1. Dr. Myles Sheehan works with a group of medical students at the medical school of Loyola University Chicago.
The Changing Face of
American Medical Education
Stritch School of Medicine in Chicago. I believe the
By MYLES N. SHEEHAN changes in medical education are much needed and provide
great hope for Ihe creation of new physicians who can treat
T HE PRACTICE OE MEDICINE in the United States
is being reshaped. Managed ciire. health maintenance
organizations, preferred provider organizations and a
number of other new entines are replacing the individual
physician, fee for service mtxlel. Along with the ways doc-
the whole person while juggling the sometimes conflicting
imperatives of personal care and the mixed blessings of
high-tech medicine.
Why is medical education changing so much? Partly, it
is changing in response to changes in medical practice.
tors practice medicine, the way medical schools teach Two other reasons give some insight into the impetus for
medicine is also undergoing tremendous change. These the changes.
changes aim to provide medical student.s with the knowl- First, many Americans have expressed dissatisfaclion
edge, skills and attitudes necessary to provide good medical in recent years with an increasingly high-technology,
caie in a future where there is much uncertainty about how super-specialized approach to patient care that leaves indi-
medicine will be practiced. As a physician involved with viduals feeling alone in their illness. Although people still
work in curriculum development for several years, first at desire technical excellence, most also want to feel that
Harvard Medical School and now at Lciyola University's they have a physician who cares for them as a person,
Consequently future doctors will have to be educated in
MYLES N. SHEEHAN, S.J., M.D., is assistant profes- more than the mechanisms of disease; they will have to
sor of medicine at Loyola University Chicago's Stritch learn how to listen to patients and know ways to care tbat
School of Medicine. Dr. Sheehan's work in curriculum go beyond the purely technical.
development and geriatric medical education is supported Second, because there is so much infonnation to learn,
in pan by a fellowship liom Ihe Brixtkdale Foundation. medical educators find themselves forced to adapt their
14 AMERICA FEBRUARY 10, 1996

2. curricula to meet the explosion in new knowledge. Human to develop curricula that are learner-centered. Lectures are
immunodeficiency virus and AIDS dramatize the prob- not abolished, but their number is dramatically decreased
lem; they have spurred enormously impotlant scientific and their use strategically planned to suppletnent other
and clinical knowledge that was unknown 15 years ago. methods that encourage more active leaming. In place of
Anatomy, biochemistry, physiology, microbiology, pathol- lectures, many medical schools are tuming to an increased
ogy and traditional courses on the pathophysiology of the use of case-based or problem-based learning. Problcm-
organ systems (e.g.. diseases of the cardiovascular, gas- and ease-based learning force students to grapple with
trointestinal and neurologic systems) remain essential issues that do not have immediate solutions, tequire active
components of medical education. But jostling lor time participation to come up witJi approaches to problem solv-
and attention with these traditional disciplines are new ing and foster student cooperation in reaching answers
topics like ethics, preventive medieine and nutrition, as together.
well as issues in geriatrics and women's health. It is also The active leaming format is usually small group ses-
imperative to grapple with the explosion of information sions of approximately 10 students, with a faculty mem-
from molecular biology and genetics—disciplines that ber serving as facilitator. Problem-based leaming. as the
will likely change medical therapeutics in the cotning name suggests, requires that students deal with a particu-
decades. The difficulty for medical educators is how to lar problem, usually raised in a clinical context, and focus
incorporate all this information. Some schools already their attention on a relatively narrow set of questions.
demand over 30 hours per week of lab and lecture for Case-based learning can be more wide-ranging. It
medical students. Trying to cram tnore material into stu- involves the presentation of a clinical case, with students
dents" heads is unlikely to result in much useful acquisi- challenged to consider a variety of issues. Case-based for-
tion of knowledge. Something different has to be done to mats lend themselves particularly well to some of the less
deal with the current information overload. biomédical aspects of medical practice—topics in ethics,
Medical education is faced with a number of chal- social issues and the doctor-patient relationship, for exatn-
lenges. It must respond to the changes in medical knowl- ple—and can create an especially rich leaming experi-
edge, to the desire to train physicians to be more respon- ence as students provide differing viewpoints and empha-
sive to the needs of the patient as a person, to develop size differing aspects of the case. Unlike lectures, where
approaehes that emphasize restraint in applying medical the content is tightly controlled by the lectuter. problem-
technology and to focus on educating students who have a and case-based learning encourage a variety of different
gcncralist perspective rather than the tightly constricted topics to be part of the discussion. The learning process
expertise of a sub-specialist. parallels the real problems doctors face, where a variety of
Much is already being done in U.S. medical schools. conflicting issues—biological, psychological and
Three specific areas provide examples of the types of social—need to be considered simultaneously.
change now underway: a switch to small group instruc- For faculty members, facilitating active learning in
tion, an increasing trend to incorporate clinical experience small group sessions with tnedical students can be initially
early in the students' medical career and the development unsettling. Students are always surprising the facilitator
of teaching sites in ambulatory care settings. Each of these with questions he or she may not know how to answer.
changes is occurring for a variety of reasons. Each change The job of the facilitator in both probletn-based and case-
also brings its own set of problems. All three provide new based leaming is not to be responsible for answering all
opportunities for leaming that will better equip the current the questions. As I leamed in facilitating Harvard Medical
generation of students for their careers. School's Human Body course, a class that uses a variety
of fomiats for leaming about the structure and function of
Small Group Instruction. the human body, not speaking can be more important than
One of the most dramatic changes in U.S. tnedical providing information. As one student wrote on the evalu-
schools is the decline of the lecture as the primary method ation of tny performance as a group leader: "Dr. Sheehan
for teaching. Until recently most tnedical students put in did a great job once he leamed to keep his mouth shut and
close to 35 hours per week in lecture and laboratory. The let us find our own way."
lecture fonnat has the advantage of highlighting important A good facilitator helps students formulate questions,
material, emphasizing key points and clarifying difficult reach strategies for problem solving and ensute that alt
concepts. But long hours of sitting in lecture halls can cre- students contribute. Once the facilitator leams the role of
ate boredom, diminish intellectual curiosity and lead helping students learn how to answer their own ques-
many students to avoid class, relying on borrowed notes tions—knowing when to keep silent and when to give a
and textbook cramming. A heavy emphasis on the lecture suggestion for students finding their own way through a
format also tends to fossilize the curriculum. Where lec- cotnpiicated problem—the experience of directing 10
ture time is rigidly divided between departments, little very bright medical students becomes more cotnfortahle,
room is allowed for innovation, and efforts to introduce though it remains unpredictable.
new topics are stifled.
In switching to the small group fomiat, tnedical schmils
Instead of a teacher-driven lecture format, the trend is faee a dual challenge. The first is to find faculty members
AMERICA FEBRUARY 10, 1996 15

3. who have the time and talent to participate. A lecture only importance of skills of patient interviewing, medical
takes a single faculty member. Problem- or case-based ethics, health care policy and developing appropriate ways
learning requires a number of faculty members to facili- to relate to patients. In addition, the rigid division of medi-
tate. In these days., when faculty members are required by cal schools into preclinical and clinical years has con-
department chairs to see an ever increasing number of tributed to the development of an academic caste system
patients and to generate more clinical revenue, teaching where the best and the brightest minimized time spent
may not be the first priority. It can be diñlcuk for medical with patients and other clinical duties, opting instead for
schiwls (o fmd the numbers of motivated, bright teachers the more prestigious and intellectually respected arena of
whom medical .students need as medical research.
instructors and role models. The If U.S. medical schools are
second challenge is related to the serious about training doctors
recruitment difficulty: namely, who combine the be.st of a strong
the need to provide faculty devel- The hospital grounding in the science of
opment sessions. Faculty devel- medicine and a broad set of
opment is crucial to instruct
would-be facilitators about the
may not be a good place skills in interacting with the
patients, then emphasis mu.st be
ins and outs of teaching and facil- placed on issues of patient inter-
itating in small groups, as well as for students to learn viewing, medical ethics, health
to ensure that all instructors have care policy and tending to the
a basic understanding of the con- about ordinary problems special needs of differing groups
tent issues in a given class. of persons. Many schools have
Along with the faculty, new that make up most set about this task with introduc-
medical students may be initially tory clinical medicine courses in
di.soriented as they grapple with the first and second years that
case- or problem-based learning
of the routine practice feature interaction with patients,
after four yean> of college with a discussion of the topics men-
heavy emphasis on lectures and of medicine. tioned above and careful atten-
seminiu-s. Students may wonder tion to what it is like lo be a
how to approach a particular patient, how people pay for their
topic, searching for sources of care, and how to handle sensitive
information and sometimes struggling to frame appropriate topics like sexuality, family violence and addictions.
questions so they can come to conclusions. In time, these Loyola University's Stritch School of Medicine has
anxieties decline as students leani the best ways to master begun a course for ail incoming .students, called Intrtiduction
new material. A feeling of uncertainty and anxiety in the to the Practice of Medicine, where the focus is on interacting
face of a complex set of issues is something that doctors with patients and developing interviewing skills. Students
have to grapple with as they care for patients in their prac- visit inner-city clinics, make house calls, work with chap-
tices. The use of small group sessions, coupled with a mod- lains and spend time with physicians in their offices.
est number of lectures to provide structure and an overview Combining this clinical experience, which usually involves
of key concepts, enables students to learn how to learn and patient interviewing, with classrcK>m instruction on the sci-
develop the skills of independent learning, teamwork and ence of medicine provides students the opfxirtunity to value
critical questioning found in the very best clinicians. learning how to talk with someone about an illness as much
as learning the molecular biology of the same illness.
Clinical Experience. Bringing students into contact with patients from the begin-
Learning (o be a clinician is part of the purpose of med- ning of their medical school career also sends the mes.sage
ical education. A second major change in the curricula of that the patient, not just the disease, is worthy of attention
many American medical schools brings medical students and care.
into contact with patients from the first days of medical
school. Traditionally, medical education has been rigidly Out-Patient Care Sites.
divided into a two-year block of classroom learning fol- A third major change in medical education is the shift
lowed by two years of hospital ba.sed clinical experience. away from the in-patient setting of the academic teaching
The first two preclinical years of medical school heavily hospital as the primiiry .site of education in the linal two years
emphasized the scientific ba.sis of medicine and have been of medical school. For many years medical sUidents in their
an important factor in producing physicians with a superb third and fourth years would follow a person from admission
knowledge base to use in confronting a variety of com- to the hospital through diagnostic testing or surgery, and
mon and esoteric illnesses. would assist in that person's care until discharge.
Unfortunately, an exclusive emphasis on basic science In the old days, in-patient care proceeded at a relatively
and classroom instruction has also de-emphasized the leisurely pace, so the student could pursue a problem in
If. AMERICA FEBRUARY 10, 199ñ

4. depth, read about the diagnostic and therapeutic issues and to see a certain number of patients in a limited amount of
play a major role in patient care without significantly time to eani an income. In addition, new methcxls of reim-
delaying or compromising eificiency. In recent years, how- bursement and managed caie practices put pressure on dcx;-
ever, the average stay for hospitalized patients has tors to see an increasing number of patients in even shorter
decreased dramatically, and the types of conditions for blocks of time. This means that medical students get in the
which people are admitted have also greatly narrowed. way—for they are often not efficient in approaching a
Most diagnostic work-ups take place in the out-patient set- patient, taking a history and physical exam, evaluating a
ting, Common illnesses and conditions no longer merit problem, devising a plan for treatment and. if needed, for
admission to the hospital. The beds of teaching hospitals further testing. Moreover, many patients do not want to take
are typically occupied by people who are critically ill, have the extra time to go through a student evaluation. To lessen
unusual illnesses or are admitted only for a very brief peri- this problem, medical schools aie now teaching students the
od for specialized testing or therapy. The hospital, there- history-taking and physical exam skills necessary to fit in
fore, may not be a good place for medical students to leam more smoothly with the pace and demands of out-patient
much about uncomplicated diabetes, common pneumonia, medicine. Given the years of experience necessary to
hernias and other ordinary problems that make up most of become a proficient clinician, however, medical students
the routine practice of medicine. will inevitably require close supervision and take time away
As medicine and surgery shift from the hospital iti- from physicians who otherwise could be seeing patients
patient setting to out-patient clinics and other ambulatory more rapidly. More time and fewer patients seen can mean
settings, medical education is trying to find effective ways that students are an incumbrance when clinicians in every
to integrate medical students into out-patient care and to type of practice are scrambling to increase patient volume
provide ways that students can be supervised and taught and clinical revenues.
there. In this context a number of problems defy easy The challenges of integrating medical students into the
solution and call for creativity in establishing new models care of ambulatory patients are not only related to issues
of patient care and student education. Three of the major of time and money but also involve the availability of
problems are finances, locating appropriate sites for stu- enough generalist clinicians with the skills to provide
dents and recruiting appropriate clinician teachers. good learning experiences. With a growing emphasis on
Dœtors taking care of patients in offices or clinics need primary care rather than sub-specialties, schools want stu-
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AMERICA iinnoiinces the
15th NATIONAL CATHOLIC CHINA CONFERENCE
TO SUBSCRIBE OR RENEW MARCH 15-17,1996
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AMERICA FEBRUARY 10, 1996 17

5. dents to have practice sites that feature primary care. At medical school and shifting clinical education from the hos-
the same time, students need to be taught and not just pital to ambulatory Ciire sites. Are there any negatives asso-
thrown into action. Clinical teaching is a skill that requires ciated with these changes? There may be. Several concerns
time and development, and many schools are scrambling stand out: not enough time spent on science, fragmentation
to find ways to teach students in tbe clinic. The problem is of the learning experience and a loss of cumculum coher-
finding physicians who are willing and able to teach. ence under the pressure of unsystematically intioducing a
With the switch to out-patient teaching, educators variety of new topics. Questions about how much science is
responsible for students in the third and fourth years of enough in medical school are not easy to answer.
medical school fmd they need to Although much routine medi-
recruit a larger faculty than they cal practice can be conducted
once needed. Teaching medical without resorting to advanced
students the care of ambulatory biomédical science, deficiencies
patients in a variety of out-patient It can happen in an understanding of how the
settings requires both more active body operates and of the molec-
paiiicipation by attending physi- that students are ular underpinnings of therapeu-
cians and a lower ratio of physi- tics can lead to physicians who
cian-teachers to students than is
the case on the in-patient wards
an incumbrance when are incapable of adapting to
change, unable to apply power-
of a hospital. Yet, as noted, a ful new therapies properly and
busy practitioner might not be clinicians are scrambling lacking in the intellectual depth
able to afford the slow-down in to advance patient care. In tak-
seeing patients that might result to increase patient ing time away from science
from the addition of medical stu- courses in medical schools,
dents to an office practice. It is
not an easy task to identify
volume and clinical responsible educators are aware
of this risk. They are also aware
olfices and other practice sites to that there is not enough time to
take on the challenges of teach- revenues. leam everything. What has to be
ing students. emphasized to students is not
Neither is it a simple task to just the material they have to
fitid physicians with the knowl- learn: they must be helped to
edge, skills and attitudes to be good teachers. Teaching learn how to learn on their own. That is why I have
medical students in out-patient settings requires a set of stressed methods that foster learner centered fonnats and
skills that is not the property of every physician. The active leaming rather than passive assimilation.
attending physician must first ensure that the patient is In abandoning the traditional lecture format, problems
receiving appropriate care. Second, the physician must be of fragmentation arising from the introduction of too
able to discover teaching opportunities and provide many themes without a coherent organization become
instruction on a broad variety of issues. Third, the physi- ahnost inevitable. For this reason, medical schools recog-
cian needs the skill and attitudes to understand the medi- nize that efforts at curriculum reform are not a one-time
cal student's learning needs and the desire to excite, venture. Continual improvement is a necessity. Central
inform and encourage the fledgling physician, Part of this organization of the cuniculum. with a group of individu-
means really attending to the student's educational experi- als responsible for its overall shape and coherence, is
ence: making sure the student knows how to take a good essential if fragmentation is to be avoided in the rush to
history and is learning how to deal with complicated or incorporate early clinical experience and new topics.
difficult patients, reviewing the skills of the student in per- Careful efforts at evaluation of all components of the cur-
forming a physical exam that is thorough, accurate and riculum—students, faculty and courses—are needed to
respectful of the patient and, fmally, listening to the stu- provide feedback and quality control.
dent as he or she tries to leam how to think like a clini- The kind of medical care Americans will receive in the
cian, sorting out diagnoses, considering what tests are future does not depend only on the education doctors
needed and trying to provide the best recommendation or receive. It is linked with the way changes in medical prac-
prescription possible. Schools are beginning to piece tice will constrain or encourage technically excellent
together the elements of increasing ambulatory education patient care that is equally sensitive to the patient as a
for third- and fourth-year medical students, but the diffi- human being. Individuals who are concerned about the
culties are real and a source of anxiety. future of medical care in this country would be wise to
consider ways in which the current changes in medical
Risks in New Approaches. practice may encourage or discourage precisely the type
I have strcs.sed the advantages of changing from lecture- of smart, caring, concerned physicians U.S. medical
based curricula, incorporating clinical experiences early in schools are trying to produce. D
18 AMERICA FEBRUARY 10, 1996