PHILADELPHIA — Writing that “our nation’s lack of research in medical education contrasts starkly with the large and essential commitment to biomedical research funded by industry, philanthropic organizations, and the public,” David A. Asch, MD, professor at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania, and executive director of Penn Medicine’s Center for Health Care Innovation, offers recommendations for the future of medical education. The article was released online first this week in The New England Journal of Medicine.
The piece, “Innovation in Medical Education,” coincides with the July 29 release by the Institute of Medicine (IOM) of a report on the governance and financing of medical education. In its new report, produced by a committee on which Asch served, the Institute of Medicine proposes a “transformation fund” to support research and innovation in medical education as well as a governance mechanism to set research priorities and coordinate multi-institutional studies and nationwide pilot programs.
“The way we practice medicine today is completely different from the way we practiced medicine 50 years ago,” Asch notes. “And thankfully so: Today, we have far better approaches for treating cancer, heart disease, and neurodegenerative diseases like Parkinson’s disease, and health care is delivered in different settings. But the way we train doctors today is largely unchanged. The reason for this mismatch is that we have invested in research to improve medical care, but we have not invested in research to improve the training of the doctors who will deliver that care.”
Medicare currently pays about $10 billion a year toward graduate medical education – the training of resident physicians, largely in teaching hospitals. Other federal sources, including Medicaid, the Department of Veterans Affairs, and the Department of Defense pay another $5 billion. The IOM notes that despite these large public expenditures in the training of physicians, there is essentially no accountability for the use of these funds, no clear objectives for what this funding is expected to achieve, and no evidence base to guide new training approaches in the future.
Asch and co-author Debra F. Weinstein, MD, of Massachusetts General Hospital, offer their own recommendations. First, they say better measures of training success need to be defined. At present, medical education is primarily assessed using “process measures,” such as whether residents get enough cases, lectures, and sleep, as well as such intermediate outcomes as exam performance. Missing, they say, is attention to measures of better patient health, and an emphasis on the quality, distribution, and cost of care delivered following training programs.
Second, the authors suggest fundamental changes to the structure and content of medical education should be tested, such as whether medical school and residency training should continue to be so long. “Medical knowledge changes so much more rapidly now,” says Asch. “With the advent of more accessible point-of-service, just-in-time information, perhaps we can reduce some of the time and money we spend getting new physicians ready to graduate and redirect those resources to efforts that keep those same physicians current for the 30 or 40 years they will practice.”
Finally, the authors recommend testing new approaches for financing medical education. For example, Medicare now provides the bulk of funds for training residents in hospitals, even though more and more patient care occurs outside of hospitals. An alternative, they suggest, might include directing some federal funds through state or regional consortia that focus on population health characteristics and needs. Other experiments might assess the benefit of using larger payments to incentivize trainees toward undersupplied specialties or geographic areas, or eliminating stipends entirely — or even charging tuition — for subspecialties that are oversubscribed. The leverage of government spending might increase if support were spread across the continuum of training (to include medical students, not just residents) or to the training of nurses or other clinicians besides just physicians.
“The research that could evaluate these and other possible new directions requires funding that simply isn’t available today,” said Asch. “While the government spends about $15 billion per year on graduate medical education, there isn’t a research and development budget to ensure that the investment is achieving its objectives. There isn’t even a clear definition of what those objectives are.”
The authors note that the “care we deliver to patients with cancer may require chemotherapy, radiation therapy, or surgery, and each of those treatments has an evidence base behind it — one that’s supported by a research investment that allows us to innovate and improve. Behind each of these treatments are also clinicians, and their development is also worthy of innovation. With some funding and an organized approach to research investment, we can innovate toward the future workforce we need.”
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