美国的医学教育：过去与未来.ppt

MEDICAL EDUCATION IN THE UNITED STATES:PAST,PRESENT AND FUTURE,Justin Clark,M.D.Neurosurgery ResidentBarrow Neurological InstitutePhoenix,Arizona,USA,INTRODUCTION,Medical SchoolsHistoryPresent day problemsFuture issuesGraduate Medical EducationNeurosurgery Residency TrainingNeurosurgery Residency Training at the Barrow Neurological Institute(BNI),HISTORY OF MEDICAL SCHOOLS,The first medical school in North America was founded in 1765 by John Morgan at the College of PhiladelphiaThis institution is now known as the University of PennsylvaniaThe faculty at the College Of Philadelphia had been trained at the University of EdinburghThe faculty used the British medical education system as the model for the school.,The History of Medical Schools in the U.S.Vault home page.Accessed 2008 June 6,FOUNDING OF NEW U.S.MEDICAL SCHOOLS,Subsequent medical schools were also founded on the U.S.East Coast:The College of Physicians and Surgeons of Columbia University,New York,NY(1767)Harvard University,Boston,MA(1782)During the next 100 years,medical schools were founded across the country;however the majority were founded in non-academic centersConsequently,during the 19th century,there existed two types of medical schools in the United States:University-based medical schoolsProprietary medical schools,MEDICAL SCHOOL CURRICULUM DURING MOST OF THE 1800s,Most medical schools did not have university paid professors;instead,medical students needed to buy a ticket from the professor,in order to hear his lectures.The University of Michigan was the only exception of this rule.Students signed-up for 2 years of studiesDuring both years,the same curriculum was taught,and learning was based on pure memorizationLectures had to be attended twice to qualify for graduationSome schools required a thesis,as wellMost students that were accepted at medical schools during this time had not graduated from a college or university,U.S.compared to the rest of the world,In the 1850s,the U.S.medical education system was far behind the European systemMedical schools in France and Germany:high entrance requirementsfour or six-year curriculumsdistinguished professorsaccess to large hospitals,T.N.bonner,Becoming a physician:Medical education in Britain,France,Germany and the United States,1750-1945(New York:Oxford Univ Press,1995),33-60,EVOLUTION,During the late 1870s,U.S.medical schools began replacing the old curriculum,which consisted of two years of repeated lectures with a new three-year graded curriculum that contained progressive lecturesLater,in 1891 schools including Harvard,Columbia,Pennsylvania and Michigan adopted a four-year graded curriculum.This increased the amount of material that could be taught to the medical students,in preparation prior to becoming a practicing physician,THE“IDEAL”MEDICAL SCHOOL,In 1893,Johns Hopkins University School of Medicine,was establishedIt was headed by William Welch and William Osler,Sonntag V.K.H.(1996).Honored Guest Presentation:The Neurosurgeon as Mentor and Student.In(Vol 51),Clinical Neurosurgery(pp.329-337).,Its new format represented a bold change from traditional medical educationIncreased priority was put on scientific learning and clinical analysisWelch first introduced miscroscopy and bacteriology to the United StatesOsler was a strong believer in student-patient interaction,and advocated extensive bedside training for medical students,THE“IDEAL”MEDICAL SCHOOL,MORE CHANGES,In the early 1900s,many U.S.medical schools began requiring students to have at least 2 years of college studies prior to entering medical schoolIn 1910,medical schools underwent vigorous scrutiny by a man named Abraham Flexner,THE FLEXNER REPORT,Abraham Flexner was a professional educator that was commissioned by the Carnegie Foundation for the Advancement of Teaching to review the conditions of medical education in the United States and CanadaThe report was a commentary on the state of medical education in the U.S.and Canada,The report was very critical of the high number and relative low quality of medical schools in the United StatesConditions in U.S.and Canada at the time of the report155 medical schools16 schools required 2 years of college work prior to admission,THE FLEXNER REPORT,All medical schools adopt a four-year curriculumtwo years of basic science educationtwo years of clinical trainingHigher admission requirements:high school diplomaminimum of two years of college science study,FLEXNERS RECOMMENDATIONS,By 1935,the landscape of North American Medical Education had changed significantlythere were 66 M.D.granting institutions that survived the reform57 of these institution were part of a university,CONSEQUENCES OF FLEXNER REPORT,http:/,CONSEQUENCES OF THE FLEXNER REPORT,Helped to introduce the standard medical curriculumThe public outcry that it caused forced many proprietary medical schools to closeSolidified the preeminent place of university-based medical schools and teaching hospitalsFlexners report and the changes it brought about signified the birth of modern medical education in the United States,STANDARDIZED TESTING,The increase in medical education standards caused by the Flexner Report did not initially lead to higher quality medical graduatesIn the first half of the 20th century,attrition rates at U.S.medical schools ranged from 5 to 50%In an effort to further increase the quality of medical education in North America,the Medical College Admission Test(MCAT)was developed in 1928By 1946,the attrition rates at U.S.medical schools had decreased to 7%,http:/,TUITION,In the 1850s,yearly tuition was very lowThe overhead associated with running a medical school was very lowIn 1850,students at the University of Michigan Medical School paid a$10 registration fee,http:/msweb.med.umich.edu/sesqui/timeline/1848-1873.htm,TUITION RISES,After the recommendations of the Flexner report were universally instituted,medical education became more expensive and tuition rates increasedIn 1940,tuition ranged from$200 to$600 per yearLaboratoryFull-time facultyTuition remained relatively low because much of the costs were subsidized by the government and private philanthropists,TUITION TODAY,In 2006-2007,tuition has markedly increasedLeast expensive public school$10,000 per yearMost expensive private school$45,000 per yearReasons:Decreased government fundingStruggling U.S.economyA common public sentiment that“doctors make too much money and medical education shouldnt be subsidized”,MEDIAN MEDICAL EDUCATON DEBT(2004),4 out of 5 members of the Class of 2004 graduated with some educational debtPrivate Medical Schools=$140,000=969,220 yuanPublic Medical Schools=$100,000=692,300 yuanMore than 28%of 2004 indebted medical school graduates had debt exceeding$150,000=1,038,450 yuan*1 Chinese yuan=0.144 U.S dollars($),Mallon WT,et al.The Handbook of Academic Medicine.(2004),CERTIFICATION&REGULATION(2006-2007),U.S.MEDICAL SCHOOL DATA(2006-2007),Number of LCME-accredited medical schools=125Full-time faculty=124,725Full-time students=69,028Number of graduates with M.D.degree=16,300men=8,269women=8,031,MEDICAL SCHOOL GRADUATESIN THE 1800s,After graduating from medical school,you could immediately start practicing,or your could undergo an apprenticeshipApprenticeships lasted a varying amount of timeThey were supervised by another physicianThey were not necessarily based in a hospital,EVOLUTION OF GRADUATE MEDICAL EDUCATION,Post-medical school education changed from a physician-based model to a hospital-based model in the 1900sHospital-based residencies allowed the residents to learn from all of the attendings at that hospitalDuring this time,residents lived at the hospital and earned an very modest salaryhence the term“house officer”,THE MATCH,Prior to 1952,Residency positions were granted based on social networking,and less on academic achievementIn 1952,the National Residency Matching Program(NRMP)was created to provide a uniform date of appointment to positions in graduate medical education(GME)Annual match designed to optimize the rank ordered choices of students and program directors,National Residency Matching Program(NRMP)Accessed 2008 June 6,Number of programs=4,214Number of resident positions=25,066Number of applicants=35,9562008 graduates of accredited U.S.medical schools=15,692“independent”applicants=20,264former graduates of U.S.medical schoolsU.S.osteopathic studentsCanadian studentsgraduates of foreign medical schools,2008 MATCH,U.S.RESIDENCY PROGRAMS,Unlike medical schools,which are run by medical schools,themselves,residency programs are run by hospitalsAny hospital can have a residency programThe number of residency programs was very small thru the mid-point of the 20th century,RESIDENCIES DURING WORLD WAR II,In 1940,the U.S.government was deferring all medical students from military service for the duration of medical school and a one-year internship.During 1942,sixty-six of seventy-eight medical schools in the U.S.and Canada instituted an accelerated program to graduate medical students in three years instead of four.Subjects of military importance were being stressed:preventive medicine,tropical disease,aviation medicine,sexually transmitted disease,fractures,industrial medicine,and psychiatry,Tarolli J.Epilogue:Building the Modern Medical Center,1941 to Present.Not Just Any Medical School.,World War II led to a period among most academic medical centers in the U.S.of marked change and expansion,as a result of the postwar boom and the increase in government-funded research and medical care.This increased funding significantly improved the influx of money into medical education,PAST,Davenport HW.Not just any medical school.Univ Michigan Press.2002,HOW DO U.S.RESIDENCY PROGRAMS GET PAID?,In 1965,U.S.President Lyndon B Johnson signed into existence Medicare.This is a government funded healthcare program the covers healthcare costs for U.S.citizens over the age of 65,as well as many handicapped individualsMedicare has many different parts to it,and it has evolved over the years,In 1966,Medicare agreed to pay hospitals for all their residents;consequently,the number of residency positions increased at that point.Medicare pays teaching hospitals for part of the costs of graduate medical education under Part Acover portion of teaching physicians salaries related to time they spend teaching residentspays a portion of the residents salariesMedicare Part B also allows for physician reimbursement for GME,under special situations,HOW DO U.S.RESIDENCY PROGRAMS GET PAID?,All residency programs conform to the specification of the ACGMEThis conformation is not mandatory for the existence of the residency;however residencies that are not ACGME-approved do no receive funding from the Federal Government for educating the residents via Medicare Parts A&B,U.S.RESIDENCY PROGRAMS,ACGME,Accreditation Council for Graduate Medical Education(ACGME)The governing body of medical education7,800 U.S.Residency programs in 118 specialties and subspecialties24 member boards of the American Board of Medical Specialties(ABMS)26 specialty-specific Residency Review Committees(RRCs),ACGME,Established in 1981 out of a consensus need in the medical community for an independent accrediting organization for graduate medical education programsIts forerunner was the Liason Committee for Graduate Medical Education,ACGME ACCREDITATION,A voluntary processResidency programs must be ACGME-accredited in order to receive graduate medical education funds from the federal Center for Medicare and Medicaid ServicesResidents must graduate from ACGME-accredited programs to be eligible to take their board certification examinations.Many states require completion of an ACGME-accredited residency program for physician licensure,DUTY HOURS,In the past,the long hours worked by medical residents were described as“a necessary component of resident education and a public symbol of a profession that requires hard work and dedication.”,Philbert I,et al.JAMA 2002;288:1112-1114,THE 80 HOUR WORK WEEK,During the 1990s,concerns from the community began to arise regarding the overworking of residentsIt was during this time that reform in residency work hours began to arise,THE 80 HOUR WORK WEEK,The new standards became effective on in July 2003Required at least 10 hour rest period between duty periodsContinuous duty limited to 24 hoursAn added period of up to 6 hours for continuity and transfer of care and didactic activities,Landrigan CP,Rothschild JM,Cronin JW,Kaushal R,Burdick E,Katz JT,Lilly CM,Stone PH,Lockley SW,Bates DW,Czeisler CA(2004).Effect of reducing interns work hours on serious medical errors in intensive care units.N Engl J Med 351(18):1838-48,LIMITS OF THE 80 HOUR WORK WEEK,This limitation does not apply to medical students or to practicing physiciansResidency programs can petition the ACGME to receive an exemption for a 10%increase in work hours,which can extend the maximum number of work hours to 88 hours per week,averaged over a 4 week period,ACGME Core Competencies,The ACGME has mandated that residents be competent in six areas be assessed before graduation.These areas are:1.Patient care2.Medical knowledge3.Practice-based learning and improvement4.Interpersonal and communication skills5.Professionalism6.Systems-based practice,SIX GENERAL COMPETENCIES,These six general competencies have also been espoused by the American Boards of Medical Specialties(ABMS)The ABMS agree that practicing physicians should also display these 6 general competencies,THE PROBLEM,The ACGME has not provided specific details on how to train or assess residents in these areasEach U.S.residency program is to develop its own training program and assessment tools to address each competencyAttempts to date have been described as“too subjective”,Leiphart JW,et al.AANS Neurosurgeron 2008;17(1),POPULATION OF RESIDENTS,THE MODEL SURGICAL RESIDENCIES,Halsted modeled his resident training program after the German Oberartz systemConsisted of serving as an assistant for 6 years in preparation for 2 years as a house surgeonThe trainees received extensive clinical experience and were expected to engage in research.In 1954,this training pattern was formalized by the Committee on Graduate Surgical Training(now the Resident Review Committee in Surgery),Sonntage,VKH.2003,NEUROSURGERY RESIDENCY,Two surgeons were most responsible to creating the neurosurgery into a subspecialtyHarvey CushingWalter DandyBoth had connections to Johns Hopkins University,HARVEY CUSHING,Trained under Halsted at Johns Hopkins UniversityEstablished himself as a“brain surgeon”early in his careerBegan training fellows early onHe would take 1 fellow each year for one year and train them to be neurosurgeons,WALTER DANDY,Started his training at Johns Hopkins as a 2nd year medical student in the fall of 1907After graduation,he became the 6th of Dr.Cushings appointees(1910-1911)From these two men sprouted the subspecialty of neurosurgery,NEUROSURGERY RESIDENC