Reforming Medical Education

reprinted from Issue 12, Spring 2012 of Frontiers of Medicine (PDF)

Carnegie Foundation invited Bridget O’Brien, PhD, David Irby, PhD, and Molly Cooke, MD, to prepare a report on medical education. They are holding their resulting book, A Call for Reform of Medical School and Residency.
photo by Noah Berger

In their new book, three UCSF faculty members say the future demands new approaches to shaping the minds, hands and hearts of physicians.

In 1910, when it was difficult to tell an elixir-shilling swindler from a legitimate physician, the Carnegie Foundation for the Advancement of Teaching commissioned Abraham Flexner to write a report on the state of medical education in North America. Flexner’s findings introduced revolutionary ideas, such as requiring four years of college as a prerequisite, creating a standardized four-year medical curriculum with two years of science courses followed by two years of clinical experience, and establishing an accreditation process.

Flexner’s recommendations were widely adopted, and within a decade, one-third of schools closed or merged with other programs. Yet these standards and structures have remained largely unchanged in the past century, creating a different set of challenges. Recognizing this, the Carnegie Foundation invited Molly Cooke, MD, David Irby, PhD, and Bridget O’Brien, PhD, to prepare a new report. The resulting book, Educating Physicians: A Call for Reform of Medical School and Residency, outlines a vision for improving the field.

“Medical education has changed remarkably little since Flexner’s template, which is pretty surprising, given how much medical knowledge and health care delivery have changed, and how much additional under-standing we have about how people learn,” says Cooke.

The trio visited 14 medical schools and residency programs across the country, including UCSF, and developed four major recommendations (see below). “One of the main problems is a one-size-fits-all approach to medical education,” says Cooke, who holds the William G. Irwin Endowed Chair and directs the Haile T. Debas Academy of Medical Educators. “We have an opportunity to create an educational framework that recognizes that people come to medicine with different backgrounds, interests and experiences, and that connects what students and residents learn to patient outcomes.”

The authors have been able to share their findings with colleagues back at UCSF. “We had this marvelous incubator within which to test the ideas that we were hatching as we were going through the study process, and brought back some of the best practices that we saw nationally,” says Irby, vice dean for medical education.

For example, the PISCES program (see p. 1) provides close faculty mentorship over medical students through their entire third years, as they have their first in-depth experiences caring for patients.

“The key is knowing your learner, and helping them move from a very peripheral, observer status into an active, engaged leadership role,” says Irby. “You want to challenge the learner to step up to the next level of ability, with support.”

In addition to fostering clinical knowledge, that support also helps students grow into their role as physicians, as they learn skills like handling patient confidentiality and setting appropriate boundaries. “These are all issues of professionalism, and how we aspire to be caring, compassionate, competent physicians,” says Irby.

Another example is the Pathways to Discovery program, which allows trainees to pursue their passions – whether they be global health, molecular medicine or medical education – and to individualize their learning experiences. “By engaging people in the processes of innovation and inquiry, we help develop lifelong habits of excellence that encourage people to read, improve, adapt, innovate and discover as they practice medicine,” says Irby. “One of the great things about UCSF is the depth of leadership in education, and the amount, number, type and diversity of educational innovations that occur here.”

– Tina Vu and Elizabeth Chur

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