JAMA 2001 Medical Education Issue
Authors: Stephen J. Lurie
Journal: JAMA (2001)

LIFE WAS CERTAINLY SIMPLER FOR MEDICAL EDUCATORS in the immediate post-Flexnerian age. The scientific discoveries of the late 19th and early 20th centuries seemed at the time to be mere promissory notes on an even more abundant harvest of medical miracles, and the public then viewed the medical profession with a mixture of veneration, deference, and gratitude. Medical education largely involved a didactic initiation into the known principles of disease, followed by a few years of bedside experience. Patients, for their part, were perhaps reassured by their inability to penetrate their physicians’ scientific training, as its complexity was also proof of its soundness. The patient-physician relationship was known to be important, but only the most august professor would have presumed to lecture to medical students or interns about it. If the art of medicine was long, as Hippocrates first asserted, it was also thought to be mostly indescribable and unteachable: students simply apprenticed themselves to practitioners of known clinical virtuosity in a proven method of education and craftsmanship whose roots stretched far beyond the Middle Ages into antiquity. Despite their common mission, early 20th-century medical schools immediately began to develop unique institutional personalities, and this diversity may have led to overall hardiness of medical schools in their particular local environments. This was a stable situation until the past few decades, when a series of interrelated and universal stresses forced every institution to adapt. For instance, the growing societal distrust of physicians, which has continued with the recent Institute of Medicine report, had been simmering for several decades in the form of rising rates of malpractice litigation. Medical schools responded with courses in medical ethics, the patient-physician relationship, interviewing skills, group problem-solving, etc, although different US medical schools continue to place varying degrees of emphasis on these issues. Ironically, these “soft” components of the medical curriculum have been added during a time of unprecedented growth in new medical knowledge, and they compete with already scarce time for teaching. In response, many medical schools have abandoned the lecture hall for various models of “clinical reasoning,” which may incorporate elements of problem-based learning, evidence-based medicine, medical informatics, and decision theory. This evidencebased approach has also spawned a variety of techniques, such as objective structured clinical examinations with standardized simulated patients, that purport to provide objective measures of clinical competence. The Internet and other new technologies will doubtlessly be integrated in various ways with these new educational priorities. Patients, however, have also found the Internet to be a handy source of the same limitless up-to-theminute information that they expect their physicians to know. In a few evenings of focused Web surfing, a motivated patient may surpass his or her physician’s familiarity with the most recent medical evidence. Thus a paternalistic approach, which has long been considered inappropriate, is now also becoming impracticable. As patients become increasingly aware of their physicians’ limitations in this newly democratized era, physicians will need to learn new ways to define and assert their own professionalism. Similarly, medical schools have not been able to shield their students’ education from relentless economic trends toward more cost-effective care. In addition to less available time for teaching, clinical faculty may find that the teaching encounter is more likely to occur in a busy ambulatory clinic than in a quiet inpatient unit, that some of their traditional functions may be appropriated by physician assistants and nurse practitioners, that they may be sorely tempted by the financial largesse of private industry, and that teaching may harm their chances for professional advancement and recognition. All of these elements of the “hidden curriculum” can exert profound influences on trainees’ ethical behavior. Medical schools are also increasingly being held accountable for their behavior in the larger social milieu. Although public support for academic medical centers has been stable over the last several years, government policy makers may demand that medical schools provide bottom-line justification for these ongoing subsidies that, in the long term, most benefit the individuals who ultimately graduate from medical school. Similarly, such institutions may be asked to help remedy societal problems that lead to ethnic and racial disparities in access to medical education, as they have been asked for decades to remedy such inequalities in access to medical care.