Improving America's Medical Education System: Perspectives From a State Regulator

The nation's medical regulators carry an enormous social responsibility. Their overarching purpose is to protect the public by ensuring the safety and quality of medical practice in their respective states and territories — via a credible and robust licensing and disciplinary process.As regulators, we are often focused on the practical, day-to-day operations that we manage — issuing licenses to physicians, implementing new rules and regulations regarding medical practice, and closely monitoring complaints and allegations of unprofessional behavior. We spend much of our time dealing with the ongoing issues and concerns of the practicing physician.But it is important to remember that regulators also have an enormous stake in the educational system that originally shaped these physicians and helps them continue to learn throughout their careers.Our medical educational system creates the intellectual and ethical foundation that guides the physicians who we, as regulators, will interact with for decades to come, once they have left medical school and residency. Thus, it is in our best interests to ensure the system provides the tools and training that will lead to the safety and quality we seek as a part of our public mandate.I was privileged recently to provide observations about the nation's medical education system, from the perspective of a medical regulator, for the Institute of Medicine (IOM) Consensus Committee on The Learning Healthcare System in America. The committee is engaged in a two-stage study that will examine the foundational elements necessary to create a more effective “learning healthcare system” in the United States — one which will lead to better innovation, quality, safety and value for patients.My observations for the committee, summarized here, provide a framework that I believe is critically important for the future of our regulatory system.While our system serves us well, there are gaps and weaknesses that require the input and advocacy of regulators to change. Most notably, we must address issues such as the affordability and accessibility of undergraduate medical education; undue influence by industry in our educational system; the need for a greater emphasis on ethical training and professionalism; variability in medical testing standards and medical residency requirements; and gaps in the effectiveness of continuing education — so-called “lifelong learning” — for professionals. As a community, regulators should advocate for greater national awareness and response to these matters.A topic as expansive as how to promote learning in health care in America can lead in myriad directions. It would be very easy to randomly propose dozens of topics of professional relevance or personal interest that have linkages to how we educate our health care professionals. In the interest of identifying issues of key importance to regulators, it is perhaps most useful to organize a review of the system chronologically, in terms of an educational “life cycle.” Here then, is a critique of our overall medical education system in the United States — from the perspective of one medical regulator — and what it needs in order to ensure it is well aligned and coordinated with our regulatory system in the future.The period when health care professionals first receive their training represents the most important and formative period in their entire career. It is during this period of time that they learn not only the critical subject matter to practice in their chosen field, but they assimilate skills, behaviors and norms that will influence how (and how capably) they practice. This includes everything from how to team with other health professionals to how to practice with compassion and empathy (which has been shown to decline as students progress through medical school1), from cultural diversity awareness to the concepts of patient safety and continuous improvement, and from the “meaningful use” of electronic medical records to the elevated risks of addiction and suicide faced by physicians.When considering the learning environment for these professionals, there are two elements I believe are essential precursors for learning. The first involves the selection of students based on aptitudes and character as well as on education and training in sciences and other prerequisites. The publication of the Flexner Report in 1910 resulted in the establishment of preparatory course-work for medical students that has changed little in a century. While the value of this was indisputable in raising the overall level of medical education and practice in the United States at the time, in recent years, there has been greater conversation about the ability of students entering medical schools with alternative backgrounds to succeed like their more traditionally-prepared counterparts. As Muller and Kase noted in Academic Medicine, there appears to be no disadvantage to students from non-pre-med backgrounds in terms of their ability to perform relative to their peers with science backgrounds, and they may actually have the benefits of greater communications skills, humanism, and interpersonal skills.2With a looming physician shortage and the prospect of over 30 million new entrants into the health insurance market in 2014 due to the federal Affordable Care Act, I would suggest that every college graduate with the interest, ability and commitment to pursue a career in health care should be encouraged to do so. We should not retain an artificial prejudice for applicants with science backgrounds. In so doing, we may also unintentionally be excluding candidates with a broader, highly desirable mix of “intangibles.” Certainly, this shift does not come without some restructuring of the existing education and training infrastructure.The second precursor necessary is a dedication on the part of educational institutions to creating and maintaining a “pristine” environment, free of undue bias or influence on students. Much has been made in recent years of the role of the pharmaceutical and medical device industries in supporting medical educational programs. This can range from such minor influences as “drug lunches” and small gifts to major financial institutional support. While this topic has been well covered by the Institute of Medicine in 20093, it bears a brief mention here.With respect to the role these organizations play relative to individuals, according to a 2004 New England Journal of Medicine review, the pharmaceutical industry, with nearly 90,000 representatives, spent nearly one-third of its revenue on marketing to physicians, a staggering $8,000 to $15,000 per physician.4 The magnitude of the marketing effort is no less spectacular at the undergraduate education level. A recent review of 33 studies5 found that:These sometimes contradictory findings illustrate a problem. At an institutional level, a similarly pronounced industry influence exists, with the accompanying contradictions. Even after years of debate about its appropriateness, a pattern of the pharmaceutical industry providing support to medical residency programs continues. A 2010 study of residency programs found that 53.9 percent of survey respondents reported accepting pharmaceutical industry support, 72 percent of which expressed the opinion that such support is undesirable.6 Interestingly, the study looked at the relationship between programs that accepted industry support and pass rates for the certification examination of the American Board of Internal Medicine (ABIM), and found that “for each 1% decrease in the ABIM pass rate, the odds of accepting support increased by 21%.” Some institutions have taken steps toward eliminating the sway that industry firms have on their campuses, but more needs to be done.Any learning health care system should be founded on the use of research and information that is not only of the highest quality, but also free of any kind of bias — commercial or otherwise. There is a compelling body of evidence that physician prescribing behavior is influenced by industry marketing. Therefore, it is imperative that health care teaching institutions not only provide students a milieu in which to impartially acquire clinical knowledge, but that they provide students the analytical tools to separate rigorous research from cleverly packaged promotional material.Of particular interest to me, in my role as a regulator, is whether or not health care professionals, as part of their education or training, gain an understanding of the legal and regulatory context in which they practice. According to the American Association of Medical Colleges (AAMC) 2007 Medical School Graduation Questionnaire, well over half of all responding graduates (61.4 percent of 12,512 respondents) felt that the time in medical education dedicated to licensure and regulation was inadequate.7 According to the 2008 AAMC Liaison Committee on Medical Education (LCME) Medical School Questionnaire, the topics of “medical jurisprudence” and “medical licensure/regulation” comprised only 1.07 percent and .35 percent, respectively, of time in overall medical school curricula. By comparison, for example, the topics of “cultural diversity” and “culturally-related health behaviors” comprised 2.07 percent and 1.74 percent respectively.8What are the implications of a lack of focus on these areas of physician practice? Consider the work of Maxine A. Papadakis et al., who found in her 2005 New England Journal of Medicine (NEJM) article9 that prior unprofessional behavior in medical school was strongly associated with later state board disciplinary action (three times the odds). The types of behavior included “severe irresponsibility” (more than eight times the odds) and “diminished capacity for self-improvement” (more than three times the odds). These results echo an earlier Papadakis study published in the March 2004 Academic Medicine.10Another example of the critical impact of the undergraduate medical education experience on physicians' career patterns comes from Tamblyn, et al., who looked at physician-patient communication examination scores as a predictor of future complaints in medical practice.11 Of a study group of 3,424 physicians who took the Medical Council of Canada clinical skills examination, Tamblyn et al. found that low clinical examination scores related to physician-patient communication significantly correlated with an increased relative risk (1.38) of complaints retained for investigation. Complementary findings, though not as strongly correlated, were reported in the Papadakis 2005 NEJM article.12There is, appropriately, a great emphasis placed on attaining technical skill and expertise in schools and training programs for health care professionals; however, in medical regulation, we continue to see professionals stumble in matters ranging from failing to provide medical records to patients to engaging in sexual misconduct with patients. 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