Managed medical education?

The forces of rationality and commodification, hallmarks of the managed care revolution, may soon breach the walls of organized medical education. Whispers are beginning to circulate that the cost of educating future physicians is too high. Simultaneously, managed care companies are accusing medical education of turning out trainees unprepared to practice in a managed care environment. Changes evident in other occupational and service delivery sectors of U.S. society as diverse as pre-college education and prisons provide telling insights into what may be in store for medical educators. Returning to academic medicine, the author reflects that because corporate managed care is already established in teaching hospitals, and because managed research (e.g., corporate-sponsored and -run drug trials, for-profit drug-study centers, and contract research organizations) is increasing, managed medical education could become a reality as well. Medical education has made itself vulnerable to the intrusion of corporate rationalizers because it has failed to professionalism at core of its curricula-something only it is able to do--and instead has focused unduly on the transmission of esoteric knowledge and core clinical skills, a process that can be carried out more efficiently, more effectively, and less expensively by other players in the medical education marketplace such as Kaplan, Compass, or the Princeton Review. The author explains why reorganizing medical education around professional values is crucial, why the AAMC's Medical School Objectives Project offers guidance in this area, why making this change will be difficult, and why medical education must lead in establishing how to document the presence and absence of such qualities as altruism and dutifulness and the ways that appropriate medical education can foster these and similar core competencies. "Anything less and organized medicine will acknowledged... that it has abandoned its social contract and entered the temple of those who clamor, 'I can name that tune in four notes.'"

Preparing the ground: contributions of the preclinical years to medical education for care near the end of life. Working Group on the Pre-clinical Years of the National Consensus Conference on Medical Education for Care Near the End of Life.

The preclinical years of medical education have rich potential for preparing medical students to provide optimal end-of-life care. Most of the opportunities and settings for this education already exist in the curricula of most medical schools, although they are underutilized for this purpose. In this report The Working Group on the Pre-clinical Years of the National Consensus Conference on Medical Education for Care Near the End of Life identifies the most promising settings and suggests how they might be used for maximum benefit in end-of-life education. Basic end-of-life care competencies are in five domains: (1) psychological, sociologic, cultural, and spiritual issues; (2) interviewing and communication skills; (3) management of common symptoms; (4) ethical issues; and (5) self-knowledge and self-reflection. A centralized group should oversee educational activities related to end-of-life care at each medical school. This group would identify and facilitate teaching opportunities in the preclinical curriculum: basic science courses; problem-based learning seminars; courses in interviewing, the doctor-patient relationship, and introduction to clinical medicine; courses in ethics, humanities, and the social-behavioral sciences; clinical preceptorships; and longitudinal experiences with patients. The group would also assess the potential impact of the "hidden curriculum."

Beyond curriculum reform: confronting medicine's hidden curriculum.

Throughout this century there have been many efforts to reform the medical curriculum. These efforts have largely been unsuccessful in producing fundamental changes in the training of medical students. The author challenges the traditional notion that changes to medical education are most appropriately made at the level of the curriculum, or the formal educational programs and instruction provided to students. Instead, he proposes that the medical school is best thought of as a "learning environment" and that reform initiatives must be undertaken with an eye to what students learn instead of what they are taught. This alternative framework distinguishes among three interrelated components of medical training: the formal curriculum, the informal curriculum, and the hidden curriculum. The author gives basic definitions of these concepts, and proposes that the hidden curriculum needs particular exploration. To uncover their institution's hidden curricula, he suggests that educators and administrators examine four areas: institutional policies, evaluation activities, resource-allocation decisions, and institutional "slang." He also describes how accreditation standards and processes might be reformed. He concludes with three recommendations for moving beyond curriculum reform to reconstruct the overall learning environment of medical education, including how best to move forward with the Medical School Objectives Project sponsored by the AAMC.

Characteristics of the informal curriculum and trainees' ethical choices.

In October 1995, the Association of American Medical Colleges held its first Conference on Students' and Residents' Ethical and Professional Development. In a plenary session and break-out sessions, the 150 participants, representing a wide variety of medical and professional specialties and roles, discussed the factors and programs that affect medical trainees' development of ethical and professional standards of behavior. The main challenge of addressing students' professional development is the enormous range of influences on that development, many of which, such as the declines in civic responsibility and good manners throughout the United States, fall outside the scope of academic medicine. Nonetheless, many influences fall within reach of medical educators. In a pre-conference survey, participants ranked eight issues related to graduating ethical physicians. The respondents ranked highest the inadequacy of the understanding of how best to influence students' ethical development, followed by faculty use of dehumanizing coping mechanisms, and the "business" of medicine's taking precedence over academic goals. The plenary speakers discussed the "informal curriculum" and the "hidden curriculum" and the need for medical faculty to take seriously the great influence they have on students' and residents' moral and professional development as they become physicians. Whether consciously or not, medical education programs are producing physicians who do not meet the ethical standards the profession has traditionally expected its members to meet. In three series of break-out sessions, the participants analyzed the nature of the ethical dilemmas that medical students and residents face from virtually the first day of their training, the use of role playing in promoting ethical development, and ways to improve policies and overcome barriers to change.

Professional dynamics and the changing nature of medical work.

The organization and delivery of health care in the United States is undergoing significant social, organizational, economic, political, and cultural changes with important implications for the future of medicine as a profession. This essay will draw upon some of these changes and briefly review major sociological writings on the nature of medicine's professional status to examine the nature of professional dynamics in a changing environment. To this end, we focus on the nature of medical work and how this work impacts on and is impacted by medicine's own internal differentiation and the presence of contested domains at medicine's periphery. We trace this dynamic through a number of issues including the multidimensional nature of medical work, the role of elites in that work, and how changes in the terms and conditions of work can exert changes at medicine's technical core. We close with some thoughts on the relationship of public policy to medicine's professional status, the role health policy might take in shaping a new professional status, the role health policy might take in shaping a new professional ethnic for medicine, and the role sociologists might play in this process.

The hidden curriculum, ethics teaching, and the structure of medical education.

The authors raise questions regarding the wide-spread calls emanating from lay and medical audiences alike to intensify the formal teaching of ethics within the medical school curriculum. In particular, they challenge a prevailing belief within the culture of medicine that while it may be possible to teach information about ethics (e.g., skills in recognizing the presence of common ethical problems, skills in ethical reasoning, or improved understanding of the language and concepts of ethics), course material or even an entire curriculum can in no way decisively influence a student's personality or ensure ethical conduct. To this end, several issues are explored, including whether medical ethics is best framed as a body of knowledge and skills or as part of one's professional identity. The authors argue that most of the critical determinants of physician identity operate not within the formal curriculum but in a more subtle, less officially recognized "hidden curriculum." The overall process of medical education is presented as a form of moral training of which formal instruction in ethics constitutes only one small piece. Finally, the authors maintain that any attempt to develop a comprehensive ethics curriculum must acknowledge the broader cultural milieu within which that curriculum must function. In conclusion, they offer recommendations on how an ethics curriculum might be more fruitfully structured to become a seamless part of the training process.

The evolution of medicine as a profession. A 75-year perspective.

The profession of medicine has changed dramatically in 75 years. Despite the commitment of individual practitioners to the highest ideals of professionalism, the profession itself has lost privilege, power, and public reputation. It has been toppled from the high moral ground of professionalism. This has happened not so much because individual clinicians have abandoned that ground, but largely because others have occupied it--primarily complex organizations that have developed public mandates to regulate and oversee health care. The issue is not one of unfeeling physicians--it is one of a health care system that has evolved so as to limit medicine's autonomy. This changing system places new constraints and pressures on the physician-patient relationship. The question we are left with is whether medicine can regain its professionalism. How do we reform a system that, by its complexity, has become amoral? The only way is for physicians to re-assume a stout position of advocacy--advocacy for individual patients in a complex and frightening system of care, advocacy for patients as a class of people in a political system that seeks to restrict care, advocacy for patients in a world of environmental and epidemic threats. Such advocacy requires an equally strong moral commitment to the principles of service. Acting in the patient's best interest is not enough. It requires that the profession avoid the appearance of blatant self-interest at every turn. It requires a revised commitment to political activism in the interest of service to patients as a community. The costs are extremely high--but the alternative, physicians-as-technicians and medicine as a slave to corporate and government interests, is hardly acceptable.

Anticipating the future: a national survey of family practice residency directors.

The directors of family practice residencies were surveyed to measure the effect on family practice of the multitude of recent changes in medical organization and practice. The survey achieved a response rate of 80% (N = 306) and revealed that 90% of program directors were generally optimistic about the current status and future vigor of the specialty. Of the respondents, 72% expressed positive opinions regarding the effects of HMOs, and 93% perceived sufficient availability of practice opportunities. Due in large part to these perceptions, only 11% supported a proposal to combine family practice and internal medicine residencies. Teachers of family medicine are encouraged to pass along these measures of positive growth and optimism to medical students considering the specialty of family practice.

Medical students view family practice.

All students at the University of Minnesota, Duluth, School of Medicine responded to a 65-item questionnaire about their perceptions of changes facing medicine, the future of family practice, and career choices. Three different orientations toward family practice were identified--"stayers," "defectors," and "potential defectors." Students who had abandoned their original preference for family medicine (defectors) were compared with students who had maintained an interest in family medicine (stayers). Defectors anticipated a diminishing clinical role for future family practitioners, expressed doubt about the financial viability of smaller community based family practices, and explicitly linked concerns about their anticipated debt load to their changes in career preferences. This study also identified a subgroup of "potential defector" students (within the stayer cohort) who maintained an interest in family practice but evidenced concerns similar to the defector students. Implications of these findings for the future supply of primary care physicians for rural and traditionally underserved communities are discussed.

Theories at the crossroads: a discussion of evolving views on medicine as a profession.

The widespread perception that medicine is undergoing significant changes in its social position and professional status is of sociological importance not only for understanding medicine's own construction of reality, but also for assessing a general sociological theory of the profession. How a profession maintains its status is reflected in the ways a dominant paradigm (professional dominance) responds to challenges from alternative concepts (deprofessionalization, proletarianization). Cross-national case studies of the position of physicians tend to reaffirm the dominant status of Freidson's paradigm. But research based on empirically verifiable data is needed to clarify further debate about the dominance of the medical profession.

Pelvic laparotomy without an indwelling catheter. A retrospective review of 949 cases.

A retrospective review of 949 cases of pelvic laparotomy without an indwelling catheter was conducted. Contrary to traditional beliefs, this study found that the use of an indwelling catheter was not necessary to assure either adequate exposure during operation or satisfactory voiding in the postoperative period. Various prophylactic steps included staff attention to the preoperative and postoperative voiding needs of patients and occasional bladder needling during operation. These efforts resulted in a low (22.1%) postoperative distress catheterization rate with no complications if needling was done. Urinary infection rates ranged from less than 1% for patients who did not require distress catheterization to 3.9% for a comparative population of patients who had an indwelling catheter during and after operation. Abstaining from the use of an indwelling catheter was also associated with lower cost and greater patient satisfaction.

A look by medical students at medical practice in the future.

Ninety-six first- and second-year students (97 percent) at the University of Minnesota, Duluth, School of Medicine responded to a questionnaire on their career choices and their perceptions of changes in the organization and financing of medical care. Their responses indicated a great deal of student concern regarding the future of medical practice. Overall, the students were the most concerned about a perceived loss of practice autonomy and inadequate financial rewards. In the face of these perceptions, the students reported changes in career preferences: from smaller to larger communities, from solo or partnership arrangements to group practice settings, and from generalist to specialist practices. A student's anticipated debt level was the most important predictor of whether the student changed career goals.

Educational strategies for targeted retention of nonphysician health care providers.

This study examined the impact of a community-based, totally decentralized training program on the likelihood that graduates would establish their first practice within predefined and limited geographic regions. We found that when students in a physician assistant/nurse practitioner program received their preclinical and terminal training (preceptorship) in a region geographically proximate to their home residence, the likelihood that they would establish their first practice in that region was greatly increased. Similar results were found for students who took their preclinical training away from their home region but returned there for terminal training. Three additional training pathways were identified as being associated with markedly lower rates of regionally based graduate retention. Discriminant analysis was used to compare the relative impact of training and personal variables on retention. The educational process itself was found to be the single most important predictor of graduate retention. When structural variables were controlled, personal variables such as marital status, age, or sex had no predictive capabilities. With appropriate attention to the structural components of training--particularly terminal training (preceptorship)--experiences, PAs and NPs can be targeted to specific and relatively focused areas of medical need. These data suggest that several decentralized training strategies exist for physician assistants and nurse practitioners that would contribute to meeting health care delivery needs in chronically underserved areas.

Improved medical care for the elderly: intervening in medical education.

It is the premise of this paper that certain instructional interventions in the medical school behavioral science curriculum will eventually improve the health care received by elderly patients. Four content areas for such intervention are reviewed: patient adherence to medication regimens, risk and management of psychosocial stress, responses to chronic illness, and doctor-patient communication patterns. The final section describes research that supports the long-term efficacy of such curricular interventions.

The effect of decentralized education versus increased supply on practice location. Experience with physician assistants and nurse practitioners in California, 1972-1982.

To improve the geographic distribution of physician assistants and nurse practitioners in California, the Primary Care Associate Program established five community-based training sites in outlying areas while continuing to operate its core program within the San Francisco Bay Area. To evaluate this effort, the authors prospectively compared the employment locations of graduates from both groups, achieving a follow-up rate of 95%. Graduates from community sites were twice as likely to locate first practices outside the Bay Area (91% vs. 43%, P less than 0.05) and in towns with less than 10,000 inhabitants (33% vs. 16%, P less than 0.05). Over the decade, the percentage of graduates practicing outside the Bay Area rose from 0 to 9% for trainees both recruited from and entirely trained within the Bay Area versus 76-84 percent for trainees experiencing any element of decentralization. The slopes of these two lines represent the effect of the increasing supply of graduates on practice location away from Stanford (9%); the distance between the lines, the greater effect of decentralization (73%). Given the goal of statewide deployment of a small number of graduates, decentralization appears to have been an effective approach.