At the SACME fall meeting held in Boston Nov. 6, Robert Watson, MD, explained the Association for American Medical Colleges new Institute for Improvement in Medical Education, which is based on a report drawn up by 10 deans who were tasked with creating a new vision of med ed.
Blast from the past
First he summarized the 30 similar reports that had gone before, which he said all boiled down to the same four basic concerns:
-Policymakers ask if institutions are creating the healthcare professionals we need for the 21st century (which he called an insulting question)
-The cost associated with med ed. "Can you explain the ACCME Data Report saying that 90 percent of the money for med ed comes from pharmaceutical companies? Academics put down pharma as they take the money."
-Competency testing for healthcare professionals
-Concern about the supply of teachers. "We now have a 4:1 faculty:medical student ratio (including adjunct and part-time teachers)," he rejoined.
He said the previous reports all came up with four main objectives for reforming healthcare education (which Watson called a recipe for reform with no changes):
1. Better serve the pubic interest.
2. Address societal needs for physician manpower.
3. Cope with the burgeoning knowledge base.
4. Increase the generalist character of student education ("helping everyone learn less and less about more and more," he snorted.)
What they ve been missing in these reports over the past century are the need to reform learners, teachers, overall health, and outcomes, he said.
Dean s report
The 10-dean panel came up with a draft report last February. Here are a few of their ideas:
1. Focusing on undergrad and graduate levels isn t enough. "The quality of care provided by doctors over the course of their professional careers will be determined increasingly by the kinds of CME activitties they pursue," said Watson. The problems the deans identified were that most CME is still lecture-based, despite growing evidence that self-directed learning gets better results in terms of behavior change. Another issue is that licensing bodies still encourage lecture-based programs, and that, for the most part, physicians still don t have to show competency maintenance for relicensure or recertification.
2. Big obstacles to reform exist, including organizations that adopt policies without really understanding the issues. The reliance on funding from industry for CME also makes reform difficult.
3. The strategies for reform they came up with are pretty familiar: develop a patient-centered approach to care, make sure that docs can provide high-quality care, and make the education process more efficient and effective. The question is how.
Fixing the system
But the ideal system they came up with, Watson said, sounds a lot like the previous 30 studies. For example, he thought their goal of creating a diverse medical workforce capable of meeting society s needs sounds a lot like "better serving the public interests." And the goal of producing docs who can provide high-quality care to patients sounds a lot like "physician manpower." The next one also didn t sound to me like anything new: Ensure that learning objectives have been achieved (burgeoning knowledge base). The last goal assure that learners have acquired and possess throughout their careers the knowledge, skills, attitudes, and values needed to be competent he thought correlates with the generalist character thing, but it sounds a little different to me.
Anyway, the strategies they came up with to reform the system so it aligns with these goals are:
1. Licensing authorities, specialty societies, and others should require that CME is effective in improving practice behaviors.
2. Med schools and teaching hospitals should develop CME that has been proven to change physician behavior.
3. The only physicians who are licensed and relicensed are those who both complete an accredited residency and can regularly demonstrate their clinical competence within their specialty.
The hope is that the institute, formed in the fall of 2002, will come up with some real reforms, though Watson didn t sound convinced that would actually happen. What he d like to see happen, but sidebars outside the session doubted would, is that "academic medical centers should either fully support CME or get out of it. How can you do it if support isn t provided? Then [the academics] get outraged over pharma s inroads into CME."
Barbara Barnes, who co-presented with Watson, said, "We also underscore the issues of financing and support. CME has to be an academic unit, just like undergrad and GME. Also, CME research needs to be supported."
He also said the prescription for good education is simple: It should be "learner-centered, teacher- centered, health-centered, and outcome-centered." The crowd, needless to say, applauded.
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