Carnegie Report Calls for Key Innovations in Medical Education

Better Integration of Formal Knowledge, Clinical Experience Needed

June 29, 2010 03:30 pm Barbara Bein

A recently released study on medical school and residency education( from the Carnegie Foundation for the Advancement of Teaching includes recommendations that emphasize standardized learning outcomes and competencies, individualized training, professionalism, and more supportive learning environments.

Family medicine educators say those recommendations, if implemented, would make physician training more patient-centered and safety-oriented and would promote quality improvement.

"We have ample evidence that professionalism training is badly needed," said Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education, in an interview with AAFP News Now. "The 'dehumanization' of the medical student is well-documented, and we need to work especially hard on avoiding that if we want to be turning out patient-centered physicians."

The study, "Educating Physicians: A Call for Reform of Medical School and Residency," was conducted by researchers at the University of California, San Francisco, and comes 100 years after Abraham Flexner laid out the first blueprint of medical education in his seminal report, "Medical Education in the United States and Canada("

According to a summary of the current study(, present-day medical education is "inflexible, excessively long and not learner-centered." Formalized knowledge and experiential learning are poorly integrated, and inadequate attention is paid to patient populations, systems of health care delivery and effectiveness.

The authors propose four broad goals for medical education:

  • Medical education should standardize learning outcomes and general competencies and then individualize the learning process for students and residents to allow "fast-tracking" in areas of particular interest or opportunities for experiences in research, policy and education.
  • Medical education should unite formal knowledge and clinical skills. Students' and residents' learning in the basic, clinical and social sciences should be integrated with their hands-on clinical experiences.
  • Medical schools and teaching hospitals should support the engagement of all physicians-in-training in inquiry, discovery and systems innovation.
  • Professional identity formation -- the development of professional values, actions and aspirations -- should be the "backbone of medical education." It should build on a foundation of clinical competence, communication and interpersonal skills, and ethical and legal understanding and extend "to aspirational goals in performance excellence, accountability, humanism and altruism."

Pugno said the Academy has long advocated standardizing learning outcomes and competencies while individualizing students' and residents' programs of learning.

The challenge, he said, is to ensure students and residents receive the "full measure" of the curriculum to give them breadth. In family medicine, for example, physicians-in-training should learn how to care for pregnant patients and perform deliveries, even if they don't plan to practice obstetrics.

At the same time, said Pugno, "Curricular flexibility is highly sought after by residency applicants. Most trainees make good use of that flexibility and achieve high levels of skill in specific areas of interest."

William Hueston, M.D., Ph.D., a member of the AAFP Commission on Education and chair of the department of family medicine at the Medical University of South Carolina in Charleston, agrees that ensuring competency while still customizing medical education is key to turning out top-notch physicians.

"Both in medical student education and residency, we have clung to the belief that if you spend a certain amount of time learning about something, then you must know it," he told AAFP News Now. "That's as ridiculous as thinking that a teenager should be given a (driver's) license just because he or she spent a set number of hours behind the wheel of a car.

"The truth is that each person comes into medical school and residency with different levels of pre-existing skills and knowledge bases. Those who are more advanced (in particular areas) should devote their time to areas where they are less skilled.

"The cookie cutter-based current system that only measures the time students spend on each topic will not result in excellence in all required areas," Hueston added. "It sometimes results in mediocre cookies."

Hueston said innovative teaching techniques, as well as a more supportive learning environment -- rather than a "blame and shame" approach to teaching -- also are needed in medical education of the future.

"Medical education needs to move away from the process of stuffing students full of trivia and then forcing them to regurgitate it on tests or rounds," he said. "We need to train physicians who are better at figuring out what they need to know and then retrieving that information rather than training people who are just repositories of data.

"Not only is this counterproductive, but implying that physicians should always know the information and never (need) to look it up is a threat to patient safety. It's better to look it up and be sure than to make a mistake."

Brooke Sciuto, M.D., of Sacramento, Calif., student member of the AAFP Board of Directors, recently graduated from the Uniformed Services University of Health Sciences in Bethesda, Md. She is about to start her training at the David Grant U.S. Air Force Medical Center Family Medicine Residency at Travis Air Force Base, Calif.

Sciuto said that after completing a highly structured medical school curriculum that included 800 hours of military-specific education and training, she would welcome more flexibility and individualized learning in medical school.

"I think one of the biggest challenges in medical school is trying to figure out what will work for you as an individual in regards to learning," she said.

"Perhaps more flexibility and more individualized learning would make it easier for students to understand what works best for their learning style, enabling them to best prepare themselves for residency."