The Undergraduate Medical Curriculum: An Adequate Preparation for a Career in Internal Medicine? ROBERT G. PETERSDORF, MD* MUCH IS GOOD, even excellent, in American medical education, and I do not m e a n to ignore or denigrate all that is positive. It is to the credit of the academic medical c o m m u n i t y that w e have always b e e n willing to take a hard look at what w e are doing and to consider ways of i m p r o v i n g the process by w h i c h w e train o u r progeny, the young physicians w h o will s u c c e e d us. I want to take two a p p r o a c h e s to the question of w h e t h e r the undergraduate medical c u r r i c u l u m adequately prepares students for graduate training in internal medicine. The first a p p r o a c h is to consider in the abstract the desirable attributes of an internist and to decide w h e t h e r medical school prepares students to assume those attributes. The second is to r e v i e w w h e t h e r students entering residencies in internal medicine consider themselves adequately p r e p a r e d for their future careers.

DESIRABLE ATTRIBUTES FOR AN INTERNIST As a devoted and c o m m i t t e d internist, I w o u l d list the following attributes as desirable for the practice of internal medicine: • The possession of an e x c e l l e n t and broad educational background. • The ability to think clearly, organize o n e ' s thoughts, and solve clinical problems. • The ability to p r o v i d e excellent patient care • Knowledge of and e x p e r i e n c e in p r i m a r y care medicine In general, graduates of U.S. and Canadian medical schools receive an excellent education. The system of p e e r r e v i e w and evaluation of medical education as exercised by the Liaison C o m m i t t e e on Medical Education (LCME) assures a relatively uniform standard of quality. The standards p r o m u l g a t e d and m o n i t o r e d b y the LCME reflect c o m m u n i t y consensus about the curr i c u l u m that is essential for awarding the medical degree. The fact that 97% of medical students are graduated speaks e l o q u e n t l y b o t h to the quality of y o u n g m e n and w o m e n attracted to m e d i c i n e as a career and to the care that goes into their education. 1

'President, Association of American Medical Colleges, 2450 N Street, NW, Washington, D.C. 20037-1126. Presented at the Symposium to Honor John Benson, Philadelphia, Pennsylvania,June 12, 1991. Address correspondence and reprint requests to Dr. Petersdorf.

American medical education is particularly excellent in the preparation of students in the basic biomedical sciences and in the clerkships that f o r m the core of the e x p e r i e n c e s in clinical education. However, it is less clear w h e t h e r o u r students are broadly educated. All too often a career in m e d i c i n e is l a u n c h e d in the rigid p r e m e d i c a l educational e n v i r o n m e n t that prevails in colleges and universities. Students b e c o m e study machines, stigmatized as h y p e r c o m p e t i t i v e and narrow-minded at best and greedy and dishonest at worst. They have b e e n characterized as being interested only in the courses that they believe will get t h e m admitted to medical school. Students in college should be broadening their educational backgrounds, experim e n t i n g in the study of various disciplines, and setting their minds to n e w intellectual horizons. W h y are 70% of our medical school applicants science majors? W h y have w e b e e n unsuccessful in convincing humanities and social science majors that they can aspire to a career in medicine? In 1990, 66% of the English majors and 70% of the history majors w h o a p p l i e d to medical school w e r e admitted, c o m p a r e d w i t h 5 5% of the biology majors. 2 The p r o b l e m , then, is not that liberal arts students do not get admitted to medical school, b u t that they do not apply. Students w h o do aspire to a career in m e d i c i n e believe they cannot afford to take liberal arts studies as undergraduates. The Association of American Medical Colleges recognizes the strong signals that its Medical College Admission Test (MCAT) sends to potential applicants. In the spring of 1991 a n e w MCAT examination was introduced. The changes in the test are m e a n t to encourage p r o s p e c t i v e medical students to pursue b r o a d undergraduate study in the social sciences and the humanities. The n e w test tries to e m p h a s i z e the i m p o r t a n c e to medical education and medical practice of critical thinking, logical reasoning, p r o b l e m solving, and comm u n i c a t i o n skills. Because so m u c h of medical education is scientific, medical schools w o u l d do w e l l to assign extra w e i g h t to nonscientific undergraduate preparation and to the non-science portions of the MCAT. This might result in future physicians' receiving the b r o a d and well-balanced education that is desirable. The second attribute for the internist is the ability to think clearly, to organize his or her thoughts, and to solve problems. These habits have their genesis in the ability to read, write, spell, and speak clearly. We should insist on literacy for o u r medical students. Physicians are d e p e n d e n t on c o m m u n i c a t i o n w i t h patients, Z13

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their families, their colleagues, and even the government. Given the necessity to c o m m u n i c a t e frequently and freely, I never cease to b e amazed at h o w p o o r l y the medical profession does it. We are masters of illegible handwriting, j u m b l e d syntax, atrocious spelling, the passive voice, and the split infinitive. We n e e d to transmit o u r thoughts in clear, relatively brief sentences, and not obfuscate t h e m in jargon and incomprehensible abbreviations. Equally necessary is the doctor's ability to stand u p on two feet and present cases, scientific information, and logical arguments before commissions, committees, and even juries. Physicians must b e able to interp r e t the medical scene before lay groups. Out with the m u m b l e r s and scribblers! Clarity of s p e e c h and writing b r e e d clarity of thought, and, Lord knows, w e n e e d m o r e of that. With April's n e w MCAT, the Association introd u c e d an essay c o m p o n e n t that will be a valuable means of evaluating applicants' c o m m u n i c a t i o n and writing skills. Think w h a t an essay will s h o w a b o u t a student's ability to organize his or her thoughts, to reason and present cogent arguments, and to demonstrate clarity of c o n c e p t s and felicity of expression. It is the AAMC's h o p e that the addition of the essay question will h e l p medical schools select candidates for their ability to think and solve problems. It does not take long for the w o r d to get around. According to a recent issue of the Chronicle of Higher Education, a p r e m e d student said that she was changing a course from calculus to w o r l d literature. Changes in the medical school selection process alone are not sufficient to assure the p r o d u c t i o n of y o u n g physicians w h o are clear and logical thinkers. Unfortunately, medical school itself has done little to teach its students h o w to think. O u r failure has b e e n that w e have e m p h a s i z e d rote learning and have relied too heavily on didactic presentations as the preferred pedagogical methodology. Happily, w e are beginning to see change. The shortcomings of the didactic lecture as a teaching m e t h o d are a matter of record, especially in preparing individuals for a profession w h o s e practitioners must d e v e l o p the habit of lifelong learning to maintain professional c o m p e t e n c e . The AAMC's Curriculum Directory indicates that f r o m 1983 to 1989 the average s c h e d u l e d hours for required first-year courses decreased f r o m 9 3 3 . 6 to 854.5. Average lecture hours declined from 465.3 to 440.8. 3,~ These changes are not m o n u m e n t a l , but they do signal a m o v e in the right direction. In m a n y schools m o r e emphasis is b e i n g p l a c e d on tutorials, small-group discussions, and i n d e p e n d e n t study. Problem-based learning allows students to acc e p t responsibility for studying at their o w n p a c e and to select the learning m e t h o d s that best fit their needs. Case-based p r o b l e m solving recognizes that some individuals identify and solve p r o b l e m s differently and that

there is a place in medical education for different learning strategies. I believe there should be m o r e centralized control of the c u r r i c u l u m to achieve clearer educational objectives. For the most part, the education of future doctors should be an institutional, not a departmental, function. A centralized educational unit w o u l d have the responsibility and authority for d e v e l o p i n g the basic curriculum. This organizational change should be acc o m p a n i e d b y i m p r o v e m e n t s in clinical teaching methods, including m o r e emphasis on p r o b l e m - b a s e d learning, medical informatics, and student-initiated learning. The idea of a centralized education unit is b y no means new. A n u m b e r of schools have very sophisticated learning resource centers, but characteristically these do not control curriculum. The N e w Pathway program of the Harvard Medical School entails a g o o d deal of centralized c u r r i c u l u m planning authority. 5 One of the central r e c o m m e n d a t i o n s of the Robert W o o d Johnson Foundation Commission on Medical Education is to centralize medical education in the dean's office; the Foundation's Medical Education Grant Program also has as one of its principles the centralization of medical education. 6 Many schools have initiated focused interventions in response to the AAMC's GPEP r e c o m m e n d a t i o n s 7 and o t h e r studies of medical education. Several schools have initiated changes that feature substantial departures from traditional teaching. A few of these schools have d e v e l o p e d separate tracks for some students b y initiating innovative curricula within the traditional c u r r i c u l u m and enrolling small subsets o f students f r o m matriculation to graduation in these n e w curricula. Schools that have d e v e l o p e d significant curricular changes are the University of N e w Mexico, Rush Medical College, Harvard Medical School (The N e w Pathway), the University o f Rochester, Southern Illinois University, and SUNY Syracuse. The third desirable attribute for an internist is the ability to provide excellent care to patients. I have always believed that the p u r p o s e of medical school and its postlude, graduate training, is to p r e p a r e a significant n u m b e r of their p r o d u c t s for office-based c o m m u nity practice. I do not believe that w e can go through life encouraging our professional offspring to b e c o m e the academic clones of faculties that, b y and large, are either primarily investigators or highly technologic subspecialists. All too often the faculty at o u r prestigious medical centers behaves as if all of o u r trainees will be practicing in the same kind of technologically oriented, highly specialized e n v i r o n m e n t in w h i c h w e teach and act as preceptors. If w e can agree that o u r primary educational mission is to p r e p a r e students for the practice o f m e d i c i n e in a non-academic setting, then w e n e e d to e x a m i n e w h y medical schools often fail in that educational mission:

JOURNALOF GENERALINTERNALMEDICINE,Volume 7

• Excessive emphasis on research. I do not w a n t to be misunderstood on this point. The discovery of n e w k n o w l e d g e by medical faculties is one of the reasons for their existence, but it is not the only reason. However, since the reward system favors a c h i e v e m e n t in the l a b o r a t o r y - - o r at least the p r o d u c t i o n of m u l t i p l e papers D in o u r presentday educational milieu, teaching and, sometimes, patient care take a back seat to research. • Excessive emphasis on training graduate students, housestaff, and fellows. The emphasis on p r o d u c i n g PhDs and educating post-docs b y basic science faculties is w e l l known. It is equally true that faculty in clinical d e p a r t m e n t s s p e n d m u c h m o r e time with housestaff and fellows than w i t h medical students. • Departmental barriers that often interfere w i t h the teaching of m o d e r n medical science. Many d e p a r t m e n t s remain traditional and fiercely provincial, w i t h course offerings that are not appreciably different f r o m those o f 40 years ago. All too often the content of these curricular offerings results in total demoralization of the students locked into such a curriculum. • Misguided career planning in academe. By this I m e a n the university's failure to reward strong c l i n i c i a n - t e a c h e r s , its t e n d e n c y to b e s t o w acad e m i c accolades only on its researchers, and its inability to recognize that a m o d e r n medical school needs good c l i n i c i a n - t e a c h e r s as w e l l as good investigators. • Excessive emphasis on private practice, w h i c h is e x t r e m e l y time-consuming. I have b e e n a champ i o n of the two-platoon system: the r e s e a r c h e r teacher and the c l i n i c i a n - teacher. What worries m e is that we are spawning a generation of c l i n i c i a n - non-teachers. While these individuals may provide e x c e l l e n t patient care, they do not devote sufficient time to teaching or training residents. * Excessive expectations of faculty. A corollary of the previous two points is that universities exp e c t their medical faculties to remain triplethreat a c a d e m i c i a n s - - g r e a t in teaching, research, and patient care. It cannot be done. The c o n s e q u e n c e of these demands is a faculty of hurried, albeit well-paid, individuals w h o are running from clinic to laboratory to c o n f e r e n c e room, always behind, always late, always reacting, and rarely thinking. Moreover, a m o n g the thoughts for w h i c h clinicians do have time, f e w are likely to be c o n c e r n e d with medical students and their education.

(March/April),

1992

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An outdated and excessively permissive curriculum. The c u r r i c u l u m in most medical schools goes from one e x t r e m e to the other m h i g h l y structured and o v e r c r o w d e d early on, and in the fourth year so permissive as to be practically useless. However, the biggest failing o f a c a d e m i c internists has b e e n in their failure to provide sufficient e x p o s u r e of their students to general internal medicine. The failure to convey the i m p o r t a n c e of general internal medicine p e r p e t u a t e s the inexorable trends toward subspecialization that I have railed against for two decades. O u r specialty needs to espouse the virtues of the general internist and to disabuse the p u b l i c and m e m b e r s of our c o m m u n i t y of the notion that the general internist is inferior to the subspecialist. This requires several steps, including the revision of medical curricula w i t h a v i e w to injecting s o m e e x c i t e m e n t into the study of general internal m e d i c i n e and, indeed, all of p r i m a r y care. A major difficulty is that undergraduate medical education does not a d e q u a t e l y p r e p a r e students for careers in general internal m e d i c i n e because it does not provide sufficient e x p e r i e n c e s in the a m b u l a t o r y setting. In o u r teaching hospitals, the n u m b e r s of inpatients w h o have c o m m o n diseases are decreasing, and the character of hospitalized patients has changed from one involving relatively m u n d a n e illnesses to one defined by critical illnesses that have transformed m a n y hospitals into giant intensive care units. As a conseq u e n c e of these developments, w e must m o v e m o r e of the teaching operation into the outpatient setting. It is necessary for academic medical centers to take four actions in order to achieve the n e e d e d transition to increased clinical education in a m b u l a t o r y settings: 1. There must be an institutional and faculty comm i t m e n t to providing an a p p r o p r i a t e level of a m b u l a t o r y care education. 2. We must d e v e l o p curricular changes that recognize these n e w educational e x p e r i e n c e s as pedagogical o p p o r t u n i t i e s requiring n e w learning objectives. 3. We must establish n e w s e t t i n g s - - p h y s i c i a n s ' offices, chronic care units, e m e r g e n c y rooms, freestanding walk-in clinics, surgicenters, etc. 4. Financial issues m u s t b e addressed. While I strongly s u p p o r t the continuation o f third-party payments for the education o f resident physicians b y means of third-party reimbursement, I call u p o n our medical centers to m e e t their obligation to educate medical students b y earmarking s o m e of their resources to s u p p o r t student education in a m b u l a t o r y settings.

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DO STUDENTS FEEL ADEQUATELY PREPARED? Another a p p r o a c h to determining w h e t h e r students are adequately p r e p a r e d for careers in internal medicine is to ask the students. My source for these data is the 1990 graduation questionnaire distributed b y t h e AAMC to all graduating seniors at U.S. medical schools. 8 Seventy-six p e r c e n t of all graduates c o m p l e t e d the survey, including 2,077 students w h o w e r e planning their first-year residencies in internal medicine. In one part of the questionnaire, students are asked to characterize the time devoted to instruction in certain topics as excessive, appropriate, or inadequate. Students planning internal m e d i c i n e careers said their instruction in the following topics was inadequate: • • • • • • • • • • • • • • •

Practice m a n a g e m e n t skills (73%) Medical care cost control (66%) Cost-effective medical practice (65%) Nutrition (65%) Literature-analysis skills (59%) Preventive care (58%) Research techniques (56%) Public health and c o m m u n i t y m e d i c i n e (52%) Use of c o m p u t e r s (49%) Patient follow-up (47%) Management of patients' s o c i o e c o n o m i c , educational, and emotional p r o b l e m s (46%) Care of a m b u l a t o r y patients (45%) Medical record-keeping skills (44%) Substance abuse (41%) Effective patient education (40%)

Skillful internists n e e d to judge h o w important these topics are to the practice of internal medicine. My v i e w is that these data confirm that students are not being trained for the type of medicine they might be e x p e c t e d to p r a c t i c e - - a s general internists in an ofrice-based setting. O f course, graduating medical students are not entering practice i m m e d i a t e l y after receiving the MD degree, but going into residency training, w h e r e they have additional opportunities to receive instruction in these topics. W h e t h e r o u r internal m e d i c i n e residencies will i m p r o v e their preparation in these subjects is an important issue.

The views of these aspiring internists are not very different from those of graduates planning to enter other specialties. We do not n e e d to feel that medical school education is any less adequate for internal medicine than for other specialties. We cannot attribute the p r o b l e m s that internal m e d i c i n e has had in the " m a t c h " in recent years to feelings on the part of students that there is u n d u e d e t a c h m e n t b e t w e e n medical school and internal medicine. The graduation questionnaire data indicate that the main reasons our graduates do not wish to go into internal m e d i c i n e stem from negative clerkship experiences or the p e r c e p t i o n that the specialty is too demanding. Many do not like the type of patient w i t h w h o m internists interact. On the other hand, the reasons cited for choosing internal m e d i c i n e include its intellectual content, the challenging diagnostic problems it poses, positive e x p e r i e n c e s offered b y its courses and clerkships, the types of clinical p r o b l e m s e n c o u n t e r e d b y internists, and the e x a m p l e s set b y sterling internists. We need to emphasize these positives, w h i l e mitigating the negatives. If w e follow this course, internal m e d i c i n e might once again b e c o m e n u m e r o u n o in medical schools and the most p o p u l a r career choice of o u r graduates.

REFERENCES 1. Cureton-Russell M (ed). Minority students in medical education: facts and figures V. Washington, DC: Association of American Medical Colleges, 1989; 12. 2. Turner CT (ed). 1 9 9 2 - 9 3 medical school admission requirements. Washington, DC: Association of American Medical Colleges, 1991;18. 3. Turner CT (ed). 1 9 8 9 - 90 AAMCcurriculum directory. Washington, DC: Association of American Medical Colleges, 1990. 4. Wilson V (ed). 1 9 8 3 - 8 4 AAMCcurriculum directory. Washington, DC: Association of American Medical Colleges, 1984. 5. Tosteson DC. New pathways in general medical education. N Engl J Med. 1990;322:234-8. 6. Marston RQ (chair). Environment for learning: an interim report of the Robert Wood Johnson Foundation Commission on Medical Education: the sciences of medical practice. Princeton, NJ: Robert Wood Johnson Foundation, 1991. 7. Muller S (chairman). Physicians for the twenty-first century: report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine. J Med Educ. 1984;59:(November) Part 2. 8. Petersdorf RG. Memorandum 9 1 - 1 7 : 1 9 9 0 AAMC graduation questionnaire summary results. Washington, DC: Association of American Medical Colleges, March 26, 1991.

The undergraduate medical curriculum: an adequate preparation for a career in internal medicine?

The Undergraduate Medical Curriculum: An Adequate Preparation for a Career in Internal Medicine? ROBERT G. PETERSDORF, MD* MUCH IS GOOD, even excellen...
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