WORCESTER MEDICINE
Students Then & Now A Roadmap of Change in Medical Education: Milestones Along the Journey, and a Preview of What’s To Come Michele Pugnaire, MD
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n these pandemic times, change in medical education is ongoing
and ever-accelerating. In grappling with “change fatigue”, let’s recognize that medical education has evolved for over a century and consider how change has shaped medical education as we now know it. What follows is a roadmap of medical education with timelines and change milestones from the 1900s to now, offering perspective on changes past as we look ahead to future change yet to come. Our roadmap begins with the 1910 Flexner Report. Commissioned by the Carnegie Foundation for the Advancement of Teaching to ensure quality in 20th century medical schools, Abraham Flexner’s report set revolutionary standards for his time (1). His “2x2” model prioritized acquiring scientific knowledge and rigorous clinical training through two years of classroom-based coursework and two years of clinical rotations in university-affiliated hospitals supervised by clinician faculty. Designed for teaching medical students “to think like scientists,” Flexner established a clear dividing line between preclinical and clinical years (2). In 1942, accreditation standards adopted the 2x2 model as the medical education prototype. By 1967, students in 92 medical schools were being taught to think like scientists through arduous hours of coursework, for example, anatomy 556 hours (median, range 252-1257) and pathology 330 hours (median, range 108-706) (3). From 1970 to 1990, complementary milestones emerged in the form of primary care workforce shortages and nationwide calls for “generalism.” Addressing workforce needs, generous federal and state funding expanded primary care education and residency training. By 1990, 22 new medical schools were accredited, with the University of Massachusetts among these state-sponsored “primary care schools” (4). Along with school expansion, primary care advocates, the Association of American Medical Colleges and the American Medical Association endorsed a general professional education preparing students with foundational skills and values required of all physicians, regardless of specialty (5). The 2x2 framework accommodated generalism teaching, by replacing basic science time with longitudinal preceptorships and patient-focused small group teaching, including patient interviewing, clinical problem solving and humanistic values in patient care. In clinical years, hospital-based clerkships carved out time for ambulatory and primary care rotations in physician offices. By 1988, accreditation standards required generalism teaching across preclinical and clinical years. Students being taught to think like scientists would graduate with a general professional education required for all physicians (5). Despite these advances, Flexner’s 2x2 dividing line between preclinical and clinical years held firm, with limited flexibility in year three, dominated by six- to 12-week rotations in medicine, surgery, obstetrics and gynecology, psychiatry, and pediatrics – much like the 1960s (6).
SEPT / OCT 2021
With the new millennium, 2010-2020 soon became a decade of curricular reform with three milestones transforming medical education beyond prior periods of curriculum change. Leading the way, companion reports from the Institute of Medicine, “To Err is Human” and “Crossing the Quality Chasm,” focused public attention on medical errors as a leading cause of death in the United States (7), while endorsing two major reforms to promote health care quality: competency-based standards across the learning continuum (student, resident, physician) and patient safety and health care quality training in all stages of learning (8). By 2008, core competencies were defined for each learner level, unifying the educational continuum through a competency-based framework. One hundred years after Flexner, his model of teaching students to think like scientists was redesigned to prepare students as competent graduates, “residency-ready” for their next phase of GME training. Building on competency reform, the Carnegie Foundation issued a second report in 2010, “A Call for Reform in Medical Education,” reappraising and dismantling the Flexner model through comprehensive reform. It features: • Enhanced curriculum flexibility to individualize student learning • Integration connecting basic, clinical and social sciences across years • Fostering inquiry and continuous life-
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