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Medical Education Reform Without Change

  • August G. Swanson
    Address reprint requests to Dr. A. G. Swanson, Association of American Medical Colleges, One Dupont Circle NW, Washington, DC 20036
    Vice President for Academic Affairs Association of American Medical Colleges Washington, DC
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      During this century, medical education in the United States has been subjected to multiple episodes of scrutiny and reform. The aggregate effect of successive waves of self-examination by medical schools and their faculties has been to accomplish essentially no change in how physicians are prepared to practice medicine. The ability of medical education institutions to maintain the status quo of their educational programs in the face of criticism from both within and without suggests that organizational priorities take precedence over the education of medical students. In 1932, a Commission on Medical Education appointed by the Association of American Medical Colleges published a report.
      • Rappleye WC
      If republished today, the observations and conclusions of that commission would be as pertinent and applicable as they were 57 years, and two generations of medical students, ago. Among the important statements of that commission were the following:
      The medical course cannot produce a physician. It can only provide the opportunities for a student to secure an elementary knowledge of the medical sciences and their application to health problems, a training in the methods and spirit of scientific inquiry, and the inspiration and point of view which come from association with those who are devoting themselves to education, research, and practice.
      Medicine must be learned by the student, for only a fraction of it can be taught by the faculty. The latter makes the essential contributions of guidance, inspiration, and leadership in learning. The student and the teacher, not the curriculum, are the crucial elements in the educational program.
      … the almost frantic attempts to put into the medical course teaching in all phases of scientific and medical knowledge, and the tenacity with which traditional features of teaching are retained have been responsible for great rigidity, overcrowding, and a lack of proper balance in the training. Attempts to correct the difficulties have been largely directed toward rearrangements of the curriculum.
      In medical education, as in other forms of education, attention should be directed more to the development of the individual student than to details of the curriculum.
      The present concept aims to develop sound habits as well as methods of independent study and thought which will equip the student to continue his self-education throughout life. This can be brought about only by freeing medical education from some of its present rigidity, uniformity, and overcrowding and by articulating it more closely with the educational needs of the student. These considerations are very likely to modify in some degree the selection of medical students and what is expected of premedical education.
      Today, those experienced in medical education would have little disagreement with these statements. The desirability of student-centered, self-directed education to prepare physicians for lifelong learning is reiterated in school catalogs, journal articles, and commencement speeches, but medical education remains faculty-centered and dependent on rote memory, supplemented by unstructured, clinical experiential learning.
      The Association of American Medical Colleges' Panel on the General Professional Education of the Physician
      • Association of American Medical Colleges
      Physicians for the twenty-first century.
      published the following statement:
      Despite frequent assertions that the general professional education of medical students is the basic mission of medical schools, it often occupies last place in the competition for faculty time and attention. Graduate students, residents, research, and patient care are accorded higher priorities.
      This statement, which directly contradicts the postures taken by medical school deans and faculties when seeking state funds or alumni contributions, is acknowledged to be true by every audience to which it is submitted. Distressingly, the lack of commitment to medical students is accepted by many deans and faculty members as if it were immutable.
      The low priority assigned to medical students and the rigidity of medical education affirm that academic medical centers are principally structured to engage in research and medical practice. Bloom
      • Bloom SW
      Structure and ideology in medical education.
      concluded that the structural dominance of research and medical practice in academic medical centers results in defensive curricular experimentations that provide a semblance of educational reform but ensure no change.
      Elevating the low status of the educational mission in academic medical centers is frequently thought to necessitate the denigration of either the research or the clinical service mission. Enhancing the educational mission, however, need not result in reciprocal changes in the energy devoted to, or the quality of, research or patient care. The Panel on the General Professional Education of the Physician
      • Association of American Medical Colleges
      Physicians for the twenty-first century.
      made the following observations:
      The organization of academic medical centers by disciplines, specialties, and subspecialties provides a reasonable basic administrative structure. When faculty members from several disciplines jointly provide patient care or conduct biomedical research, as is often done, special administrative structures are usually required for sustained success. These structures vary, depending upon the size and the complexity of the undertaking, as well as the resources needed to accomplish it. Most institutions have established special centers or institutes for patient care and for research projects that involve individuals from diverse academic departments. For these undertakings to succeed, faculty members must be willing to work together to accomplish the common goal, and departmental chairmen must recognize contributions of faculty members involved in missions extending beyond conventional disciplinary boundaries.
      Such an interdisciplinary and interdepartmental organizational framework, one that enjoys the full and enthusiastic support of the faculty members involved and their departmental chairmen, is required for an effective program for the general professional education of medical students. Few medical schools have such an environment. To provide coherent general professional education, interdisciplinary and interdepartmental consensus on its purpose, its content, and its resources is necessary. Curriculum committees are rarely able to achieve such a consensus.
      Accordingly, that panel
      • Association of American Medical Colleges
      Physicians for the twenty-first century.
      made the following recommendation:
      Medical school deans should identify and designate an interdisciplinary and interdepartmental organization of faculty members to formulate a coherent and comprehensive educational program for medical students and to select the instructional and evaluation methods to be used. Drawing on the faculty resources of all departments, this group should have the responsibility and the authority to plan, implement, and supervise an integrated program of general professional education.
      Implementation of this recommendation would provide a structural adaptation to the organization of most academic medical centers that would focus and elevate their educational missions. It could also provide reform with change. Thus far, the leaders of medical faculties have resisted establishing a body of the type recommended. Although quite willing to adapt organizational structures to research and practice opportunities, many faculties remain unwilling to adapt to new educational opportunities. Until this structural rigidity is changed by strong leaders who are willing to take risks, curriculum reforms will continue to be nothing more than cosmetic hindrances to genuine improvement in medical education.


        • Rappleye WC
        Medical Education: Final Report of the Commission on Medical Education. Association of American Medical Colleges Commission on Medical Education, New York1932
        • Association of American Medical Colleges
        Physicians for the twenty-first century.
        J Med Educ. 1984; 59: 1-200
        • Bloom SW
        Structure and ideology in medical education.
        J Health Soc Behav. 1988; 29: 294-306