DESPITE THE ONGOING revolution in biomedical science--with gene splicing being but the latest episode--the formula for training physicians has changed little in the last half-century. In 1910 a microbiologist by the name of Abraham Flexner published a seminal report entitled Medical Education in the United States and Canada, which was highly critical of the disorganized and generally unscientific state of medical education. It argued that universities, rather than proprietary schools, should have the sole responsibility for medical education so that the full force of academia could be brought to bear on the rapidly developing field of biomedical science.
With the support of American philanthropy and the American Medical Association, Flexner's dictum succeeded marvelously well. Within two decades medical education was overhauled, schools that could not meet the new standards-- more than a third of those operating-- were closed and medical education was firmly and exclusively planted in the American university.
Flexner has been acclaimed for his accomplishment; and, indeed, the high standard of technological excellence achieved by American medicine through the middle years of this century owes much to his ideas. At the same time, however, the standardization brought about by the Flexnerian reforms has produced a uniformity and professional subspecialization which has created a set of problems in the practice of medicine.
Medical schools since Flexner's time have divided their education into the preclinical years (24 months of patient- less, basic science--anatomy, physiology etc.) followed by the clinical years (two years spent on hospital wards learning medical practice, specialty by specialty). Few schools have varied from this narrow format. Flexner's emphasis on the scientific method (as opposed to the various forms of charlatanism that flourished in 19th-century America) unwittingly abetted the enormous swing to subspeciality medicine that occurred following World War II.
By 1970 the United States found itself alarmingly short of physicians. The problem, though, was not entirely one of numbers--in fact, the doctor-patient ratio in the United States remained stable from 1930 until 1965 when it began to rise slowly. The problem was that American physicians had, in huge numbers, become urban, subspecialized and technology-dependent. They tended to cluster around medical centers and among populations that were well-to-do or well insured. While the strain could be felt everywhere, the legacy of Flexner's revolution in medical education left many rural areas, many public institutions and the poor almost without physicians.
The last decade has seen a number of tentative but important experiments in changing that model of medical education.
"We plan to train doctors who will know what primary care in a rural community is all about," says Dr. Scott Obenshain, assistant dean and director of the Prime Care Curriculum at the University of New Mexico School of Medicine. "Students are learning how to be rural doctors from rural doctors."
The PCC--as it is called in New Mexico--is trying to train a new generation of physicians whose skills and outlook will be more attuned to rural practice than those of standard medical school graduates. Funded by a four-year $743,000 grant from the W. K. Kellogg Foundation and some help with operating expenses from the New Mexico legislature, the PCC functions as a separate but parallel curriculum within the School of Medicine. Now in its third year, the program enrolls 20 students each fall, roughly 30 percent of the entering class.
"The PCC is more humanist and more fun," states Obenshain, "The education is student centered and practical. In the long run the students help us determine what they need to become good doctors." There are four parts to the PCC, the first of which is a basic clinical science program that lasts for eight months. Unlike the punishing metronome of lecture and lab that the usual medical student encounters at this point, the PCC students attend small group tutorials and do independent study. For the next four months the students leave the medical center and travel to rural communities in New Mexico where they work as apprentices to primary care physicians (i.e. internists, pediatricians or family practitioners.)
"I was very slow (seeing patients) at first," says Randy Davis, a third-year student who spent his first working session in Silver City, a small mining town in southwestern New Mexico. "I might see two or three patients during the course of a morning, but I would only concentrate on one. Every afternoon I had off for study. I would take the problems of that one patient and read everything I could about them. . . . I learned a lot." Davis, who grew up in a New Mexico town with the unlikely name of Truth or Consquences, wants to go back to a small town and jumped at the chance to join the PCC. "I liked the psychology of the approach and I think it's teaching me what I need to know. Silver City is a good place to learn medicine. My preceptor taught me a lot."
The third stage of the curriculum lasts 10 months and rounds out what traditionally has been the "pre-clinical" years of medicial school. Again, the PCC approach at this point is quite clinical, with a return to the tutorial groups focusing on more complex medical problems.
"We worked a lot with simulated patients," Davis reports. "People trained to act out the symptoms and complaints of diseases. They keep you honest and they keep you interested." During this phase PCC students also use an innovation called the "Portable Patient Problem Pack", the so-called P4, a color-coded, computer-based card deck developed at McMaster University in Canada for teaching the symptoms, lab data and treatment of basic illnesses.
In fact, a great deal of the problem- based teaching approach used in the PCC was initially developed at McMaster as a startling departure from the encyclopedic, memory-based education that has predominated in the United States and Canada over the years.
"Many of the things that standard medical students memorize have no correlation with their function as physicians. Yet that is what they learn and that is what they are tested on," says Obenshain. "The problem-based approach takes medical problems like, say, an ear infection and has the student learn everything from the anatomy of the inner ear to the pharmacology of penicillin based on that one problem. Students really thrive on that kind of learning."
For the last two years the PCC students join their colleagues in the traditional track, spending time on hospital rotations in medicine, surgery and pediatrics as well as some specialties. There is a generous amount of elective time with at least three months spent back in a small rural community working with a country doctor. While PCC students are not required to stay in New Mexico or limit their professional goals to primary care, those objectives are clearly encouraged by the program's curriculum and faculty.
What of the future? According to Obenshain, both the Kellogg Foundation and the University of New Mexico will watch carefully as the first PCC practitioners set their professional courses. Davis, who has a U.S. Army scholarship, will take a family practice residency and fulfill his four-year service obligation. After that he plans to return to rural New Mexico. When asked if the PCC model could be used for all medical education, Davis responds, "Anybody who is motivated enough to get into medical school in the first place is motivated enough for PCC. . . . Basically it is good medical education."
Although he is an articulate booster of the program, Obsenshain is realistic about its place in medical colleges. "It is unlikeeed tly that Harvard will adopt the PCC in the next few years," he notes acidly. "But I am convinced it is the right approach to medical education. Whether the doctors are going to Madison Avenue or El Rito, New Mexico. The implications of the PCC are great not only for American medical education, but for worldwide need. For instance, the registrar of the University of Guyana was here last week and plans to use much of what he saw in his own national medical school."
The future of PCC in New Mexico is not certain. To date it is an appealing demonstration project that is not yet a tradition either at the school or in the annual state budget. "Unless the PCC becomes the curriculum at UNM," says Obenshain, "it may not survive in the future. Not many schools, including the wealthy ones, can afford to educate two different kinds of doctors." Now that it is up and running, longevity is probably the Primary Care Curriculum's greatest challenge.
DDD "TAKE THIS TEST (it may change your life!)," announces a recruitment brochure for the Sophie Davis School of Biomedical Education of the City College of New York. The brochure goes on to ask, "Do you know that there is a shortage of primary care physicians?" and "Would you like to be part of the vanguard of physicians working to improve the way in which health care is delivered?" Training that vanguard is the purpose of Biomed --as it is known. Started in 1973, the program is not formally a medical school but rather a five-year curriculum at CCNY that provides a college education and the first two years of medical school with the guarantee that its graduates will be admitted into the final two years at one of seven participating medicial schools -- five in New York State plus Howard here in Washington and Meharry Medical College in Nashville, Tennessee. Courses in community medicine, the humanities and the social sciences are scattered throughout the curriculum, and each student spends a summer working in a primary care facility in the inner city.
"The early years of the program were devoted to establishing a sound scientific base so that our students would do as well as anybody else," states Dean Leonard E. Meiselas. "More than 90 percent of our graduates have passed part I of National Boards (given to all medical students after the first two years) on their first try and that compares favorably with any school. "Our job now is to sharpen the interface between the medical sciences and the social sciences."
Biomed has not been without problems. Not only did 50 percent of those minority students recruited directly from ghetto high schools drop out during the first two years, but the emphasis on minority recruitment got Biomed into legal difficulties as well. In 1976, two years before the Allan Bakke case was decided by the Supreme Court, a federal district Court ruled that Biomed had discriminated against three white applicants and ordered the school not to consider race as a factor in admission.
Since then, Biomed has taken a creative approach to minority recruitment and has developed the Bridge to Medicine Program in which a select group of high school seniors spend four hours a day, five days a week at Biomed doing college preparatory work in chemistry, physics, math and problem solving. Criteria for selection include placement in the top 10 percent of the class, family income below $13,500 annually and evidence of "educational disadvantage" which is defined as scores on Regents exams below the level normally expected of students with high class ranking. Of the 75 students who have participated in the program over the past several years, a third have been accepted at Biomed, and the others have all gone on to premedical course work at competitive colleges.
"You have to be sure you want to be a doctor at a early age," says David Hodges, a student in his fifth and final year at Biomed. "But if you are sure, it provides a chance for people who would never be in traditional medical school." Hodg tes, a black who founded a Third World organization at Biomed, is chary about the school's success in minority recruitment. "We haven't seen a whole lot of change for the better lately, but I think they are committed. The Bridge Program is the best thing to have come along."
Not only does the Biomed curriculum attempt to infuse a commitment to community medicine in its students, but it bears responsibility for the general education experience that most students have as undergraduates.
"We focus on the humanities' unique role in medicine," says Meiselas. "Right off the bat, in the first year, we give them a course called 'Creative Process.' They read Galileo and Einstein, Freud and da Vinci. They study the history of the family in New York City, including the impact of successive waves of immigration and urbanization. Everyone takes medical Spanish."
Hodges, who is also captain of the City College tennis team, speaks of the importance of the community health and social medicine sequence of courses. "They aren't concrete like studying cancer or the cell. They're hard to teach but they're a critical part of what we learn."
The future of Biomed appears comparatively sure since it is now a formal part of the state budget and generally receives good marks in Albany as well as at City Hall. Meiselas is candid in discussing what he calls "the missing link"--the five years of medical school and residency that the students will experience after they leave City College. This period worries him. It is too soon to tell how well Biomed will do in producing doctors for the streets of New York, since its first graduates are only this year finishing their residencies. But all indications are that the majority have chosen primary care specialities and most are doing their training in New York, intending to work in the city's neighborhoods.
"But we're only one of the two shoes," says Dr. Jack Geiger, professor of community medicine. Inner city clinics--frequently sponsored by federal programs-- have traditionally been the most effective practice sites for doctors seeking to serve disadvantaged populations. "The current federal cutbacks offer every disincentive to a motivated physician who wants to deliver on his Biomed commitment."
Will programs like New Mexico's PCC or City College's Biomed catalyze more innovation in medical education? There is a growing interest in these experiments but, as Geiger points out, it is coming as much from political realities as from academic concern. "The stimulus for our program is not coming from medical educators but from a realization of social need. It is our hope that other areas might get already-established universities and medical schools to set up similar programs. It's not so much a question of new resources as it is redirecting the institutions that already exist."