The Accreditation Council for Graduate Medical Education, the governing organization for postgraduate physician training, requires the mastery of six particular competencies before one can be recognized as a specialist in a particular discipline. These are medical knowledge, communication skills, practice-based learning, patient care, professionalism and systems of health care. That last term refers to the ability of a physician in training to understand the differing environments in which patients are cared for, to work with the health care system to ensure continuity of care and to cooperate with efforts that ensure patient safety and standards of quality and proficiency.
Increasingly, medical education combines knowledge of basic science and skills in caring for patients with explicit curricula in communication, simulation and team training. It also develops in practitioners a habit of reflection that leads them to review individual cases and make comparisons with the evidence in the literature and in conformity with national standards.
The problem is that this broader curriculum is being developed at a time when faculty members of medical schools already feel pressed by productivity demands that limit the time clinicians can spend with students and that force researchers to juggle classroom teaching and writing applications for the grants necessary for ongoing funding.
What lies beneath the current discussion about professionalism in medicine is that, despite increasing technical and scientific opportunities, the purpose of medical education is still to train physicians who understand the values they profess, the meaning of what they do and the importance of their relationships with patients, other caregivers and society at large. The struggle for medicines soul is being waged on the field of medical education.
Training in Virtue
Medicine is a humane discipline that combines art and science, but it depends above all on practitioners who are passionate about caring for patients. To use terminology from scholastic philosophy, medical education is training in virtue, with virtue understood as a human potential brought to action by education, training, reflection, consideration of role models and experience. Medical education requires growth in both intellectual and moral virtues. The intellectual virtues of art and prudence aim at finding the reality of the clinical encounter. The moral virtues of temperance, fortitude and justice aim at right action in the best interests of ones patient.
The struggle about how best to form physicians is not new, but a variety of new challenges makes it especially pressing. The possibilities in medicineof treating individuals, of providing a variety of technological solutions for a particular problem (including the promise of molecular genetics)are dazzling. Yet physicians also struggle with how to live well as persons, how to care for the poor and how to befriend those who seek their assistance. These days there is more to distract us, like worries about how to maintain a reasonable income, meet productivity demands and deal with regulatory and bureaucratic requirements. Education that ensures respect for patients while not diminishing the humanity of those in training remains a daunting challenge.
Focusing on the Physician in Training
When developing a curriculum, my aim is to train students who are ready for the demands of patient-centered medicine. Such students can deliver personalized care while using knowledge and skills that are highly technical. They can understand how a persons individual genetic makeup will allow appropriate therapeutic choices, tailor treatment for cancer and other illnesses, and make prudent decisions about ways to limit risk. But personalized care and patient-centered medicine also mean retaining and deepening an older tradition: the ability to communicate with those in our care and to work with them in making decisions about their health care that serve their best interests.
It is hard to see how students can grow in their ability to provide patient-centered care if medical educators do not grow in student-centered education. Behind this assertion are some simple considerations. Medical school curricula are too often dominated by a feudal mind-set; individual departments hold sway over students as they move from discipline to discipline. Increasingly, however (accelerated in the United States by accreditation and regulatory requirements calling for demonstrated proficiency in core competencies), a curriculum is being developed that looks at the objectives necessary to prepare those ready for the next stage of training. Individual disciplines are crucial but in an instrumental manner; each works to provide training that imparts the necessary knowledge, skills and attitudes to developing the ideal graduate.
My own training has given me a high level of knowledge in biochemistry, physiology, anatomy, microbiology and pathology, plus a more practical set of skills and knowledge in the clinical disciplines. But it did not prepare me well to take care of people with a cold or individuals facing a life-limiting illness, or to talk to a person who has just received a bad diagnosis or to work in the best way with nurses and social workers. With a bit of exaggeration, I suggest that my medical school and residency training emphasized personal mastery, but did not address well how to deal with change or conflicting evidence or how to work as a team member or to act like a human being with patients. I could detail biochemical pathways about carbohydrate metabolism (and am still fairly good at that), but I had much difficulty telling a poor obese patient what to do with diet, exercise and medication in the face of Type II diabetes mellitus.
At Loyola University we emphasize an education committed to ethics and service and to a translational knowledge of basic science as well as to the development of robust clinical skills. We seek to provide very strong student services (part of the Jesuit educational tradition of cura personalis) while delivering a value-laden education that gives students extensive exposure to care of the poor, international service trips and rigorous basic science training. In addition, our clinical rotations are very demanding, with many overnights on call and an expectation that the student will become increasingly independent in responsibility, while under appropriate supervision.
If the medium is the message, far too much of medical education is passive in format: lengthy lectures impart much information but can leave a learner bewildered about what is essential. Focusing on objectives helps, but it is not enough. For a format that relies too much on lectures not only ignores the needs of active learning but also fails to recognize the experience students bring to their education. Small-group learning focused on cases or problems may improve on this, but it is no panacea. For this to succeed, faculty members must be willing to facilitate, not control, learning. Most threatening in my experience were the times I had to admit I was not sure of an answer when the students moved a discussion beyond my intellectual safety zone. Modeling how to address such questions helps students get used to the need to work together and figure out how to find an answer, rather than passively receive it.
It is difficult for some medical school faculty people to recognize that the old methods of learning are not effective for this generation, which was brought up on computers, accustomed to streaming video and hooked up to an iPod. Given the glut of information, teachers must acknowledge that some of what they cherish in a particular discipline may not be very relevant in contemporary practice. As a new graduate in 1981, I could have told you much about the life cycle of the pinworm, but I look back on that now with some horror, recalling that more than 20 hours in my curriculum were devoted to lectures on parasites, but only an hour or two on end-of-life topics. As a geriatric specialist today, I realize I was not well prepared. Pinworm rarely afflicts my centenarians. My students and I can search the Web to learn about parasites when we need to. The faculty does have essentials to impart, but students and faculty alike must still learn much more once the core topics are mastered.
Focusing on the Patient
Although not every physician will work directly with patients, the goal of medical education is to provide the best care possible. Part of the rationale behind competency-based objectives and standards for training is to move beyond knowledge-based examinations. That emphasis may be new, but medicine has always recognized the exemplary performance of physicians who care for patients with a deep wealth of basic and clinical knowledge. Such physicians are also attuned to each patients individual characteristics and specific needs as human beings. They show a willingness to try to heal a patient even when a cure or technological remedy is not always possible. Developing patient-centered care requires practitioners who are ready to grow as humans and as clinicians during their training and afterward. It also demands that they become increasingly sophisticated in mobilizing the resources of a particular health care system. A physician must use the talents and skills of other health care professionals in a collaborative manner, while attending to best practices, prevention, quality and safety.
How does one promote an education by which students and novice physicians can grow in technical skills, practical knowledge and some degree of wisdom? Let me suggest three steps. First, take medical education seriously as a formation process whose goal is to develop men and women who are both skilled and caring. Second, put the best and brightest physicians who care about students and physicians in training into positions of authority and leadership. Third, recognize the importance of role models and ensure that the doctors who represent the ideals of what a doctor can be provide most of the clinical teaching.
Formation in technical knowledge, practical knowledge and wisdom does not mean training nice people who are ignorant but pleasant; rather it aims toward growth in virtue, which is hard work and inevitably entails some failure and frustration. This model is not typical. In the United States, assigning responsibility for running a training program has often been a way of providing a salary to some bright young academic physician while he or she develops a research agenda and searches for outside funding. The training program provided relatively cheap labor (the physicians in training), with minimal supervision. Much learning still took place, but what counted was that the young physicians got the work done, did not complain and passed their specialty exams. A student could be thoroughly objectionable in matters great and small but still advance.
Training doctors in person-centered care works only if the educators doing the formation understand the process of giving such care and also care deeply about the doctors they are training. Such learner-centered education requires individual assessment, assistance in areas where growth is required and encouragement of students questions. It takes discipline to ensure that the education is properly balanced: ongoing learning in science, attention to skill training, team development and personal growth. It takes educators willing to work with trainees who may be very bright but manifest little interest in developing communication skills, behaving professionally or learning other behaviors that may once have been considered pleasant but merely optional.
Ultimately, the future of medical education depends on medical school faculty and administrators who care about education and patient care. In a very complex environment, that means devoting time and resources to students and physicians in training. It also requires selecting, paying and promoting faculty members who excel in both their particular discipline and devotion to their students.