Three Questions for the LCME

The opposite of a true statement is an untrue statement. The opposite of a profound truth may be another profound truth.—NEILS BOHRFigure. David: P. Stevens, MDThe Liaison Committee on Medical Education (LCME) has established a context for sound and accountable medical education in North America that spans nearly 60 years. Medical schools, in their preparation of the next generation of physicians, profoundly influence the future of medicine. As we contemplate an uncharted era of dramatic change in health care, there exists a timely opportunity for medical school accreditation to provide leverage for even more effective improvements in both education and patient care. For example, what are the implications for medical education when everything that a doctor memorizes—and more—is available to everyone—doctors and patients alike—via expanding information technology? Already our patients arrive in the clinic, computer printouts in hand, with information that might be correct or not, and is frequently unfamiliar to the doctor. Our background has schooled us to dread the proffered printout. Yet this scenario will only become more common. This is but one example of a place to start in the definition of accreditation principles that might provide leverage for effective change. The test of the excellent physician may no longer entirely be what is memorized at any given time—particularly in medical school. Might it be more appropriate to judge a physician's education also by how he or she manages knowledge for his or her patients' benefit over a lifetime of practice? As the LCME explores how it can best provide leverage for improvement, this academic year it is pursuing its own “self-study.” Three central questions have emerged, which I discuss below. First, how can the measurement of outcomes be most effectively employed in the accreditation of medical schools? Second, how can medical school accreditation better align with the public's expectations? And third, can sound evidence be developed on which to base the standards and processes of accreditation? 1. How can the measurement of outcomes be most effectively employed in the accreditation of medical schools? The medical school curriculum does not exist in isolation but is part of a continuum of learning that spans a physician's career. The fundamental competencies that define a physician over his or her career are unlikely to change greatly even though the knowledge that a physician must acquire, and its application, will change dramatically. The LCME is exploring the ramifications of using competencies as measurable outcomes for medical school accreditation. Implicit in such an approach is the recognition that there is a core set of defining outcomes that apply across the times and places that a physician learns throughout his or her career. The AAMC's Medical School Objectives Project took us in this direction with its 1998 consensus report, which described four overriding objectives: physicians must be altruistic, knowledgeable, skillful, and dutiful. The recent focus of the Accreditation Council for Graduate Medical Education (ACGME) provides an example of outcomes for accreditation of residency training programs. To define these outcomes, it started with a review of over 2,500 references from the published literature. Based on that review, a list of 84 competencies was developed. Then, with focus groups, surveys of constituents, and a lot of negotiation, this list was winnowed to a fundamental six: patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. The American Board of Medical Specialties (ABMS) has also adopted the same six general competencies as it has pursued the application of outcomes to specialty certification. Residency review committees, residency training programs, and specialty boards have begun to wrestle with the meanings of these competencies for their respective specialties. We in medical education have traditionally focused the bulk of our efforts on teaching and testing medical knowledge. When we pursue similarly rigorous assessment of communication skills, evidence of professionalism, knowledge for improvement, and knowledge of complex systems, we explicitly define broader and more comprehensive expectations for our learners and their teachers. Why should accreditation address these outcomes only when our students have progressed to residency training and beyond? A focus on these or similar outcomes for accreditation at the medical school level, where the educational foundation is laid, provides an even greater opportunity for creating excellent physicians. 2. How can medical school accreditation better align with the public's expectations? Canvassing the public for its expectations of medical education can reveal issues that are important to our legitimate stakeholders. This does not mean that we abdicate our responsibility and authority for medical education. However, it can yield valuable information as we strive to anticipate new expectations that the next generation of physicians will need to meet. It is said that when physicians went on strike in Ontario in 1987, they were greeted with the political reality that the Public held little sympathy for their cause. The strike was brief. When it ended medical schools in Ontario, to their credit, embarked on the task of querying the public to identify just what outcomes they wanted from their medical schools. Ultimately Canadian citizens—by way of the CanMEDS 2000 Project—told their medical schools that they wanted their physician to be a medical expert/clinical decision maker, communicator, collaborator, professional, scholar, manager, and health advocate. Something telling emerges when one lines up the list that emerged from the Canadian process with the list given earlier that was developed by the ACGME:With allowances for differences in terminology, there is considerable congruence between the two perspectives—one public and the other professional. This suggests to me that these two criteria-defining processes, despite their substantially different origins, focused on the same bedrock of medical education. I doubt that a similar canvas of public stakeholders in the United States would yield dramatically different conclusions. I urge, however, that we carry out such a survey to find out. 3. Can sound evidence be developed on which to base the standards and processes for accreditation? It now seems realistic to attempt to establish a base of sound evidence for the processes and standards for accreditation. Our harshest critics have complained that curricular reform has not always resulted in curricular improvement. In this era of evidence-based medicine, we need to commit to moving toward evidence-based accreditation. Information technology now provides tools, for example, that could allow comparisons between students' medical school preparation and aggregated data that describe residents' performances at the graduate-training-program level. Such assessment tools may be limited only by our abilities to frame the right questions and our willingness to acknowledge and address the answers. In an era where resources are limited and accountability is an ever-greater expectation in health care, it is reasonable to expect that medical school accreditation demonstrate its value to the larger health care environment. We have justifiably assumed the value of accreditation in more stable times. As our environment calls for greater attention to the prudent use of resources for health care, the value of accreditation for both improved education and improved patient care is a reasonable expectation. By addressing the three questions presented above, the LCME seeks to provide a measure of that value.

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