Medical Education: Current Status and Promising Practices David Irby, PhD Senior Scholar, Carnegie Foundation for the Advancement of Teaching Vice Dean and Professor of Medicine, UCSF

Preview 100 years of change in American medicine Carnegie study Initial observations of current status and promising practices

Abraham Flexner Abraham Flexner hired by Carnegie Foundation Site visited every medical school in U.S. and Canada Flexner Report (1910) transformed medical education

Flexner’s Model University-based medical education Uniform Curriculum –Basic sciences for two years –Clerkships for two years Internships and residencies came later Pedagogy –Active learning - labs, clerkships –Taught by clinician scientists Teaching hospital

Central Story Line Medical education in 1910 –Medical education in midst of change & chaos –Flexner – promoted compelling model –The model has been normative for 100 years Medical education in 2010 –Medical education in midst of rapid change –Old model stretched to breaking point –New model needed

Medical Education 100 Years Later Biomedical research explodes –Reductionist science and subspecialization –Physician scientists no longer teach/care for patients Teaching hospitals complex & specialty oriented –Acute, complex, subspecialty, rapid turnover –Common, chronic illnesses seen elsewhere Curriculum extends –4 yrs for MD, 3-7 yrs residency, 2+ yrs fellowship Medicare, managed care, patient safety grow Teaching and learning challenged

Carnegie Foundation for the Advancement of Teaching Cross-comparison study –Engineers, Lawyers, Clergy, Nurses, Physicians Three apprenticeships –Knowledge (head) –Skillful practice (hands) –Professionalism (heart) Qualitative/policy study based on site visits

Carnegie Research Team William Sullivan, PhD Molly Cooke, MD David Irby, PhD Lee Shulman, PhD Ann Colby, PhD Bridget O’Brien, PhC

Institutions Site Visited Atlantic Health Harvard Henry Ford Mayo Northwestern Southern Illinois U UCSF University of Florida University of North Dakota University of Penn University of South Florida UTMB University of WA

Clinical Education in Medicine Doctoring Courses Residency Clerkships

Components of Clinical Education Teaching Curriculum Context Assessment Learning

General Observations Ineffective learning on wards –Wasted time and effort of residents, students and faculty –Learning driven by service demands –Conflicting expectations of students –Competency vs. time conflicts –Systems improvement needed Longitudinal relationships lost Innovations abound in UME –Structures for doctoring and clerkships

Doctoring Course Structures Classroom and preceptorships Classroom and standardized patients College mentoring system Second year clerkships

Third Year Structures Stand alone clerkships –Plus intersessions, longitudinal ambulatory experience, and clinical skills centers Blended clerkships Community-based ambulatory clerkships Patient-centered, year-long clerkships Apprenticeship clerkships

Rethink Clinical Education Redesign patient care & learning together –Primacy of learning over service –Longitudinal relationships –Off-load some learning from clinical practice Shift balance from inpatient to outpatient Create competency-based assessment Fund and reward core teaching faculty Create new funding models for GME

Flexner New Model Model University Basic Sciences Clerkships Clinician scientists Teaching hospital University, community Integrated sciences Clerkship & residency –Competency-based –Mentored, longitudinal Core teaching faculty Teaching & community hospitals and clinics

Summary Exciting time for medical education – rapid change The Carnegie study will –Describe the current state of medical education –Propose a new conceptual model –Point to promising practices Stay tuned