16 Physicians and
Medicine in
the Twenty-first Century
The challenge
Premedical education
Admission to medical school
Medical school education
Medical students
Medical practice
Specialists versus primary care
physicians
Medical litigation crisis
Cybermedicine
Medical informatics
THE CHALLENGE
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, con-
sidering 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.
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