The Development of New MD-Granting Medical Schools in the United States in the 21st Century.

No new MD-granting medical schools were established during the 1980s and 1990s due to concerns that existed within the academic and policymaking communities that the United States was going to experience a major oversupply of physicians in the coming decades due to the increase that had occurred in medical school enrollment in the 1960s and 1970s. However, the results of studies conducted in the 1990s suggested that the country was actually going to experience a major shortage of physicians in the coming decades. As a result, new medical schools began to be established in the country after the turn of the 21st century. Since then, 29 new MD-granting medical schools have been established in the United States. This Invited Commentary examines some of the characteristics of the new schools and provides an overview of various factors that contributed to their development, including financial resources and geographic location.

Transforming Medical Education: Is Competency-Based Medical Education the Right Approach?

There is growing recognition within the medical education community that medical education in this country needs to be changed to better prepare doctors for the challenges they will face in providing their patients high-quality medical care. A competency-based medical education (CBME) approach was endorsed by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties approximately 15 years ago, and a self-designated group-the International Competency-Based Medical Education (ICBME) Collaborators-is now calling on members of the medical education community to join them in their effort to establish CBME as the approach to be used in transforming medical education, not only in the United States but also around the world.In response to an article in this issue by a group of ICBME Collaborators, the author argues that more evidence about the effectiveness of CBME is needed before a global shift to this approach is undertaken. It is time for major organizations and foundations that are committed to improving medical education to step forward and take the lead in partnering with the medical education community to conduct a critical evaluation of CBME. In addition, maintenance of certification, relicensure, and continuing medical education programs should be evaluated for their effectiveness in ensuring that physicians are clinically competent not only at the beginning of their career but also until the end.

Decreasing the length of residency training: a public policy perspective.

It is widely recognized that the United States is going to experience a serious shortage of physicians in the coming years unless the number of physicians completing residency training and entering practice is greatly increased. Members of the academic medicine community have approached this issue by calling on Congress to eliminate the cap that currently limits the number of residency positions that Medicare will support. Simply eliminating the cap, however, will not ensure an adequate supply of physicians. In this commentary the author argues that decreasing the length of training required in core clinical specialties will be required to effectively address the workforce shortage by allowing more residents to be trained in core specialties without greatly increasing the number of training programs and the aggregate amount that Medicare currently spends on graduate medical education.

Commentary: Meeting future medical care needs: a perfect storm on the horizon.

Recent studies indicate that the number of first-year residency positions must increase to meet the United States' projected need for physicians, but these studies rarely consider whether it will be possible to increase the country's graduate medical education system to meet the need. State-level studies suggest that most existing programs have already reached their approved capacity, and nonteaching hospitals are unlikely to create new programs because of the financial impact and their lack of faculty and staff who would meet accreditation standards as program directors and institutional officials. A perfect storm is therefore brewing: The effects of the Patient Protection and Affordable Care Act of 2010, the obesity epidemic, the rise in chronic disease, and the aging and continuing growth of the population will combine to create a much greater demand for medical services at the same time as the relative size of the physician workforce will begin to decline. Given the urgency of the situation, the author calls for medical professionals (with significant representation from the academic medicine community) to enter into meaningful partnerships with state and federal officials to develop strategies for addressing this challenge. They must work together to increase the number of entry-level positions to the level needed to produce the doctors required to meet the growing demand for medical care. Otherwise, the perfect storm will soon disrupt the U.S. health care system.

Commentary: Flexner Redux 2010: graduate medical education in the United States.

The author posits that if Abraham Flexner could be brought back to write a report to address the same question that his 1910 report answered-How are doctors being prepared for practice?-he would not focus on the state of medical students' education, because today's medical students no longer enter practice on graduation from medical school. Instead, he would ask how the country's graduate medical education (GME) system is preparing residents for clinical practice. Such a report is needed because (as concluded by a variety of sources, including recent reports by the Institute of Medicine) GME training must be changed as part of the effort to improve medical care quality. Despite this finding, professional organizations that regulate how GME is designed and conducted have been unwilling to make substantive changes in the ways residents are being prepared for practice. The author reviews the reasons for this, emphasizes the need for a new Flexner-type report to make the public aware of the training deficiencies so the public could exert pressure on government officials to take action, describes groups that have already recognized the problem and proposed solutions (such as having individual programs held accountable for their residents' performance in practice), and makes recommendations, such as (1) having the Medicare program, the single largest payer of GME costs, require certain needed reforms in residents' training, and (2) modernizing state laws so that residents completing training would have to demonstrate that they are adequately prepared to enter practice before being granted licenses.

Preparing the personal physician for practice (P(4)): meeting the needs of patients: redesign of residency training in family medicine.

Family medicine stands at a critical point in its history. To achieve a place of enhanced prominence within American medicine, the discipline must acknowledge the fundamental changes that have occurred in the country's health care system in recent decades and discard its historical attachment to the fundamental beliefs that led to the establishment of the specialty almost 40 years ago. If the discipline is to serve the most critical needs of the American public, family medicine residency programs must be redesigned to train family physicians who will be experts in the ambulatory care of patients with chronic disease. To accomplish this, family medicine residency programs should provide residents in training with a more concentrated experience in the care of such patients. The enhanced focus of training on education for chronic illness care can be accomplished within a 2-year training period by eliminating training requirements that are no longer relevant to the practice of family medicine in most communities.