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1、MEDICAL EDUCATION IN THE UNITED STATES: PAST, PRESENT AND FUTURE,Justin Clark, M.D. Neurosurgery Resident Barrow Neurological Institute Phoenix, Arizona, USA,INTRODUCTION,Medical Schools History Present day problems Future issues Graduate Medical Education Neurosurgery Residency Training Neurosurger
2、y Residency Training at the Barrow Neurological Institute (BNI),HISTORY OF MEDICAL SCHOOLS,The first medical school in North America was founded in 1765 by John Morgan at the College of Philadelphia This institution is now known as the University of Pennsylvania The faculty at the College Of Philade
3、lphia had been trained at the University of Edinburgh The faculty used the British medical education system as the model for the school.,The History of Medical Schools in the U.S. Vault home page. . Accessed 2008 June 6,FOUNDING OF NEW U.S. MEDICAL SCHOOLS,Subsequent medical schools were also founde
4、d on the U.S. East Coast: The College of Physicians and Surgeons of Columbia University, New York, NY (1767) Harvard University, Boston, MA (1782) During the next 100 years, medical schools were founded across the country; however the majority were founded in non-academic centers Consequently, durin
5、g the 19th century, there existed two types of medical schools in the United States: University-based medical schools Proprietary medical schools,MEDICAL SCHOOL CURRICULUM DURING MOST OF THE 1800s,Most medical schools did not have university paid professors; instead, medical students needed to buy a
6、 ticket from the professor, in order to hear his lectures. The University of Michigan was the only exception of this rule. Students signed-up for 2 years of studies During both years, the same curriculum was taught, and learning was based on pure memorization Lectures had to be attended twice to qua
7、lify for graduation Some schools required a thesis, as well Most students that were accepted at medical schools during this time had not graduated from a college or university,U.S. compared to the rest of the world,In the 1850s, the U.S. medical education system was far behind the European system Me
8、dical schools in France and Germany: high entrance requirements four or six-year curriculums distinguished professors access to large hospitals,T.N. bonner, Becoming a physician: Medical education in Britain, France, Germany and the United States, 1750-1945 (New York: Oxford Univ Press, 1995), 33-60
9、,EVOLUTION,During the late 1870s, U.S. medical schools began replacing the old curriculum, which consisted of two years of repeated lectures with a new three-year graded curriculum that contained progressive lectures Later, in 1891 schools including Harvard, Columbia , Pennsylvania and Michigan adop
10、ted a four-year graded curriculum. This increased the amount of material that could be taught to the medical students, in preparation prior to becoming a practicing physician,THE “IDEAL” MEDICAL SCHOOL,In 1893, Johns Hopkins University School of Medicine, was established It was headed by William Wel
11、ch and William Osler,Sonntag V.K.H. (1996). Honored Guest Presentation: The Neurosurgeon as Mentor and Student. In (Vol 51), Clinical Neurosurgery (pp. 329-337).,Its new format represented a bold change from traditional medical education Increased priority was put on scientific learning and clinical
12、 analysis Welch first introduced miscroscopy and bacteriology to the United States Osler was a strong believer in student-patient interaction, and advocated extensive bedside training for medical students,THE “IDEAL” MEDICAL SCHOOL,MORE CHANGES,In the early 1900s, many U.S. medical schools began req
13、uiring students to have at least 2 years of college studies prior to entering medical school In 1910, medical schools underwent vigorous scrutiny by a man named Abraham Flexner,THE FLEXNER REPORT,Abraham Flexner was a professional educator that was commissioned by the Carnegie Foundation for the Adv
14、ancement of Teaching to review the conditions of medical education in the United States and Canada The report was a commentary on the state of medical education in the U.S. and Canada,The report was very critical of the high number and relative low quality of medical schools in the United States Con
15、ditions in U.S. and Canada at the time of the report 155 medical schools 16 schools required 2 years of college work prior to admission,THE FLEXNER REPORT,All medical schools adopt a four-year curriculum two years of basic science education two years of clinical training Higher admission requirement
16、s: high school diploma minimum of two years of college science study,FLEXNERS RECOMMENDATIONS,By 1935, the landscape of North American Medical Education had changed significantly there were 66 M.D. granting institutions that survived the reform 57 of these institution were part of a university,CONSE
17、QUENCES OF FLEXNER REPORT,http:/ OF THE FLEXNER REPORT,Helped to introduce the standard medical curriculum The public outcry that it caused forced many proprietary medical schools to close Solidified the preeminent place of university-based medical schools and teaching hospitals Flexners report and
18、the changes it brought about signified the birth of modern medical education in the United States,STANDARDIZED TESTING,The increase in medical education standards caused by the Flexner Report did not initially lead to higher quality medical graduates In the first half of the 20th century, attrition
19、rates at U.S. medical schools ranged from 5 to 50% In an effort to further increase the quality of medical education in North America, the Medical College Admission Test (MCAT) was developed in 1928 By 1946, the attrition rates at U.S. medical schools had decreased to 7%,http:/ the 1850s, yearly tui
20、tion was very low The overhead associated with running a medical school was very low In 1850, students at the University of Michigan Medical School paid a $10 registration fee,http:/msweb.med.umich.edu/sesqui/timeline/1848-1873.htm,TUITION RISES,After the recommendations of the Flexner report were u
21、niversally instituted, medical education became more expensive and tuition rates increased In 1940, tuition ranged from $200 to $600 per year Laboratory Full-time faculty Tuition remained relatively low because much of the costs were subsidized by the government and private philanthropists,TUITION T
22、ODAY,In 2006-2007, tuition has markedly increased Least expensive public school $10,000 per year Most expensive private school $45,000 per year Reasons: Decreased government funding Struggling U.S. economy A common public sentiment that “doctors make too much money and medical education shouldnt be
23、subsidized”,MEDIAN MEDICAL EDUCATON DEBT (2004),4 out of 5 members of the Class of 2004 graduated with some educational debt Private Medical Schools = $140,000 = 969,220 yuan Public Medical Schools = $100,000 = 692,300 yuan More than 28% of 2004 indebted medical school graduates had debt exceeding $
24、150,000 = 1,038,450 yuan * 1 Chinese yuan = 0.144 U.S dollars ($),Mallon WT, et al. The Handbook of Academic Medicine. (2004),CERTIFICATION & REGULATION (2006-2007),U.S. MEDICAL SCHOOL DATA (2006-2007),Number of LCME-accredited medical schools = 125 Full-time faculty = 124,725 Full-time students = 6
25、9,028 Number of graduates with M.D. degree = 16,300 men = 8,269 women = 8,031,MEDICAL SCHOOL GRADUATES IN THE 1800s,After graduating from medical school, you could immediately start practicing, or your could undergo an apprenticeship Apprenticeships lasted a varying amount of time They were supervis
26、ed by another physician They were not necessarily based in a hospital,EVOLUTION OF GRADUATE MEDICAL EDUCATION,Post-medical school education changed from a physician-based model to a hospital-based model in the 1900s Hospital-based residencies allowed the residents to learn from all of the attendings
27、 at that hospital During this time, residents lived at the hospital and earned an very modest salary hence the term “house officer”,THE MATCH,Prior to 1952, Residency positions were granted based on social networking, and less on academic achievement In 1952, the National Residency Matching Program
28、(NRMP) was created to provide a uniform date of appointment to positions in graduate medical education (GME) Annual match designed to optimize the rank ordered choices of students and program directors,National Residency Matching Program (NRMP) Accessed 2008 June 6,Number of programs = 4,214 Number
29、of resident positions = 25,066 Number of applicants = 35,956 2008 graduates of accredited U.S. medical schools = 15,692 “independent” applicants = 20,264 former graduates of U.S. medical schools U.S. osteopathic students Canadian students graduates of foreign medical schools,2008 MATCH,U.S. RESIDENC
30、Y PROGRAMS,Unlike medical schools, which are run by medical schools, themselves, residency programs are run by hospitals Any hospital can have a residency program The number of residency programs was very small thru the mid-point of the 20th century,RESIDENCIES DURING WORLD WAR II,In 1940, the U.S.
31、government was deferring all medical students from military service for the duration of medical school and a one-year internship. During 1942, sixty-six of seventy-eight medical schools in the U.S. and Canada instituted an accelerated program to graduate medical students in three years instead of fo
32、ur. Subjects of military importance were being stressed: preventive medicine, tropical disease, aviation medicine, sexually transmitted disease, fractures, industrial medicine, and psychiatry,Tarolli J. Epilogue: Building the Modern Medical Center, 1941 to Present. Not Just Any Medical School.,World
33、 War II led to a period among most academic medical centers in the U.S. of marked change and expansion, as a result of the postwar boom and the increase in government-funded research and medical care. This increased funding significantly improved the influx of money into medical education,PAST,Daven
34、port HW. Not just any medical school. Univ Michigan Press. 2002,HOW DO U.S. RESIDENCY PROGRAMS GET PAID?,In 1965, U.S. President Lyndon B Johnson signed into existence Medicare. This is a government funded healthcare program the covers healthcare costs for U.S. citizens over the age of 65, as well a
35、s many handicapped individuals Medicare has many different parts to it, and it has evolved over the years,In 1966, Medicare agreed to pay hospitals for all their residents; consequently, the number of residency positions increased at that point. Medicare pays teaching hospitals for part of the costs
36、 of graduate medical education under Part A cover portion of teaching physicians salaries related to time they spend teaching residents pays a portion of the residents salaries Medicare Part B also allows for physician reimbursement for GME, under special situations,HOW DO U.S. RESIDENCY PROGRAMS GE
37、T PAID?,All residency programs conform to the specification of the ACGME This conformation is not mandatory for the existence of the residency; however residencies that are not ACGME-approved do no receive funding from the Federal Government for educating the residents via Medicare Parts A & B,U.S.
38、RESIDENCY PROGRAMS,ACGME,Accreditation Council for Graduate Medical Education (ACGME) The governing body of medical education 7,800 U.S. Residency programs in 118 specialties and subspecialties 24 member boards of the American Board of Medical Specialties (ABMS) 26 specialty-specific Residency Revie
39、w Committees (RRCs),ACGME,Established in 1981 out of a consensus need in the medical community for an independent accrediting organization for graduate medical education programs Its forerunner was the Liason Committee for Graduate Medical Education,ACGME ACCREDITATION,A voluntary process Residency
40、programs must be ACGME-accredited in order to receive graduate medical education funds from the federal Center for Medicare and Medicaid Services Residents must graduate from ACGME-accredited programs to be eligible to take their board certification examinations. Many states require completion of an
41、 ACGME-accredited residency program for physician licensure,DUTY HOURS,In the past, the long hours worked by medical residents were described as “a necessary component of resident education and a public symbol of a profession that requires hard work and dedication.”,Philbert I, et al. JAMA 2002;288:
42、1112-1114,THE 80 HOUR WORK WEEK,During the 1990s, concerns from the community began to arise regarding the overworking of residents It was during this time that reform in residency work hours began to arise,THE 80 HOUR WORK WEEK,The new standards became effective on in July 2003 Required at least 10
43、 hour rest period between duty periods Continuous duty limited to 24 hours An added period of up to 6 hours for continuity and transfer of care and didactic activities,Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA (2004).
44、 “Effect of reducing interns work hours on serious medical errors in intensive care units“. N Engl J Med 351 (18): 1838-48,LIMITS OF THE 80 HOUR WORK WEEK,This limitation does not apply to medical students or to practicing physicians Residency programs can petition the ACGME to receive an exemption
45、for a 10% increase in work hours, which can extend the maximum number of work hours to 88 hours per week, averaged over a 4 week period,ACGME Core Competencies,The ACGME has mandated that residents be competent in six areas be assessed before graduation. These areas are: 1. Patient care 2. Medical k
46、nowledge 3. Practice-based learning and improvement 4. Interpersonal and communication skills 5. Professionalism 6. Systems-based practice,SIX GENERAL COMPETENCIES,These six general competencies have also been espoused by the American Boards of Medical Specialties (ABMS) The ABMS agree that practici
47、ng physicians should also display these 6 general competencies,THE PROBLEM,The ACGME has not provided specific details on how to train or assess residents in these areas Each U.S. residency program is to develop its own training program and assessment tools to address each competency Attempts to dat
48、e have been described as “too subjective”,Leiphart JW, et al. AANS Neurosurgeron 2008;17(1),POPULATION OF RESIDENTS,THE MODEL SURGICAL RESIDENCIES,Halsted modeled his resident training program after the German Oberartz system Consisted of serving as an assistant for 6 years in preparation for 2 year
49、s as a house surgeon The trainees received extensive clinical experience and were expected to engage in research. In 1954, this training pattern was formalized by the Committee on Graduate Surgical Training (now the Resident Review Committee in Surgery),Sonntage, VKH. 2003,NEUROSURGERY RESIDENCY,Two surgeons were most responsible to creating the neurosurgery into a subspecialty Harvey Cushing Walter Dandy Bo