Reforming medical education:A review and synthesis of five critiques of medical practice
Christopher S.Sales,Anthony L.Schlaff *
Tufts University School of Medicine,Public Health &Community Medicine,136Harrison Avenue,Boston,MA 02111,USA
a r t i c l e i n f o
Article history:
Available online 10March 2010Keywords:
Medical education Health care reform Quality of health care Physicians USA Review Training
a b s t r a c t
For physicians to provide appropriate healthcare at a reasonable cost,health reform may not be enough.This essay discuss the scope of educational reform needed in the train tomorrow ’s physicians to practice effectively in an increasingly complicated health care arena.We undertook a revi
ew and synthesis of five critiques of medical practice in the U.S.:of quality,evidence-bad medicine,population medicine,health policy and heuristics.Our findings suggest that physicians are inadequately trained to function in the complex organizational and social systems that characterize modern practice.Successful health care reform in the U.S.will require physicians who are trained not only in bio-medicine,but also in the social sciences.Other developed countries,which have both greater government control of health care and a culture less oriented to individualism,may have less need for speci fic efforts to train physi-cians in the social sciences but could still bene fit from considering an expanded curriculum.Effective educational reform must address the medical admissions process,academic and intellectual preparation,and professional and clinical training.
Ó2010Elvier Ltd.All rights rerved.
Introduction
As the United States revisits health care reform,cost and quality,not just access,must be addresd.Will system reform,including changes in coverage mechanisms,payment incentives,and delivery structure,transform physician behavior to deliver appropriate health care at an affordable price,or are physicians and the way they are trained themlves part of the problem?
Physicians are no doubt highly skilled as a result of their biomedical education and clinical training,but bad on an overview and synthesis of five critiques of medical practice,this essay argues that the lack of physicians ’preparation in the social sciences may limit their ability to confront contemporary health care problems.The critiques have come from the vantage points of quality,evidence-bad medicine,population medicine,policy,and heuristics.Collectively,they suggest that the basic tenets of physician socialization need to be challenged again e much as they were by Flexner 100years ago.This will require signi ficant reform of medical education,well beyond the scope of tho propod or adopted in recent years.In this review we consider 5critiques of medical practice in the US:of quality,evidence-bad medicine,population medicine,health policy
and heuristics.A synthesis of the critiques forms the basis of our asssment of the scope of educational reform needed to train tomorrow ’s US doctors.Quality
The Institute of Medicine has published major reports on the high levels of error,iatrogenic injury,waste,and overtreatment in medical care.(Institute of Medicine,2001;Kohn,Corrigan,&Donaldson,2000)Despite its scale and scope,respon to the “quality chasm ”has been slow becau reform efforts have ignored how physicians are trained to view errors.To reduce error and improve quality,physicians must be trained to focus on system desig
n,not on individual failures.Yet,today ’s physicians expect perfection of themlves,(Leape,1994)thereby discour-aging error reporting and hindering system improvements that acknowledge fallibility and mitigate its conquences.In respon to the medical culture of lf-reliance,social science frameworks and methods could provide the perspective that physician training currently lacks.(Bhuiyan &Baghel,2005;Colton,2000)Improvements in medical practice require team work and the ability of team members,including physicians,to understand the social and cognitive frameworks in which other members of the team have been trained (Gittell,2000;Whitehead,2007).
*Corresponding author.Tel.:þ16176366584;fax:þ16176364017.E-mail address:anthony.schlaff@tufts.edu (A.L.
Schlaff).Contents lists available at ScienceDirect
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0277-9536/$e e front matter Ó2010Elvier Ltd.All rights rerved.doi:10.1016/j.socscimed.2010.02.018
Social Science &Medicine 70(2010)1665e 1668
Evidence bad medicine
Proponents of evidence-bad medicine(EBM)note that much of medical practice in the1980s e1990s was rooted in apprentice-ship and expert opinion(Starr,1982).EBM’s focus on outcomes and evaluation of pooled clinical trial data has since continued to challenge clinical intuition,tradition,anecdotal experience,and patho-physiologic rationale as insufficient grounds for defending expensive,ineffective,or even harmful practices(Evidence-Bad Medicine Working Group,1992).
A literature review of the development,introduction,u and evaluation of four medical practices was undertaken.Two are screening tests:exerci testing for asymptomatic coronary artery dia(Fletcher et al.,1995;Fowler-Brown et al.,2004;Giagnoni et al.,1983;McHenry,O’Donnell,Morris,&Jordan,1984)and prostate specific antigen assay(PSA)for pre-clinical prostate cancer (Catalona et al.,1991;Fowler et al.,1998;Harris&Lohr,2002;Mitka, 2004;Sharifi&Kramer,2007;U.S.Preventive Services Task Force, 1996;Voss&Schectman,2001).Two are monitoring technologies intended to guide treatment decisions:electronic fetal monitoring (EFM)during delivery(American College of Gynecology Technical Bulletin1995;Banta&Thacker,1979,2001;Graham,Petern, Christo,&Fox,2006;Greene,2006;Hon&H
ess,1957)and pulmonary artery catheterization(PAC)for managing the critically ill.(Connors et al.,1996;Robin,1985;Rubenfeld,McNamara-Aslin, &Rubinson,2007;Shah et al.,2005;Wiener&Welch,2007).All were rapidly and widely adopted despite a lack of evidence demonstrating clinical utility.Early enthusiasm was followed by data revealing limited benefits and in some cas potential harm. Evidence mounted,but the medical profession was slow to oppo the status quo,and even after guidelines were published,physi-cians were resistant to change.
All four examples demonstrate physicians’readiness to apply “science”bad on technology and patho-physiologic data,but relative unwillingness to apply science bad on empiric evidence and epidemiologic data.Physicians would benefit from training in a broader and more nuanced approach to the epistemological challenges inherent to how they consider evidence.(Goldenberg, 2009)In an era shaped by pressures to rapidly adopt new tech-nology(Rothman,1997)and by direct-to-consumer marketing, (Wolfe,2002)such training may prove instrumental in efforts to curb overtreatment and contain healthcare costs.
Population medicine
Medicine and public health have long had a troubled relation-ship,(Starr,1982)and debate about inte
grating population medicine into general medical education continues.Some have argued that physicians would be better clinicians if they were taught to apply a population perspective to clinical practice becau they would be better trained to u clinical epidemiology and coordinate care with other community resources.(Allan et al.,2004;Maeshiro,2008) The methods of clinical epidemiology rest in part on lecting an appropriate denominator.(Sackett,1991)Misplaced enthusiasm for the screening and evaluative tests discusd above can be partially attributed to applyingfindings from specific subts of patients to broader populations.Similarly,the overu of many medications stems from reliance on relative risk rather than absolute risk. (Gigerenzer&Edwards,2003)Underutilization may also be explained by failure to u population denominators.Low levels of screening for alcohol and drug u,HIV,or depression,for example, might be the result of physicians not knowing the prevalence of subclinical dia prent in their patients’communities.
With minimal education on the vast literature on social, economic,behavioral,and environmental determinants of health,physicians with an exclusively biomedical focus may limit their interventions to bio-technology.They may,in turn,be less likely to partner with community resources,which can include family, social workers,schools,hospices,recreational facilities,and government agencies.Physicians trained with a population perspective should be better able to coordinate their c
are with community resources.(Gadon,2007;Ockene et al.,2007)A broader perspective provided by a social science education would help physicians not only understand some of the social determinants of health but also intervene constructively,both through modifica-tions in how they provide health rvices,and through a broader rearch and advocacy agenda(McCally et al.,2000).
Policy
Most clinicians know that health policy intrudes on the patient-provider relationship.The allotted time of the visit,payment structures,rules,formularies,referral networks,and third-party oversight all matter to what a patient and provider do.Some clinicians develop experti in a range of policy issues,but the vast majority does not ek such knowledge and skills,or e it as their professional responsibility to constructively influence the policy environment.Medical schools and residencies have to varying degrees sought to teach health care policy,but not in ways that come clo to matching the rigor of training in the biological sciences.(Cooke,Irby,Sullivan,&Ludmerer,2006)Exposure to the political and social science discour early and consistently in medical education might increa physician involvement in policy as well as help physicians better understand the value of coalition work in advocacy.(Chavis,1995;Crosby,1996;Elison,1997;Zigler& Muenchow,1984).
Heuristics
The public idealizes the physician as a master of all relevant information,who applies it rationally and judiciously;but,in reality,physicians are fallible.In a recent book intended primarily for a lay audience,Jerome Groopman summarizes errors in thinking in medicine.(Groopman,2007)The include the avail-ability and anchoring heuristics:the tendencies to ttle early and toofirmly on more likely or more recently encountered diagnos; and affective and attribution errors:the tendencies to let emotion and stereotyping bias the approach taken to patients’illness. Groopman encourages patients to reduce medical error by recog-nizing the patterns and challenging their doctors.He also gives examples of excellent clinicians who lf-monitor and suggests that each physician is obligated to understand and monitor heuristics.He does not,however,offer any recommendation as to how physicians might be trained to do so.Considerable social science rearch exists on strategies to minimize bias introduced by heuristics,and in some cas is being applied to the medical encounter(Schwab,2008).
A propod synthesis of critiques of medicine
What the above critiques of medicine have in common is an implicit recognition that medicine is prac
ticed in a context of social and organizational structures distinct from its biomedical substrate.Understanding the structures is esntial not only to health care reform,but also to delivering optimum medical care. They include the clinical environment and institution,the family and social milieu of the patient,the community and environment in which the patient lives,and the health care system and its struc-tures of access,cost,and quality.They also include the personal attributes,identity,bias,and emotions of both the patient and
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doctor.Physicians must be cognizant of the contextual systems surrounding medicine and adapt their practice in respon. In short,physicians must be social as well as natural scientists. Medical education:a call for systemic reform
This analysis points to the need for physicians to understand and value the social science disciplines if they are to work effectively in a medical context not shaped exclusively by the biomedical para-digm.Therefore,significant medical education reform must accompany reforms in systemfinance and delivery.Successful reform aimed at delivering appropriate,affordable health care will require physicians who are trained not only in bio-medicine,but also in the social science disciplines engaged in this complex milieu. The Flexner revolution100years later
In1910,Flexner obrved that the scientific building blocks needed for a medical mind were already in place,but that they were not cemented together through applied learning.(Flexner& Pritchett,1910)Seeing the improvements that scientific rigor could bring to patient care,Flexner propod an educational model that wedded theory to clinical practice.What emerged was the modern academic medical center,where clinical practice and teaching could continually benefit from the methodology and discoveries of scientific rearch.
Today,however,the claim that clinicians are trained as scientists may be more rhetoric than reality.Diagnostic tools have become more numerous and complex,physician’s routine application of science has been marginalized to laboratories and technicians,and medical training has reverted to a model shaped predominantly by anecdote.Today’s medical student focus on memorizing the existing biomedical canon rather than on asking new questions and applying rearch methods to answer them.In particular,they are markedly unprepared to think critically in the realm of the social sciences,and yet,as the critiques of medicine tell us,this is where they will encounter many of the challenges to delivering optimum medical care to their communities.
To be a scientist of medical care today involves much more than bio-medicine,just as it involved much more than hearsay following the microbiology revolution.For the physician in-training,the frame
works of quality improvement,evidence-bad medicine, population health,policy,and heuristics are not made sufficiently relevant enough to clinical practice.A century ago,biological knowledge and the scientific method were integrated into medical training to the benefit of patient care.Today,reinvigorating that same methodology by way of the social sciences may be the catalyst needed to spark a new wave of quality improvement.
The scope of education reform
To date,the majority of medical education reform has confined social science training almost exclusively to the pre-clinical years. This approach is fundamentallyflawed becau it parates theory from practice,thereby diminishing the perceived relevance to patient care.An understanding of the contextual structures of practice should become a central part of education,taught not only in the classroom,but valued and applied scientifically at all levels of clinical training.Students and residents should have the opportu-nity to obrve knowledge and skills in the areas applied by their mentors to improve patients’health.Attention to the social sciences should also be reflected in considering who is brought into the profession by recruiting students with talent and interest in the subjects.Effective reform must therefore stem from three inparable components:medical admissions,academic and intellectual preparation,and professional and clinical training.
Medical admissions
Motivated in part by the density of material taught in the pre-clinical years,medical schools have sought applicants with not just the capacity to understand natural science,but the ability to excel in competitive exams that stress memorization.Although qualita-tive factors assd in the interview and personal statement have become increasingly valued,grade point average in the natural sciences and the medical college admissions test remain para-mount.(Albane,Snow,Skochelak,Huggett,&Farrell,2003) Applicants for medical school should be evaluated“whole cloth.”All attributes required for a good physician should be considered,including but certainly not limited to their abilities in both the natural and social sciences.Clearly,ability in the natural sciences must be maintained at a level sufficient to understand the scientific basis of clinical care,but the admissions process should be structured to assure that attention to this ability does not crowd out other desired attributes.Even before they start their training, students should know the full range of abilities expected of them. This can only occur if all attributes are explicitly valued compo-nents of the admissions criteria.
Academic and intellectual preparation
Parts of the social science framework needed for medical prac-tice can be found in many existing pre-clinical curricula and in the public health education available to some physicians in training. Perhaps more broadly,the profession should consider the challenge put forward by Jerome Groopman,who notes that a good physician needs“a arching mind,”to lf-reflect,avoid cognitive errors,and improve.(Groopman,2007)Although students might not often think independently in training,one day e faced with a difficult patient in a difficult health system context e they will need to do so.Training should prepare them for such moments.
What kind of education encourages the development of“a arching mind”?A liberal arts education stimulates“arching”by prompting students to view the world critically through many disciplinary lens,including the arts and humanities,as well as the social sciences.(Seifert et al.,2008)Such an education before and during medical training,might be an important compliment to the natural sciences in preparing physicians for the challenges of practice.Flexner himlf complained that medicine was,“.sadly deficient in cultural and philosophical background.”(Flexner,1925)
Professional and clinical training
Flexner’s critique is best re-applied in its place of origin:clinical training.Quality improvement method
s,health systems and tech-nology asssment rearch,clinical epidemiology,and manage-ment and behavioral sciences,must be applied to benefit each patient’s care.Moreover,the relationship between the challenges of clinical practice and the influences of administrative and policy frameworks must be taught overtly and be embraced as part of a physician’s required realm of experti,rather than as the“bother”that“interferes with practice.”Ideally,students and residents would have opportunities to conduct rearch in such areas as quality improvement,or health policy,or other systems aspects of care.
Residency curricula and faculty will have to change,and academic medical centers will have to reshape how they practice, and model,medicine.This may require that experti be developed or imported into the academic medical center,as was the ca after the Flexner report.
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Conclusion
Medicine in the US is practiced in a complex organizational context,and good medical practice requires an ability to work knowledgably in this context.Health care reform must be accom-panied by changes in medical education,with more attention to the social sciences.U of this broader educatio
n must be applied and modeled in clinical practice by the academic physicians who train medical students and residents,and it must inform the lection of future physicians.
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