- Email: [email protected]
Education of Medical Students: Present Innovations, Future Issues
Editorial Education of Medical Students: Present Innovations, Future Issues In this editorial, we will review some of the problems that make this a particularly challeng ing time to educate medical students. Such aspects as the shrinking pool of applicants, the changing profile of the applicants, and the effect of economics on medical education will be con sidered. Recent innovations in medical educa tion such as problem-based learning, use of computers in teaching, and the teaching and assessment of clinical skills will be examined critically. Problem-Based Learning.—Although prob lem-based learning produced an initial flurry of excitement, no objective data support the con tention that the end product of this type of learning is a "better" physician.1 In its purest form, problem-based learning implies that all requisite medical knowledge can be acquired as a result of researching and understanding pa tient problems. This clinically based "need to know" will cause better retention of basic science and clinical information because it will be hinged on a patient problem. This approach, however, has several fundamental problems. The first deficiency is that, without meticulous planning, students may complete their medical training and have large gaps in their knowledge base. The second difficulty is that problem-based learn ing is a faculty-intensive approach to training. Group leaders must undergo training, meet with students on an ongoing basis or until the case is solved, and be retrained in the complexities of each new problem. This concentrated use of faculty members makes problem-based learning expensive. Address reprint requests to Dr. J. B. Hanshaw, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655. Mayo Clin Proc 64:1175-1179, 1989
As we look toward the future, we should iden tify alternative approaches that would facilitate achievement of the major goals of problem-based learning in a more cost-effective, less laborintensive fashion. One suggestion is the rebirth of clinical correlations. Although they were widely used 10 to 15 years ago, their application seems to have declined with the advent of prob lem-based learning. This trend may have been attributable to a failure to develop master teach ers who could effectively conduct clinical corre lation exercises with a large group of students. The students might first be presented with background reading or a lecture in a basic sci ence area to provide them with the requisite knowledge. This introductory material could be followed by a case presentation, and the stu dents would be requested to ask a faculty mem ber for information from the patient's history and physical examination. For each piece of information requested, the faculty person would inquire why it was necessary and how it would help solve the patient's problem. A master teacher could engage 50 to 100 students with this process and provide great economy in fac ulty time. Such a clinical correlation encourages students to think in a logical and clinical fashion and to use basic science information to solve clinical problems. The role model has certainly been established with the case study method used in business and law schools.2 An alternative approach is to use problembased learning episodically throughout a tradi tional curriculum. For each session, the group of students might be presented with a case that would anticipate upcoming course material while also incorporating information from recently completed courses. The case could have multiple parts, and groups of students could identify learning issues for each segment. Objectives could be developed and provided by the group leader to ensure coverage of key issues and uniformity in the learning process. Clinical demonstrations and interaction with patients
1175
1176 EDITORIAL
(actual or simulated) could be included as ancil lary learning activities. The case might culmi nate with the presentation of an actual patient who mirrors many of the issues discussed during the case. For the past 3 years, this model has been used successfully at the University of Massachusetts and has received enthusiastic support from students and faculty. It is one strategy for introducing some problem-based learning into a traditional curriculum. Use of Computers in Teaching and Learning.—Computers have been widely touted as essential tools for the teaching and evaluation of medical knowledge and skills. Without an adequate definition of the term "computer liter acy," medical educators have considered it criti cal for the next generation of physicians. Un doubtedly, knowledge of word processing, spread sheets, and data bases for information retrieval has greatly simplified our existence. Except in isolated instances, however, little evidence has shown computers to be effective in teaching and testing. Computer graphics generated in live time are a magnificent way to illustrate pres sure-flow relationships. Ideas that require threedimensional axes for presentation can best be demonstrated on a computer screen rather than on a two-dimensional sheet of paper. Computers are useful for drill exercises with a large bank of questions in which students are allowed to pro gress at their own pace and ability level. Com puters also provide a strategy to allow more answer options to be presented than can be easily managed with a paper and pencil exercise. The interaction of computers and videodisks is a striking technique that allows the visualization of some extraordinary clinical material. We suspect that computer-assisted instruc tion and evaluation will probably be important in the future, but the currently available soft ware does not support widespread use at this time. Programs are expensive to produce, and few high-quality programs exist. Although computers are a useful tool for medical educa tion, they should not be presumed to be capable of teaching and evaluating all aspects of medi cine. Their use should be reserved for compe tency areas in which they have demonstrated
Mayo Clin Proc, September 1989, Vol 64
benefit for efficiency and effectiveness. We are eagerly awaiting the development of new soft ware programs that can be integrated into our curriculum. Teaching and Assessment of Clinical Skills.—What is the best way to teach students clinical skills? How do they learn to take medical histories, perform physical examinations, and talk to patients? Neither the current hospital nor ambulatory environment provides an oppor tunity for students to learn to talk to patients about sensitive issues such as sexual concerns, to tell a patient about the recurrence of a malig nant lesion, to request an autopsy from the next of kin, or to deal with an abusing parent. Ideally, these skills should be practiced repeatedly be fore students are required to use them with actual patients. Over the years, we have developed a system atic approach to teaching students basic clinical skills and evaluating their competence. We have also been able to ensure that students will be exposed to common clinical problems and will learn how to diagnose and treat them capably. We believe that this model will become even more useful in the future as the practice of medicine continues to evolve. During a course on physical diagnosis, our first-year medical students practice their basic skills on each other before being exposed to actual patients. A detailed behavioral checklist is used as both a teaching and an evaluation instrument. To learn basic interviewing skills, small groups of first-year students work with a faculty facilitator in role-play exercises and inter actions with simulated patients. During the course of a semester, each second-year student is required to see a minimum of 10 patients, for each of whom a complete history must be re corded and a physical examination must be performed. The student must then prepare a detailed write-up on each patient and present the case to a preceptor, who is either a full-time or a voluntary faculty member. For some degree of quality control, each student performs a complete physical examination, obtains an adult history, and obtains a pediatric history on a "standardized patient." Standardized patients
Mayo Clin Proc, September 1989, Vol 64
are nonphysicians who are trained to function in the roles of patient, teacher, and evaluator.3 To present an objective and individualized critique of each student's performance, the standardized patients use detailed behavioral checklists and evaluation instruments with preset mastery criteria. Each student also interacts with a female standardized patient to learn how to perform breast and pelvic examinations and a male standardized patient to learn how a geni tourinary examination should be done in a male patient. Third-year medical students also have con tact with several standardized patients. During the internal medicine clerkship, they practice a complete physical examination on a standard ized patient and are required to perform at an established level of competence. Each student also interacts with several patients who have common ambulatory problems. For most stu dents, this is the first opportunity to elicit a brief but relevant history and to perform a physical examination on an actual patient, inasmuch as an outpatient experience is not a part of the medicine clerkship. As part of the obstetricsgynecology clerkship, students perform a pelvic and breast examination on a standardized pa tient. During the pediatric clerkship, they inter act with a standardized patient who first acts as a pediatric parent and then evaluates the stu dent's history-taking skills. This experience is followed by an oral examination with a faculty member, who evaluates the case presentation, knowledge base, and problem-solving skills with use of the history from the standardized patient just seen. For the past 4 years, fourth-year students have participated in a day-long multiple-station clinical assessment exercise with standardized patients who have common ambulatory prob lems. This project has been conducted in con junction with several medical schools in New England.4·5 After each encounter, the standard ized patient documents and evaluates the stu dent's performance. At the end of the day-long exercise, the students discuss the cases with a faculty member and receive written feedback on their performance as well as a comparison of
EDITORIAL 1177
their scores with those of the other students who saw the same patients. If students who have weak clinical skills are identified, their respec tive schools provide special remediation pro grams. With increasing pressure on faculty to gener ate research and patient-care revenues, we anticipate that in the future more medical schools will use standardized patients as an integral part of their teaching and evaluation programs. Standardized patients are a logical strategy for helping students practice basic history-taking and physical examination skills and for guaran teeing that each student is exposed to patients with certain common clinical problems. We also expect that a multiple-station clinical assess ment examination will become part of the licensure process for all graduates. Some Major Issues in Medical Education.—The decline in applicants to medical school is striking. In 1976, more than 42,000 candi dates applied to American medical schools. By 1988, the number had declined to 26,721. The reasons for the decline are multifactorial but can be attributed in large measure to the cost, to the time it takes to become certified (11 to 15 years after secondary school), and to the increased dissatisfaction of many practitioners who feel beleaguered by the high malpractice insurance premiums, increased governmental regulations, and declining reimbursement from third-party payers. In 1988, the average indebtedness of 82% of American medical school graduates was $38,489. More than 24% of these students had debts in excess of $50,000. The applicant pool is also changing. Increased numbers of applications are now received from women, older students, and minorities. It is expected that all three categories of students will be less willing than traditional students to assume a high debt burden. It is difficult to see how quality can be sus tained in all medical schools when there are now only 1.7 applicants for each position. The ques tion of decreasing class size may well become a key issue in medical education if the number of applicants does not stabilize.
1178 EDITORIAL
Effect of Economic Realities on Medical Education.—During the past decade, faculties of American medical schools have had increas ing amounts of pressure to generate research and clinical revenues. Despite a doubling of fulltime faculty from 1972 to 1986, it is increasingly difficult to provide "protected" time for teaching. Although good teaching receives administrative lip service, only rarely are such activities re warded. Thus, faculty members are primarily committed to those activities that generate their salaries. Such a trend is even apparent in the recruitment of the chairperson of a clinical de partment, who is often chosen for the capacity to ensure continued and expanding grant support rather than a commitment to medical educa tion.6 Other economic factors that have an influence on medical education are evident in the hospital. Patients must be admitted and dismissed in the shortest possible time to ensure maximal reimbursements to the hospital through the prospective-payment mechanisms. There fore, the student may not even have a chance to interview and examine the patient, much less follow the natural history of the disease. The quaint tradition of ordering laboratory tests out of curiosity has long since disappeared, an ap propriate evolution because these tests often became a poor substitute for the development of basic clinical skills. The Ordering of Academic Priorities.— The current conventional wisdom is that the "triple threat" of medical academia is a rarity. Few faculty members can compete for federal research grants, generate substantial clinical dollars, and mesmerize students and residents with the skills of a master teacher. Most wise clinical chairpersons divide their faculty into clinicians and researchers. Both groups are expected to teach, and ideally, each group should spend at least a portion of time in the other group's major activity. Apart from these two revenue-generating groups, a third group, the scholarly teachers, need to be supported because they are rarely subsidized completely by scarce institutional funds. These individuals are the master teachers—few in number but indispens able to the teaching mission of every medical
Mayo Clin Proc, September 1989, Vol 64
school. The sequestration of funds for "pro tected" teaching time is essential. When a chair person of a clinical department is recruited, it is vital that the candidate selected understands the need for the division of professional priori ties in the modern clinical department. It is also important that the researcher participate in some clinical activities and that the clinician engage in some scholarly activities. Unless this cross-participation happens, walls will separate the laboratory from the bedside, to the detri ment of teaching, research, and clinical care. Because our current hospital population con sists of sicker patients with shorter durations of stay, it might not be prudent to allow students to learn and practice basic skills on these patients. A patient with multisystem disease or one who is admitted to the hospital for a diagnostic pro cedure may be an inappropriate candidate for a beginning student. Some educators suggest that students should be trained in an ambula tory patient setting,7 where the opportunity would exist to see patients with common prob lems such as hypertension, angina, minor gas trointestinal upsets, headaches, and backaches. These complaints would be typical of those en countered in practice. Teaching in the ambula tory setting, however, has other inherent prob lems because physicians and clinical facilities are under pressure to process patients as rapidly as possible. Therefore, this setting is not ideal for a beginning student who requires a consider able expenditure of time for history-taking and physical examinations. Also, many private patients may not readily accept the arrange ment of being seen by a beginning student. In addition, when multiple physician preceptors in different specialties interact with students and are assigned the responsibility of teaching basic skills, the result may be a loss of quality control and uniformity in these learning experiences. The teaching might be "uneven" because each student may be exposed to the unique patient base of the preceptor. Can We Decrease the Cost of Medical Education?—Recently, Ebert and Ginzberg8 pro posed, rather bravely, that medical school begin after 3 years of undergraduate school and that
Mayo Clin Proc, September 1989, Vol 64
EDITORIAL 1179
medical school be lengthened to 6 years in order REFERENCES 1. Schmidt HG, Dauphinee WD, Patel VL: Comparing to graduate generalists ready for licensure. They the effects of problem-based and conventional curric thought that a continuum of 4 clinical years, ula in an international sample. J Med Educ 62:305315, 1987 beginning with the third year of medical school, 2. Christensen CR, Hansen AJ: Teaching and the Case should be sufficient time to train physicians in Method. Second edition. Boston, Harvard Business the primary-care specialties. This plan would School, 1987 decrease the total training period for certifica 3. Stillman PL, Burpeau-Di Gregorio MY, Nicholson GI, Sabers DL, Stillman AE: Six years of experience tion by 2 years. Students at Oxford and Cam using patient instructors to teach interviewing skills. bridge planning to enter medicine complete the J Med Educ 58:941-946, 1983 equivalent ofthe first IV2 years of medical school 4. Stillman PL, Swanson DB: Ensuring the clinical competence of medical school graduates through before they receive their bachelor of arts degree standardized patients. Arch Intern Med 147:1049in physiology. In addition, during much of the 1052, 1987 fourth year of medical school, elective courses 5. Stillman PL, Regan MB, Swanson DB, Fourth-Year Performance Assessment Task Force Group: A diag "outside the framework of a cohesive educa nostic fourth-year performance assessment. Arch tional plan" are studied. Commenting on the Intern Med 147:1981-1985, 1987 9 proposal from Ebert and Ginzberg, Bondurant 6. Weller TH: As it was and as it is: a half-century of made the following statement: "...I do not be progress. J Infect Dis 159:378-383, 1989 7. Gastel B, Rogers DE (eds): Clinical Education and the lieve that most young men and women would be Doctor of Tomorrow. New York, The New York so qualified in knowledge, experience, judgment, Academy of Medicine, 1989 and perspective for medical practice after the 8. Ebert RH, Ginzberg E: The reform of medical educa tion. Health Aff (Millwood) 7 (Suppl):5-38, 1988 best six-year curriculum that I can conceive. I 9. Bondurant S: Perspectives: a medical school dean. wish that the experiment that is judiciously Health Aff (Millwood) 7 (Suppl):63-65, 1988 recommended were not doomed to success." This statement reflects the ambiguity in the thinking of many medical educators when a foreshorten ing of the time for training of physicians is contemplated. The future of American medicine can be as exciting as its past, but it will take bold initia tives and realistic assessments of our current situation to preserve the considerable achieve ments of the past. Paula L. Stillman, M.D. Associate Dean for Curriculum James B. Hanshaw, M.D. Dean and Provost University of Massachusetts Medical School Worcester, Massachusetts
As we look toward the future, we should iden tify alternative approaches that would facilitate achievement of the major goals of problem-based learning in a more cost-effective, less laborintensive fashion. One suggestion is the rebirth of clinical correlations. Although they were widely used 10 to 15 years ago, their application seems to have declined with the advent of prob lem-based learning. This trend may have been attributable to a failure to develop master teach ers who could effectively conduct clinical corre lation exercises with a large group of students. The students might first be presented with background reading or a lecture in a basic sci ence area to provide them with the requisite knowledge. This introductory material could be followed by a case presentation, and the stu dents would be requested to ask a faculty mem ber for information from the patient's history and physical examination. For each piece of information requested, the faculty person would inquire why it was necessary and how it would help solve the patient's problem. A master teacher could engage 50 to 100 students with this process and provide great economy in fac ulty time. Such a clinical correlation encourages students to think in a logical and clinical fashion and to use basic science information to solve clinical problems. The role model has certainly been established with the case study method used in business and law schools.2 An alternative approach is to use problembased learning episodically throughout a tradi tional curriculum. For each session, the group of students might be presented with a case that would anticipate upcoming course material while also incorporating information from recently completed courses. The case could have multiple parts, and groups of students could identify learning issues for each segment. Objectives could be developed and provided by the group leader to ensure coverage of key issues and uniformity in the learning process. Clinical demonstrations and interaction with patients
1175
1176 EDITORIAL
(actual or simulated) could be included as ancil lary learning activities. The case might culmi nate with the presentation of an actual patient who mirrors many of the issues discussed during the case. For the past 3 years, this model has been used successfully at the University of Massachusetts and has received enthusiastic support from students and faculty. It is one strategy for introducing some problem-based learning into a traditional curriculum. Use of Computers in Teaching and Learning.—Computers have been widely touted as essential tools for the teaching and evaluation of medical knowledge and skills. Without an adequate definition of the term "computer liter acy," medical educators have considered it criti cal for the next generation of physicians. Un doubtedly, knowledge of word processing, spread sheets, and data bases for information retrieval has greatly simplified our existence. Except in isolated instances, however, little evidence has shown computers to be effective in teaching and testing. Computer graphics generated in live time are a magnificent way to illustrate pres sure-flow relationships. Ideas that require threedimensional axes for presentation can best be demonstrated on a computer screen rather than on a two-dimensional sheet of paper. Computers are useful for drill exercises with a large bank of questions in which students are allowed to pro gress at their own pace and ability level. Com puters also provide a strategy to allow more answer options to be presented than can be easily managed with a paper and pencil exercise. The interaction of computers and videodisks is a striking technique that allows the visualization of some extraordinary clinical material. We suspect that computer-assisted instruc tion and evaluation will probably be important in the future, but the currently available soft ware does not support widespread use at this time. Programs are expensive to produce, and few high-quality programs exist. Although computers are a useful tool for medical educa tion, they should not be presumed to be capable of teaching and evaluating all aspects of medi cine. Their use should be reserved for compe tency areas in which they have demonstrated
Mayo Clin Proc, September 1989, Vol 64
benefit for efficiency and effectiveness. We are eagerly awaiting the development of new soft ware programs that can be integrated into our curriculum. Teaching and Assessment of Clinical Skills.—What is the best way to teach students clinical skills? How do they learn to take medical histories, perform physical examinations, and talk to patients? Neither the current hospital nor ambulatory environment provides an oppor tunity for students to learn to talk to patients about sensitive issues such as sexual concerns, to tell a patient about the recurrence of a malig nant lesion, to request an autopsy from the next of kin, or to deal with an abusing parent. Ideally, these skills should be practiced repeatedly be fore students are required to use them with actual patients. Over the years, we have developed a system atic approach to teaching students basic clinical skills and evaluating their competence. We have also been able to ensure that students will be exposed to common clinical problems and will learn how to diagnose and treat them capably. We believe that this model will become even more useful in the future as the practice of medicine continues to evolve. During a course on physical diagnosis, our first-year medical students practice their basic skills on each other before being exposed to actual patients. A detailed behavioral checklist is used as both a teaching and an evaluation instrument. To learn basic interviewing skills, small groups of first-year students work with a faculty facilitator in role-play exercises and inter actions with simulated patients. During the course of a semester, each second-year student is required to see a minimum of 10 patients, for each of whom a complete history must be re corded and a physical examination must be performed. The student must then prepare a detailed write-up on each patient and present the case to a preceptor, who is either a full-time or a voluntary faculty member. For some degree of quality control, each student performs a complete physical examination, obtains an adult history, and obtains a pediatric history on a "standardized patient." Standardized patients
Mayo Clin Proc, September 1989, Vol 64
are nonphysicians who are trained to function in the roles of patient, teacher, and evaluator.3 To present an objective and individualized critique of each student's performance, the standardized patients use detailed behavioral checklists and evaluation instruments with preset mastery criteria. Each student also interacts with a female standardized patient to learn how to perform breast and pelvic examinations and a male standardized patient to learn how a geni tourinary examination should be done in a male patient. Third-year medical students also have con tact with several standardized patients. During the internal medicine clerkship, they practice a complete physical examination on a standard ized patient and are required to perform at an established level of competence. Each student also interacts with several patients who have common ambulatory problems. For most stu dents, this is the first opportunity to elicit a brief but relevant history and to perform a physical examination on an actual patient, inasmuch as an outpatient experience is not a part of the medicine clerkship. As part of the obstetricsgynecology clerkship, students perform a pelvic and breast examination on a standardized pa tient. During the pediatric clerkship, they inter act with a standardized patient who first acts as a pediatric parent and then evaluates the stu dent's history-taking skills. This experience is followed by an oral examination with a faculty member, who evaluates the case presentation, knowledge base, and problem-solving skills with use of the history from the standardized patient just seen. For the past 4 years, fourth-year students have participated in a day-long multiple-station clinical assessment exercise with standardized patients who have common ambulatory prob lems. This project has been conducted in con junction with several medical schools in New England.4·5 After each encounter, the standard ized patient documents and evaluates the stu dent's performance. At the end of the day-long exercise, the students discuss the cases with a faculty member and receive written feedback on their performance as well as a comparison of
EDITORIAL 1177
their scores with those of the other students who saw the same patients. If students who have weak clinical skills are identified, their respec tive schools provide special remediation pro grams. With increasing pressure on faculty to gener ate research and patient-care revenues, we anticipate that in the future more medical schools will use standardized patients as an integral part of their teaching and evaluation programs. Standardized patients are a logical strategy for helping students practice basic history-taking and physical examination skills and for guaran teeing that each student is exposed to patients with certain common clinical problems. We also expect that a multiple-station clinical assess ment examination will become part of the licensure process for all graduates. Some Major Issues in Medical Education.—The decline in applicants to medical school is striking. In 1976, more than 42,000 candi dates applied to American medical schools. By 1988, the number had declined to 26,721. The reasons for the decline are multifactorial but can be attributed in large measure to the cost, to the time it takes to become certified (11 to 15 years after secondary school), and to the increased dissatisfaction of many practitioners who feel beleaguered by the high malpractice insurance premiums, increased governmental regulations, and declining reimbursement from third-party payers. In 1988, the average indebtedness of 82% of American medical school graduates was $38,489. More than 24% of these students had debts in excess of $50,000. The applicant pool is also changing. Increased numbers of applications are now received from women, older students, and minorities. It is expected that all three categories of students will be less willing than traditional students to assume a high debt burden. It is difficult to see how quality can be sus tained in all medical schools when there are now only 1.7 applicants for each position. The ques tion of decreasing class size may well become a key issue in medical education if the number of applicants does not stabilize.
1178 EDITORIAL
Effect of Economic Realities on Medical Education.—During the past decade, faculties of American medical schools have had increas ing amounts of pressure to generate research and clinical revenues. Despite a doubling of fulltime faculty from 1972 to 1986, it is increasingly difficult to provide "protected" time for teaching. Although good teaching receives administrative lip service, only rarely are such activities re warded. Thus, faculty members are primarily committed to those activities that generate their salaries. Such a trend is even apparent in the recruitment of the chairperson of a clinical de partment, who is often chosen for the capacity to ensure continued and expanding grant support rather than a commitment to medical educa tion.6 Other economic factors that have an influence on medical education are evident in the hospital. Patients must be admitted and dismissed in the shortest possible time to ensure maximal reimbursements to the hospital through the prospective-payment mechanisms. There fore, the student may not even have a chance to interview and examine the patient, much less follow the natural history of the disease. The quaint tradition of ordering laboratory tests out of curiosity has long since disappeared, an ap propriate evolution because these tests often became a poor substitute for the development of basic clinical skills. The Ordering of Academic Priorities.— The current conventional wisdom is that the "triple threat" of medical academia is a rarity. Few faculty members can compete for federal research grants, generate substantial clinical dollars, and mesmerize students and residents with the skills of a master teacher. Most wise clinical chairpersons divide their faculty into clinicians and researchers. Both groups are expected to teach, and ideally, each group should spend at least a portion of time in the other group's major activity. Apart from these two revenue-generating groups, a third group, the scholarly teachers, need to be supported because they are rarely subsidized completely by scarce institutional funds. These individuals are the master teachers—few in number but indispens able to the teaching mission of every medical
Mayo Clin Proc, September 1989, Vol 64
school. The sequestration of funds for "pro tected" teaching time is essential. When a chair person of a clinical department is recruited, it is vital that the candidate selected understands the need for the division of professional priori ties in the modern clinical department. It is also important that the researcher participate in some clinical activities and that the clinician engage in some scholarly activities. Unless this cross-participation happens, walls will separate the laboratory from the bedside, to the detri ment of teaching, research, and clinical care. Because our current hospital population con sists of sicker patients with shorter durations of stay, it might not be prudent to allow students to learn and practice basic skills on these patients. A patient with multisystem disease or one who is admitted to the hospital for a diagnostic pro cedure may be an inappropriate candidate for a beginning student. Some educators suggest that students should be trained in an ambula tory patient setting,7 where the opportunity would exist to see patients with common prob lems such as hypertension, angina, minor gas trointestinal upsets, headaches, and backaches. These complaints would be typical of those en countered in practice. Teaching in the ambula tory setting, however, has other inherent prob lems because physicians and clinical facilities are under pressure to process patients as rapidly as possible. Therefore, this setting is not ideal for a beginning student who requires a consider able expenditure of time for history-taking and physical examinations. Also, many private patients may not readily accept the arrange ment of being seen by a beginning student. In addition, when multiple physician preceptors in different specialties interact with students and are assigned the responsibility of teaching basic skills, the result may be a loss of quality control and uniformity in these learning experiences. The teaching might be "uneven" because each student may be exposed to the unique patient base of the preceptor. Can We Decrease the Cost of Medical Education?—Recently, Ebert and Ginzberg8 pro posed, rather bravely, that medical school begin after 3 years of undergraduate school and that
Mayo Clin Proc, September 1989, Vol 64
EDITORIAL 1179
medical school be lengthened to 6 years in order REFERENCES 1. Schmidt HG, Dauphinee WD, Patel VL: Comparing to graduate generalists ready for licensure. They the effects of problem-based and conventional curric thought that a continuum of 4 clinical years, ula in an international sample. J Med Educ 62:305315, 1987 beginning with the third year of medical school, 2. Christensen CR, Hansen AJ: Teaching and the Case should be sufficient time to train physicians in Method. Second edition. Boston, Harvard Business the primary-care specialties. This plan would School, 1987 decrease the total training period for certifica 3. Stillman PL, Burpeau-Di Gregorio MY, Nicholson GI, Sabers DL, Stillman AE: Six years of experience tion by 2 years. Students at Oxford and Cam using patient instructors to teach interviewing skills. bridge planning to enter medicine complete the J Med Educ 58:941-946, 1983 equivalent ofthe first IV2 years of medical school 4. Stillman PL, Swanson DB: Ensuring the clinical competence of medical school graduates through before they receive their bachelor of arts degree standardized patients. Arch Intern Med 147:1049in physiology. In addition, during much of the 1052, 1987 fourth year of medical school, elective courses 5. Stillman PL, Regan MB, Swanson DB, Fourth-Year Performance Assessment Task Force Group: A diag "outside the framework of a cohesive educa nostic fourth-year performance assessment. Arch tional plan" are studied. Commenting on the Intern Med 147:1981-1985, 1987 9 proposal from Ebert and Ginzberg, Bondurant 6. Weller TH: As it was and as it is: a half-century of made the following statement: "...I do not be progress. J Infect Dis 159:378-383, 1989 7. Gastel B, Rogers DE (eds): Clinical Education and the lieve that most young men and women would be Doctor of Tomorrow. New York, The New York so qualified in knowledge, experience, judgment, Academy of Medicine, 1989 and perspective for medical practice after the 8. Ebert RH, Ginzberg E: The reform of medical educa tion. Health Aff (Millwood) 7 (Suppl):5-38, 1988 best six-year curriculum that I can conceive. I 9. Bondurant S: Perspectives: a medical school dean. wish that the experiment that is judiciously Health Aff (Millwood) 7 (Suppl):63-65, 1988 recommended were not doomed to success." This statement reflects the ambiguity in the thinking of many medical educators when a foreshorten ing of the time for training of physicians is contemplated. The future of American medicine can be as exciting as its past, but it will take bold initia tives and realistic assessments of our current situation to preserve the considerable achieve ments of the past. Paula L. Stillman, M.D. Associate Dean for Curriculum James B. Hanshaw, M.D. Dean and Provost University of Massachusetts Medical School Worcester, Massachusetts