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A Roadmap of Change in Medical Education: Milestones Along the Journey, and a Preview of What’s To Come
Michele Pugnaire, MD
In 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).
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-
long learning in diverse settings, including community and population-based experiences focused on health care quality and equity • Continuous professional development emphasizing student wellness and self-care (2)
Coinciding with Carnegie’s call for reform, a second workforce shortage emerged nationwide across all medical specialties. From 2010-2020, 24 new schools were established (4), many with pioneering innovations. For example, Kaiser Permanente Tyson School of Medicine was established in part to “prepare students for future-facing clinical practice and health system leadership” (9). Spearheaded by newcomer innovations, medical schools nationwide comprehensively redesigned their curricula by dismantling Flexner’s 2x2 model. Common trends featured integrated systems-based courses replacing basic sciences; more time for small group interactive learning and independent study displacing lecture time; diversification of learning venues in community settings outside the hospital; earlier start to the clerkships in year two by shortening the “preclinical” years, and six- to 12-month longitudinally integrated clerkships replacing “stand-alone” clerkship blocks. To enhance individualization, parallel tracks, scholarly concentrations and expanded electives across all years offered students choice and customization of their learning experience (10).
And then came the pandemic in March 2020. In just weeks, in-person classes became remote and clinical rotations were comprehensively redesigned for student and patient safety. In this time of curricular redesign, how else did medical education respond to pandemic-driven change? Some early, impressive trends emerged, including: • Fourth year “residency-ready” medical students joined the COVID-19 workforce through early graduation, licensure and deployment in school-affiliated health care systems at UMass (11) and in schools nationwide. • Interest in medical school soared, with record numbers of applicants in 2020 and 2021 (12). • Students became change agents and valued pandemic partners in communities and health care systems locally and nationwide. In June 2021, Academic Medicine compiled publications from 2020-2021 addressing pandemic-related changes in medical education. Of these, 56 publications (38%) included student authors, showcasing student activism spanning systemic racism; racial and ethnic disparities; student diversity in medical schools; interprofessional partnerships; social justice reform; student wellness; and humanism; as examples (13).
Looking ahead, what future change is anticipated for post-pandemic medical education? While uncertain, we know medical education is now more adaptable than ever, without Flexnerian constraints and with cutting-edge innovations underway. Student interest in medicine is stronger than ever, undeterred by pandemic-related change. And, today’s students are competency-prepared, socially conscious and ready to advocate for and contribute to much needed forward-facing change, particularly targeting socio-demographic barriers to health care equity, access and quality. Come what may, post-pandemic, future change in medical education rests in the very best of caring and competent hands.+
references
1. A. Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching 1910 reprinted Science and Health Publications: 1960
2. Irby, David M et al. “Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching”: 1910 and 2010”, Academic Medicine: February 2010 - Volume 85 - Issue 2 - p 220-227 doi: 10.1097/ ACM.0b013e3181c88449
3. Undergraduate Medical Education. JAMA. 1972;222(8):965–991. doi:10.1001/jama.1972.03210080045014
4. https://lcme.org/directory/
5. Muller, S. (chair) Physicians for the Twenty-first century: Report of the Project Panel for the General Professional Education of the Physician and College Preparation for Medicine J.Med Educ.59 part2 (November 1984).
6. Jonas HS, Etzel SI. Undergraduate Medical Education. JAMA. 1988;260(8):1063–1071. doi:10.1001/jama.1988.03410080033005
7. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 2000.
8. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press, 2001.
9. https://medschool.kp.org/about/mission-vision-and-values . accessed
10. Novak, Daniel A. et al “Continuum of Innovation: Curricular Renewal Strategies in Undergraduate Medical Education”: 2010–2018, Academic Medicine: November 2019 - Volume 94 - Issue 11S - p S79-S85 doi: 10.1097/ ACM.0000000000002909
11. Flotte, Terence R et al. “Accelerated Graduation and the Deployment of New Physicians During the COVID-19 Pandemic.” Academic medicine : journal of the Association of American Medical Colleges vol. 95,10 (2020): 1492-1494. doi:10.1097/ACM.0000000000003540
12. https://www.aamc.org/media/37816/download
13. https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=68
Michele P. Pugnaire, M.D. Professor Emeritus Office of Educational Affairs Department of Family Medicine and Community Health University of Massachusetts Medical School
