http://www.milbank.org/reports/0507FiveFutures/0507FiveFutures.pdf
The report is worth reading and should be a major discussion point for all involved in medical education.
With just a quick read I found it a fascinating parallel with other academic reports and the future of family medicine, especially in the emphasis at the tail end rather than the front end of the medical life cycle. For example, the word "education" was listed 10 times and always referred to medical education, never referring to earlier education or the preparation and selection of those who will be the future of medical education and health care.
As you have heard from me before, the problem with medical education is a matter of who becomes a physician and how they are prepared. This problem is a problem of all professionals and leaders in this nation and others. The major points of the report are in italics followed by my comments.
Instabilities in Academic Medicine
• There is widespread, even universal, agreement that things are not right but little agreement on the exact nature of the problem. This speaks to a focus on areas not being studied, such as how students get to become physicians and areas of study not involving medical school.
• There is a lack of capacity for "translational research," or what brings innovations directly to patients This points out the need for physicians to have relevant connections with patients and to be more like them. Physicians other than the 18% who are involved in direct primary care with patients, are isolated from patients by assistants and habit, Physicians are also isolated in socioeconomic origin with 60% coming from the top 20% in income in one of the richest nations in the world. The US is also recruiting the richest students from other nations as well. Also there is a great need for older medical students, those with more life experiences that give a translational edge. AAMC President Jordan Cohen has touted the advantages of older students but few have apparently listened and younger students are preferred. Older students are admitted only when there are fewer younger and higher scoring students in the applicant pool
• The gap between the best, evidence-based practice and what actually happens is substantial. Evidence-based is a new concept that needs to be introduced much sooner than medical or professional school. There is an education revolution that must happen.
• The gap between academics and practitioners is growing. Those admitted to medical school have origins in the highest income, must urban, most academic-oriented families. This is not a surprise. Even family medicine administrators, researchers, and teachers as noted in the AMA Masterfile 2005 tend to come from the same origins, areas of over 1 million and the elite 22 schools not graduating many family physicians. Those family physicians in practice are more likely to come from rural or lesser metro areas of the nation and the 100 non-elite schools.
• It is becoming impossible for a person to be competent simultaneously in practice, research, and teaching. This is a dangerous concept in my view, and one that does not follow from the previous major statements above. Although it will always be more difficult, the three must be viewed as complementary, not competitive. Unless physicians and researchers are grounded in reality and practice before teaching and research careers, there will be continued divisions. The role of academic centers and leadership is to facilitate career transitions enough to keep a broader focus on research and teaching, to keep all worlds of academic medicine more relevant and sustainable. Jack Verby is my model here. 20 years rural fp, 20 years academics, last half evaluation and research. This is a logical progression of efforts. Starting with research first as we do more and more makes little sense and is likely to be less productive and more costly in many ways.
• The use of citation indices in research assessment is inappropriate and may be obstructive. This one is beyond me as stated. What I did understand about the passage noted problems assessing basic science vs applied research and the poor academic rewards for teaching compared to research. You could also throw in the physician researcher vs PhD (and resentment issues) and the problems with rewarding those with names or egos or both vs the grunt researchers who work for passion and often are diamonds in the rough awaiting discoveries. Then there is the incredible stress load on graduate students and the abuses of same and also the growing fraud in research. The academic reward and funding system is important and flawed. Enlightened leadership that reaches deep into faculty to understand what they are doing can facilitate those with potential, but most time is administrative not relational, just like the orientation of those pursuing such leadership positions.
• Fewer doctors want to pursue a career in research. The 4 physician careers pursued by older medical school graduates as compared to younger are family medicine, rural careers of all types, psychiatry, and research. Each of these may well tend to flow out of significant life experiences. Each career has a 50 – 100% increase in choice (or more) for those age 29 or 30 compared to the youngest graduates 24 or 25. Medical schools with younger and more narrowly focused students, as in most other nations, may not have the research output. US schools admitting the highest scoring students early (in competitive moves) succeed in the elite schools, but fail in the other 100 schools. In all US medical schools the older graduates are more likely to choose research. In the 100 normal schools younger graduates are no more likely to choose research, neither are urban born, foreign born, or higher income and because of these, nor are higher scoring students more likely. The elite 22 schools are good at picking out researchers and do graduate half of the physician researcher graduates of the nation. Also there are brain and life experience factors. The teenage 16 year old mind is just not capable of the skills and judgment needed for driving a car. Those entering medical school at the earliest ages may also not be capable of the connections, dedication, versatility needed for a career in research. Research careers require the ability to overcome obstacles of many types. Also the research opportunities available may not fit these older and more mature folks. Less funding and support is available in primary care, mental health, health access, workforce, “translational” research, and applied efforts such as evidence-based. Those who fund research need to ask some basic questions such as “Are we still funding research and the same research projects that we did 50 years ago when research developed out of WWII needs?” and “Where in the heck did public health research and investment go?”
http://www.milbank.org/reports/0507FiveFutures/0507FiveFutures.html
• Careers in academic medicine are discouraged by financial disincentives. Turn this statement around and it reads “Financial incentives are distorting careers in academic medicine” and you have the answer. As long as we reward teaching poorly from the preschool level to primary to secondary to college and professional, we will have a problem with such incentives. All teaching and service careers are disadvantaged, primarily because those involved are more likely to be selfless types who would rather teach and serve than whine and negotiate. It is the task of leadership at all levels, those who obtain college education, to recognize the primary importance of education and service in any nation. Studies demonstrate that the differences between advantaged and disadvantaged kids can be erased by moving the best teachers to the worst schools in the elementary years, with billions in potential dollars saved in the long term.
• The career path is unclear and inflexible. No help on this one, academic medicine will always have many possible paths. Flexibility may be a matter of funding support. Again life experience helps with so many of these decisions and youth makes them more confusing.
• Problems with career progression are particularly salient for women. Gender issues are a concern, but there are pressing gender issues not even "discovered." Given the fewer males going to college and professional school, there will be equity much sooner than later, but the loss of lower income males is has been present for decades. Gender equity is an issue, but so is socioeconomic equity. Until nations realize that violence and terrorism are about hopelessness and poverty in young males, military and prison and legal and social costs and health care costs will continue to eat education expenditures.
• Research is often not concerned with the biggest health problems. Again the need is to have leadership that is grounded in real life as they grow up. Isolation in private schools, private families, and academic environments may be a primary element of poor decisions made by leaders of all types.
• Medical education does not prepare graduates for careers in modern medicine The report goes on to state that “Medical students themselves are rarely part of the decision-making or planning processes.” This is a reflection of the problem. I was hoping to read into this statement that someone was recognizing that the lack of medical student ability to “become” physicians was a problem in becoming a doctor, but this statement referred more to students acting as stakeholders regarding decisions. Clearly there is a need for medical education to diversify. Psychiatry needs a whole new approach with training closer to- and integrated with- other mental health providers and less like typical medical schools. There need to be primary care medical schools and some may even set up rural primary care schools as in other countries. The example of the Accelerated family medicine training programs is important. Six years of a medical school and family medicine residency can graduate over 50% of 150 graduates in 12 schools to rural practice and another 50% of urban graduates to urban poverty locations plus additional academic family physicians to replicate the model and the discipline. When a nation terminates such a program that costs less and has the best distributional outcomes, including the ability to focus specifically on rural or inner city underserved populations, there are serious flaws in training, accreditation, leadership, and accountability.
• The great pressures on health services and the introduction of health care reform mean that academic medicine is often squeezed. Great changes offer opportunities as well as challenges. Academic medicine was unwilling to listen to leaders such as Butler and Cohen and others providing sufficient warnings. As long as leadership efforts are ignored, these problems will continue. search google on butler academic medicine season of accountability or http://www.unmc.edu/Community/ruralmeded/season_of_accountability.htm
• The lack of basic infrastructure in many developing countries has meant an absence of academic medical institutions. In many countries, academic medicine lacks a well-resourced institution to speak for it. Academic medicine needs a voice, but there are many needs in developing nations. In other nations with basic problems regarding water quality and distribution of food and health and virtual absence of education, development of an academic center means more educated people exiting the country, as in Ghana where half of the physicians are in other nations and the medical school leaders are proud of this fact. The war against terrorism, violence, pandemics, and more is about distribution of education and health resources within and among all nations.
• Leadership has often been inadequate. Dealt with above
"The Association of American Medical Colleges asserted that academic medicine needs "deans and chairs who conceptualize their work as values-based and collaborative and who will build the consensus and garner the resources necessary for medical schools to become better learning organizations" 12. The Royal College of Physicians of London emphasized that failing to recruit academics of the highest caliber would lead to lower-quality medicine and poor leadership in the health service and universities 14."
In the US the primary reason for firing a dean is failure to deal with the practice plan. Deans not perceived to do well in research would also be at risk. Deans who attempted to emphasize the teaching of medical students, broader admissions of more mature and dedicated students who just happened to have slightly lower MCAT scores, who attempted to weed out the students who did not have the necessary character and dedication that slipped past the admissions committee, and who assumed a leadership role in a state to help lead a state to greatness in education would last very few months, especially when LCME raised questions about USMLE 1 or other areas. When academic medicine begins to reverse these values and distorted traditions, there will be hope for better medical education and better medical care, worldwide.
Robert C. Bowman, M.D.
Academic Medicine's Season of Accountability and Social Responsibility
Reconciling science, technology, cultures, and humanity at
Technology Character and Family Medicine
Technology: Shaping It or Shaping Us?
Admissions Ratios and US Medical Students