, the evo-lution of appropriate systems has been fragmen-tary and dependent on the dedication of individu-als and a few institutions. To achieve the scope ofchange in medical education recommended by theCouncil, a greater, more pervasive, and more sys-tematic national effort to achieve quality and ac-countability in all aspects of medical education isnecessary.

Recommendations:

• Medical educators should continuously as-sess both short-term and longitudinal out-comes in the learner, the teacher, and theprogram.

TABLE 2Examples of Educational Components and

Possible Assessment Strategies

Potential AssesmentsEducational Component

Direct observation with patients–by faculty–by trained observers

History taking, physical examskills, interpersonal skills, verbalability, technical facility

Structured record auditsProblem formulation, diagnosticreasoning

Indirect observation using preparedalgorithms

Diagnostic and therapeutic strat-egies

Review of patient charts, pharmacyand laboratory reports

Test ordering, prescribing pat-terns, cost effectiveness

Conferences, rounds, journal clubsInformation-seeking

Traditional testing strategiesBasic medical knowledge

Oral review of charts, reports fromfaculty and peers, patient manage-ment problems

General judgment in care

Standardized patients, review of pa-tient charts

Patient management

Standardized patients, evaluation byteachers

Technical abilities

Patient logsRange of experience

Feedback from staff, patients, fac-ulty; attitude measures

Personal characteristics


• Assessment techniques must be selected toprovide reliable and valid measurementof educational outcomes across a varietyof teaching environments.

• Academic health centers, educational pro-grams, and accrediting agencies shouldcontinue to develop monitoring and as-sessment approaches that meet the needsof different constituencies.

VII.VII.VII.VII.VII. FINANCING THE EVFINANCING THE EVFINANCING THE EVFINANCING THE EVFINANCING THE EVOLOLOLOLOLUTIONUTIONUTIONUTIONUTIONOF GRADUOF GRADUOF GRADUOF GRADUOF GRADUAAAAATE MEDICTE MEDICTE MEDICTE MEDICTE MEDICALALALALALEDUCEDUCEDUCEDUCEDUCAAAAATIONTIONTIONTIONTION

FINDING 7: The system of funding graduatemedical education through teaching hospi-tals has inherent limitations and disincen-tives that inhibit the development of ambu-latory experiences and community-basededucational programs. There is still no con-sensus on how to appropriately fund andexpand the curriculum to reach into commu-nity settings.

The financing of graduate medical educationis complex and poorly understood. Studies havereported little consensus on the costs and other fi-nancial aspects of graduate medical education(Burg, Kelley, Zervanos, 1994). New models ofgraduate medical education, especially the substan-tial shifting of the locus of teaching to the commu-nity, further complicate this situation. Many authorshave reported on the cost of education in the ambu-latory setting, particularly for medial students. Asdiscussed earlier in this report, studies emphasizethe time commitment of medical school and com-munity faculty, and loss or gain in clinical produc-tivity at the training site (Jones, Korn, 1997/Goodwin, Gleason, Kontos, 1997/Rein, Randolph,Short et al, 1997/Franzini, Low, Proll, 1997) butassumptions drawn from the undergraduate expe-rience may not be valid for residents. In particular,residents generate clinical income and may be val-ued by the community site as potential physicianrecruits (Adams, Eisenberg, 1997/Jones, Culpepper,Shea, 1995). An expert panel has recently proposeda general cost model for education in ambulatorysettings as a basis for informed national debate(Boex, Blacklow, Boll et al, 1998).

While the funding of the educational missionis highly specific to each school or residency pro-gram, certain generalizations can be made. State-supported medical schools receive a variable pro-portion of their revenues from their respectivelegislatures, usually in the form of faculty salary

support for the educational enterprise. Private medi-cal schools are relatively more dependent on re-search grants and contracts, tuition, gifts, and en-dowments for the support of their medical studentprograms. Both public and private schools gener-ate about one third of total revenues from practiceplans (Jones, Ganem, Williams, Krakower, 1998).

GME is currently supported in substantial pro-portion by Medicare. Medicare funding is paid inthe form of a direct capitation to teaching hospitalsfor each resident (Direct Medical Education sup-port or DME), and through a percentage added topatient care payments to teaching hospitals (Indi-rect Medical Education support or IME). The im-plications of recent and proposed changes in thefunding of GME on the numbers and types of resi-dents and their educational process is unclear.

It is currently difficult to foresee any substan-tial new funding for medical education from tradi-tional sources. The role of Federal government inGME is currently being reviewed. Medical schooland residency program faculty are overextended intheir current roles as they struggle to maintain teach-ing, research and clinical activities. Tuition ac-counts for only 3% of revenues for public schoolsand 5% for private institutions (Jones, Ganem,Williams, Yrakower, 1998), yet progressive in-creases in tuition fees at State-supported and privatemedical schools are becoming increasingly burden-some for students (Chhabra, 1996). Over 80% ofthe 1997 graduating class had educational debts—the highest percentage in eight years. The rate ofincrease of debt of medical students is increasingat alarming rates, particularly the growing propor-tion of graduating students carrying more than$100,000 in educational debts (Garrard, 1998). Themean debt for 1997 graduates of public medicalschools was $69,000 compared to over $97,000 forgraduates of private schools (Beran, Lawson, 1998).

COGME believes that neither faculty nor learn-ers can be imposed upon for further increases intheir financial contribution to medical education.As new systems of funding graduate medical edu-cation are developed, they must be based on effec-tive partnerships involving the health insurance in-dustry, organizations representing medicaleducation, and State and Federal government agen-cies (Pew Commission Federal Policy Task Force,1998/Fogelman, Goode, Behrens et al, 1996,AAMC and COGME consortia reports).

A major difficulty in designing new financialmodels for medical education is the lack of reli-able, specific financial data on the current system.Without baseline data concerning costs and value,it is difficult to estimate the financial implications


of proposed changes in medical education or todraw conclusions about their value to institutionsand, more important, to the public.

The nature of medical education makes the de-velopment of discrete educational budgets ex-tremely difficult. Learning by immersion in clini-cal activities and quasi-apprenticeship with rolemodels are core values, but they are also carriedout together with other activities, as “joint prod-ucts” which are the ones actually being supportedfinancially. Many faculty members contribute to theteaching of residents and medical students with nodirect remuneration from a teaching budget. Re-search faculty, who are often funded entirely fromtheir research budgets, may also participate in teach-ing. Clinician faculty frequently teach both medi-cal students and residents in the course of provid-ing care to their own patients. Students and residentslearn in environments where multiple other activi-ties may be taking place simultaneously using asingle set of personnel and resources. For exampleclinical, educational, and research projects couldall be active in a clinic where patients were beingmonitored for the results of their treatment. Thesynergy between the three activities of teaching,research and patient care has been central to teach-ing institutions for almost a century. The currentemphasis on cost-consciousness exposes the cross-subsidies and threatens the ability to succeed in anysingle mission. The costs of each activity must bedisentangled (Pew Commission Federal PolicyTaskforce, 1998).

The value, as distinct from the cost, of GME tothe sponsoring academic medical center or otherteaching hospital should also be assessed. The pres-tige of an affiliation with a teaching program mayprovide a marketing advantage with patients andhealthcare plans. Other indirect benefits such as theability to attract a higher quality medical staff andthe creation of a more stimulating intellectual en-vironment may also accrue. While it will not be aneasy task, the development and testing of more so-phisticated fiscal models may assist in arriving atprogressively more accurate estimates of the costof medical education.

Medicare teaching funds have always been pro-vided on the basis that medical residents provideclinical service for which the sponsoring institu-tion should be reimbursed. Therefore, funds labeledas education have in fact been paid for an insepa-rable nexus of service and education. Because ofthe long-standing ambiguity on this point, this long-established principle is currently under serious re-view by the Medicare Payment Advisory Commis-sion, and the National Bipartisan Commission on

the Future of Medicare. The Pew Commission(1998) has recently drawn attention to another “pub-lic good”, that of uncompensated clinical care ren-dered by residents and faculty.

In the private sector, similar arguments are tak-ing place. Many managed care organizations per-ceive no obligation to pay for medical education,particularly in the current highly competitive envi-ronment. These organizations will have still lessincentive to contribute to medical education if aprojected excess of physicians becomes reality andgraduating physicians are perceived as poorly-pre-pared for managed care practice (Gold, 1996). Edu-cation is perceived as peripheral to theorganization’s mission and, in the corporate view,may be more appropriately supported through othersources.

In spite of the difficulties and complexities, dis-crete budgets for each activity are essential to moni-tor and manage the undertakings of teaching, pa-tient care and research. Without good financial datait is impossible to advocate for resources appropri-ate to any one of the trilogy or make meaningfulproposals to enhance the synergy between them.More meaningful systems of financial managementare crucial to achieve the levels of accountabilityand logical evolution of medical education advo-cated in this report.

Alternative or supplementary mechanisms offunding resident education have been proposed.Among these are strategies to uncouple the fund-ing of residency programs from teaching hospitalbudgets and channel it more directly to the trainingprogram. Under these circumstances, the educationprogram, with less dependence on the hospital forsupport, would have more flexibility to develop aprogram that more closely serves the educationalneeds of the residents. Perhaps more importantly,mechanisms might be developed to link funding tothe learning and demonstration of specific compe-tencies. Thus, program funding would be linked notto hospital service but to the attainment of compe-tencies in its graduates that prepare them for medi-cal practice. (COGME Resource Paper, 1997/COGME Sixth Report, 1995/ Pew,1998).

Preparation for the evolving medical practiceenvironment requires that residents have experi-ences in non-traditional sites, which could includecommunity health centers, health departments, phy-sician offices, free-standing surgical centers, andintegrated health systems. Educators should be freeto place resident learners wherever the higheststandards of medical care are practiced in their com-munities and the best learning environments existor can be developed.


Establishing and sustaining quality teachingprograms in community sites as advocated in thisreport requires resources. In the absence of newfunding, medical schools and residency trainingprograms will be faced with the necessity of redis-tributing their current budgets (Kassirer, 1996), anddispersing funds to clinician teachers in the com-munity. While this may create tension for adminis-trators and faculty alike, community clinicians andthe organizations for which they work are becom-ing increasingly resistant to assuming a greater rolein teaching without funding (Fogelman et al, 1996).Unquestionably paying clinical teachers in the com-munity does create additional cost for teaching in-stitutions, but it also imposes greater accountabil-ity on community faculty.

Regardless of the extent to which the principleof subsidizing medical education through clinicalrevenues will continue to be recognized, compe-tency-based educational goals will not be achiev-able without significant levels of accountabilitythroughout the system. COGME believes that teach-ing institutions should re-examine the financing oftheir education programs. They should attend to theurgent needs and recommendations set forth herewithout waiting for new sources of support to befound.

The GME system that finally emerges shouldrecognize the vital national interest of educatingthe country’s future physicians appropriately whiledistributing the costs to those, including patientsand the health care industry, who benefit most. Thesystem and its financing must be constructed toprovide value. The asset to society, health care or-ganizations, and individuals of well-prepared phy-sicians must represent excellent value for the re-sources invested through taxes, payments and otherforms of financing.

Recommendations:

• A stable, reliable source of funding forgraduate medical education is essential.While it is appropriate to assume that theFederal government through the Medi-care program will continue to supportgraduate medical education, COGME en-dorses efforts to ensure that all payers in-cluding the Federal government supportan equitable share of medical educationcosts.

• Medical schools, teaching hospitals andmajor stakeholders should prepare to fi-nance physician education programs thatincorporate the changes recommended inthis report. Most of the funds to support

these changes will require shifting exist-ing internal resources within the academicenterprise.

• Funding for residency programs mustprovide the flexibility to meet the educa-tional needs of residents. Program fund-ing should be structured to enable gradu-ates to attain the knowledge, skills,attitudes and values that will meet boththe profession’s goals and communityneeds.

• The value of graduate medical educationto the sponsoring institution should be de-termined through a candid and explicitassessment of its financial, educationaland service contribution to the achieve-ment of the institution’s mission.

VIII.VIII.VIII.VIII.VIII. SUSTSUSTSUSTSUSTSUSTAINING QUAINING QUAINING QUAINING QUAINING QUALITY ANDALITY ANDALITY ANDALITY ANDALITY ANDVITVITVITVITVITALITY IN MEDICALITY IN MEDICALITY IN MEDICALITY IN MEDICALITY IN MEDICAL EDUCAL EDUCAL EDUCAL EDUCAL EDUCAAAAATIONTIONTIONTIONTION

Finding 8: Creating and sustaining the edu-cational changes required to respond to thechanging medical environment will continueto be a challenge given the pressures of themedical marketplace and the complex mis-sions of medical schools, academic medicalcenters and other teaching hospitals.

U.S. medical schools have experienced severalchanges in their culture during the last century.Since the Flexner report in 1910, a scientifically-based curriculum has been the core of medical edu-cation. This emphasis has contributed immeasur-ably to the establishment of modern medicine as ascience-based profession. While there have been anumber of significant evolutionary changes, revi-sions of the magnitude created by the Flexner re-port have not occurred. This report calls for com-prehensive and profound change in full recognitionthat this challenge is made at a time of unprec-edented difficulty for medical schools and residencyprograms. For many reasons, modification of ex-isting educational programs and the introductionof new ones is becoming progressively more diffi-cult. Resources are diminishing and there aremounting pressures on medical school and resi-dency faculty to generate clinical income to sup-port educational programs and research activities.The missions of research, clinical service and teach-ing are often in conflict, creating a tension betweenmedical school and residency administrators andtheir faculty. Teaching institutions increasingly relyon clinical and contractual income to support mul-tiple activities with consequent reduction of faculty


time available for teaching and the development ofeducational programs.

In spite of these pressures, medical schools andresidency programs are institutions of enormousvitality, commanding impressive intellectual andother resources. Some schools and programs havebeen remarkably successful in introducing curricu-lum change. Their strategies may serve as modelsto other programs. A comprehensive approach tothe introduction of new curriculum topics is hardto achieve and maintain particularly as in many“new” curricular areas such as human sexuality,alcoholism, and health care economics, the contentdoes not fit well with traditional departmental re-sponsibilities and courses may serve learners fromseveral disciplines or health professions. As statedpreviously, some institutions may address the chal-lenge to prepare physicians for the future by an in-cremental approach of continual modification to theexisting curriculum. For others, perhaps the major-ity, major curricular reform will be the only fea-sible method of adequately preparing graduates forthe realities of practice. Whatever approach is se-lected, the development of a substantial system ofcommunity sites to complement the role of the AHCand teaching hospital will be essential to providethe range of experiences required in modern medi-cal education.

Many institutions have recognized the magni-tude of the necessary change. In order to identify,implement, and sustain revisions in their educa-tional programs medical schools and residency pro-grams are reexamining their missions and culture,and committing the necessary funding and otherresources to re-affirm their educational mission andtradition. Cultural change in any organization isdifficult to accomplish and does not occur rapidly.Perpetuating comfortable and familiar strategieswill simply widen the gap between the content ofcurrent educational programs, and the realities ofmedical practice for which graduates must be prepared.

This report emphasizes the development ofteaching sites in the community that reflect the bestof medical practice. The clinical teachers at com-munity sites will be responsible for carrying out asignificant portion of the clinical teaching missionof medical schools and residency training programs.As they come to understand that mission and par-ticipate in the growth and development of educa-tional programs they will add an enriching perspec-tive. Their contribution to the institution’s programsand policies promises to be an influence that willmaintain program relevance and strengthen links tothe community. In spite of the many implications ofcloser relationships between “traditional” and com-

munity faculty, this strategy has enormous potentialbenefit to medical schools and residency programs.

As discussed previously, the development of anexpanded teaching faculty in the community islikely to redefine the role of some “traditional” fac-ulty members, requiring greater emphasis on plan-ning, management, and evaluative functions. Theclearer definition of the educational administrativerole and its legitimization by the development ofappropriate academic promotion systems is likelyexpand the cadre of faculty focused on medicaleducation. The consequent expansion of researchand development in medical education has the po-tential for enormous vitality and benefit to medicalschools and residency programs.

The availability of funding from private foun-dations and Federal and State funding agencies hasoften been necessary to initiate curriculum change.The role of accrediting organizations at the Stateand national level has also been significant. Clearly,patients and health care organizations will continueto exert an influence on the quality standards ofnew graduates. Feedback from graduates may bethe most effective stimulus to change as these indi-viduals can articulate their experiences of discrep-ancies between their professional preparation andthe expectations and realities of practice.

In the final analysis, the responsibility of medi-cal schools to educate medical students is a uniqueand valued function. Other institutions conduct re-search and deliver medical care. Further, medicalschool is the foundation for graduate education,fellowship training and eventual practice. Thechanges recommended here must, therefore, beginin our medical schools. The vitality to implementand sustain a system of medical education whichcontinually evolves to meet the changing needs ofpatients will come from the faculty, learners, gradu-ates, community partners, and society at large. Theimplicit dedication of faculty members will be en-hanced by greater clarity of professional roles, im-proved concordance between rewards (both finan-cial and academic) and actual responsibilities,systems of continuous career development, greatersense of accomplishment in appropriately prepar-ing physicians, and the potential of expanded areasfor scholarship in educationally-based topics. Vi-tality in learners will be enhanced by appreciationof the appropriateness of their training and the ex-panded use of adult learning techniques. Finally, in-teraction with vigorous community partners in the neweducational systems and the acknowledgment by so-ciety that its physicians are superbly prepared for prac-tice, will enable medical educators to sustain excel-lence throughout times of continual change.


Recommendations:

• Medical schools, residency training pro-grams and teaching hospitals must bal-ance their competing roles and reaffirmtheir educational mission. They shouldembrace the task of meeting societal needthrough the education of their graduates.

• The standards for accreditation and finan-cial support of residency programs shouldbe revised to encourage and facilitate newcurriculum content and opportunities toacquire additional knowledge, skills, atti-tudes and values.


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Selected Internet ResourSelected Internet ResourSelected Internet ResourSelected Internet ResourSelected Internet Resourcescescescesces

The volatility of the Internet precludes the development of “comprehensive” listings of resources sites.Faculties are urged to use the resources of the net to exploit its capabilities. Examples of the types ofresources available at the time of this publication include the following (Note that no endorsement isimplied and as with all net resources caveat emptor):

U.S. DISTANCE LEARNING ASSOCIATION

http://usdla.orgA membership organization of professionals in-terested in distance learning.

CENTER FOR EXCELLENCE IN DISTANCE

LEARNING

http://www.lucent.com/cedlListings of technologies, alliances and resources.

THE EDUCATION COALITION

http://www.tecweb.orgIn existence since 1933 promoting systematiceducational reform through the use of multipletechnologies.

PARTNERSHIPS FOR QUALITY EDUCATION

http://www.pqe.orgListing of participating residency programs andtheir managed care partners

UNDERGRADUATE MEDICAL EDUCATION FOR

THE 21ST CENTURY (UME-21)http://www.aacom.org/UME-21/schools.htmA demonstration of curriculum innovations tokeep pace with the changing health care envi-ronment

MEDICAL EDUCATION RING

http://www.med.jhu.edu/medcenter/merEducational resources per se and links to sitesthat contain information relative to medical edu-cation.

THE INTERACTIVE PATIENT

http://medicus.marshall.edu/medicus.htmA web-based interactive patient encounter simu-lation.

MEDICAL INFORMATION FOR STUDENTS AND

PROFESSIONALS

http://www.teleport.com/~megan/health.shtmlLinks to information regarding basic and clini-cal science courses.

MEDUCATION

http://www.meducation.comA comprehensive world wide listing of medicaleducation links.

WEB DOCTOR

http://www.gretman.com/webdocotr/home.htmA comprehensive index of Internet medical re-sources. A virtual library of peer-reviewed, pro-fessional medical information.


HRSA-99-18

Documents

Physician Education for a Changing Health Care EnvironmentDivision of General Medicine Brigham & Women’s Hospital Boston, Massachusetts Carl J. Getto, M.D. Dean and Provost Southern