Personalizing the M.D.

A hundred years after the release of the Flexner Report, which set many of the standards that still guide North American medical education, a report being published today aims to stimulate reforms to reshape medical schools and residency programs for the next century.

Commissioned by the Carnegie Foundation for the Advancement of Teaching -- the same group that sponsored Abraham Flexner’s early-20th century examination of all 155 medical schools in the United States and Canada -- the new report lays out the case for drastic reconsideration of how North American medical education works. Published in book form as Educating Physicians: A Call for Reform of Medical School and Residency (Wiley), the study is the culmination of four years of research and site visits to medical schools and teaching hospitals. It calls for major change and innovation -- “new approaches to shaping the minds, hands and hearts of physicians.”

As the U.S. health care system has changed, a need has emerged for the medical profession to “rethink how we do education all over again,” said one of the report’s co-authors, David M. Irby, vice dean for education and a professor of medicine at the University of California at San Francisco School of Medicine. “The report speaks to both specific and general ways in which teaching and learning can be enhanced. But our intent here is to stimulate reform and to encourage innovation and creativity, and is less about specific requirements or changes we’d like to see.”

Central to the report’s recommendations is a shift away from the regimentation and regulation that created the four-year Doctor of Medicine degree and two-to-four-year residency toward a more flexible model that could adapt to students’ interests and learning styles. For some students, that shift might translate into shorter time to degree or a briefer residency period.

“Medical school and residency need to shift from one-size-fits-all to a much more individualized program,” said Molly Cooke, another co-author and a professor of medicine at the UCSF School of Medicine. “Students bring different dispositions, talents, career interests -- and medical education ought to support that.” The report’s third author, Bridget C. O’Brien, is an assistant professor of medicine at UCSF and a researcher in the university’s Office of Medical Education.

Individualization, Irby acknowledged, “would be a huge challenge for the accrediting, licensing and certifying agencies who find it much more reassuring to focus on the number of weeks or months of training.” But, he added, “by focusing on competencies -- the milestones at each level of training -- we can ensure that physicians are capable of doing what we’d like them to be able to do.”

There would still be a core of skills and knowledge that all students would need to master, Cooke said, cautioning that individualization wouldn’t translate into “people can go to medical school and just learn whatever.” But it would be balanced with a “flexible component” aligned with students’ professional interests, whether to become a bench researcher or a community health advocate.

By shifting to competency-based assessments, medical education could become more self-paced and less tied to how much time a student spends doing any one thing.

For some students, Cooke said, that might translate into a degree that takes fewer than four years to complete. For others, it might take longer. “It ought to take as long as it takes, but eight or nine years to get a doctorate, as is the case in some Ph.D. programs, that’s a step in the wrong direction.”

Texas Tech University said in March that it would begin offering a three-year primary care M.D., squeezing some of the traditional third-year clinical work into the second year of study and some of the fourth-year work into the third. At the time of the announcement, Irby told Inside Higher Ed that the move was well-aligned with the report’s objectives. Less time to degree, he said, “ought to be an option for every student -- regardless of specialty."

But both he and Cooke stressed that they were not calling for a drop in standards. “We’d just be changing from specified time to specified quality of performance,” Cooke said. “And in no way am I comfortable saying every degree should be reduced from four years to three years.”

So far, Cooke said, feedback on the report has been mixed. When presenting before professors, deans and presidents last fall at a meeting of the Association of American Medical Colleges, “people were very enthusiastic.”

But the groups that sponsor the United States Medical Licensing Examination, for instance, are likely to be less enthusiastic. “The oversight of medical education is very complicated and nobody means to be doing a bad job or to be a retrogressive influence, so to the extent that we say that the content of the three USMLE exams is not particularly helpful, that frankly tends to offend those groups,” Cooke said. “But if we didn’t stir things up a bit and really point out where we thought there were opportunities to significantly improve this enterprise, I don't think we'd be doing what we set out to do."

Matthew Stull, a recent graduate of the University of Pittsburgh School of Medicine who has put his residency on hold for a year to work as the American Medical Student Association’s education and research fellow, said that just as “the Flexner Report was such a monumental wake-up call,” the new report was “likely to be a very big deal in medical education.”

The curricular flexibility the report calls for, he added, “was the most innovative thing” he had identified in the report and would, he thought, be well-received by medical students.