Chapter 6

Medical Education and the

Changing Practice of
Medicine

CHAPTER OBJECTIVES
Understand influences that have shaped
U.S. medical education and practice
Understand how scientific and clinical
advances contributed to the evolution of
specialty medicine
Acquire knowledge of current delivery
system developments and how they have
and will affect medical education and
practice
Review Affordable Care Act and other
reform impacts on physician education
and practice

Medical Education: Colonial

America to the 19th Century (1)
No medical schools
Sick were treated with medicinal
herbs and anecdotal information in
their homes
Few university-trained European
physicians emigrated to America;
trained colonial medical students in
apprenticeships
No formal methods of testing new
physicians; practiced without
regulation of any kind

Medical Education: Colonial

America to the 19th Century (2)
Apprenticeship training with mentors
continued until hospitals founded in
mid- 1700s
First medical school established in
1756 (College of Philadelphia), 2nd at
Kings College, 1768 (later Columbia
Univ.)
1800: only four U.S. medical schools
added; each had a few faculty
members teaching all courses

Medical Education: Colonial

America to the 19th Century (3)
1821: Georgia restricted practice to medical
school graduates over apprentice-trained
physicians protest; medical school
graduates increased & MD degree became
the standard
State medical societies formed in mid-1800s
to advocate for education improvements and
affiliated with newly formed AMAs education
agenda; educational reforms failed for
decades due to members vested interests

Medical Education: Colonial

America to the 19th Century (4)
1876: American Assn. of Medical
Colleges (AAMC- 22 medical schools)
advocated a 4 yr. training program
1892: Harvard 1st to require 4 years
training, followed by Johns Hopkins in
1893

Flexner Report and Medical

School Reforms (1)
1904, AMA developed
Council on Medical Education: address
needed educational improvements and
standards
JAMA: published medical school state
licensing failure statistics and group
schools by failure rates, demanding poor
schools to improve or resign the
association

Flexner Report and Medical

School Reforms (2)
1905: Support for AMA reforms by
Carnegie Foundation for the
Advancement of Teaching; examine
all 155 US & Canadian schools
entrance requirements, faculty,
laboratories & hospital relationships
Schools cooperated believing that
review would lead to Carnegie
Foundation support

Flexner Report and Medical

School Reforms (3)
Medical Education in the U.S. and Canada
Lauded some schools: Harvard, Western
Reserve, McGill, U of Toronto, Johns Hopkins
(cited as a model for medical education)
Stimulated support from foundations & wealthy;
University affiliated schools w/favorable ratings
were primary recipients establishing future
influence over future directions
Licensing legislation pursued; new standards for
training duration, labs & other facilities

Flexner Report and Medical

School Reforms (4)
1942: AMA & AAMC est. Liaison
Committee on Medical education as
official U.S. and Canadian medical
school accrediting body

Transition from Academic

Medical Centers to Academic
Health Centers (1)

1950s & 1960s federal grants: support

research-oriented medical schools &
teaching hospitals in technology advances
1965-1974: Regional medical program
funded upgrading medical knowledge
about heart disease, cancer & stroke
with research, training, regional
networking
Academic medical centers broadened to
Academic Health Centers (AHCs) with
other professional schools: nursing,
pharmacy, dentistry, allied health

Transition from Academic

Medical Centers to Academic
Health Centers (2)

AHCs with affiliated hospitals became

primary sites of health professional
training, basic medical and clinical
research; affiliated hospitals:
Major providers of most complex tertiary
care, e.g. neonatal, trauma, burn,
neurologic, heart disease; major
providers of primary care for low-income
patients in outpatient clinics
6% of nations hospitals but provide
50%+ of care to underserved

Transition from Academic

Medical Centers to Academic
Health Centers (3)

AHCs technology, teaching requirements

generate the highest costs of American
system; pressures to reduce costs
Teaching requires ordering more tests,
procedures, consultations
Medical school revenues: faculty clinical
practice plan contributions, research grants
& contracts, state & local government,
tuition & fees, other grants, contracts,
endowments; Medicare & Medicaid subsidy
reductions

Graduate Medical Education

Consortia (1)
Formal associations of medical schools,
teaching hospitals, other organizations
involved in residency training to
improve organization, governance, MD
supply and distribution through local
coordination.
MD: allopathic physicians (138 schools);
DO (Doctor of osteopathy- 29 schools);
degrees are equivalent
No national licenses; state medical
boards license with specific
requirements; 3-7 yr. residency
accredited by Accreditation Council for

Graduate Medical Education

Consortia (2)
ACGME: not-for-profit independent
organization dedicated to quality of
residents training
Accredits ~ 9,000 U.S. residency programs;
also addresses MD distribution and supply
2012 transition to outcomes-based
evaluation system to measure competencies.
ACA: redistribute specific resident training
slots to needed specialties and areas with
Medicare reimbursement flexibility

Delineation and Growth of

Medical Specialties (1)
AMA concerns began in mid 1800s:
Fragmented care (not treating
whole patient)
AMA slow response prompted
specialists to form their own societies
Late 1800s: specialty associations
formed in ophthalmology, otology,
obstetrics & gynecology, pediatrics

Delineation and Growth of

Medical Specialties (2)
Deficient training of medical
specialists
At 1910 Flexner Report, huge variations
in specialty training duration & quality;
virtually any physician could call
themselves a specialist.
1917 WWI army recruitment revealed
shocking unfit to practice as
specialist MDs and some overall
unfit
American College of Surgeons est.

Delineation and Growth of

Medical Specialties (3)
Deficient training of medical specialists,
contd
1924: AMA Council on Medical Education
began approving hospitals for residency
specialty training programs; for next 40+
years, poorly conducted programs persisted
AMA: Citizens Committee on GME, chaired by
John Mills; 1966 report eliminated independent
internships, awarding residency accreditation
to institutions, not hospital departments;
report led to current residency requirements

Delineation and Growth of

Medical Specialties (4)
Deficient training of medical specialists,
contd
1970: internship dropped; AMA endorsed first
year graduate training in a program approved
by a residency review committee (RRC); by
1980 AMA issued training recommendations for
the first postdoctoral year.
Current curriculum for specialization: well
defined & standardized: medical school
graduation-> approved residency program->
pass qualifying examination(s).

Specialty Boards & Resident

Performance (1)
American Board of Medical Specialties (ABMS)
est. 1933 as independent not-for-profit entity; to
maintain, improve medical care quality by
assisting member boards in developing and
using professional & educational standards for
certifying specialists in U.S. & internationally.
ABMS member boards ensure proper instruction
& resident performance by exam & practice in
24 medical specialties & 130 subspecialties
trained in fellowships for subspecialty practice
and/or research (Table 6-1)

Specialty Boards & Resident

Performance (2)
Hospitalists
Growing field outside of formal specialty
training; sole responsibility caring for
hospitalized patients; 30,000 in practice in 70%
of U.S. hospitals
Most trained in internal medicine or pediatrics
Hospitalist benefits: expedite & improve
coordination of hospital care, reduce costs,
enable continuity, improve patient satisfaction
Current initiatives to certify role in relevant
specialties

Physician Workforce Supply and

Distribution (1)
Mid 1960s: Government predicted
national MD shortage; policies to
increase no. of MDs
Medical schools increased by 50%:
students by 100%

1980-2000: MDs increased from

467,679-> 813,770 (74%): 2012:
834,769 active U.S. physicians,
median of 244/100,000 population
Issues: U.S. lacks national
methodology to predict

Physician Workforce Supply and

Distribution (2)
Wide variations in practice locations not
actual supply, e.g. Massachusetts415/100,000; 176/100,000 in Mississippi;
rural and inner-cities chronically plagued
by undersupply
International Medical Graduates (IMGs) fill
residency gaps in shortfall of U.S.
graduates; about 6000 per year.

Physician Workforce Supply and

Distribution (3)
Ratios of Generalist to Specialist Physicians
and the Changing Demand
Primary care physicians (PMDs): family
medicine, pediatrics, general internal
medicine (sometimes obstetrics &
gynecology included); historically, numbers
considered deficient with concerns about
specialists contributing to rising costs
1990s managed care growth -> federal &
state policies increasing primary care
physician supply

Physician Workforce Supply and

Distribution (4)
Ratios of Generalist to Specialist
Physicians and the Changing
Demand, contd
2012 Annals of Family Medicine study52,000 more PMDs needed by 2025;
33,000 for sheer population growth,
10,000 for aging, 8,000 for newly
insured.
ACA & ARRA provisions include supports
for increasing PMD supply
Specialist to generalist ratio: 67:33

Physician Workforce Supply and

Distribution (5)
Ratios of Generalist to Specialist
Physicians and the Changing
Demand, contd
Demand for specialists is strong: growth
in general population and aging
population
Medical students career choices
influenced by training role models
values, skills; major income differentials
between primary care & specialties;
experience in clinical training sites;

Preventive Medicine (1)

Historically, medical education has not made
health promotion, disease preventive high
priorities due to systems complaint-response
approach; reimbursement favoring after-the-fact
interventions; most $$ treat preventable diseases
Current public awareness, media attention,
system leadership resulting in collaborations
between clinical & preventive medicine on e.g.
childhood obesity, diabetes, smoking cessation
2012 IOM report highlights primary care/public
health opportunities

Preventive Medicine (2)

2012 IOM report Primary Care and
Public Health: opportunities of ACA
to advance population/preventive
mindset & community linkages
between AHCs and community
based providers to research, develop,
implement system changes for
improved population health status.

Changing Physician-Hospital
Relationships (1)
Historically, unique, interdependent relationship
based on patient admissions; MDs paid fee-forservice, hospital for costs incurred; medical staff
organization carried out responsibilities to ensure
quality care; MDs sole decision-makers about
admissions, lengths of stay, resource use &
referrals.
System changes: hospital fiscal penalties for
lengths of stay; admissions require payer
approval; readmissions carry penalties; health
plans select hospitals based on cost-effectiveness

Changing Physician-Hospital
Relationships (2)
Technology advancements allow MDs
to compete with hospitals for
outpatient services (diagnostic,
surgical, etc.)
Hospital MD employment increase of
32% since 2000.
MDs leaving private practices due to:
flat reimbursement, complex insurance,
HIT requirements, desire for work-life
balance

Changing Physician-Hospital
Relationships (3)
Hospitals desire MD employment to
secure market share, use of diagnostic &
outpatient services, referrals to highrevenue specialty services, ACO
development

AMA concerns in 2012: conflicts

between MD loyalty to employerhospital and patient best interests;
MDs should inform patients about
financial incentives related to
treatment options

Evidence-based Clinical Practice

Guidelines (1)
Clinical practice guidelines: protocols based on
scientific evidence from rigorous review &
synthesis of published medical literature
Evolved from data showing wide variations
of medical procedures in different
geographic regions and use of questionable
services that added costs
AHRQ created by Congress in 1989 to develop
guidelines; taken up by many professional &
scientific organizations and evaluated by AHRQ

Evidence-based Clinical Practice

Guidelines (2)
14,000+ guidelines in online AHRQ
National Guideline Clearinghouse

Evidence-based guidelines now

considered most objective, least
biased standards: help prevent use
of unnecessary treatments, avoid
errors with patient safety &
consistent care priorities

Physician Report Cards and

Physician Compare (1)
1970s: AMA ethics prohibited
exposing any information allowing
comparisons among doctors; state
laws supporting AMA deemed
violations of 1st amendment; freedom
of information acts removed more
barriers
1986: Health Care Financing
Administration release Medicare
patient hospital-specific mortality

Physician Report Cards and

Physician Compare (2)
1991: Newsday published NY states hospitalspecific, severity adjusted, heart surgery mortality
rates; FIA court decision forced release of
individual surgeon data
Many states release MD disciplinary actions,
hospital privilege status; medical societies support
Physician Compare: ACA requires Medicare by
2014 to list quality data on MDs in Physician
Quality Reporting System and E-prescribing
Incentive Program; concerns will continue about
quality, accuracy, of information.

Health Information Technology

and Physician Practice (1)
HIT supported by ARRA, HITECH Act, ACA
to incentivize EHR use, educate MDs in einformation collection, transfer & use
Medical schools, hospitals provide medical
informatics training on spectrum of
subjects, e.g. patient management, EHRs,
e-Rx, research.
ABMS now certifies a MD subspecialty in
clinical informatics within existing
medical specialties.

Health Information Technology

and Physician Practice (2)
HITECH: focus on EHR adoption among
MDs, other professionals, hospitals
through financial incentives for
meaningful use paid through Medicare &
Medicaid.
Eligible providers categories specified
under Medicare & Medicaid; incentives
paid on demonstrating highly specific
meaningful use criteria by 1st stage
deadline dates.

Health Information Technology

and Physician Practice (3)
2nd stage meaningful use criteria
require demonstrating active consumer
engagement in communication with
providers
Participation rates to date have met
expectations
HIT applications expected to transition
medical care to new norms of
computerized decision support systems,
evidence-based practice, EHR use,
computerized physician order entry and eprescribing

Escalating Costs of Malpractice

Insurance
Steeply rising insurance costs affect
physicians, medical schools,
hospitals.
In 10 years, premium increases 6-10fold, thousands to millions
Rising malpractice jury awards; during
economic downturn, insurance
companies dependent on investment
income increased premiums
Physicians in high-premium states retire
early, relocate or limit practices

Ethical Issues (1)

Two areas of major physician concerns in
the changing health care system
1. Medical care use: insurers efforts to
manage costs, quality, access, subject
physicians to numerous cost-avoidance
parameters prompting issues of patient
risk; traditional fee-for service practice
yielding unnecessary procedures,
ineffective treatments, fragmented care

Ethical Issues (2)

2. Technology advancements: life
prolonging capabilities lack
accompanying standard procedures
for making terminal care decisions
that must be dealt with by
physicians, families, hospital ethics
committees; gene manipulation and
therapies present formidable
use/abuse potential, e.g. genetic
blueprints predicting future

Physicians and the

Internet
86% of physicians use Internet in
practices
Use personal websites to market
services
Email with patients increasingly
common
Obtain current data on 132,000+
clinical trials in 179 countries from
NIH for their and patient information

Future Perspectives (1)

Although astounding medical progress, U.S.
ranks poorly among 6 other developed
nations in key areas: quality of care, access to
care, equity of care, healthy lifestyle; ranks
50th worldwide in life expectancy at birth.
HIT advances & added primary care workforce
hold future promise for system improvements
Physician resiliency among many prior
changes is expected to continue with practice
adaptations required by the reformed system

Future Perspectives (2)

Physicians will transition from piece-meal
fee-for-service (volume-driven) to
population health (value-driven) focus by
participating in PCMHs & ACOs that align
financial incentives with desired
population health, i.e. public health
outcomes
Public reporting on physician quality will
increase overall quality and empower
consumers

Future Perspectives (3)

Medical schools will enhance public &
population health curriculum content and
include content in national licensing
examinations.
In the reformed system, medicine will seize
opportunities to improve population health
status through collaborations with other
health & community-serving professionals,
citizens & elected officials to ensure a
coherent, effective and efficient delivery
system for all Americans