BUILD­ING A BET­TER DOC­TOR

NEW AC­CRED­I­TA­TION STAN­DARDS, MED SCHOOL EN­TRY EXAM AND WORK-HOUR RULES CON­VERGE

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Med­i­cal ed­u­ca­tion re­form is ev­ery­where, but will the ef­fort im­prove pa­tient care?

New doc­tors in 2020 will have a good bed­side man­ner and work well with other care­givers while still pos­sess­ing the med­i­cal and tech­ni­cal skills to pro­vide ef­fec­tive pa­tient care. At least that’s the goal of a num­ber of re­forms of the med­i­cal ed­u­ca­tion sys­tem. Those re­forms be­gan in 2011 with lim­its on res­i­dent work hours and will con­tinue with a new ac­cred­i­ta­tion sys­tem for res­i­dency pro­grams and a new med­i­cal school en­trance exam. Also on the draw­ing board is a plan to de­velop co-train­ing pro­grams with other care­givers, in­clud­ing nurses and phar­ma­cists.

A two-year, phased re­struc­tur­ing of the na­tion’s physi­cian-train­ing pro­grams—which in­cludes fo­cus­ing on ed­u­ca­tion out­comes over process mea­sures—be­gins in July 2013. In 2015 med­i­cal school ap­pli­cants will start tak­ing a re­vised Med­i­cal Col­lege Ad­mis­sion Test that in­cludes new sec­tions on crit­i­cal anal­y­sis and rea­son­ing and the psy­cho­log­i­cal, so­cial and bi­o­log­i­cal foun­da­tions of be­hav­ior.

At the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges an­nual meet­ing last year, and again at a news con­fer­ence held this month to an­nounce the MCAT changes, the or­ga­ni­za­tion’s pres­i­dent and CEO, Dr. Dar­rell Kirch, cited a sur­vey the AAMC con­ducted in 2010 that found that 85% of the public thought med­i­cal schools were do­ing a good or ex­cel­lent job in ed­u­cat­ing new doc­tors in med­i­cal knowl­edge, but al­most onethird said they were do­ing only a fair or poor job at de­vel­op­ing their stu­dents’ bed­side man­ner.

As part of its plan to cor­rect this, the AAMC board ap­proved the MCAT re­vi­sions on Feb. 16. The changes to res­i­dency and grad­u­ate med­i­cal ed­u­ca­tion pro­grams were an­nounced in a spe­cial re­port posted on the New Eng­land Jour­nal of Medicine web­site Feb. 21. Dr. Thomas CEO of the Ac­cred­i­ta­tion

Nasca, Coun­cil for Grad­u­ate Med­i­cal Ed­u­ca­tion, said the con­ver­gence of these changes “is a lit­tle more than co­in­ci­dence, but a lot less than by de­sign.” Health­care ed­u­ca­tion lead­ers, he said, meet three or four times a year to dis­cuss is­sues and ac­tively look for so­lu­tions to com­mon prob­lems.

“It’s com­ing from dif­fer­ent or­ga­ni­za­tions,” Nasca said of the changes. “But what I think is in­ter­est­ing—and what I think speaks to the qual­ity of the com­mit­ment to this—is that they’re all go­ing in the same di­rec­tion.”

Nasca said the re­struc­tur­ing of med­i­cal school ac­cred­i­ta­tion re­moves small de­tails “that some might say mi­cro­man­age a pro­gram,” while main­tain­ing core ed­u­ca­tion el­e­ments. “We are cre­at­ing a sys­tem that al­lows GME pro­grams en­hanced flex­i­bil­ity and the abil­ity to in­no­vate,” he said, de­scrib­ing how this par­tic­u­lar re­form was a re­sponse to what over­bur­dened pro­gram ad­min­is­tra­tors re­quested, but that the col­lec­tive changes were a re­sponse by the ed­u­ca­tion com­mu­nity as a whole to what the public was ask­ing for.

Jorge Girotti, as­so­ci­ate dean and di­rec­tor of ad­mis­sions for the Univer­sity of Illi­nois Col­lege of Medicine in Chicago, agreed but said it may take a while to no­tice a dif­fer­ence in the physi­cian work­force. (The first doc­tors to take the test will en­ter the work­force in July 2020.)

“Will the exam change the na­ture of the ap­pli­cant pool? It’s too early to make that type of as­sess­ment,” Girotti said. It was hoped that

the ad­di­tion of a writ­ing sec­tion to the test back in 1991 could lead to more well-rounded ap­pli­cants who took English and lit­er­a­ture cour­ses to pre­pare them­selves for this por­tion of the test, Girotti noted.

The writ­ing sec­tion has been re­moved from the re­vised test. Girotti said the sec­tions took too long to read and were hard to judge in a fair, stan­dard­ized man­ner.

Adding be­hav­ioral and so­cial sci­ences to the MCAT will ac­com­plish the same goal, will be eas­ier to mea­sure, and will help ap­pli­cants bet­ter pre­pare, Girotti said.

“There’s a be­lief that, if you in­clude it in the MCAT, stu­dents will un­der­stand its im­por­tance and take it as part of their un­der­grad­u­ate course load,” he said, adding that at­tempts at broad­en­ing the ap­pli­cant pool to “non­tra­di­tional” pre-med ma­jors have not al­ways worked. “The AAMC has been pub­licly pro­mot­ing that an ap­pli­cant’s col­lege ma­jor is not as crit­i­cal (for ad­mis­sion), but that hasn’t swayed col­lege stu­dents” from fol­low­ing tra­di­tional pre-med paths.”

UIC re­ceived 7,400 ap­pli­cants for 300 po­si­tions this fall. Of those, Girotti said the rough break­down was that 60% ma­jored in bi­ol­ogy, chem­istry or bio­chem­istry; about 20% ma­jored in be­hav­ioral, eco­nomic, po­lit­i­cal or so­cial sci­ences; about 12% were en­gi­neer­ing ma­jors; and the rest ma­jored in hu­man­i­ties or some other non­science sub­ject.

Most stu­dents can com­plete grad­u­a­tion re­quire­ments for their ma­jors while in­cor­po­rat­ing med­i­cal school qual­i­fi­ca­tion re­quire­ments in four years, though en­gi­neer­ing stu­dents of­ten have dif­fi­culty in this re­gard be­cause their field has sub­stan­tial re­quire­ments of its own for grad­u­a­tion, Girotti said.

At the AAMC, Kirch has sug­gested one way to avoid stretch­ing out an un­der­grad ca­reer is for col­leges to de­velop cour­ses that sat­isfy mul­ti­ple re­quire­ments, and at UIC, Girotti said a neu­ro­science course has be­come very pop­u­lar, and it in­cludes in­struc­tion in both phys­i­cal and be­hav­ioral sci­ence.

Course cor­rec­tion

El­iz­a­beth Wi­ley, the Amer­i­can Med­i­cal Stu­dent As­so­ci­a­tion’s vice pres­i­dent for in­ter­nal af­fairs, grad­u­ated from Smith Col­lege in Northamp­ton, Mass., with a ma­jor in phi­los­o­phy and a mi­nor in women’s stud­ies, and is now at­tend­ing the Ge­orge Washington Univer­sity School of Medicine in Washington. She said she had to take some cour­ses af­ter grad­u­a­tion in or­der to meet all her med­i­cal school re­quire­ments (and she also earned a law de­gree and a mas­ter’s in public health pol­icy along the way.)

Wi­ley called the changes a step in the right di­rec­tion. One com­plaint she hears fre­quently from her friends who have gone on to res­i­dency Re­searchers asked par­tic­i­pants to rate the im­por­tance of sev­eral tasks for per­form­ing a job. Thirty min­utes later they asked par­tic­i­pants to rate the tasks again, but this time the tasks were paired with a ran­dom rat­ing. Par­tic­i­pants were told that rat­ings were av­er­ages pro­vided by their peers. Then, they asked par­tic­i­pants to rate the tasks again. Which of the fol­low­ing re­sults would you pre­dict when com­par­ing re­sults from the first and sec­ond rat­ing? Par­tic­i­pants rated tasks with: Lower “peer rat­ings” as more im­por­tant the sec­ond time. Mod­er­ate “peer rat­ings” as less im­por­tant the sec­ond time. Higher “peer rat­ings” as more im­por­tant the sec­ond time. The same, re­gard­less of “peer rat­ings.” pro­grams is that “the things that are im­por­tant are not nec­es­sar­ily the things they are eval­u­ated on.” She added that she hopes the changes to the MCAT “will her­ald a new sort of era that will be part of a recog­ni­tion of the mis­sion of a physi­cian.”

Wi­ley de­scribed spend­ing the last month at a hospi­tal in ru­ral Hawaii with an “in­cred­i­bly com­plex and un­der­served” pa­tient pop­u­la­tion, and she’s been im­pressed by the skill with which at­tend­ing physi­cians and staff com­mu­ni­cate end-of-life is­sues with in­ten­sive-care pa­tients and their fam­ily mem­bers. “Be­fore go­ing into the de­tails of pa­tient care, they step back and get to know the fam­ily mem­bers and what their val­ues are,” she said.

Dr. Robert Wig­ton, as­so­ci­ate dean for grad­u­ate med­i­cal ed­u­ca­tion at the Univer­sity of Ne­braska Med­i­cal Cen­ter Col­lege of Medicine in Omaha, has led his in­sti­tu­tion’s GME pro­gram for 36 years and said he’s seen steady, pos­i­tive change through­out his ca­reer, but he cred­its Nasca for ac­cel­er­at­ing the pace. “He’s a par­tic­u­larly good nuts-and-bolts ad­min­is­tra­tor in terms of get­ting things go­ing,” Wig­ton said, ex­plain­ing that Nasca has been able to turn “ide­al­is­tic con­cepts” into im­ple­mented pro­grams.

“I think the aim of all this is to pro­duce bet­ter and bet­ter-trained doc­tors,” Wig­ton said of the new GME struc­ture that will use ed­u­ca­tion “mile­stones” to judge a res­i­dent’s com­pe­tency in pa­tient care, med­i­cal knowl­edge, prac­tice­based learn­ing and im­prove­ment, sys­tems­based prac­tice, pro­fes­sion­al­ism, and in­ter­per­sonal skills and com­mu­ni­ca­tion.

Parts of the pro­gram were tested in in­ter­nal and emer­gency medicine pro­grams and at in­sti­tu­tions in Sin­ga­pore.

Nasca said the tests proved that out­come­based ac­cred­i­ta­tion of a res­i­dency pro­gram was pos­si­ble, and that it was also pos­si­ble to track the de­vel­op­ment of a res­i­dent’s pro­fes­sion­al­ism and in­ter­per­sonal skills.

Girotti said the next step, and one that he thinks would re­sult in the most no­tice­able changes for pa­tients, is the de­vel­op­ment of in­te­grated train­ing where med­i­cal, nurs­ing, phar­macy and ther­apy stu­dents learn to work as a team. He says this con­cept has been the topic of much dis­cus­sion, but lit­tle adop­tion—de­spite be­ing vi­tal to ad­dress­ing how medicine will be prac­ticed in the fu­ture.

This was echoed some­what by Dr. John Prescott, chief aca­demic of­fi­cer for the AAMC, though he be­lieves that the con­cept is tak­ing hold. “I’ve seen more move­ment in the past year than I’ve seen in the pre­vi­ous 10, and I think it will only ac­cel­er­ate,” Prescott said, cit­ing as ev­i­dence the for­mal cre­ation on Jan. 25 of the In­ter­pro­fes­sional Ed­u­ca­tion Col­lab­o­ra­tive, whose found­ing mem­bers in­clude the AAMC along with the Amer­i­can As­so­ci­a­tion of Col­leges of Nurs­ing, the Amer­i­can As­so­ci­a­tion of Col­leges of Os­teo­pathic Medicine, the Amer­i­can As­so­ci­a­tion of Col­leges of Phar­macy, the Amer­i­can Den­tal Ed­u­ca­tion As­so­ci­a­tion and the As­so­ci­a­tion of Schools of Public Health.

“I think this is a chal­leng­ing time for medicine in Amer­ica,” Prescott said. “And I think these are the type of changes we need to be mak­ing to meet those chal­lenges.”

GETTY IMAGES

Res­i­dents make their rounds at a Vet­er­ans Af­fairs med­i­cal cen­ter in Hamp­ton, Va. Fu­ture gen­er­a­tions of med­i­cal stu­dents will see sig­nif­i­cant changes in their med­i­cal school ex­pe­ri­ence.

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