Think quick –
If a man running at 12 miles per hour in a northern direction on a horizontal plane grabs hold of a bird traveling at 18 miles per hour moving in a westward direction at 45 degrees above horizontal, what will be the final speed and direction of the pair? (just typing this was exasperating, phew!)
The better question should be, what does this have to do with medicine, or the training of an able-minded and bodied physician? In all honesty, I couldn't answer that directly. For good measure, I couldn't answer a very similar question to the one proposed above on my official MCAT, either.
I'm sure some would argue that this sort of questioning tests critical thinking skills, determination, and the ability to work under pressure and time constraints. That is reasonable. But then again, I also spent countless hours memorizing physics equations in college - hours that could have been spent studying pharmacological interactions or anatomic details. Or better yet, hours spent studying medical ethics, health law, health policy, communication skills, or the history of medicine. Wouldn't intense courses in those topics push critical thinking skills? I'm not arguing that there is a perfect system. But then again, I haven't needed to measure the work and force of a spring anytime recently.
Without a doubt, questions like this weed out the competition. I can recall countless classmates that fell to the wayside during physics, organic chemistry, and MCAT preparation. Some that I thought would have otherwise made excellent physicians. So, is our system weeding out the right students? Well, it looks like the AAMC might not think so. A recent announcement indicates that a change in the emphasis of the MCAT examination may be in the works.
“In the next several months, the MR5 Committee will continue its dialogue with stakeholders on the proposed recommendations, leading up to final approval by the AAMC Board of Directors in February 2012. If approved, the recommendations will be introduced with the 2015 MCAT examination.”
The overall goal of the proposed MCAT changes would reflect a greater emphasis on the social sciences, medical ethics, and evaluation of thought processes.
If the AAMC believes that the MCAT may need modification – what other areas of academic medicine could be addressed? How about the requisite pre-medicine courses? Or lecture topics and areas of focus in medical school? Residency structure? CME and physician licensing? I believe that the success of the future of medicine demands a robust review of each of these areas of medical training.
Our health care system must embrace a new academic aim of integrating longitudinal experiences and enhancing the team-based approach. I believe that the future of health care leadership is dependent upon development of leaders now that are adept at both technical and non-technical competencies - communication, effective team-management, time-management, emotional intelligence, awareness of policy and current affairs, to name a few.
Along these lines, MedPAC has laid out recommendations in their June 2010 report to Congress to modify GME payment schemes to create incentive toward just this sort of health care development at the residency level. Their is some indication that MedPAC will go even further in more specific terms for these recommendations in their coming June 2011 report.
"The standards established by the Secretary should, in particular, specify ambitious goals for practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice, including integration of community-based care with hospital care."1
I am encouraged that groups like AAMC, MedPAC, and others recognize and support these needs. This demonstrates a recent shift in ideals of physician character and workforce expectations. In the past, the four year academic medical track focused almost entirely on the preparation of physicians that could meet the myriad of pathologic disease. While bedside manner and patient communication were emphasized in this training, left out were business skills, political awareness, health system development, personal leadership, and development of non-technical competencies.
All of this speaks to what I believe – that there is a fundamental difference between developing clinicians for the sole focus of patient care, and developing physicians that have the skills to be both team-members and leaders in the future of health care. Clearly, in the past, academic medicine has focused on the former. The modern health care climate, and the rapid transition of health reform demand attention to the latter. In the future, we need to more fully consider this balance between service and education.
This begs the question - are we developing great clinicians or are we training health care leaders?
Considering this question is absolutely imperative for the success of the future of family medicine. As we look towards advanced systems of health care delivery – the ACOs and PCMHs of the world will hinge their success on the leadership of those family doctors at the center of patient care. Family physicians in these models MUST have strong communication skills, the ability to manage a team, an appreciation for the business of medicine and health system development. Ever increasing political involvement in health care necessitates a comfort with health policy, legislation, and the political process – not to mention advocacy. Single-minded family physicians cannot expect to be efficient and successful providers of care for their patients. And I believe it is up to our academic institutions to encourage development and growth in these areas.
The problem is that I do not necessarily see these characteristics in many of my classmates, or in the residents with whom I train. My colleagues remain content to stick their heads in the proverbial sand for the duration of their medical school and residency years – with the expectation that they will peek out at the end of the hibernation and everything will be perfect. This is largely a product of a medical education and residency structure that encourages these sorts of behaviors. Textbooks, tests, and H&Ps are the name of the game in these outdated models.
We need to continue to encourage efforts like those of the AAMC's and MedPAC. We should embrace medical school projects such as Dartmouth's approach to engaging students in systems development and quality improvement. And we should look to continue to find ways to balance service with education in the longitudinal structure of residency programs. These goals will continue to streamline and advance the process of developing a successful and productive family physician in modern health care. The kind of family doctor that is best for his patients, his community, and his profession.
1. MedPAC Report to Congress, Aligning Incentives in Medicare. June, 2010. Pages 103-125
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