John McGinnis and Russell Mangas published a startling opinion piece in the Wall Street Journal recently: “First Thing We Do, Let’s Kill All the Law Schools.” They postulated, “The high cost of graduate legal education limits the supply of lawyers and leads to higher legal fees… States should permit undergraduate colleges to offer majors in law that will entitle graduates to take the bar exam.” You may ask, Do we have a workforce shortage of lawyers? Does young lawyers’ student loan indebtedness really drive their fees?
My first thought was, What are the corollaries for medical education?
Many reflect that our traditional didactic lectures and experiential method of clinical training have not measurably changed for a hundred years. Certainly, advances in techniques and technologies have changed what we do, but much of how we learn is still through shoulder-to-shoulder apprenticeship. Even our behaviors are grounded in traditional role modeling.
There are many committed experts who have been studying how we can transform medical education for years. Educators are also actively discussing how to move from a time-based to a competency-based advancement system. There is an increasing sense of urgency, however, to move faster.
Victor Fuchs published an article, “Rethinking Medical Education,” on the Healthcare Blog that proposes radical change in how we approach medical education. Fuchs suggests that we figure out how to train physicians in a shorter period of time for lower cost.
“Changing the structure of medical education will not be easy, even for those who are enthusiastic about the goal,” Fuchs writes. “Opponents will be numerous, and the arguments varied… For more than fifty years I have observed and participated in attempts to reform college curricula, and I can tell you that reforms that are not controversial are inconsequential.”
I recently heard a presentation by a physician named Richard Reznick from Canada, who has done some very interesting things with simulation. He presented a pilot study involving orthopedic surgery residents who, for the first four months of their training, were placed in simulation labs. There they learned the basic surgical skills and specific procedural skills for orththopedic surgeons. Reznick said the residents tied knots until they were cross-eyed.
When they were unleashed on the clinical services, their surgical responsibilities were always as the primary surgeon or the first assistant, never as retractor holder. They could then focus on attaining mastery rather than just random skill acquisition; and could focus on learning the judgment and patient care management skills that are just as important as the technical skills.
In a 2006 article in the New England Journal of Medicine, Reznick proposed:
The earlier stages of teaching technical skills should take place outside the operating room; practice is the rule until automaticity in basic skills is achieved. This mastery of basic skills allows trainees to focus on more complex issues, both technical and nontechnical, in the operating room. To return to the example of knot tying, the learner who still has to think about how to tie a square knot is much less likely to pick up on other teaching that transpires in the operating room than is the learner who has mastered this simple skill.
(“Teaching Surgical Skills — Changes in the Wind,” Richard K. Reznick, M.D., M.Ed., and Helen MacRae, M.D. N Engl J Med 2006; 355:2664-2669, December 21, 2006)
So much of our early focus was on skill acquisition—and it often happened haphazardly. Our focus and anxieties were often around attaining these skills rather than the judgment and behavioral skills that are perhaps more important.
Institutions have tried to formalize clinical and technical skills using OSCEs and simulation labs, but are we just nibbling around the edges instead of creating radical testing environments for medical education?
I had hoped that CMMI’s Innovation Challenge would include some bold proposals for retooling medical education. I expect that many of the awardees will be focused on care transitions and decreasing the cost of care.
Perhaps we have missed an opportunity…