Medical education still evolving 100 years after Flexner report

Today's medical schools are focusing on patient safety and community-based care, and students are getting earlier exposure to clinical medicine.

By — Posted Oct. 4, 2010

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A century ago, droves of medical students sat in stark lecture halls to absorb hours of oration by physician instructors. Many students had no more than a high school education, and they were expected to memorize didactic descriptions of symptoms and diagnostic methods with little interaction with actual patients.

Medical education has undergone major changes since 1910, when educator Abraham Flexner published his evaluation of 155 medical schools in the U.S. and Canada. His report often is credited with having laid the groundwork for modern medical education, said Barbara Barzansky, PhD, director of the American Medical Association Division of Undergraduate Medical Education.

"We hear occasionally at least that medical education hasn't changed since Flexner, and 'Why doesn't medical education change?' Well, the answer is it does, and it has all the time," she told attendees at the New Horizons in Medical Education conference in Washington, D.C., Sept. 20-22, co-sponsored by the AMA and the Assn. of American Medical Colleges.

In the last decade, medical schools increasingly have incorporated technology and expanded instruction to simulated exam rooms, regional centers and clinical facilities, said M. Brownell Anderson, senior director of educational affairs for the AAMC.

New medical schools have opened, and existing medical schools have expanded and opened satellite campuses. There's an increased focus on community-based care, patient safety and global health, Anderson said.

Many medical students today are exposed to clinical training in their first year.

The New Horizons conference brought together about 300 health leaders and educators to discuss the changing face of medical education. The AMA and AAMC are committed to implementing positive ideas that resulted from conference discussions, AMA President Cecil B. Wilson, MD, said at the conference.

"It's our job to make sure future physicians are prepared to deliver nothing but absolute excellence in patient care," said Dr. Wilson, a Winter Park, Fla., internist. "Educational standards need to be refreshed, refined and improved as technology changes and the data fog thickens."

By bringing medical school officials together, the conference should serve as a catalyst for new advancements, said Susan Skochelak, MD, MPH, the AMA vice president of medical education. "The goal is to move the national dialogue beyond 'What do we need to do?' to 'How do we do what we need to do?' "

Evolution of education

A supplement in the September Academic Medicine highlights changes at medical schools throughout the U.S. and Canada during the past decade. It's a follow-up to a 2000 report.

The supplement emphasized an increased focus on interdisciplinary education, team- and community-based learning, and a growth in the use of simulation labs and standardized patients.

"Institutions are shifting their focus to evaluate students on competencies as well as on outcomes to ensure new physicians will be able to care for a variety of patients from diverse backgrounds and be able to adapt to an ever-changing health care environment," said AAMC President and CEO Darrell G. Kirch, MD.

Courses have expanded to include subjects such as patient safety and quality improvement, bioterrorism, geriatrics and health care disparities.

At Yale University School of Medicine in Connecticut, students in the "Power Dynamics in Medicine" program are introduced to the complicated power dynamics they will encounter in medical practice.

It's designed to get students thinking about how to use the authority they will have as physicians responsibly and make them aware of how others around them use or abuse authority, said Nancy Rockmore Angoff, MD, MPH, associate professor and associate dean for student affairs at the school.

Students from medicine, nursing and other health professions observe and discuss the power dynamics they see in the hospital during their training. "We all have [power], and we all can use it well or misuse it. If they think about it now, they will be aware of it as they go on in their career," Dr. Angoff said.

The University of South Florida College of Medicine in Tampa is among the schools that have expanded their programs to improve teaching students.

In 2006, it opened the Center for Advanced Clinical Learning, where students practice doing physical exams and diagnosing standardized patients in 12 model exam rooms. The program gives students a chance to present themselves professionally, improve communication skills and get direct feedback.

"It gives them a chance to practice in a safe zone so they can be really prepared," said Dawn Schocken, MPH, the center's director.

Earlier exposure to patients

At some schools, exposure to clinical medicine is starting sooner.

Beginning this year, first-year students at Dartmouth Medical School in New Hampshire get their first insights to clinical practice at orientation. They are introduced to a lung cancer patient who describes his symptoms. They are then broken into groups and told to make a diagnosis, said David W. Nierenberg, MD, Dartmouth's professor and senior associate dean for medical education.

Students listen as physician specialists discuss the patient's diagnosis and treatment options.

"Right away the students are confronted with 'What is wrong with this gentleman?' " said Dr. Nierenberg, section chief of clinical pharmacology and toxicology at Dartmouth-Hitchcock Medical Center. "We are really trying to get the students to jump in on day one and get them excited about a real patient."

First-year students are assigned a physician in the community who they shadow once or twice a week.

In addition, Dartmouth has integrated quality and safety into instruction. For example, Dr. Nierenberg teaches a pharmacology course aimed at improving effectiveness and efficiency of prescribing.

What students learn in medical school is key to improving the overall quality of health care, he said.

"We really want to turn out physicians who are going to be creative and knowledgeable," he said. "If change is going to happen, it's going to happen with individual physicians."

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A look back at Flexner

Medical education was changing when educator and scholar Abraham Flexner published his 1910 evaluation of 155 medical schools in the U.S. and Canada for the Carnegie Foundation for the Advancement of Teaching. His report built on previous efforts of several organizations, including the AMA Council on Medical Education and the AAMC. Among Flexner's recommendations:

  • Medical schools should require students to have studied biology, chemistry and physics at the college level before admission.
  • First-year curriculum should include lecture and laboratory instruction in anatomy, histology, embryology, physiology and biochemistry.
  • Second-year curriculum should include pharmacology, pathology, bacteriology and physical diagnosis.
  • Students should have access to hospitals and dispensaries where they can get supervised clinical experience.
  • Medical schools should have salaried faculty in both the basic and clinical sciences devoted to teaching and research.

Source: "Abraham Flexner and the era of medical education reform," Academic Medicine supplement, September (link)

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External links

"A snapshot of medical student education in the United States and Canada," Academic Medicine supplement, September (link)

"Abraham Flexner and the era of medical education reform," Academic Medicine supplement, September (link)

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