Like many aspects of health care, medical education evolves slowly. The modern curriculum is based on the Flexner Report — a review published in 1910. It hasn’t changed much since then.
It needs to.
As a medical student at Stanford, I’ve seen firsthand the limitations of today’s physician training. We can do better. Here are five reforms that I think would prepare doctors for medicine in the 21st century.
Teach skills, not just facts
Every medical school course list includes a slew of classes on physiology, pathology, and pharmacology. All important topics, but the emphasis on scientific information leaves physicians unprepared in a world where today’s facts may be outdated tomorrow.
Schools should instead teach students skills that we can deploy in a shifting landscape.
All students should graduate with a firm understanding of data science and statistics. The advent of electronic health records and the continued march of medical research have generated reams of data that physicians must be able to sift through, synthesize, and act upon. A strong quantitative background will help doctors understand and direct the continued development of precision medicine.
The same can be said for many technologies. For instance, telemedicine is increasingly ubiquitous in the clinical setting, but students receive no training on its applications and limitations. That must change if digital health tools are to reach their full potential.
Incorporate a “mini-MBA” into medical school
In addition to my medical degree, I am pursuing an MBA. I’m often asked why; isn’t 14 years of postsecondary medical training enough?
I would argue that the knowledge and skills developed in business school have never been more relevant. Many doctors are comically uninformed about issues surrounding cost and access. As the regulatory environment grows more complex, this limits physicians’ ability to provide the highest quality care, whether advising patients on cost-effective treatments, interacting with insurance companies, or running a practice.
Physicians would also benefit from dedicated leadership training. Health care is trending toward team-based care with a doctor managing nurses, pharmacists, social workers, and more, each of whom has a distinct role. At present, medical school teaches clinical decision making in silos. A mini-MBA would instill a new mindset.
Make room for new content
Critics of curricular reform often argue there’s no time to add this type of material. We can make time.
The first two years of medical school are typically “preclinical,” where students receive classroom-based instruction. However, courses are often redundant and a lot of what students learn could be covered in undergraduate prerequisites.
The second two years are “clinical,” during which students participate in patient care by rotating through various specialties. Rarely does this require two full years; at Stanford, rotations take approximately 16 months.
Four years of medical school provides enough time to teach what we currently learn and more. Several schools have experimented with condensed curricula without a negative impact on student performance. The saved time should be used to broaden our education.
Promote more than academic research
Alongside coursework, medical schools place a tremendous emphasis on student research, whether lab work or clinical. There are several proposed reasons for this emphasis — it improves critical thinking, stimulates curiosity, etc. — but it largely stems from tradition. Academic medical centers train physicians who are supposed to conduct research, even if it is at the expense of other pursuits.
But the role of a physician has changed over time. Doctors now play an integral part in management, policy, and entrepreneurial ventures, to name a few. It is time for the training system to recognize and promote work that advances medicine — whether or not it is published in a journal.
Nurture teachers who teach
One of the most memorable quotes I’ve heard in medical school came during a grand rounds discussion on education: “Academic physicians are paid to see patients and are promoted for their research. No one cares about teaching.”
In theory, doctors who work in teaching hospitals are instructors; working with students and residents is part of their job. In practice, physicians have little incentive to care about trainees. Of course, many doctors are excellent teachers. But that is by coincidence rather than design.
This incentive problem can lead to a corrosive and occasionally abusive culture. Medical trainees have high rates of burnout and suicide. A recent study found that nearly one-third of residents were depressed. A host of factors play a role, but a lack of effective mentorship and support almost certainly contributes.
Medical schools need to take steps to reward good teachers and help bad ones improve. Neurology is one of the highest rated rotations at Stanford. That is not by chance; the department chair reviews teaching evaluations with every attending and resident. Simply giving faculty a reason to care about teaching can dramatically improve the student experience.
Medicine is a dynamic field that mandates continual innovation and improvement. Medical education must be held to the same standard. These five reforms can help create a physician workforce equipped to meet the challenges of a new era.
Akhilesh Pathipati is a fourth-year student in Stanford’s MD/MBA program.
The only value I see in basic medical curricula is in clinical correlations. Medical students need to apply fundamental concepts to issues directly related to patient care. Listening to endless lectures that emphasize facts and terms and their associated theory predominantly delivered via PowerPoint, a tool that often oversimplifies rather than cultivating deep learning, provides medical students with only recognition rather than greater depth and understanding. Only by associating this knowledge to clinical knowledge will medical students truly understand what they are learning actually means.
No, medical education has changed drastically since the Flexner Report of 1910 which ended proprietary (paid) education in favor of a uniformly agreed upon knowledge-based curricula for medicine and the future teaching of it. The scientific advancements alone since 1910 have surpassed anyone’s best guestimates, and the new findings continue to do so more than 100 years later. As for the article, is any of the past knowledge relevant for the current or future practice of medicine? I proffer a contrary opinion to say, for the most part, yes; however, there’s validity to some of the topics touched upon by the author.
1. Teach what skills? Communication? Cultural? Computer-based? The “reams of data” generated are useless in dealing with patients. The pertinent “negatives” identified by the EMR are nothing more than billing tools–who in the hell would ever write a hand-written H&P with two to three pages of negatives? No one. Precision medicine / genetic or molecular profiling is a burgeoning field unto itself. This is good. The negatives, or speculative history, are not relevant here; treatment is based upon profiling of the current–testing replaces history or conjecture. As for telemedicine, it is generally specialty specific at this time and by no means a substitute for either questioning the patient face-to-face or laying hands on the patient, a lost art form.
2. The issue of business skills are relevant, but one needs to ask, to what extent? Chiropractors, as well as funeral directors, graduate with the minimum or necessary business skills needed to run their practices, and they do not receive an advanced degree unless it is pursued outside of the curriculum. Although one can say that a dual degree provides theoretical training, it does not provide experience. Hence, a newly minted MD-MBA is neither, for practical purposes. Even the top MBAs picked up by the major firms on Wall Street are taught the ways of the company that hires them before being put to use.
Not all graduates need an MBA degree, and not all graduates are either willing to do the required work or are inclined to do so during their lifetimes. It’s the experience that counts here, and that takes time.
Team-based care is a departure from the traditional “I run the ship” paradigm. Regardless of what method is used, one person must be in charge; teamwork in the medical profession is not a participatory democracy when it comes to patient care. One person must be in charge. Diluting this responsibility may have serious consequences that are often learned the hard way.
Physicians have always been leaders, leaders in patient care and patient advocacy. Those that can lead will do so, and others will follow. That is ok. Physician executives are poised to lead for the future, and we want our fellow physicians to follow with us for the benefit of us all. Should this even be a point of contention?
3. Of course new content needs to be introduced. Knowledge doubles at an ever-decreasing time interval. Will the content introduce be of benefit to those that employ it and will the patients also benefit? Right now, the academics may be able to answer this, but ultimately it will be the private practitioners in conjunction with the patients that will have the final say so in the usefulness. Those that enter medicine are likely to have a predisposition toward managerial or entrepreneurial characteristics already ingrained in them, and others will develop it with guidance. All will find their way.
4. Research is useful if that is your thing; if not, bag it, and let those so inclined to do it do it.
5. Interestingly not all of the so-called “Academics” are of the “those that can, do; those that can’t, teach” genre. Some are found almost strategically interspersed among our pathway to provide guidance and excellent counsel along the way—that is the nature of things, and it is good. As for improving those that are deficient, don’t waste your time—classic business doctrine says to move on in this situation and invest your time and resources in those that are producers.
You can also search the volunteer programs at https://www.abroaderview.org over 25 countries and 245 programs to choose from. From 1 week up to 12 weeks volunteering and internships. This way you can see other realities and apply what you learn abroad in your studies. Most programs will let you have hands on and allowe din the surgery sectioon and rotate in the different areas of hospital, clinics and rehabilitation centers.
I agree with many aspects, in fact I share some of those thoughts. I’ve bern teaching internal and pulmonary medicine for 16 years and I feel obsolete, my skills as a teacher are outdated for the reality of these times, of this medicine. I would like to know if you can share a general picture of Stanford’s pregraduate medical programm, it would be interesting. I work in a public university, the third best medical school in Mexico, but I think we are attached to the past
Will be citing this on my KHIT Blog. One glaring omission, no mention of the skill of “empathy.”
Going out on a limb here, but if you need an MBA to practice medicine, then the system is broken.
Why don’t you address the elephant in the room? Namely, that American doctors for some reason must first spend four years getting *other* degree, whereas those in the rest of the world can start at 18? Which is why doctors in i.e. the UK are totally incompetent and their patients get killed at alarming rates.
I do not know what these rankings are based on, maybe life span, infant mortality, that sort of thing, but this WHO study finds France best. Maybe our science education and medical education could trend more toward what France does? http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/
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