Physicians and Medicine in the Twenty-first Century

The description of the unfortunate state of physician training published in 1910 in the Flexner report served to revolutionize medical education in the United States. As this century nears its end, a new crisis seems to be looming. U.S. schools are producing some of the most technologically well-trained physicians in the world; nevertheless, critics argue that while our educational system is readily meeting the challenges of our technological advancement in medicine, it is failing in other respects. Physicians-in-training are being overwhelmed by the exploding volume of scientific knowledge and are not equipped to face the oncoming changing health care environment.

The planned reforms in the health care system will probably alter it dramatically and it is therefore essential that students be kept informed of the needs and opportunities that emerge. It is believed that one of the most significant needs will be for primary care physicians, and a surplus of specialists is predicted early in the twenty-first century. Thus, health care reform is linked to medical education reform, because overreliance on specialists results in excessive costs and reduced access to health care. Additionally, market factors have not served to equalize distribution and specialists are less likely to practice in rural areas.

The decade between 1980 and 1990 saw a drop in the percentage of primary care physicians from 40% to about 30%. Some believe that medical education contributed to this downward trend, due to the fact that the first two years of medical school usually provides little clinical exposure and, in the last two years, student role models are sub-specialists. In addition, many schools still do not require clerkships in family medicine. Some students are told by their teachers that general practice is not challenging enough. Others are dissuaded by the heavy debt loads that they have built up in medical school. Primary care is less remunerative than specialties; therefore, eliminating this debt is more difficult for a primary care physician than a specialist.

The response to demographic shifts in population has also been slow on the part of the medical education establishment. Minority groups are the fastest growing population segment, mandating an awareness of the impact of socioeconomic conditions that are specific to them. There is an increasing call for education in population medicine, considering the impact of social and economic factors on health. In addition, there is a belief that medical students are not taught disease prevention or how to encourage good health habits.

Preparing medical students to work in the new managed health care environment is another major challenge. In such settings, a health care team effort involves such allied health care professionals as physician assistants or advanced practice nurses, but this experience does not usually occur while one is a student.

There are those who feel that interpersonal and communication skills are not adequately emphasized during the educational phase. In addition, the system tends to diminish the students' sense of altruism during the course of their demanding education but some efforts to improve this situation have been initiated.

Educators argue that the curriculum is presently full and will become overloaded as biomedical information expands into new areas. Incorporating new information presents another challenge. Problem-based learning is an approach being tried in order to address this issue. The supporters of this educational method believe that the teaching under this system is more relevant and the students are therefore more inclined to become lifelong learners. Many are using actors as standardized patients to present certain symptoms and thus better evaluate clinical competence. Increased use of computers can prove beneficial in the learning process.

Impeding better integration of the basic and clinical sciences is thought by some to be the timing of the USMLE, with Step 1 covering the basics and Step 2 the clinical sciences. Some have urged combining them, with both steps taken at the end of the medical education program, thus eliminating the focus of teaching solely for board preparation. Reforms that involve providing students with earlier clinical experience are difficult and costly to bring about. Translating sound ideas into practice presents major problems. In addition, central curriculum planning is frequently opposed at the departmental level.

There are those who call for reexamining the mission of medical schools, especially at state institutions. The reassessment, if undertaken, can result in significant reforms.

Another problem is the lack of continuity between undergraduate and graduate education. Several schools are initiating programs that serve to combine both of these phases, with the usual aim being to encourage primary care.

More radical suggestions being heard are related to shortening medical education by accepting students into medical schools after their junior year in college and to eliminating the last year of medical school, which is in significant part devoted to securing a residency appointment. Thus, the undergraduate process would be reduced to six years, which is an option offered by a number of schools and is standard in Europe. Shortening the educational process would lower the debt obligations of medical students and, consequently, may reduce the pressures to seek training in higher paid subspecialties so as to wipe out such debt sooner and easier. This debt problem and its impact has prompted calls to make medical school tuition-free, an approach that in some quarters is being seriously considered. Supporters of this goal feel that it reinforces the concept that medicine is a profession with social obligations. Behind this approach is the desire to mandate that half of the residency appointments should be in primary care. Tuition relief, if elected, would be traded off by future professional choice limitation. There are even calls for a national program of mandatory service obligation. While it is quite unlikely that it will be introduced, some schools are requiring that their students perform community activities.

To graduate more socially responsible physicians, some schools are reviewing admission criteria and are looking beyond grades and MCAT scores to such factors as altruism and community involvement. To better judge this, some have appointed lay people to their admissions committee. One of the reasons for increasing minority representation is the fact that such students may be more responsive to community needs.

While medical schools can contribute to the increase in the number of primary care physicians, it is hoped that market forces will impact on this issue so that an overabundance of subspecialists will be translated into more primary care physicians.

An awareness of the future needs of society, which should be provided by medical schools, can influence residency choices. Health care reform may impact significantly on medical education. Schools will need to be offered the means of gaining a broad enough experience to train students to meet the needs of the coming century. Ideas for reforms are under active discussion and some have been made over the years. The prospects are favorable for significant progress in the foreseeable future.

While recognizing the need to develop a new type of physician, there is a realization that medical schools can't, on their own, generate more primary care M.D.s. The market forces seem now to be slowly reversing the equation, making subspecialists less in demand, while generalists are becoming more attractive. As the impact of these forces become known to medical students, their career goals may better fall in line with prospects for employment.

Medicine is a very dynamic profession. It changes not only as a result of advances in medical knowledge and technology, but also because of changes in the way medical care is offered. For the past number of years, health care has been the subject of a national debate. The reforms that will take place in the U.S. health system will significantly impact on all aspects of medicine including premedical education, admission to medical school, medical education, medical students, health care delivery, and physicians' specialties. The effect on each of these the components will be discussed in the rest of this chapter.