Preclerkship

Curriculum Resources

ACGME Competencies

Home Page for Special Topics

User's Guide

FMCR Members

How to Cite FMCR

pdf files

Areas for Greater M1-2 Curricular Emphasis
Recommendations of the Collaborative Curriculum Project

HRSA Contract # 240-00-0107

FMCR Preclerkship Collaborative Project (Family Medicine, Internal Medicine, and Pediatrics) Workgroup

Background

The increasingly complex and pressured patient care environment that characterizes modern health care delivery requires that students entering clinical clerkships be better prepared than ever before if they are going to survive and learn effectively in the clinical setting. Not only are the wards and office practices busier than ever before, but also society is more multicultural, and it is aging. Moreover, financial pressures limit faculty time, and time constraints compromise the environment for learning. Previous preclerkship reforms pertinent to preparation for the clinical years included earlier and enhanced teaching of interviewing and introduction to principles of clinical epidemiology. In view of the increasingly problematic environment for clinical learning, it appears to be time to reexamine preclerkship preparation. The reason for looking at the preclerkship educational program is that the learning of the core competencies of doctoring must begin on day one of medical school and continue throughout one's professional lifetime.

Overview

As part of the Family Medicine Curriculum Resource Project, a faculty consortium representing internal medicine, pediatrics, and family medicine has undertaken a reconsideration of the preclerkship curriculum from the perspective of the necessary preparation for the core clinical clerkships, particularly in the primary care specialties, but not exclusively so. What follows is a set of consensus recommendations from this consortium for consideration by curriculum planners. The recommendations focus on the core competencies of doctoring. The recommendations are expressed in terms of (1) what students should be able to do by the time of initial entry into their core clinical clerkships, (2) what types of actions curriculum leaders and course directors ought to take to ensure this capability, and (3) the rationale and supporting evidence. The spirit of the recommendations is to stimulate debate and engage curriculum planners in a dialogue that can lead to meaningful educational reform pertinent to ensuring and enhancing the learning of our students.

Interviewing and Physical Examination Skills

Recommendations

1. Before beginning the core clinical clerkships, students should be able to:

• Adapt basic history and physical examination skills to a variety of settings and populations (e.g., inpatient, outpatient, different ages, gender, and sociocultural background). Time limitations and patient concerns are factors that require adaptation, necessitating algorithms for choosing focused vs. comprehensive approaches to the history and physical examination.
• Incorporate patient-centered skills into data gathering, including noting patient's perspective on illness (ideas, concerns, and expectations) in the understanding, description, and communication of the history. (It is, after all, the patient's story, not a history to be "taken" from him.)

2. Schools should examine the barriers to evolving from a traditional approach to teaching the "complete history and physical" toward a more adaptable methodology recognizing time and contextual aspects. This will likely include expansion of ambulatory experiences, incorporating a diverse spectrum of patients, and limits on clinical encounters, methods of assessment, and faculty resources.

3. Course directors should regularly update and improve clinical skills teaching by reference to:

• Validating evidence in the scientific literature
• Medical students' performance on standardized, clinical, high-stakes performance assessments
• Participation in educational scholarship at the local and national level.

4. The medical school administration must develop and institute specific faculty development methods for the physicians responsible for teaching this set of attitudes, knowledge, and skills.

Importance/Rationale

Eliciting a history, performing a physical examination, and communicating the results and assessment are fundamental to the practice of all fields of clinical medicine.

Despite the explosion of new diagnostic modalities, these basic competencies remain the fundamental tools of the clinician. Because of the large volume of clinical information that must be imparted during the clinical clerkships, little time is typically left to enhance the learning of interviewing and physical examination. The scarcity of teaching time and the challenges of the busy ward and office settings put considerable stress on the student's nascent skills. To function effectively during the clerkships, medical students entering the clerkship phase of undergraduate medical education must be better prepared in these core clinical competencies if they are to function effectively under time pressure and across the spectrum of age, gender, cultural, and socioeconomic backgrounds encountered in clinical settings.

Most students entering the clinical phase of undergraduate medical education have been prepared to perform only a comprehensive history and physical examination on a hospitalized adult patient under minimal, if any, time constraints. When students enter the clerkships they are confronted with a diversity of patients and stressful clinical situations that they are ill prepared to cope with. Often they resort to an interrogatory style of interviewing and a mechanistic performance of the physical exam, with little reference to the patient as a whole. Superficially, such behavior may appear efficient and may even be encouraged by their residents, who are eager for a few screening facts, but dysfunctional habits often develop and errors in diagnosis result from incomplete and inaccurate data collection. Many of the critical elements of history and physical examination taught in the first two years become supplanted by bad habits developed under duress. Deterioration of learned physical examination skills from the preclinical to the clinical years has been documented, (1) but curricular enhancement of clinical skills teaching can improve students' basic abilities to effectively perform the history and physical examination. (2)

Approaches used successfully prior to the clerkships include use of senior medical students, (3) nurse practitioners, (4) standardized patients, (5) trained community volunteers, (6) gynecologic teaching associates, (7) elderly disabled patients, (8) and trained mothers. (9) Successful sites of teaching interview and examination skills have included day care centers, (10) nursing homes, (11) and ambulatory clinics. Teaching in the ambulatory setting is at least as effective as inpatient-oriented courses (12) and may provide valuable additional skills. (13)

1. Dunnington G et al. Teaching and evaluation of physical examination skills on the surgery clerkship. Teach Learn Med. 1992; 4:110-114.
2. Pfeiffer CA et al. The impact of a curriculum renewal project on students' performances on a fourth-year clinical skills assessment. Acad Med. 2001; 76:173-175.
3. Haist SA et al. Are fourth-year medical student effective teachers of the physical examination to first-year medical students. J Gen Intern Med. 1997; 12:177-181.
4. Johnson H et al. The effectiveness of pediatric nurse associates as clinical instructors of medical students. Am J Dis Child. 1979; 133:178-180.
5. Davidson R et al. Using standardized patients as teachers: a concurrent controlled trial. Acad Med. 2001; 76:840-843.
6. Antonelli MA. Practicing physical evaluation skills on community volunteers. Acad Med. 1994; 69:214-215.
7. Plauche WC et al. Students' and physicians' evaluations of gynecologic teaching associate program. J Med Educ. 1985; 60:870-875.
8. Coletta EM et al. Using elderly disabled patients to teach history taking and physical examination. Acad Med. 1993; 68:901-902.
9. Still PL et al. Use of trained mothers to teach interviewing skills to first-year medical students: a follow-up study. Pediatrics. 1977; 60:165-169.
10. Davis BE et al. Day care centers as resources for teaching physical diagnosis. Acad Med. 1994; 69:416.
11. Wiener M. The nursing home as a site for teaching medical students. Acad Med. 1990; 65:412-414.
12. Barclay DM et al. Effect of training location on students' clinical skills. Acad Med. 2001; 76:384.
13. Kurth RJ et al. A model to structure student learning in ambulatory care settings. Acad Med. 1997; 72:601-606.

Communication Skills

Recommendations

1. Before beginning the core clinical clerkships, students should be able to:

• Elicit basic patient requests, expectations, and concerns, recognizing the effects of contexts like setting and patient diversity.
• Present verbally and in writing the basic elements of the history and physical examination to colleagues, including the patient's perspective.
• Transform this information into a basic problem list that can be used to develop a multifaceted plan with the patient.

2. For students to achieve these competencies prior to the core clinical clerkships, curricular leaders must:

• Recognize that communication is the basic building block to forming the doctor-patient relationship. This means developing high profile, high stakes curricula to teach these skills, based on explicit, well articulated, and validated models of effective communication.
• Examine current barriers to more explicit and effective teaching of communication skills and develop plans to address these challenges.

3. Accomplishment of these communication skills competencies will require faculty champions and a critical mass of master teachers who model, teach, and value these skills.

Importance/Rationale

Outstanding communication is not a luxury of medical care. Specific patient outcomes, such as diagnostic accuracy, adherence to therapy, postoperative complication rates, patient satisfaction, and malpractice incidence are affected by the quality of communication. Health disparities among different races and ethnic groups have been related to the quality of physician-patient communication as well. Effective and compassionate communication has always been a core value of the medical profession, dating back to the very beginning of medicine, as well.

Communication between physicians and patients is directly influenced by sociocultural factors. If a physician fails to understand or elicit sociocultural issues, there is likely to be a greater chance for patient dissatisfaction, poorer outcomes, and racial differences in access to care. (1-5) Clinical decision-making and management are also influenced by sociocultural differences between physician and patient. (6) Failure to take these differences into account has led to instances of discriminatory treatment based on race, culture, language proficiency, or social status. (7-9)

In response to reports (Institute of Medicine's Report on Primary Care, Pew Health Professions Commission) emphasizing the importance of cultural sensitivity training in medical school, accreditation bodies for medical training (Liaison Council on Medical Education, Accreditation Council on Graduate Medical Education) now have standards that require cross-cultural curricula as part of undergraduate and graduate medical education. (10,11) Currently these standards are fairly nonspecific, but they are being expanded in detail and remain enforceable.

It is clear that teaching communication cannot be relegated to the belief that good communication is an inherent skill and quality of all doctors, by virtue of their character and will be easily attained by apprenticeship training. This approach, although practiced at many institutions, has proven to be inadequate.

The fairly recent acceptance of the principle that outstanding communication is a high stakes competency, with a direct impact on health outcomes, has led to more explicit and visible curricula and more objective and high stakes assessment strategies. However, there is a general sense that medical schools, residency training programs, certification bodies, and continuing training programs need to be even more explicit and visible in this area. International consensus statements, medical school (AAMC) and residency training requirements (ACGME), and professional standards testing requirements have demanded more refined and validated curricula and more proof through objective assessment that students and doctors are effective communicators.

All medical schools must continue to make communication one of the highest profile and highest stakes competencies, in medicine and in medical training. This means that there must be a core faculty with refined expertise in the principles of effective communication, to act as curricular leaders and faculty development sponsors. It also means that all clinical faculties, including residents, must be trained to teach explicit communication skills.

All medical school curricula should include explicit references to well-established models of effective communication, such as the Kalamazoo Consensus Essential Elements, the Patient Centered Clinical Model, the Three Function Model (Brown Interview Checklist), the Calgary-Cambridge Observation Guide, the SEGUE model of Effective Communication, and the Bayer Institute E4 Model, to name a few. Students should reach competency in facilitating a medical interview, following the principles of one of these models. Since the medical history is the most performed procedure in the career of any physician, students and curricula must demonstrate an explicit and reproducible approach to performing this procedure.

All medical schools should have explicit assessment of student competencies in these areas. Licensing examinations will all include standardized assessment of communication skills within the next few years.

1. Flores G et al. The teaching of cultural issues in the US and Canadian medical schools. Acad Med. 2000; 75: 451-455.
2. Betancourt JR et al. Hypertension in multicultural and minority populations: linking communication to compliance. Current Hypertension Reports . 1999; 1:482-488.
3. Stewart M, Brown JB, Boon H, et al. Evidence on patient-doctor communication. Cancer Prev Control. 1999; 3:25-30.
4. Langer N. Culturally competent professionals in therapeutic alliances enhance patient compliance. J Health Care Poor Underserved . 1999 Feb; 10(1): 19-26.
5. Morales LS, Cunningham WE, Brown JA, et al. Are Latinos less satisfied with health communication by health care providers? J Gen Intern Med. 1999; 14:409-417.
6. Eisenberg JM. Sociologic influences on medical decision making by clinicians. Ann Intern Med . 1979; 90:957-964.
7. Schulman KA, Berlin JA, Harless W, et al. 1999. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med. 1999; 340:618-26.
8. Van Ryn M, Burke J. 2000. The effect of patient race and socio-economic status on physicians' perceptions of patients. Soc Science & Med. 2000; 50:813-828.
9. Donini-Lenhoff FG, Hedrick HL. Increasing awareness and implementation of cultural competence principles in health professions education. J Allied Health. 2000; 29:241-245.
10. Pew Health Professions Commission. 1995. Critical challenges: Revitalizing the health professions for the twenty-first century. San Francisco. UCSF Center for the Health Professions.
11. Liaison Committee on Medical Education. Accreditation Standards. http://www.lcme.org/standard.htm#culturaldiversity .

PROFESSIONALISM

Recommendations

1. Before beginning the core clinical clerkships, students should be able to demonstrate basic behaviors of professionalism and humanism and be observed at least once during peer and patient encounters for confirmation of these behaviors and specific feedback.

2. Curricular leaders must communicate that professionalism is a central tenet of medical care. High profile, high stakes curricula must be developed, including validated methods of instruction and assessment, and integrated into the preclerkship years.

3. Barriers to the evolution in teaching professionalism from informal (i.e., "hidden" or tacit curricula) to explicit, visible curricular and assessment strategies must be examined, and strategies to address these challenges must be developed.

4. Faculty development regarding professionalism is critical for all faculty, with identification of "master teachers."

Importance/Rationale

Professionalism is a central tenet of medical care, and numerous consensus statements, curricular guidelines, and organizational statements reinforce its primacy. It is a philosophical set of core values and principles (ABIM Project Professionalism, ABP Professionalism Statement, Physician Charter) and it is a set of actions and behaviors that is linked to concrete patient outcomes. It is also a set of behaviors that is linked to concrete societal outcomes, such as an equitable distribution of services. Therefore, medical schools have an imperative to create explicit, high stakes, and highly visible curricula and assessment strategies.

Many medical schools include professionalism in their official curricula. However, many of the approaches are challenged as nebulous curricula, which review aphorisms (Ginsburg et al.) or are difficult to apply in specific contexts. Students are allowed to marginalize these principles as being abstract and irrelevant to patient care. There is a perception that this is reinforced during the major clinical years of medical school, during which resident role models demonstrate survival based medical practice, rather than optimal medical care. Furthermore, explicit and well-validated evaluation of professionalism is rare. There are a number of validated methods of instruction, which are context- and behavior-based, and a number of evaluation methods, which have been well validated (Arnold).

All schools must judge their curricula and evaluation methods by how context- and behavior-based they are, by how well integrated they are into the general curriculum and evaluation methods, and by how high stakes they are.

Humanism, with its quality of compassion and connection to patients and families, must be singled out for its primacy in professional medical behavior. Humanism's emphasis on explicitly identifying and conveying respect and compassion for the patient's perspective is the core competency of professional behavior (Miller and Schmidt). Curricula and evaluation methods must address this core competency in an integrated manner as well.

LIFECYCLE AND SELF-AWARENESS

Recommendations

1. Before beginning the core clinical clerkships, students should be able to:

• Recognize that every interaction with patients and their families is only a snapshot in an ongoing cycle of growth and development.
• Recognize interactions between environmental stressors and well-being in their personal lives and those of their patients.
• Identify a menu of behavioral strategies for enhancing well-being and preventing adverse effects of stress.
• Demonstrate awareness of patients' lifecycle issues through oral and written communication.

2. Curricular leaders should:

• Provide students with opportunities to examine issues from their own family of origin, to consider the common clinical problems at each developmental stage and stresses associated with transition between stages, and to develop insight into the impact of developmental stage on the patient-physician relationship.
• Offer experiences to foster students' increasing self-awareness and commitment to the values of the profession through personal and professional development, including reflective experiences, opportunity to process experiences in small groups, and values clarification exercises; and to reflect on changes in self-understanding over time.

4. The medical school administration and curriculum leaders should:

• Provide early clinical experiences that match beginning students with mentors who provide continuing care to patients, who can demonstrate commitment to personal and professional development and the effect of patient/physician developmental issues in continuous healing relationships with patients over time.
• Identify barriers to providing these opportunities and develop strategies to address them.

Importance/Rationale

The term "lifecycle" describes a dynamic progression of human growth and development in physical, psychoemotional, and spiritual domains. (1,2) Students currently learn about the biological stages of fetuses, newborns, children, adolescents, and adults, and the psychoemotional development of the infant, child, and adolescent. Some curricula cover the developmental tasks of the lifecycle stages of adults, but few address the stages through which families move, from the couple, to children, to empty nest, to the end of life, and the many variations thereof. It is uncommon for curricula to include how the interaction of individual and family lifecycle stages affects risk factors for illness, prevention needs, or the medical conditions with which adult patients present for care. (3) Students need to learn about health effects of these expected and unexpected lifecycle transitions, and how to consciously appreciate the effect of their personal adjustment in their own individual or family lifecycle stage on their interactions with patients in the same or different stages. (4,5)

Most medical students meet patients who must deal with anxiety-provoking issues such as loss of health or bodily integrity, diagnosis of a terminal illness, and death, while the students themselves may be at a relatively early stage in their own lifecycle development. They may also be entering early stages in the establishment of their nuclear family or other intimate relationship, the developmental tasks of which may be incompatible with the demands of educational experiences like clerkships. Students are encouraged to be compassionate and empathetic, but their schedules and educational demands may be more conducive to cynicism than compassion. (6,7) Students should be encouraged to reflect on how their medical education shapes their personal values and attitudes, including the possibility of conscious choices; and be mindful of how these experiences and choices influence their effectiveness as physician healers. (8,9,10,11,12)

Clinicians who are unaware of how dynamic issues within their own families affect interactions with patients will be less effective and may encounter repeated interactive patterns that are frustrating both for the clinician and the patient. (4,13) Physicians must learn to deal with stressful issues at each stage of the life cycle for maximal health and well-being. (12,14) Each physician and physician-in-training has the responsibility to intentionally focus on developing self-awareness throughout his or her professional lives through seeking feedback from colleagues, mentors, and patients and personal reflection.

A systemic understanding of interactional patterns allows the clinician to both conceptualize and intervene with patients' presenting problems within a broader context. Some problems such as non-adherence due to family interference in therapy and resistant hypertension due to transitional stress in the family life cycle (1) can only be satisfactorily addressed with a contextual understanding.

Students require the attitudes and skills to consider and elicit relevant history, negotiate treatment goals, and develop biological, psychoemotional, and sociospiritual interventions, using a patient- (versus disease) focused approach and maintaining sensitivity to the influence of patient gender, class, ethnicity, and culture. Medical education tends to extinguish patient-centeredness in medical students. (6,15) Thus role-modeling and explicit experiences are required to demonstrate the critical importance of appreciating each patient's unique experience, and to foster understanding of the relationship between personal development and patient care. Approaches that have been successfully employed to foster learners' self-awareness, personal growth, and well-being, emphasizing qualitative, process-oriented, and individually tailored methods (5) include mentorships, (16) small-group discussions, support groups, Balint groups, reflective experiences, and values clarification exercises.

1. Korin EC, McGoldrick M, Watson MF. "The Individual and Family Life Cycle." Mengel, Holleman and Fields, 2 nd ed., 7.
2. Novak D. Calibrating the physician. JAMA.
3. Carter B, McGoldrick M. The Expanded Family Life Cycle: Individual, Family, and Social Perspectives, ed. 3. Boston: Allyn & Bacon, 1999.
4. Rolland JS: Families, Illness and Disability: An Integrative Treatment Model. New York: Basic Books, Inc. 1994.
5. Pfeiffer RJ. Early-adult development in the medical student. May Clin Proc. 1983 58(2): 127-34.
6. Niemi PM. Medical students' professional identify: self-reflection during the preclinical years. Med Educ. 1997 33(6): 408-15.
7. Coulehan J, Williams PC. Vanquishing virtue: the impact of medical education. Acad Med. 2001; 76:598-6058.
8. Kaufman DM, Laidlaw TA, Langille D, Sargeant J, MacLeod H. Differences in medical students' attitudes and self-efficacy regarding patient-doctor communication. Acad Med. 2001 76(2): 188.
9. Novack DM, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997 26:278(20).
10. Westberg J and Jason H. Fostering Reflection and Providing Feedback: Helping Others Learn From Experience. Springer, 2001.
11. Epstein RM. Mindful practice. JAMA. 1999; 282:833-9.
12. Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997; 72:941.
13. Novack D H, Epstein RM, Paulsen RH. Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being. Acad Med. 1999 74(5) 516-20.
14. Balint M. The patient, his story and the illness.
15. Physician health and well-being. CMAJ 1998 158(9): 1191-200.
16. Haidet P. Dains JE, Paterniti DA, Hechtel L, Chang T, Tseng E, Rogers JC. Medical students' attitudes toward the doctor-patient relationship. Med Educ. 2002 36(6): 568-74.
17. Ogrinc G, Mutha S, Irby DM. Evidence for longitudinal ambulatory care rotations: a review of the literature. Acad Med. 2002 77(7): 688-93.

PROBABILISTIC THINKING

Recommendations

1. Before beginning the core clinical clerkships, students should be able to:

• Discuss the concept of decision-making for patients and populations using a probabilistic approach.
• Apply an understanding of disease risk, prevalence, and likelihood in the development of differential diagnosis, test ordering, and interpretation.
• Appreciate the skills of interpreting rest results and medical information in a probabilistic manner in negotiating diagnosis and treatment plans with patients, including assessing patients' understanding.

2. Curricula must be developed or reinforced that impart basic, current concepts of evidence-based medicine and clinical epidemiology.

Importance/Rationale

Physicians are responsible for the diagnostic evaluation of a broad range of patients, including acutely and chronically ill patients. To direct the diagnostic evaluation of patients in a safe and cost-effective manner, physicians must have a firm grasp of the principles of modern clinical epidemiology and probabilistic thinking. They must be able to elicit appropriate clinical information, keeping in mind the value of a careful history and physical examination. They must be able to order tests wisely. They also must be able to interpret the results of tests properly to determine how the results should influence patient management. This requires mastery of probabilistic thinking. Indeed, many treatment decisions will tip one way or another depending on how patients view the probability of a desired outcome compared to the costs or the probability of potential complications or adverse effects. Physicians clearly need well-developed skills in these fundamental aspects of therapeutic decision-making so that they can apply evidence from studies to individual patients.

Students must be able to access and use the growing body of evidence that defines the accuracy and limitations of the history, physical examination, and tests in quantitative terms. They also must apply the evidence in a manner that reflects understanding of the probability of disease in the communities or populations in which they practice. This is particularly challenging in a time of rapidly proliferating tests. Students therefore need well-developed skills in these fundamental aspects of diagnostic decision-making that influence test ordering and test interpretation.

Students also must be facile in applying the principles of modern clinical epidemiology and probabilistic thinking to the therapeutic management of a wide variety of acute and chronic medical problems. They must identify and apply up-to-date evidence that quantifies the benefits, risks and costs of different management options. They also must be able to translate the evidence into terms that patients can understand.

1. Weiss ST, Samet JM. An assessment of physician knowledge of epidemiology and biostatistics. J Med Educ. 1980; 55: 692-7.
2. Parkes J, Hyde C, Deeks J, Milne R. Teaching critical appraisal skills in health care settings. Cochrane Database Syst Rev. 2001; (3): CD001270.
3. Green ML. Graduate medical education training in clinical epidemiology, critical appraisal, and evidence-based medicine: a critical review of curricula. Acad Med. 1999; 74: 686-94.
4. Norman GR, Shannon SI. Effectiveness of instruction in critical appraisal (evidence-based medicine) skills: a critical appraisal. CMAJ 1998; 158: 177-81.
5. Bradley P, Humphris G. Assessing the ability of medical students to apply evidence in practice: the potential of the OSCE. Med Educ. 1999; 33: 815-7.
6. Astin J, Jenkins T, Moore L. Medical students' perspective on the teaching of medical statistics in the undergraduate medical curriculum. Stat Med. 2002; 21: 1003-6.

SYSTEMS OF CARE

Recommendations

1. Before beginning the core clinical clerkships, students should be able to:

• Discuss the basic elements of local and federal health care systems that provide care to patients they are likely to see, including how costs are borne by patients and the system.
• Discuss impact of systems on delivery and outcomes of care.
• Describe indicators of health care quality, including patient-centered outcomes (mortality, morbidity, quality of life, satisfaction, and cost). Recognize physicians' responsibility to monitor and provide effective interventions to improve health care outcomes.
• Discuss the barriers to access to health care for patients.

2. Course directors should develop experiential approaches to teaching about systems of care, especially regarding the effect of various forms of health insurance on access to care and utilization of services (including pharmaceuticals).

3. Curriculum leaders should insure that the basic principles of a team approach to health care within the health care system be part of the preclerkship curriculum, with attention to the application of these principles to improving the safety and care of populations and individuals.

Importance/Rationale

Over the last 10-20 years, the practice of medicine has become increasingly more complex and, therefore, the preparation for that practice has become increasingly complex. (1,2) Some of these increasing complexities include the evolution of managed health care, the increasing bureaucracy of medical practice, constant changes in Medicaid and Medicare, increasing changes in federal and state health care policies and regulations, competition from other health care providers, rise of complementary medicine, rising cost of medications and biomedical technologies, and increasing accountability of physicians to third parties. (3,4) Most physicians and students are not trained to think about practices as complex systems, and approximately half of all medical schools have no formal managed care curricula. (4,5) Clinical algorithms, guidelines for preventive screening, and ambulatory care standards come from multiple, varied sources and contain conflicting recommendations that, many times, are not evidence-based but based on opinion or political agenda. Formulas for cost-containment, utilization, and algorithms ignore the diversity in practices and in individuals. (1,2)

The practice of medicine is more than a commodity delivery business. It is a complex, adaptive system. (2) This can be extremely confusing for medical students, especially if they do not understand or have never received any training in the history and evolution of these systems. Students may not understand the variation between practices and between practitioners. They may not understand the different insurance plans and health care systems. They may not understand complexity theory that guides all these systems. Variations include how practices are organized, relations with staff and other providers, involvement with third party payers, physician profiling and utilization review, different uses of technology, plus individual work style and personality. (6) Students need a firm foundation on these macro level issues including health economics, delivery systems, community health, and medical sociology so that they can avoid being overwhelmed when placed in physicians' offices or on rotations in the hospital. They will be the future medical experts helping to shape future health care systems and without firm background and understanding of these systems could be overwhelmed by external factors and interests.

Understanding the micro level issues of working as a member of a team and professionalism has an obvious bearing on the macro issues. A gulf now exists between the medical profession and society, with professionalism being the bridge for this gulf. All countries currently have threats to professionalism in medicine. Physicians must participate in shaping the future and must understand the principles of professionalism, since the social contract between society and medicine hinges on professionalism. (7,8)

1. Miller WL, Crabtree BR, McDaniel R, Stange KC. Understanding change in primary care practice using complexity theory. J Fam Pract. 1998; 46(5): 369-376.
2. Miller WL, McDaniel RR, Crabtree BF, Stange KC. Practice jazz: understanding variation in family practices using complexity science. J Fam Pract. 2001; 50(10): 872-878.
3. Mechanic D. Managed care and the imperative for a new professional ethic. Health Affairs. 2000; 19:100-111.
4. DiBartola L, Moore B, Pawlson G. The managed care education clearinghouse. Acad Med. 2000; 75:302.
5. LaRosa J, Whelton P, Litwin M. Academic medicine and managed care: seeking common ground. Acad Med. 1999; 74:488-492.
6. Pasko T, Seidman B, Birkhead S. Physician Characteristics and Distribution in the United States, 2001-2002 Ed.
7. Daniet B, Cyran E, Anderson RJ. Common issues in medical professionalism: room to grow. Am J Med 2000; 108(2): 136-142.
8. Hensel WA, Dickey NW. Teaching professionalism: passing the torch. Acad Med. 1998; 73(8): 865-870.

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated November 6, 2004