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Is it time for a fundamental reexamination of medical education?

THE AMERICAN MEDICAL ASSOCIATION has completed and its House of Delegates has adopted a report by the Council on Medical Education entitled "Future Directions for Medical Education." The report has 36 recommendations which address many facets of medical education including specialty training, continuing medical education, practice performance and the training of foreign medical graduates, as well as preparation for medical school and the curricula in medical schools. The Association of American Medical Colleges has just embarked on a three-year study of "the general professional education of the physician-the eight years that include college preparation and medical school." And the Institute of Medicine of the National Academy of Sciences has begun a one-year project to prepare a plan for a major review of medical education in the United States. There is a real need for a reexamination of medical education at this time and these three generic organizations are to be commended for their interest and willingness to have a go at it. In 1910 a study commissioned by the American Medical Association (to become known as the Flexner Report) firmly rooted medical education in the then nascent biomedical science. This orientation became institutionalized and has persisted. As the amount of biomedical knowledge increased in subsequent decades it became impossible to teach or learn it all in the four-year medical school curriculum, or for any one physician to practice competently throughout the whole gamut of medicine, for that matter. Specialities and specialty training began to appear and this has now become the order of the day, with the result that additional years of training (three to seven) have been added beyond the four years of medical school, and a complex system of specialty boards and specialty training is now in place. Medical knowledge continues to increase (some say it doubles every five to ten years) and the time seems to be coming when further add-ons of years in the formal preparation for practice will become impractical, if indeed this is not already so. Perhaps, as was the case in 1910, there is need once again for a fundamental reexamination of medical education. It seems that the inexorable and certainly welcome progress in biomedical science has had at least three important effects on medical practice and patient care that have yet to be fully taken into account in medical education. First, there is the sheer mass of medical knowledge now and what may be expected in the future. It has long since been obvious that no medical student or physician can any longer hope to learn or remember all that he or she should know, and furthermore it has become obvious that what needs to be known and used in practice is changing all the time. Especially to deal with the changing nature of medical knowledge, medical education should be viewed and structured more as a continuing process than is the case at present. Second, the specialization in medical education and medical practice that has occurred as a result of the proliferation of reductionist biomedical science has been at the expense of less attention being paid to two factors: ( I ) the oneness of this science (the interdependencies among the specialties or subspecialties) and (2) the wholeness of the person