美国的医学教育过去与未来

MEDICALEDUCATIONINTHEUNITEDSTATES PAST PRESENTANDFUTURE JustinClark M D NeurosurgeryResidentBarrowNeurologicalInstitutePhoenix Arizona USA INTRODUCTION MedicalSchoolsHistoryPresentdayproblemsFutureissuesGraduateMedicalEducationNeurosurgeryResidencyTrainingNeurosurgeryResidencyTrainingattheBarrowNeurologicalInstitute BNI HISTORYOFMEDICALSCHOOLS ThefirstmedicalschoolinNorthAmericawasfoundedin1765byJohnMorganattheCollegeofPhiladelphiaThisinstitutionisnowknownastheUniversityofPennsylvaniaThefacultyattheCollegeOfPhiladelphiahadbeentrainedattheUniversityofEdinburghThefacultyusedtheBritishmedicaleducationsystemasthemodelfortheschool TheHistoryofMedicalSchoolsintheU S Vaulthomepage Accessed2008June6 FOUNDINGOFNEWU S MEDICALSCHOOLS SubsequentmedicalschoolswerealsofoundedontheU S EastCoast TheCollegeofPhysiciansandSurgeonsofColumbiaUniversity NewYork NY 1767 HarvardUniversity Boston MA 1782 Duringthenext100years medicalschoolswerefoundedacrossthecountry howeverthemajoritywerefoundedinnon academiccentersConsequently duringthe19thcentury thereexistedtwotypesofmedicalschoolsintheUnitedStates University basedmedicalschoolsProprietarymedicalschools MEDICALSCHOOLCURRICULUMDURINGMOSTOFTHE1800 s Mostmedicalschoolsdidnothaveuniversitypaidprofessors instead medicalstudentsneededtobuyaticketfromtheprofessor inordertohearhislectures TheUniversityofMichiganwastheonlyexceptionofthisrule Studentssigned upfor2yearsofstudiesDuringbothyears thesamecurriculumwastaught andlearningwasbasedonpurememorizationLectureshadtobeattendedtwicetoqualifyforgraduationSomeschoolsrequiredathesis aswellMoststudentsthatwereacceptedatmedicalschoolsduringthistimehadnotgraduatedfromacollegeoruniversity U S comparedtotherestoftheworld Inthe1850 s theU S medicaleducationsystemwasfarbehindtheEuropeansystemMedicalschoolsinFranceandGermany highentrancerequirementsfourorsix yearcurriculumsdistinguishedprofessorsaccesstolargehospitals T N bonner Becomingaphysician MedicaleducationinBritain France GermanyandtheUnitedStates 1750 1945 NewYork OxfordUnivPress 1995 33 60 EVOLUTION Duringthelate1870 s U S medicalschoolsbeganreplacingtheoldcurriculum whichconsistedoftwoyearsofrepeatedlectureswithanewthree yeargradedcurriculumthatcontainedprogressivelecturesLater in1891schoolsincludingHarvard Columbia PennsylvaniaandMichiganadoptedafour yeargradedcurriculum Thisincreasedtheamountofmaterialthatcouldbetaughttothemedicalstudents inpreparationpriortobecomingapracticingphysician THE IDEAL MEDICALSCHOOL In1893 JohnsHopkinsUniversitySchoolofMedicine wasestablishedItwasheadedbyWilliamWelchandWilliamOsler SonntagV K H 1996 HonoredGuestPresentation TheNeurosurgeonasMentorandStudent In Vol51 ClinicalNeurosurgery pp 329 337 ItsnewformatrepresentedaboldchangefromtraditionalmedicaleducationIncreasedprioritywasputonscientificlearningandclinicalanalysisWelchfirstintroducedmiscroscopyandbacteriologytotheUnitedStatesOslerwasastrongbelieverinstudent patientinteraction andadvocatedextensivebedsidetrainingformedicalstudents THE IDEAL MEDICALSCHOOL MORECHANGES Intheearly1900 s manyU S medicalschoolsbeganrequiringstudentstohaveatleast2yearsofcollegestudiespriortoenteringmedicalschoolIn1910 medicalschoolsunderwentvigorousscrutinybyamannamedAbrahamFlexner THEFLEXNERREPORT AbrahamFlexnerwasaprofessionaleducatorthatwascommissionedbytheCarnegieFoundationfortheAdvancementofTeachingtoreviewtheconditionsofmedicaleducationintheUnitedStatesandCanadaThereportwasacommentaryonthestateofmedicaleducationintheU S andCanada ThereportwasverycriticalofthehighnumberandrelativelowqualityofmedicalschoolsintheUnitedStatesConditionsinU S andCanadaatthetimeofthereport155medicalschools16schoolsrequired 2yearsofcollegeworkpriortoadmission THEFLEXNERREPORT Allmedicalschoolsadoptafour yearcurriculumtwoyearsofbasicscienceeducationtwoyearsofclinicaltrainingHigheradmissionrequirements highschooldiplomaminimumoftwoyearsofcollegesciencestudy FLEXNER SRECOMMENDATIONS By1935 thelandscapeofNorthAmericanMedicalEducationhadchangedsignificantlytherewere66M D grantinginstitutionsthatsurvivedthereform57oftheseinstitutionwerepartofauniversity CONSEQUENCESOFFLEXNERREPORT CONSEQUENCESOFTHEFLEXNERREPORT HelpedtointroducethestandardmedicalcurriculumThepublicoutcrythatitcausedforcedmanyproprietarymedicalschoolstocloseSolidifiedthepreeminentplaceofuniversity basedmedicalschoolsandteachinghospitalsFlexner sreportandthechangesitbroughtaboutsignifiedthebirthofmodernmedicaleducationintheUnitedStates STANDARDIZEDTESTING TheincreaseinmedicaleducationstandardscausedbytheFlexnerReportdidnotinitiallyleadtohigherqualitymedicalgraduatesInthefirsthalfofthe20thcentury attritionratesatU S medicalschoolsrangedfrom5to50 InanefforttofurtherincreasethequalityofmedicaleducationinNorthAmerica theMedicalCollegeAdmissionTest MCAT wasdevelopedin1928By1946 theattritionratesatU S medicalschoolshaddecreasedto7 TUITION Inthe1850 s yearlytuitionwasverylowTheoverheadassociatedwithrunningamedicalschoolwasverylowIn1850 studentsattheUniversityofMichiganMedicalSchoolpaida 10registrationfee http msweb med umich edu sesqui timeline 1848 1873 htm TUITIONRISES AftertherecommendationsoftheFlexnerreportwereuniversallyinstituted medicaleducationbecamemoreexpensiveandtuitionratesincreasedIn1940 tuitionrangedfrom 200to 600peryearLaboratoryFull timefacultyTuitionremainedrelativelylowbecausemuchofthecostsweresubsidizedbythegovernmentandprivatephilanthropists TUITIONTODAY In2006 2007 tuitionhasmarkedlyincreasedLeastexpensivepublicschool 10 000peryearMostexpensiveprivateschool 45 000peryearReasons DecreasedgovernmentfundingStrugglingU S economyAcommonpublicsentimentthat doctorsmaketoomuchmoneyandmedicaleducationshouldn tbesubsidized MEDIANMEDICALEDUCATONDEBT 2004 4outof5membersoftheClassof2004graduatedwithsomeeducationaldebtPrivateMedicalSchools 140 000 969 220yuanPublicMedicalSchools 100 000 692 300yuanMorethan28 of2004indebtedmedicalschoolgraduateshaddebtexceeding 150 000 1 038 450yuan 1Chineseyuan 0 144U Sdollars MallonWT etal TheHandbookofAcademicMedicine 2004 CERTIFICATION REGULATION 2006 2007 U S MEDICALSCHOOLDATA 2006 2007 NumberofLCME accreditedmedicalschools 125Full timefaculty 124 725Full timestudents 69 028NumberofgraduateswithM D degree 16 300men 8 269women 8 031 MEDICALSCHOOLGRADUATESINTHE1800 s Aftergraduatingfrommedicalschool youcouldimmediatelystartpracticing oryourcouldundergoanapprenticeshipApprenticeshipslastedavaryingamountoftimeTheyweresupervisedbyanotherphysicianTheywerenotnecessarilybasedinahospital EVOLUTIONOFGRADUATEMEDICALEDUCATION Post medicalschooleducationchangedfromaphysician basedmodeltoahospital basedmodelinthe1900 sHospital basedresidenciesallowedtheresidentstolearnfromalloftheattendingsatthathospitalDuringthistime residentslivedatthehospitalandearnedanverymodestsalaryhencetheterm houseofficer THEMATCH Priorto1952 Residencypositionsweregrantedbasedonsocialnetworking andlessonacademicachievementIn1952 theNationalResidencyMatchingProgram NRMP wascreatedtoprovideauniformdateofappointmenttopositionsingraduatemedicaleducation GME Annualmatchdesignedtooptimizetherankorderedchoicesofstudentsandprogramdirectors NationalResidencyMatchingProgram NRMP Accessed2008June6 Numberofprograms 4 214Numberofresidentpositions 25 066Numberofapplicants 35 9562008graduatesofaccreditedU S medicalschools 15 692 independent applicants 20 264formergraduatesofU S medicalschoolsU S osteopathicstudentsCanadianstudentsgraduatesofforeignmedicalschools 2008MATCH U S RESIDENCYPROGRAMS Unlikemedicalschools whicharerunbymedicalschools themselves residencyprogramsarerunbyhospitalsAnyhospitalcanhavearesidencyprogramThenumberofresidencyprogramswasverysmallthruthemid pointofthe20thcentury RESIDENCIESDURINGWORLDWARII In1940 theU S governmentwasdeferringallmedicalstudentsfrommilitaryserviceforthedurationofmedicalschoolandaone yearinternship During1942 sixty sixofseventy eightmedicalschoolsintheU S andCanadainstitutedanacceleratedprogramtograduatemedicalstudentsinthreeyearsinsteadoffour Subjectsofmilitaryimportancewerebeingstressed preventivemedicine tropicaldisease aviationmedicine sexuallytransmitteddisease fractures industrialmedicine andpsychiatry TarolliJ Epilogue BuildingtheModernMedicalCenter 1941toPresent NotJustAnyMedicalSchool WorldWarIIledtoaperiodamongmostacademicmedicalcentersintheU S ofmarkedchangeandexpansion asaresultofthepostwarboomandtheincreaseingovernment fundedresearchandmedicalcare Thisincreasedfundingsignificantlyimprovedtheinfluxofmoneyintomedicaleducation PAST DavenportHW Notjustanymedicalschool UnivMichiganPress 2002 HOWDOU S RESIDENCYPROGRAMSGETPAID In1965 U S PresidentLyndonBJohnsonsignedintoexistenceMedicare ThisisagovernmentfundedhealthcareprogramthecovershealthcarecostsforU S citizensovertheageof65 aswellasmanyhandicappedindividualsMedicarehasmanydifferentpartstoit andithasevolvedovertheyears In1966 Medicareagreedtopayhospitalsforalltheirresidents consequently thenumberofresidencypositionsincreasedatthatpoint MedicarepaysteachinghospitalsforpartofthecostsofgraduatemedicaleducationunderPartAcoverportionofteachingphysician ssalariesrelatedtotimetheyspendteachingresidentspaysaportionoftheresident ssalariesMedicarePartBalsoallowsforphysicianreimbursementforGME underspecialsituations HOWDOU S RESIDENCYPROGRAMSGETPAID AllresidencyprogramsconformtothespecificationoftheACGMEThisconformationisnotmandatoryfortheexistenceoftheresidency howeverresidenciesthatarenotACGME approveddonoreceivefundingfromtheFederalGovernmentforeducatingtheresidentsviaMedicarePartsA B U S RESIDENCYPROGRAMS ACGME AccreditationCouncilforGraduateMedicalEducation ACGME Thegoverningbodyofmedicaleducation7 800U S Residencyprogramsin118specialtiesandsubspecialties24memberboardsoftheAmericanBoardofMedicalSpecialties ABMS 26specialty specificResidencyReviewCommittee s RRCs ACGME Establishedin1981outofaconsensusneedinthemedicalcommunityforanindependentaccreditingorganizationforgraduatemedicaleducationprogramsItsforerunnerwastheLiasonCommitteeforGraduateMedicalEducation ACGMEACCREDITATION AvoluntaryprocessResidencyprogramsmustbeACGME accreditedinordertoreceivegraduatemedicaleducationfundsfromthefederalCenterforMedicareandMedicaidServicesResidentsmustgraduatefromACGME accreditedprogramstobeeligibletotaketheirboardcertificationexaminations ManystatesrequirecompletionofanACGME accreditedresidencyprogramforphysicianlicensure DUTYHOURS Inthepast thelonghoursworkedbymedicalresidentsweredescribedas anecessarycomponentofresidenteducationandapublicsymbolofaprofessionthatrequireshardworkanddedication PhilbertI etal JAMA2002 288 1112 1114 THE80HOURWORKWEEK Duringthe1990 s concernsfromthecommunitybegantoariseregardingtheoverworkingofresidentsItwasduringthistimethatreforminresidencyworkhoursbegantoarise THE80HOURWORKWEEK ThenewstandardsbecameeffectiveoninJuly2003Requiredatleast10hourrestperiodbetweendutyperiodsContinuousdutylimitedto24hoursAnaddedperiodofupto6hoursforcontinuityandtransferofcareanddidacticactivities LandriganCP RothschildJM CroninJW KaushalR BurdickE KatzJT LillyCM StonePH LockleySW BatesDW CzeislerCA 2004 Effectofreducinginterns workhoursonseriousmedicalerrorsinintensivecareunits NEnglJMed351 18 1838 48 LIMITSOFTHE80HOURWORKWEEK ThislimitationdoesnotapplytomedicalstudentsortopracticingphysiciansResidencyprogramscanpetitiontheACGMEtoreceiveanexemptionfora10 increaseinworkhours whichcanextendthemaximumnumberofworkhoursto88hoursperweek averagedovera4weekperiod ACGMECoreCompetencies TheACGMEhasmandatedthatresidentsbecompetentinsixareasbeassessedbeforegraduation Theseareasare 1 Patientcare2 Medicalknowledge3 Practice basedlearningandimprovement4 Interpersonalandcommunicationskills5 Professionalism6 Systems basedpractice SIXGENERALCOMPETENCIES ThesesixgeneralcompetencieshavealsobeenespousedbytheAmericanBoardsofMedicalSpecialties ABMS TheABMSagreethatpracticingphysiciansshouldalsodisplaythese6generalcompetencies THEPROBLEM TheACGMEhasnotprovidedspecificdetailsonhowtotrainorassessresidentsintheseareasEachU S residencyprogramistodevelopitsowntrainingprogramandassessmenttoolstoaddresseachcompetencyAttemptstodatehavebeendescribedas toosubjective LeiphartJW etal AANSNeurosurgeron2008 17 1 POPULATIONOFRESIDENTS THEMODELSURGICALRESIDENCIES HalstedmodeledhisresidenttrainingprogramaftertheGermanOberartzsystemConsistedofservingasanassistantfor6yearsinpreparationfor2yearsasahousesurgeonThetraineesreceivedextensiveclinicalexperienceandwereexpectedtoengageinresearch In1954 thistrainingpatternwasformalizedbytheCommitteeonGraduateSurgicalTraining nowtheResidentReviewCommitteeinSurgery Sonntage VKH 2003 NEUROSURGERYRESIDENCY TwosurgeonsweremostresponsibletocreatingtheneurosurgeryintoasubspecialtyHarveyCushingWalterDandyBothhadconnectionstoJohnsHopkinsUniversity HARVEYCUSHING TrainedunderHalstedatJohnsHopkinsUniversityEstablishedhimselfasa brainsurgeon earlyinhiscareerBegantrainingfellowsearlyonHewouldtake1felloweachyearforoneyearandtrainthemtobeneurosurgeons WALTERDANDY StartedhistrainingatJohnsHopkinsasa2ndyearmedicalstudentinthefallof1907Aftergraduation hebecamethe6thofDr Cushing sappointees 1910 1911 Fromthesetwomensproutedthesubspecialtyofneurosurgery NEUROSURGERYRESIDENCY 2006 2007 Numberofprograms 97Numberofapprovedpositions 858Numberofresidentsonduty 814 NEUROSURGERYRESIDENCY Medianlengthoftraining 7years1 2yearsdevotedtoresearchMediannumberofresidentsacceptedeachyear 2 range 1 4residentsperyear MedianPGY1salary 43 000 298 611yuan NEUROSURGERYTRAININGATTHEBARROWNEUROLOGICALINSTITUTE Dr RobertSpetzler DepartmentChairDr VolkerSonntag ResidencyDirector NEUROSURGERYTRAININGATTHEBARROWNEUROLOGICALINSTITUTE Sevenyearprogram2yearsdevotedtoresearchFourresidentsacceptedperyearTotalof23residentsintheprogramTwospinefellowsacceptedperyearTwovascularfellowsacceptedperyearTwoendovascularfellowsacceptedperyear Allareasofneurosurgeryarerepresented VascularEndovascularSpineFunctionalPeripheralSkullbaseRadiosurgery NEUROSURGERYTRAININGATTHEBARROWNEUROLOGICALINSTITUTE FUTUREDIRECTIONOFNEUROSURGICALRESIDENCIES Competency basedtrainingATieredapproachtoneurosurgicaltraining perhapsnotallneurosurgeonsneedtobetrainedtoperformthemostdifficultprocedures BrownAJ etal Neurosurgery2007 61 1314 1321 PHYSICIANSHORTAGE Currently theResidentPhysicianShortageReductionActof2007hasbeenproposedtohelpfinancetheeducationofmoreresidentsRightnow thereareover400teachinghospitalsthatareabovetheircapsbyanaggregateamountofmorethan4500positions thesearepositionsthatarenotbeingfundedbyMedicare AAMCfeelsthattoomuchdiscretionisgiventotheSecretaryofHHSinmakingresidencypositionalloc