Remodeling the House of Medicine: Update on the Medical Continuum

Dear Colleague,

Advances in medical knowledge and our capabilities as physicians, coupled with the transformation of healthcare delivery, call for a reassessment of how we educate,train, and equip physicians to provide safe, high-quality, patient-centered care. A number of national health organizations have begun this process, and many of you maybe familiar with the American Medical Association's (AMA) Initiative to Transform Medical Education (ITME) and the Association of American Medical Colleges' Institute to Improve Medical Education. As every aspect of the medical education continuum is being comprehensively evaluated and critiqued, you have the opportunity to take an active role in this process and influence the future of medical education.

The Initiative to Transform Medical Education

In 2002, the AMA House of Delegates adopted a report of the AMA Council on Medical Education, "Comprehensive Reform at the Interface of Medical Education and Health Care." This report concluded that an evaluation and reform of medical education was needed to ensure that physicians were prepared to practice in a continuously evolving healthcare system. In addition, systematic changes to medical education were recommended to better equip physicians with the knowledge, skills, ethics, and approach necessary to provide quality medical care in this changing environment. Thus the AMA's ITME Task Force was formed, to address goals that were broken down into 3 phases:

1. Identify current strengths and gaps/opportunities for improvement in the preparation of physicians
2. Develop plans and strategies for change in medical education across the continuum from premedical preparation and admission to medical school through continuing physician professional development
3. Form partnerships with appropriate stakeholders within and outside the medical education community to bring about the needed changes.

Phase 1 and phase 2 are now complete, and the full summary/report can be found at www.amaassn.org/ama1/pub/upload/mm/16/itme_final_rpt.pdf. Recommendations from phase 2 that pertain to graduate medical education include:

1. Apportion more weight in admissions decisions to characteristics of applicants that predict success in the interpersonal domains of medicine. Use valid and reliable measures to assess these traits.

To promote the altruistic and compassionate characteristics of physicians, medical schools may consider requiring undergraduate courses in the humanities or social sciences, in addition to the biological and physical science requirements. ITME also suggests the development, validation, and utilization of new tools in the admissions process to assess relevant personalqualities of applicants, such as analytical thinking, service and team orientation, commitment to lifelong learning, and likelihood of maintaining altruism. By identifying personality characteristics that foster the development of these traits and creating methods to assess them using evaluation tools and specialized interviews, these attributes can be accorded more weight during the admissions process. This would have a significant impact on students applying to medical school, as well as on the admissions process itself.

2. Consider creating alternatives to the current sequence of the medical education continuum, including introducing options so that physicians can re-enter or modify their practice.

With so many physicians taking extended leaves from practice for personal reasons or to facilitate a change in their practice, it is important to develop flexible and efficient mechanisms that provide sound training and competency assessment to ease these transitions. This particularly affects residents and young physicians who take time away from medical practice for reasons such as having children, or those who choose to change their training track or specialty.

3. Introduce core competencies across the medical education continuum in new and expanded content areas that are necessary for practice in the evolving healthcare system.

4. Introduce new methods of evaluation that are appropriate to assess the core competencies.

Undergraduate and graduate medical education provides little instruction on skills such as selfassessment, professionalism, and specialized communication skills. The development and implementation of a longitudinal education in these areas would improve physicians' ability to critically evaluate their practice and to develop andcarry out a lifelong learning curriculum. These new methods of evaluation, however, must not only be valid and reliable but also provide an opportunity for formativeas well as critical evaluation. ITME is also searching for ways to incorporate the Accreditation Council Graduate Medical Education core competencies and move them fromthe status of "add-ons" to fundamental elements of graduate medical education training. This new framework, combined with new assessment and evaluation methods, will change not only what we teach but how we teach it.

5. Ensure that the organizational environment in medical schools and teaching institutions values and rewards participation in education.

6. Ensure that the learning environment throughout the medical education continuum is conducive to the development of appropriate attitudes, behaviors, and values, as well as knowledge and skills.

Recommendations 5 and 6 directly address the "hidden curriculum" that underlies the teaching environment, and emphasize the importance that this environment plays in the development of personal qualities in future physicians. Intimidation is a significant issue for residents and fellows today, and these recommendations seek to foster a training environment that is best suited to the development of the positive attitudes, healthy behaviors, and honorable values necessary to provide safe, high-quality, patient-centered care.

Phase 3 of this process is now under way, and will begin by focusing on the "hidden curriculum" and improving the educational environment to facilitate learning and the development of the positive professional attributes of physicians-in-training.

Putting It All Together

In summary, a substantive remodeling of the "house of medicine" is under way, and your participation is essential to ensure that physicians are thoroughly engaged in this process. You know firsthand what training and skills you need, and what type of learning environment best enables you, as a physician, to learn how to best care for your patients. Armed with that knowledge and with a vision for the future, you, along with your resident and fellow colleagues, can help chart the path this process will take. The opportunity to leave your mark on medical education reform and affect the foundation of our prefession is here. I charge you to work with your colleagues and representatives on ITME and other organizations and councils during this monumental process.

A list of your AMA Resident and Fellow Section representatives on these groups can be found at www.ama-assn.org/ama/pub/category/5647.html; in addition, a list of key stakeholders and participants can be found in the Appendix of the "Recommendations for Change in the System of Medical Education" (ITME, June 2007), available at www.ama-assn.org/ama1~itme_final_rpt.pdf.

Janet West, MD

Membership and Outreach Officer

AMA?Resident and Fellow Section