Editor Discusses the Evolution of Medical Education

Medical education and training prepares physicians and other healthcare providers for a lifetime of professional work. However, the learning environment which shapes and reinforces the professional attitudes and behavior of physicians throughout their continuum of learning is quite diverse. That environment begins in medical school and extends through residency training and hopefully to lifelong learning.

The formal curriculum requires that students meet certain objectives and requirements that are defined by accreditation agencies. Each of these educational activities have learning objectives and address the core competencies required to meet the requirements of the accrediting agencies, of which there are many.

American medical education has evolved from pure apprenticeships to proprietary medical schools to a reformed and formal educational system that stresses both science and professionalism. In one development, the latter half of the last century saw the growth of requirements by state licensing boards and specialty certification boards for demonstrated participation in accredited continuing education activities.

There are presently 141 accredited MD-granting institutions American Association of Medical Colleges (AAMC) and 29 accredited DO-granting institutions (AACOM) who have begun to share programs in some areas. There are approximately 400 major teaching hospitals, with thousands of faculty members and medical students.

There are more than 8,000 accredited residency programs for all specialties and subspecialties. Additionally, there are more than 16,000 active full-time and part-time residents, more than 740 national providers of accredited continuing medical education and 1,600 accredited state providers and, last but not least, the Liaison Commission on Medical Education (LCME). LCME is the oversight agency that is responsible for the accreditation of the nation’s medical schools. Its members are appointed by the AAMC and the American Medical Association (AMA). The Accreditation Council for Graduate Medical Education (ACGME) accredits residency training programs in the United States. The sponsoring institution for a residency program may be a hospital, medical school, university, or group of hospitals. Accreditation bodies define the core competencies for students, residents, and fellows and ensure that the formal curriculum covers all essential aspects of medical education. ACGME board members are appointed by AAMC, AMA, the American Board of Medical Specialties, the American Hospital Association (AHA), and the Council of Medical Specialty Societies (CMSS). Accredited continuing medical education providers are accredited by the Accreditation Council for Continuing Medical Education (ACCME). Its member organizations are AHA, AMA, AAMC, CMSS, the Association for Hospital Medical Education, and the Federation of State Medical Boards. You can begin to understand what a complicated process we have, and I am not sure my understanding is correct! However, many medical educators are frustrated by the lack of cooperation among boards, associations and institutions.

Therefore, a cultural change must take place so that a top down bottom up system of medicine can be established.

My colleague and editor of Civil Aviation and Training (CAT), Chris Lehman, discussed cultural leadership in a recent editorial. An extract is provided below. This is part of a great cultural shift needed in the medical community to meet the demands of 21st century medicine, including the Affordable Care Act.

Cultural Leadership

“One of my favorite truisms is ‘Organizational culture is set at the top and measured at the bottom.” Yet another is “Unless you can measure it, you can’t improve it.’ A lengthier one that resonated for me recently is “Look, each air operator within a specific route structure and flying the same equipment has essentially the same cost paradigms: fuel, aircraft maintenance, catering, airport fees, and salaries. The only competitive advantage one operator may have over another is their corporate culture – and that culture drives everything from safety operations to customer care.”

And while economic realities are exacerbating aviation recruitment at the moment, an even more important issue is the degree that they may be contributing to employee-management strain and internal communications within aviation operations. Is there an impact to safety as a result?

Since the greatest threats to safety have their roots in organizational issues, making the system even safer will always require specific action by the organization. We are all familiar with Safety Management Systems (SMS), and know that it’s a system that integrates certain tools, including senior management commitment, identification of hazards, risk management, safety reporting, investigation, education and remedial activity. A good SMS can be seen to generate a Safety Culture and provide the positive management environment necessary to identify and resolve safety issues. A Safety Culture is often viewed as an enduring or pervasive characteristic of an organization, created over time, which gives rise to a consistent way of dealing with safety issues.

A central tenet of a Safety Culture is excellence in communications from the bottom up, but particularly from the top down. Senior management encourages and rewards employee initiative in providing safety information, and analysis and action quickly occurs. Feedback is continuous with all employees clear on what is acceptable and unacceptable, and they are motivated to apply their own skills and knowledge to enhance organizational safety.

Senior management must have the knowledge, vision and commitment to ensure that a true Safety Culture is created and nurtured. In the current environment of cost-pressures, strained labor relations, extreme competition and little customer loyalty, this is more than a challenge. If these internal and external pressures are mitigating an organization’s Safety Culture, can the deterioration be measured? No doubt we all have our views, but when we see a decline in internal communications, a fall-off in morale, or a noticeable disconnect between senior management and employees, there is cause for concern.

In my view, one can always obtain a hint of an organization’s culture – safety or otherwise – by that first contact. That first subjective assessment often remains consistent right through the entire experience with an organization.

Ultimately a positive organizational culture is the responsibility of senior management and if it can provide a competitive advantage in the marketplace, I can’t think of anything more important to the executive suite.”

Can the same aviation tenets be applied to medicine? This editor certainly believes they can.