ORIGINAL ARTICLE
The Current Format and Ongoing Advances of Medical Education in the United States Kriya Gishen, BS, Steven Ovadia, BA, Samantha Arzillo, BS, BA, Yash Avashia, MD, and Seth R. Thaller, MD, DMD
Abstract: The objective of this study was to examine the current system of medical education along with the advances that are being made to support the demands of a changing health care system. American medical education must reform to anticipate the future needs of a changing health care system. Since the dramatic transformations to medical education that followed the publication of the Flexner report in 1910, medical education in the United States has largely remained unaltered. Today, the education of future physicians is undergoing modifications at all levels: premedical education, medical school, and residency training. Advances are being made with respect to curriculum design and content, standardized testing, and accreditation milestones. Fields such as plastic surgery are taking strides toward improving resident training as the next accreditation system is established. To promote more efficacious medical education, the American Medical Association has provided grants for innovations in education. Likewise, the Accreditation Council for Graduate Medical Education outlined 6 core competencies to standardize the educational goals of residency training. Such efforts are likely to improve the education of future physicians so that they are able to meet the future needs of American health care. Key Words: Advances in education, plastic surgery, educational reform, residency training, medical education, medical school (J Craniofac Surg 2014;25: 35Y38)
W
ith the establishment of the first American medical school at Johns Hopkins University in 1893, the foundations to a widely revered educational enterprise were initiated. The ‘‘Hopkins’’ model What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the Division of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Leonard Miller School of Medicine, Miami, Florida. Received August 25, 2013. Accepted for publication September 30, 2013. Address correspondence and reprint requests to Seth R. Thaller, MD, DMD, FACS, Division of Plastic, Aesthetic and Reconstructive Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami, Leonard Miller School of Medicine, Clinical Research Building (CRB), 1120 NW 14th St, Room 410, Miami, FL 33136; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/01.scs.0000436737.67665.ab
The Journal of Craniofacial Surgery
of a university affiliated with a teaching hospital was successfully imitated. However, there was little propensity for critical evaluations of its curriculum. The Hopkins formula was declared the ‘‘model for medical education’’ in the Flexner report. This urged all American medical schools to raise their graduation standards and to conform to a strict set of guidelines. The goal was to improve the quality of their teaching and research outcomes. This report heralded the notion that fewer physicians of superior quality were preferable. It subsequently led to the closing of hundreds of unregulated ‘‘proprietary’’ schools. It limited medical education, by advocating only ‘‘modern’’ forms of medicine. Also, it questions the validity of osteopathic and alternative medicine. Throughout the early part of the 20th century, efforts were made to standardize medical education and to adhere to the tenets of the Flexner report.1 By 1928, residency programs in hospitals were established. This was followed by the establishment of examining boards for the certification of specialists.2 In 1959, the Surgeon General Consultant Group on Medical Education produced the Bane Report. This led to a shortage of approximately 40,000 physicians.3 Between 1965 and 1980, the number of physicians graduating doubled to 18,200. This has remained stable until today.4 For the most part, the basic tenets of American medical education remained largely stagnant until 2006. The American Medical Association embarked on the Initiative to Transform Medical Education to optimize the Medical Education Learning Environment.2 With the health care system undergoing major fundamental changes, focus has shifted once again in medical education. The future of health care calls for improved and expanded primary care along with the necessity for a medical system that can support a growing population. These basic tenets must remain synchronized with the rapid evolution of science. For this reason, ‘‘the current period is one of vigorous and incisive reappraisal and evaluation of medical education, medical knowledge, and the significance of medicine as a factor in social well-being and development.’’1
UNDERGRADUATE EDUCATION Most medical education begins at the undergraduate level with a premedical curriculum. Generally, premedical students are free to choose a major in any field. However, they must complete specific courses such as biology, chemistry, organic chemistry, and physics. These courses are necessary for adequate preparation for the Medical College Admission Test (MCAT). Requirements are expected to change. The MR5 Committee, which is responsible for changes to the MCAT, has created a new set of core competencies required for success in medical education. These include molecular genetics, biochemistry, and concepts of multicultural sensitivity, ethics, and philosophy.2 However, these changes have not yet been instituted. Current premedical course requirements lead most premedical students to complete a major in the scientific realm. However, current trends do indicate that in recent years students with humanities background are becoming a more significant portion of the applicant pool.5
& Volume 25, Number 1, January 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
35
The Journal of Craniofacial Surgery
Gishen et al
In recent years, the premedical curriculum has come under criticism. Many suggest that the traditional premedical requirements lack clinical significance. It cannot keep up with the current rate of scientific advancement. These opponents have suggested that information technology undermines the need to memorize large amounts of information. The current framework discourages lifelong learning. The number of premedical students has increased from 34,860 in 2001 to 45,266 in 2012. The mean total MCAT score has jumped from 26.8 to 28.3. Students have become embroiled in a competitive quest for high grades, constricting creative thinking, collaboration, and appropriate professional behavior.6
‘‘Flexner’s proposals for more structured curricula were right for his era and revolutionized the teaching, investigation, and practice of medicine. But we have failed him by allowing premedical curricula to ossify despite advances in science, clinical practice, and technology. Our times, too, require the objectivity, commitment, and courage to pursue better ways of preparing students for careers in medicine and biomedical science.’’7
MEDICAL SCHOOL Medical school typically follows a 4-year track. The first 2 years serve as the preclinical years, during which time students learn the basic sciences through lecture-based learning. Organization and methodology of the medical curriculum have adapted over time. In the traditional format of medical education, students complete individual course blocks for the various disciplines. These include anatomy, biochemistry, pathology, and physiology. In an organ systemYbased approach, which is becoming more prevalent, course
& Volume 25, Number 1, January 2014
blocks are organized into modules that integrate subject matter from the various basic science disciplines that are relevant to the specific organ system.8 Many medical schools incorporate clinical activities during these years; however, the bulk of the clinical experience begins during the third year (Table 1). Students complete core clerkships in fields such as internal medicine and surgery. In addition, they may participate in elective clerkships that can be completed at the student’s home institution or as ‘‘externships’’ at outside institutions. If a student is interested in a particular field, he/she may complete a subinternship at the end of the third year or during the fourth year. Students will often decisively identify their area of interest during these clinical years. Students interested in plastic surgery often demonstrate this interest relatively early in their career to develop a competitive application for residency acceptance. Medical students generally begin their career-specific education by completing a rotation with the plastic surgery service at their home institution. During this time, they will scrub in operative cases, learn about preoperative and postoperative management of plastic surgery patients, and attend conferences, lectures, and grand rounds. Thereafter, these students should generally complete 1 or more plastic surgery externships. These may serve to enhance the student’s fundamental knowledge of this specific area of medicine. It may also provide an opportunity to work in a different health care setting. Externships can serve as an extended interview. Matching into an integrated plastic surgery position has become increasingly more competitive. Completing externships is an important element for a successfully matched candidate. Some institutions mandate externships at their institution as integral to the application process. Matching into a combined or integrated plastic surgery position has become a highly competitive process, with 203 applicants applying for 116 positions in 2013.9 Another important aspect of ‘‘getting to know’’ you at your home institution is to develop a relationship with a mentor. This can be an invaluable educational relationship. In addition to pursuing their medical doctorate degree, medical students with certain career goals pursue joint degrees to further enhance their education and application. While some medical students take a leave of absence to complete the second degree, many medical schools offer joint degree programs to accommodate these students. Students interested in a career focused in research typically pursue joint MD/PhD degrees. Through these programs, students first complete 2 or 3 years of medical school, then complete their PhD, and then return to medical school to finish their MD degree.10 The MD/MBA degree is generally a 5-year program. During this
TABLE 1. Abbreviations of Educational Organizations and Medical Certification Examinations AAMC
AMA
ACGME
RRC MCAT
USMLE Board certification examinations
36
The Association of American Medical Colleges is responsible for the American Medical College Application Service and the Electronic Residency Application Service. This nonprofit organization incorporates 141 accredited US and 17 accredited Canadian medical schools, 400 teaching hospitals, 51 Department of Veterans Affairs medical centers, and 90 scientific societies. The organization’s stated goal is ‘‘to improve education, research, and patient care activities.’’21 The American Medical Association strives to improve outcomes for patients, reduce health care costs, create a sustainable health care system, and support medical students. The AMA supports legislation that is beneficial to health care and raises funds for medical education. About 15% or 217,490 of US physicians are members of the AMA.22 The Accreditation Council for Graduate Medical Education accredits 9200 residency education programs, ensuring that they meet specified educational guidelines. Established in 1981, the ACGME manages training for MD physicians. By 2015, the ACGME will also direct the Unified Accreditation System for MDs and DOs.23 Specialty-specific resident review committees develop the accreditation standards for each specialty.23 The MCAT is a standardized examination for premedical students that evaluates a candidate’s problem-solving ability and scientific knowledge. Since 2007, the examination has been computer based. Scored out of 45 points, the average score in 2012 was 25.2.24 The US Medical Licensing Examination is a 3-step examination series that tests for the ability to apply scientific knowledge and perform patient-centered skills. To practice medicine, a physician must pass all 3-step examinations.25 Board certification for a particular medical specialty is either a written, practical, or simulator-based test that determines the eligibility of a physician to practice medicine.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
time, students pursue an MBA degree to gain a better understanding of the business aspects of medicine.11 This additional degree can be useful for students planning a career in private practice or in health care administration. The MD/MPH degree provides students with an understanding of health policy, health care systems, and epidemiology.12 These students can then utilize the population sciences from their MPH training to shape health care policies to enhance disease prevention. Another current trend in medical education has been an increasing emphasis on primary care. With a growing demand for and projected deficits of primary care physician, medical education has placed an increased emphasis on training students in this field.13 One innovation intended to help address the growing need has been the emergence of 3-year medical education programs. Currently, 3 schools offer the accelerated program.14 Accelerating the curriculum entails mandatory summer courses and shortening breaks to meet the Liaison Committee on Medical Education requirement of 130 weeks of medical education.13 Of the 3 programs, which currently offer 3-year accelerated degrees, 2 of the programs are geared toward training primary care physicians.14 Students accepted into these programs commit to pursuing primary care residencies. Several universities are in the process of developing a new strategy for medical education. This innovative program combines traditional lectures with an interactive self-directed learning technique. This radical shift from traditional curriculum formats will allow students to learn information at an individual pace. The reason for this new approach is to deliver medical education to a wider group of upcoming physicians more effectively and efficiently. This program intends divide physiology, pathology, and specific organ systems into short videos that can be viewed several times. Students will attend scheduled small-group, case-based learning sessions. Students will collaborate on cases early in their schooling. This teamwork is an essential skill for future medical professionals.
RESIDENCIES AND FELLOWSHIPS Upon completion of medical school, physicians enter a residency training program for continued education in a specialty of their choice. To standardize residency programs the ACGM, in 2007, outlined 6 core competencies upon which residents are to be evaluated: patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication (Table 2). This goal-oriented format of residency training has yielded improved performance on board examinations. It suggests that residents are better able to master the increasing quantity of information in their specialties and provide enhanced clinical care. To diminish the administrative challenges faced by program directors, the Accreditation Council for Graduate Medical Education began to reformat the accreditation system in 2009, resulting in the
Advances of Medical Education
Next Accreditation System.16 Next Accreditation System, beginning in 2013, will enhance the peer review system so that accreditation can be determined based on educational outcomes or milestones.16 It requires that the review committees of each specialty to complete yearly evaluations of resident testing methods and monitor resident preparedness throughout their training. It is expected that this system will better illuminate the deficient areas of education and allow for more rapid correction. Next Accreditation System will begin with emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urology. Specialties such as plastic and reconstructive surgery are expected to implement Next Accreditation System in July 2014.17 Plastic surgery has developed a standardized milestone project under the leadership of Dr. Mary McGrath, professor of plastic surgery at University of California, San Francisco. In the meantime, alterations have been made in plastic surgery residency programs to further the educational experience. The resident review committee for plastic surgery states that plastic surgeons should be competent in the areas of reconstruction and aesthetic alteration of the integument and underlying anatomical structures ranging from craniofacial structures to the extremities. To achieve this goal, residents can choose the independent model of training. This requires 3 years of plastic surgery training after completing the prerequisite training in a surgical field. Residents may instead elect to complete the integrated model. This requires 5 or 6 years of plastic surgery training following medical school. Under the supervision of the plastic surgery program director, 2 of the 6 years must be devoted to plastic surgery training. A third option, the combined program, has been eliminated as an option.18
CONTINUED EDUCATION On completion of residency, physicians undoubtedly continue their medical education through their daily practices. However, most states mandate continuing medical education. Among the states with continuing medical education requirements, the average number of annual credits required ranges from 12 to 50 State Medical Licensure.19 Credits can be earned through various activities such as attending lectures and conferences, online courses, podcasts, and reading journal articles with associated quiz questions.
RESOURCE ALLOCATION In January 2013, the American Medical Association announced the ‘‘Accelerating Change in Medical Education Initiative.’’20 Through the program, the AMA will be awarding $10 million in grants to promote continued innovation in medical education. From 119 medical schools applying for grants, the AMA selected 11 medical schools to receive funding. Two of the selected proposals were geared toward training primary care physicians. The University of California, Davis, School of Medicine was selected to set up a
TABLE 2. Six Core Competencies of Resident Training15 Patient care Medical knowledge Practice-based learning and improvement
Interpersonal and communication skills Professionalism
Systems-based practice
Residents must provide appropriate clinical care that is both effective and compassionate. Residents must have knowledge of clinical, behavioral, and biomedical sciences and must be able to apply this knowledge to patient care. Residents must evaluate the care provided to their patients and must continually aim to improve their skills by self-appraisal and learning. Residents are expected to participate in the education of other health care providers such as medical students and are required to use information technology to enhance their abilities and learning methods. Residents must be able to communicate information effectively and to work with health care teams as well as patients and their families Residents are compassionate physicians who fulfill their professional responsibilities while respecting patient privacy and autonomy, acting in accordance with ethical principals widely accepted by the medical field, and practicing medicine in a culturally sensitive manner. Residents must be able to efficiently work in all health care settings and incorporate the resources of the health care system into their care for patients. They should practice medicine in a cost-effective manner while advocating quality of care.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
37
The Journal of Craniofacial Surgery
Gishen et al
6-year program to include a 3-year accelerated medical program and a 3-year primary care residency. The Warren Alpert Medical School of Brown University received grants to establish an MD-MS program focused on primary care and population health. Also, among selected proposals was Indiana University School of Medicine, which received a grant to further electronic learning with the development of a virtual health care system and a training course for utilizing electronic medical records.20 For over 100 years, the American medical education system has produced some of the most well-respected physicians in the world. They have been at the forefront of scientific discovery and have revolutionized patient care. With large-scale changes being made to American health care, it is imperative that medical education at all levels remains dynamic. This is the only way we will be able to successfully and efficiently train physicians who can manage the current and future challenges of an evolving health care system.
REFERENCES 1. Field J. Some current trends in medical education. Bull Med Libr Assoc 1957;45:20Y29 2. American Medical Association. Historical Timeline. Available at: http:// www.ama-assn.org//ama/pub/about-ama/our-people/ama-councils/ council-medical-education/historical-timeline.page. Accessed August 11, 2013 3. Blumenthal D. New steam from an old cauldronVthe physician-supply debate. N Engl J Med 2004;350:1780Y1787 4. Washington Policy Center. The Looming Doctor Shortage. Available at: http://www.washingtonpolicy.org/sites/default/files/The-LoomingDoctor-Shortage-PN.pdf. Accessed August 11, 2013 5. American Association of Medical Collages. Table 18: MCAT and GPAs for Applicants and Matriculants to U.S. Medical Schools by Primary Undergraduate Major. Available at: https://www.aamc.org/download/ 321496/data/2012factstable18.pdf. Accessed August 11, 2013 6. American Association of Medical Collages. Table 17: MCAT Scores and GPAs for Applicants and Matriculants to U.S. Medical Schools, 2001Y2012. Available at: https://www.aamc.org/download/321494/data/ 2012factstable17.pdf. Accessed August 11, 2013 7. Muller D. Reforming premedical educationVout with the old, in with the new. N Engl J Med 2013;368:1567Y1569 8. Bandaranayake RC. The Integrated Medical Curriculum. London: Radcliffe, 2011 9. National Resident Matching Program. Results and Data 2013 Residency Match. Available at: www.nrmp.org/data/resultsanddata2013.pdf. Accessed August 7, 2013
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10. MD/PHD Program University of Miami Miller School of Medicine. Program Description & Sequence. Available at: http:// biomed.miami.edu/?p=284&s=96. Accessed August 7, 2013 11. University of Miami School of Business and Administration. University of Miami MD/MBA Program. Available at: http://www.bus.miami.edu/ graduate-programs/full-time-mba/md-mba/. Accessed August 7, 2013 12. University of Miami Miller School of Medicine. Graduate Programs in Public Health. Available at: http://publichealth.med.miami.edu/mph. Accessed August 7, 2013 13. Page L. New Three-Year Track Seeks to Boost Family Medicine, Reduce Student Debt; AAMC Reporter. Available at: https://www.aamc.org/ newsroom/reporter/october2012/308506/family-medicine.html/. Accessed December 9, 2013 14. Hartocollis A. N.Y.U. and Other Medical Schools Offer Shorter Course in Training, for Less Tuition. The New York Times. 2012:A16 15. American Association of Physicians of Indian Origin. ACGME Six Competencies. Available at: http://www.aapiusa.org/resources/acgmesix-competencies.aspx. Accessed August 11, 2013 16. Nasca T, Philibert I, Brigham T, et al. The next GME accreditation systemVrationale and benefits. N Engl J Med 2012;366:1051Y1056 17. Accreditation Council for Graduate Medical Education. Frequently Asked Questions about the Next Accreditation System. Available at: http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf. Accessed August 11, 2013 18. American Council of Academic Plastic Surgeons. Pathways to Plastic Surgery. Available at: http://acaplasticsurgeons.org/residency-resources/ Pathways-to-Plastic-Surgery.cgi. Accessed August 11, 2013 19. State Medical Licensure Requirements and Statistics. Continuing Medical Education for Licensure Registration. Available at: www.ama-assn.org/ama1/pub/upload/mm/40/table16.pdf. Accessed August 7, 2013 20. American Medical Association. Accelerating Change in Medical Education. Available at: http://www.ama-assn.org/sub/acceleratingchange/grant-projects.shtml. Accessed August 7, 2013 21. Association of American Medical Collages. About the AAMC. Available at: https://www.aamc.org/about/. Accessed August 11, 2013 22. Collier R. American Medical Association membership woes continue. CMAJ 2011;183:E713YE714 23. Accreditation Council for Graduate Medical Education. About ACGME. Available at: https://www.acgme.org/acgmeweb/tabid/116/About.aspx Accessed August 11, 2013 24. Association of American Medical Collages. About the MCAT Exam. Available at: https://www.aamc.org/students/applying/mcat/about/. Accessed August 11, 2013 25. USMLE United States Medical Licensing Examination. What is USMLE? Available at: http://usmle.org Accessed August 11, 2013
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Current Format and Ongoing Advances of Medical Education in the United States Kriya Gishen, BS, Steven Ovadia, BA, Samantha Arzillo, BS, BA, Yash Avashia, MD, and Seth R. Thaller, MD, DMD
Abstract: The objective of this study was to examine the current system of medical education along with the advances that are being made to support the demands of a changing health care system. American medical education must reform to anticipate the future needs of a changing health care system. Since the dramatic transformations to medical education that followed the publication of the Flexner report in 1910, medical education in the United States has largely remained unaltered. Today, the education of future physicians is undergoing modifications at all levels: premedical education, medical school, and residency training. Advances are being made with respect to curriculum design and content, standardized testing, and accreditation milestones. Fields such as plastic surgery are taking strides toward improving resident training as the next accreditation system is established. To promote more efficacious medical education, the American Medical Association has provided grants for innovations in education. Likewise, the Accreditation Council for Graduate Medical Education outlined 6 core competencies to standardize the educational goals of residency training. Such efforts are likely to improve the education of future physicians so that they are able to meet the future needs of American health care. Key Words: Advances in education, plastic surgery, educational reform, residency training, medical education, medical school (J Craniofac Surg 2014;25: 35Y38)
W
ith the establishment of the first American medical school at Johns Hopkins University in 1893, the foundations to a widely revered educational enterprise were initiated. The ‘‘Hopkins’’ model What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article.
From the Division of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Leonard Miller School of Medicine, Miami, Florida. Received August 25, 2013. Accepted for publication September 30, 2013. Address correspondence and reprint requests to Seth R. Thaller, MD, DMD, FACS, Division of Plastic, Aesthetic and Reconstructive Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami, Leonard Miller School of Medicine, Clinical Research Building (CRB), 1120 NW 14th St, Room 410, Miami, FL 33136; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/01.scs.0000436737.67665.ab
The Journal of Craniofacial Surgery
of a university affiliated with a teaching hospital was successfully imitated. However, there was little propensity for critical evaluations of its curriculum. The Hopkins formula was declared the ‘‘model for medical education’’ in the Flexner report. This urged all American medical schools to raise their graduation standards and to conform to a strict set of guidelines. The goal was to improve the quality of their teaching and research outcomes. This report heralded the notion that fewer physicians of superior quality were preferable. It subsequently led to the closing of hundreds of unregulated ‘‘proprietary’’ schools. It limited medical education, by advocating only ‘‘modern’’ forms of medicine. Also, it questions the validity of osteopathic and alternative medicine. Throughout the early part of the 20th century, efforts were made to standardize medical education and to adhere to the tenets of the Flexner report.1 By 1928, residency programs in hospitals were established. This was followed by the establishment of examining boards for the certification of specialists.2 In 1959, the Surgeon General Consultant Group on Medical Education produced the Bane Report. This led to a shortage of approximately 40,000 physicians.3 Between 1965 and 1980, the number of physicians graduating doubled to 18,200. This has remained stable until today.4 For the most part, the basic tenets of American medical education remained largely stagnant until 2006. The American Medical Association embarked on the Initiative to Transform Medical Education to optimize the Medical Education Learning Environment.2 With the health care system undergoing major fundamental changes, focus has shifted once again in medical education. The future of health care calls for improved and expanded primary care along with the necessity for a medical system that can support a growing population. These basic tenets must remain synchronized with the rapid evolution of science. For this reason, ‘‘the current period is one of vigorous and incisive reappraisal and evaluation of medical education, medical knowledge, and the significance of medicine as a factor in social well-being and development.’’1
UNDERGRADUATE EDUCATION Most medical education begins at the undergraduate level with a premedical curriculum. Generally, premedical students are free to choose a major in any field. However, they must complete specific courses such as biology, chemistry, organic chemistry, and physics. These courses are necessary for adequate preparation for the Medical College Admission Test (MCAT). Requirements are expected to change. The MR5 Committee, which is responsible for changes to the MCAT, has created a new set of core competencies required for success in medical education. These include molecular genetics, biochemistry, and concepts of multicultural sensitivity, ethics, and philosophy.2 However, these changes have not yet been instituted. Current premedical course requirements lead most premedical students to complete a major in the scientific realm. However, current trends do indicate that in recent years students with humanities background are becoming a more significant portion of the applicant pool.5
& Volume 25, Number 1, January 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
35
The Journal of Craniofacial Surgery
Gishen et al
In recent years, the premedical curriculum has come under criticism. Many suggest that the traditional premedical requirements lack clinical significance. It cannot keep up with the current rate of scientific advancement. These opponents have suggested that information technology undermines the need to memorize large amounts of information. The current framework discourages lifelong learning. The number of premedical students has increased from 34,860 in 2001 to 45,266 in 2012. The mean total MCAT score has jumped from 26.8 to 28.3. Students have become embroiled in a competitive quest for high grades, constricting creative thinking, collaboration, and appropriate professional behavior.6
‘‘Flexner’s proposals for more structured curricula were right for his era and revolutionized the teaching, investigation, and practice of medicine. But we have failed him by allowing premedical curricula to ossify despite advances in science, clinical practice, and technology. Our times, too, require the objectivity, commitment, and courage to pursue better ways of preparing students for careers in medicine and biomedical science.’’7
MEDICAL SCHOOL Medical school typically follows a 4-year track. The first 2 years serve as the preclinical years, during which time students learn the basic sciences through lecture-based learning. Organization and methodology of the medical curriculum have adapted over time. In the traditional format of medical education, students complete individual course blocks for the various disciplines. These include anatomy, biochemistry, pathology, and physiology. In an organ systemYbased approach, which is becoming more prevalent, course
& Volume 25, Number 1, January 2014
blocks are organized into modules that integrate subject matter from the various basic science disciplines that are relevant to the specific organ system.8 Many medical schools incorporate clinical activities during these years; however, the bulk of the clinical experience begins during the third year (Table 1). Students complete core clerkships in fields such as internal medicine and surgery. In addition, they may participate in elective clerkships that can be completed at the student’s home institution or as ‘‘externships’’ at outside institutions. If a student is interested in a particular field, he/she may complete a subinternship at the end of the third year or during the fourth year. Students will often decisively identify their area of interest during these clinical years. Students interested in plastic surgery often demonstrate this interest relatively early in their career to develop a competitive application for residency acceptance. Medical students generally begin their career-specific education by completing a rotation with the plastic surgery service at their home institution. During this time, they will scrub in operative cases, learn about preoperative and postoperative management of plastic surgery patients, and attend conferences, lectures, and grand rounds. Thereafter, these students should generally complete 1 or more plastic surgery externships. These may serve to enhance the student’s fundamental knowledge of this specific area of medicine. It may also provide an opportunity to work in a different health care setting. Externships can serve as an extended interview. Matching into an integrated plastic surgery position has become increasingly more competitive. Completing externships is an important element for a successfully matched candidate. Some institutions mandate externships at their institution as integral to the application process. Matching into a combined or integrated plastic surgery position has become a highly competitive process, with 203 applicants applying for 116 positions in 2013.9 Another important aspect of ‘‘getting to know’’ you at your home institution is to develop a relationship with a mentor. This can be an invaluable educational relationship. In addition to pursuing their medical doctorate degree, medical students with certain career goals pursue joint degrees to further enhance their education and application. While some medical students take a leave of absence to complete the second degree, many medical schools offer joint degree programs to accommodate these students. Students interested in a career focused in research typically pursue joint MD/PhD degrees. Through these programs, students first complete 2 or 3 years of medical school, then complete their PhD, and then return to medical school to finish their MD degree.10 The MD/MBA degree is generally a 5-year program. During this
TABLE 1. Abbreviations of Educational Organizations and Medical Certification Examinations AAMC
AMA
ACGME
RRC MCAT
USMLE Board certification examinations
36
The Association of American Medical Colleges is responsible for the American Medical College Application Service and the Electronic Residency Application Service. This nonprofit organization incorporates 141 accredited US and 17 accredited Canadian medical schools, 400 teaching hospitals, 51 Department of Veterans Affairs medical centers, and 90 scientific societies. The organization’s stated goal is ‘‘to improve education, research, and patient care activities.’’21 The American Medical Association strives to improve outcomes for patients, reduce health care costs, create a sustainable health care system, and support medical students. The AMA supports legislation that is beneficial to health care and raises funds for medical education. About 15% or 217,490 of US physicians are members of the AMA.22 The Accreditation Council for Graduate Medical Education accredits 9200 residency education programs, ensuring that they meet specified educational guidelines. Established in 1981, the ACGME manages training for MD physicians. By 2015, the ACGME will also direct the Unified Accreditation System for MDs and DOs.23 Specialty-specific resident review committees develop the accreditation standards for each specialty.23 The MCAT is a standardized examination for premedical students that evaluates a candidate’s problem-solving ability and scientific knowledge. Since 2007, the examination has been computer based. Scored out of 45 points, the average score in 2012 was 25.2.24 The US Medical Licensing Examination is a 3-step examination series that tests for the ability to apply scientific knowledge and perform patient-centered skills. To practice medicine, a physician must pass all 3-step examinations.25 Board certification for a particular medical specialty is either a written, practical, or simulator-based test that determines the eligibility of a physician to practice medicine.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
time, students pursue an MBA degree to gain a better understanding of the business aspects of medicine.11 This additional degree can be useful for students planning a career in private practice or in health care administration. The MD/MPH degree provides students with an understanding of health policy, health care systems, and epidemiology.12 These students can then utilize the population sciences from their MPH training to shape health care policies to enhance disease prevention. Another current trend in medical education has been an increasing emphasis on primary care. With a growing demand for and projected deficits of primary care physician, medical education has placed an increased emphasis on training students in this field.13 One innovation intended to help address the growing need has been the emergence of 3-year medical education programs. Currently, 3 schools offer the accelerated program.14 Accelerating the curriculum entails mandatory summer courses and shortening breaks to meet the Liaison Committee on Medical Education requirement of 130 weeks of medical education.13 Of the 3 programs, which currently offer 3-year accelerated degrees, 2 of the programs are geared toward training primary care physicians.14 Students accepted into these programs commit to pursuing primary care residencies. Several universities are in the process of developing a new strategy for medical education. This innovative program combines traditional lectures with an interactive self-directed learning technique. This radical shift from traditional curriculum formats will allow students to learn information at an individual pace. The reason for this new approach is to deliver medical education to a wider group of upcoming physicians more effectively and efficiently. This program intends divide physiology, pathology, and specific organ systems into short videos that can be viewed several times. Students will attend scheduled small-group, case-based learning sessions. Students will collaborate on cases early in their schooling. This teamwork is an essential skill for future medical professionals.
RESIDENCIES AND FELLOWSHIPS Upon completion of medical school, physicians enter a residency training program for continued education in a specialty of their choice. To standardize residency programs the ACGM, in 2007, outlined 6 core competencies upon which residents are to be evaluated: patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication (Table 2). This goal-oriented format of residency training has yielded improved performance on board examinations. It suggests that residents are better able to master the increasing quantity of information in their specialties and provide enhanced clinical care. To diminish the administrative challenges faced by program directors, the Accreditation Council for Graduate Medical Education began to reformat the accreditation system in 2009, resulting in the
Advances of Medical Education
Next Accreditation System.16 Next Accreditation System, beginning in 2013, will enhance the peer review system so that accreditation can be determined based on educational outcomes or milestones.16 It requires that the review committees of each specialty to complete yearly evaluations of resident testing methods and monitor resident preparedness throughout their training. It is expected that this system will better illuminate the deficient areas of education and allow for more rapid correction. Next Accreditation System will begin with emergency medicine, internal medicine, neurologic surgery, orthopedic surgery, pediatrics, diagnostic radiology, and urology. Specialties such as plastic and reconstructive surgery are expected to implement Next Accreditation System in July 2014.17 Plastic surgery has developed a standardized milestone project under the leadership of Dr. Mary McGrath, professor of plastic surgery at University of California, San Francisco. In the meantime, alterations have been made in plastic surgery residency programs to further the educational experience. The resident review committee for plastic surgery states that plastic surgeons should be competent in the areas of reconstruction and aesthetic alteration of the integument and underlying anatomical structures ranging from craniofacial structures to the extremities. To achieve this goal, residents can choose the independent model of training. This requires 3 years of plastic surgery training after completing the prerequisite training in a surgical field. Residents may instead elect to complete the integrated model. This requires 5 or 6 years of plastic surgery training following medical school. Under the supervision of the plastic surgery program director, 2 of the 6 years must be devoted to plastic surgery training. A third option, the combined program, has been eliminated as an option.18
CONTINUED EDUCATION On completion of residency, physicians undoubtedly continue their medical education through their daily practices. However, most states mandate continuing medical education. Among the states with continuing medical education requirements, the average number of annual credits required ranges from 12 to 50 State Medical Licensure.19 Credits can be earned through various activities such as attending lectures and conferences, online courses, podcasts, and reading journal articles with associated quiz questions.
RESOURCE ALLOCATION In January 2013, the American Medical Association announced the ‘‘Accelerating Change in Medical Education Initiative.’’20 Through the program, the AMA will be awarding $10 million in grants to promote continued innovation in medical education. From 119 medical schools applying for grants, the AMA selected 11 medical schools to receive funding. Two of the selected proposals were geared toward training primary care physicians. The University of California, Davis, School of Medicine was selected to set up a
TABLE 2. Six Core Competencies of Resident Training15 Patient care Medical knowledge Practice-based learning and improvement
Interpersonal and communication skills Professionalism
Systems-based practice
Residents must provide appropriate clinical care that is both effective and compassionate. Residents must have knowledge of clinical, behavioral, and biomedical sciences and must be able to apply this knowledge to patient care. Residents must evaluate the care provided to their patients and must continually aim to improve their skills by self-appraisal and learning. Residents are expected to participate in the education of other health care providers such as medical students and are required to use information technology to enhance their abilities and learning methods. Residents must be able to communicate information effectively and to work with health care teams as well as patients and their families Residents are compassionate physicians who fulfill their professional responsibilities while respecting patient privacy and autonomy, acting in accordance with ethical principals widely accepted by the medical field, and practicing medicine in a culturally sensitive manner. Residents must be able to efficiently work in all health care settings and incorporate the resources of the health care system into their care for patients. They should practice medicine in a cost-effective manner while advocating quality of care.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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6-year program to include a 3-year accelerated medical program and a 3-year primary care residency. The Warren Alpert Medical School of Brown University received grants to establish an MD-MS program focused on primary care and population health. Also, among selected proposals was Indiana University School of Medicine, which received a grant to further electronic learning with the development of a virtual health care system and a training course for utilizing electronic medical records.20 For over 100 years, the American medical education system has produced some of the most well-respected physicians in the world. They have been at the forefront of scientific discovery and have revolutionized patient care. With large-scale changes being made to American health care, it is imperative that medical education at all levels remains dynamic. This is the only way we will be able to successfully and efficiently train physicians who can manage the current and future challenges of an evolving health care system.
REFERENCES 1. Field J. Some current trends in medical education. Bull Med Libr Assoc 1957;45:20Y29 2. American Medical Association. Historical Timeline. Available at: http:// www.ama-assn.org//ama/pub/about-ama/our-people/ama-councils/ council-medical-education/historical-timeline.page. Accessed August 11, 2013 3. Blumenthal D. New steam from an old cauldronVthe physician-supply debate. N Engl J Med 2004;350:1780Y1787 4. Washington Policy Center. The Looming Doctor Shortage. Available at: http://www.washingtonpolicy.org/sites/default/files/The-LoomingDoctor-Shortage-PN.pdf. Accessed August 11, 2013 5. American Association of Medical Collages. Table 18: MCAT and GPAs for Applicants and Matriculants to U.S. Medical Schools by Primary Undergraduate Major. Available at: https://www.aamc.org/download/ 321496/data/2012factstable18.pdf. Accessed August 11, 2013 6. American Association of Medical Collages. Table 17: MCAT Scores and GPAs for Applicants and Matriculants to U.S. Medical Schools, 2001Y2012. Available at: https://www.aamc.org/download/321494/data/ 2012factstable17.pdf. Accessed August 11, 2013 7. Muller D. Reforming premedical educationVout with the old, in with the new. N Engl J Med 2013;368:1567Y1569 8. Bandaranayake RC. The Integrated Medical Curriculum. London: Radcliffe, 2011 9. National Resident Matching Program. Results and Data 2013 Residency Match. Available at: www.nrmp.org/data/resultsanddata2013.pdf. Accessed August 7, 2013
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10. MD/PHD Program University of Miami Miller School of Medicine. Program Description & Sequence. Available at: http:// biomed.miami.edu/?p=284&s=96. Accessed August 7, 2013 11. University of Miami School of Business and Administration. University of Miami MD/MBA Program. Available at: http://www.bus.miami.edu/ graduate-programs/full-time-mba/md-mba/. Accessed August 7, 2013 12. University of Miami Miller School of Medicine. Graduate Programs in Public Health. Available at: http://publichealth.med.miami.edu/mph. Accessed August 7, 2013 13. Page L. New Three-Year Track Seeks to Boost Family Medicine, Reduce Student Debt; AAMC Reporter. Available at: https://www.aamc.org/ newsroom/reporter/october2012/308506/family-medicine.html/. Accessed December 9, 2013 14. Hartocollis A. N.Y.U. and Other Medical Schools Offer Shorter Course in Training, for Less Tuition. The New York Times. 2012:A16 15. American Association of Physicians of Indian Origin. ACGME Six Competencies. Available at: http://www.aapiusa.org/resources/acgmesix-competencies.aspx. Accessed August 11, 2013 16. Nasca T, Philibert I, Brigham T, et al. The next GME accreditation systemVrationale and benefits. N Engl J Med 2012;366:1051Y1056 17. Accreditation Council for Graduate Medical Education. Frequently Asked Questions about the Next Accreditation System. Available at: http://www.acgme-nas.org/assets/pdf/NASFAQs.pdf. Accessed August 11, 2013 18. American Council of Academic Plastic Surgeons. Pathways to Plastic Surgery. Available at: http://acaplasticsurgeons.org/residency-resources/ Pathways-to-Plastic-Surgery.cgi. Accessed August 11, 2013 19. State Medical Licensure Requirements and Statistics. Continuing Medical Education for Licensure Registration. Available at: www.ama-assn.org/ama1/pub/upload/mm/40/table16.pdf. Accessed August 7, 2013 20. American Medical Association. Accelerating Change in Medical Education. Available at: http://www.ama-assn.org/sub/acceleratingchange/grant-projects.shtml. Accessed August 7, 2013 21. Association of American Medical Collages. About the AAMC. Available at: https://www.aamc.org/about/. Accessed August 11, 2013 22. Collier R. American Medical Association membership woes continue. CMAJ 2011;183:E713YE714 23. Accreditation Council for Graduate Medical Education. About ACGME. Available at: https://www.acgme.org/acgmeweb/tabid/116/About.aspx Accessed August 11, 2013 24. Association of American Medical Collages. About the MCAT Exam. Available at: https://www.aamc.org/students/applying/mcat/about/. Accessed August 11, 2013 25. USMLE United States Medical Licensing Examination. What is USMLE? Available at: http://usmle.org Accessed August 11, 2013
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
