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EVP Update: Nine Reasons to Redesign Education

The internal medicine community is demanding fundamental redesign of the discipline’s educational continuum.

First, stakeholders, policymakers, and other observers have expressed concerns about the quality of medical education in the United States for more than two decades. Because internal medicine educates more physicians than any other discipline, concerns about the overall quality of medical education resonate disproportionately within departments of internal medicine.

Kenneth M. Ludmerer, MD, summarizes these issues as he describes academic medicine in the United States at the end of the 20th century in Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. “Major characteristics of this period included the erosion of the clinical learning environment, the diminishing of faculty scholarship, and the reemergence of a proprietary system of medical schools in which the faculties’ financial well-being was placed before education and research” (1).

Second, medical education is slow to adapt to changes in health care that result from scientific advances (such as genetics), further subspecialization (such as interventional cardiology), and adjustments in delivery (such as hospital medicine). Because internal medicine conducts more research and cares for more patients, these changes are of greater consequence and affect other areas within the discipline. Moreover, the evolution of medicine demands that physicians-in-training learn as part of multidisciplinary teams that “may include nurses, social workers, care managers, dietitians, physical and occupational therapists, and others” (2).

The expansive nature of internal medicine raises fundamental questions about the future of the educational continuum. Should internal medicine residency programs create separate tracks for ambulatory general internal medicine and hospital medicine? Is the traditional academic fellowship the best mechanism for physicians who seek further subspecialization? How should highly specialized areas relate to the rest of internal medicine as well as to other non-medical specialties? How much freedom should physicians-in-training have to customize their educational experiences?

Third, new internists worry about the relevancy of their medical education to practice. Dubbed the “training-practice gap,” this situation reflects the failure of the educational continuum to offer physicians-in-training opportunities to experience “the real world practice of medicine,” especially in ambulatory settings (3).

In “Closing the Gap between Internal Medicine Training and Practice: Recommendations from Recent Graduates,” Vineet Arora, MD, and colleagues note, “internal medicine training has been slow to evolve” to meet the demands of “cost containment, specialization, and increasing medical knowledge and technological advancement” (4). Dr. Arora and the other recent graduates also raise concerns about the “uneasy marriage of service and graduate medical education” (4).

Fourth, the current financing of medical education discourages institutions from educating physicians in settings other than hospitals. Local, state, and federal governments provide approximately $15 billion in annual funding for medical education (5). The majority of this funding goes to hospitals. For example, through the direct graduate medical education (DGME) payment and indirect medical education (IME) adjustment, Medicare pays $8 billion annually to teaching hospitals for medical educationrelated costs. Congress noted this problem and attempted to correct it through the Balanced Budget Act of 1997 (PL 105-33), which allowed Medicare to pay DGME and IME to hospitals even if residents and fellows were located in “non-hospital” settings.

However, the Centers for Medicare & Medicaid Services (CMS) has disallowed payments under this provision unless the hospitals have paid “all or substantially all” of the medical education costs in non-hospital settings, including payment to faculty even if they choose to volunteer their time. The Medicare Prescription Drug and Modernization Act (PL 108-173), which became law in December 2003, mandated that the Department of Health and Human Services (HHS) develop alternative methodologies to pay for graduate medical education in non-hospital settings (6). Although the HHS Office of the Inspector General released a report outlining alternatives last December, CMS refuses to alter its position on the issue. Without appropriate support for training outside of teaching hospitals and their clinics, residents and fellows experience a significant lack of exposure to the actual practice of modern medicine.

Fifth, physicians are not adequately trained to provide the safest, highest quality care possible. This situation creates a challenge for the academic internal medicine community. How can internal medicine train future internists to provide safe, high quality care in an environment characterized, in a study of six industrial nations, as having the highest rate of medical errors and the least efficient coordination of care (7)?

As part of its Health Care Quality Initiative, the Institute of Medicine (IOM) in 2003 published Health Professions Education: A Bridge to Quality. This report encourages medical educators as well as “accreditation, licensing, and certification organizations” to ensure that health professionals “maintain proficiency in five core areas: delivering patient-centered care, working as part of interdisciplinary teams, practicing evidence-based medicine, focusing on quality improvement, and using information technology” (8).

Sixth, recent studies point to a shortage of health care providers, including physicians. After advocating for nearly one decade that the United States should reduce the supply of physicians, the Association of American Medical Colleges (AAMC) earlier this year reversed its position on the physician workforce. AAMC “recommends that the total enrollment in US medical schools should be increased by 15 percent from the 2002 level over the next decade” (9). The association also “recommends that the aggregate number of graduate medical education positions should be expanded to accommodate the increased number of graduates from accredited medical schools” (9).

Projections of the health care workforce are notoriously difficult, but it is clear that health professionals are poorly distributed. At least 30 million people in the United States live in“health professional shortage areas” (10). Additionally, the number of underrepresented minorities matriculating into US medical schools has declined “despite the increase of minorities as a proportion of the US population (now approximately 28 percent and projected to increase substantially by the year 2010)” (11).

Seventh, because US medical school graduates (USMGs) are incurring more debt than ever, some authorities are concerned about the length of formal medical education. According to a report published by AAMC, student debt was 4.5 times higher in 2003 than it was in 1984; graduates of private medical schools incurred a median debt of $135,000 in 2003, contrasted with $27,000 in 1984; and the “median amount of debt for graduates of public medical schools was $100,000” in 2003 compared with $22,000 in 1984 (12). (The inflationary increases for the graduates of private and public schools should have been approximately $47,000 and $39,000, respectively, in 2003.)

Citing this burden,W. Bruce Fye, MD (on behalf of the American College of Cardiology), Thomas A. Blackwell, MD, and Lee Goldman, MD, published separate articles in 2004 that recommended shortening the educational continuum in internal medicine (13-15). For example, Dr. Fye asserts, “Some, perhaps many, outstanding US medical school graduates choose not to become cardiologists because they do not want to delay the start of their ‘goal’ specialty training by three or more years” (13). Of course, this observation is difficult to reconcile with the explosion of medical knowledge (reason two for education redesign) and the “training-practice gap” (reason three).

Eighth, internal medicine has become less appealing as a career choice for USMGs. In 2005, 1,225 fewer graduates selected categorical residency programs in internal medicine than in 1985 (16). Besides concerns about debt, fewer students are selecting internal medicine because they have more professional choices than ever before, recognize that internal medicine (particularly general internal medicine) offers lower salaries than other disciplines, seek controllable lifestyles, sense that internists in practice are unhappy, and consider internal medicine the field of chronic disease and geriatrics (care that the current system does not value) (17).

Recognizing this trend, the American College of Physicians (ACP) held a summit in November 2003 on revitalizing internal medicine. After two days of discussion, the participants helped ACP develop four goals for making internal medicine a more appealing career option for the next generation of physicians:
  • Repair the dysfunctional payment system.
  • Redesign the practice of internal medicine.
  • Define and articulate the value of internal medicine.
  • Educate and train internists for the future practice of internal medicine (18).

And ninth, the transitions between undergraduate and graduate and continuing medical education (CME) require reinforcement. In his final address as AAMC President, Jordan J. Cohen, MD, challenged the academic medical community “to strengthen the continuum of medical education” (19). According to Dr. Cohen, “the ultimate goal is to tie CME directly to an assessment of individual physician performance, identifying specific areas for improvement, crafting appropriate educational interventions, and documenting whether the doctor’s practice actually gets better as a result” (19).

Unfortunately, subspecialists are debating whether to maintain certification (recertifying) in both general internal medicine and their subspecialty. This situation is causing the American Board of Internal Medicine (ABIM) to reconsider the links between graduate medical education and CME. Approximately 60 percent of subspecialists also attempt to maintain their certification in general internal medicine when they recertify through ABIM (20). This percentage is a classic example of the glass being half full or half empty. Regardless, the community needs to define core competency in internal medicine. This “core” is part of all forms of internal medicine practice, which means internists should maintain these skills, knowledge, and attitudes irrespective of their careers as generalists, hospitalists, geriatricians, or subspecialists.

To address these nine challenges and continue the momentum for redesigning the educational continuum in internal medicine, the Alliance for Academic Internal Medicine (AAIM) and ABIM will co-sponsor a retreat in December 2005 on “Recognizing Focused Practice and Redesigning the Educational Continuum.” The retreat will include representatives from AAIM and ABIM as well as the Residency Review Committee for Internal Medicine (RRC-IM), ACP, the ACP Council of Associates (which includes physicians-in-training), and the societies that represent the 15 specialties within internal medicine.

Together, these constituencies—AAIM, ABIM, RRC-IM, ACP, the Council of Associates, and the specialty societies—include every element of the internal medicine community. For the past year, John P. Fitzgibbons, MD, and Frederick J. Meyers, MD, have headed the AAIM Education Redesign Task Force. This task force is attempting to determine how the educational continuum in internal medicine should change to train the internist of the future as well as defining the core competencies every internist must have in the future, regardless of career direction.

Between this task force and the December retreat, I anticipate that the internal medicine community will finally begin to reach consensus on redesigning education. To address the nine challenges I have outlined in this update, the community must reach such an agreement.

Sincerely,

Tod Ibrahim
Executive Vice President

References
  1. Ludmerer KM. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999.
  2. Weinberger SE. Personal Communication. November 6, 2005.
  3. Fitzgibbons JP and Meyers FJ. AAIM response to closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118:685-686.
  4. Arora V, Guardiano S, Donaldson D, Storch I, and Hemstreet P. Closing the gap between internal medicine training and practice: recommendations from recent graduates. Am J Med. 2005;118:680-685.
  5. Lesky LG. Redesigning (internal medicine) medical education: content, structure, and financing. Presented at: 2005 Clerkship Directors in Internal Medicine National Meeting. October 21, 2005.
  6. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (PL 108-173). Available at http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=108_cong_public_laws&docid=f:publ173.108. Accessed November 11, 2005.
  7. Schoen C, Osborn R, Huynh PT, Doty M, Zapert K, Peugh J, Davis K. Taking the pulse of health care systems: experience of patients with health problems in six countries. Health Affairs (web exclusive). Available at http://content.healthaffairs.org/
    cgi/content/full/hlthaff.w5.509/DC1. Accessed November 4, 2005.
  8. Institute of Medicine Committee on Health Professions Education Summit, Greiner AC and Knebel E, editors. Health Professions Education: A Bridge to Quality. Washington, DC. National Academies Press; 2003.
  9. Association of American Medical Colleges. The Physician Workforce: Position Statement (February 22, 2005). Available at www.aamc.org/workforce. Accessed November 4, 2005.
  10. Dall T. Understanding physician workforce data and projections. Presented at the AAIM Forum on the Future of the Health Care Workforce. September 14, 2004.
  11. King TE, Dickinson TA, DuBose TD, Flack JM, Hellmann DB, Pamies RJ, Todd RF, Torres EA, Wesson DE. The case for diversity in academic internal medicine. Am J Med. 2004;116:284-289.
  12. Jolly P. Medical School Tuition and Young Physician Indebtedness. Washington, DC: Association of American Medical Colleges, 2004.
  13. Fye BW. Cardiology’s workforce shortage: implications for patient care and research. Circulation. 2004;109:813-816.
  14. Blackwell TA, Powell DW. Internal medicine reformation. Am J Med. 2004;117:107-109.
  15. Goldman L. Modernizing the paths to certification in internal medicine and its subspecialties. Am J Med. 004;117:133-136.
  16. National Resident Matching Program. Results and Data 1975-2005. Washington, DC: National Resident Matching Program; 2005.
  17. Ibrahim T. The case for invigorating internal medicine. Am J Med. 2004;117:365-369.
  18. Doyle E. Internal medicine takes a hard look at itself during summit on revitalization. ACP Observer. December 2003.
  19. Cohen JJ. AAMC president’s address 2005: the work ahead. Available at http://www.aamc.org/newsroom/ pressrel/2005/051106.htm. Accessed November 7, 2005.
  20. Holmboe ES and Lipner RS. Personal communication. November 5, 2005.