Faculty Development and Diversity

Two days after many candidates running on belt-tightening platforms won election seems like an awkward time to endorse a plan to increase government spending. Still, a call to arms by T. Samuel Shomaker, Dean of Medicine at Texas A & M, warrants consideration.

Dr. Shomaker likens the state of medical education to Europe after World War II. The Marshall Plan cost the United States $13 billion in the short-term but earned it lasting, prosperous allies. Something similar could be done with medical students. He proposes that the federal government pay the first two years of medical school tuition in exchange for a postgraduate year providing primary care in an underserved area.

Upon completion of the year, doctors could earn forgiveness for their remaining medical school debt by staying on in the position or matching with a primary care residency. They may choose a specialty residency, but then the last two years of medical school tuition loans will be theirs to pay back.

Former Labor Secretary Robert Reich has made a similar proposal for undergraduate education. Making tuition free may sound radical, but it promises to lower barriers to entry for many students while also producing more of the educated citizens we need.

This week in Washington, DC the Association of American Medical Colleges and the American Medical Association are hosting a conference on the state of medical education. Coming 100 years after the publication of the Flexner Report, the conference also coincides with several proposals to reform how medical faculty teach.

Several panelists have critiqued the standard model of medical education, which relies on prolonged exposure to a predetermined content. They favor quality over quantity and more flexible models of learning. Speakers have also suggested placing more emphasis on outcomes. This would require more rigorous assessment of teaching and careful attention to what kinds of jobs graduates take.

So far the talk about reform has stayed mostly at the level of talk. The focus on flexibility and quality is not controversial, but implementing them may be. As long as faculty get rewarded for teaching the way they always have, little change will reach medical students.

McGill University in Montreal will no longer require Canadian applicants to its medical school to take the MCAT. The admissions committee hopes the move will increase the number of Francophone students in its program. Applicants from outside Canada will still be required to submit MCAT scores.

Although McGill has no objection to standardized testing (and indeed tried to arrange for a translated test), the move fits into a trend of test-optional undergraduate institutions. Bates College eliminated the SAT for applicants 25 years ago and has seen no drop in student quality. By some measures, applicants are more qualified.

With the push for learner-centered medical education and the empathetic physicians, it seems contradictory that medical schools would still rely heavily on a multiple-choice test for admissions decisions.

Ever since the Internet became the predominant source of information for students, new concerns about plagiarism have arisen. Certainly academic dishonesty existed before, but now a sneaky student does not even have to take the time to copy purloined passages by hand. It's just a cut and a paste away.

The New York Times reported on this trend recently. Now the Annals of Internal Medicine have published a study called "Plagiarism in Residency Application Essays." The authors analyzed application essays for the five largest residency programs at Brigham and Women's Hospital using the Turnitin application. They found that 5% of the essays registered as plagiarized.

In general, international students and students with lesser qualifications were more likely to plagiarize, but the study found instances of top students plagiarizing, too. I tend to think that part of the blame lies with the assignment. A personal narrative is such a vague prompt. Applicants don't intend to be dishonest, but they have little guidance for what kind of essay is appropriate. In this case, it seems safe to borrow from a supposedly trusted source. This is not to excuse their actions, but it does suggest that the application process could be tailored to elicit more original responses.

Abraham Flexner was not a physician, but his report, Medical education in the United States and Canada: a report to the Carnegie Foundation for the Advancement of Teaching changed the way medical students learned. It professionalized training and standardized teaching practices.

One hundred years later, the Carnegie Foundation has released another report. Educating Physicians: A Call for Reform of Medical School and Residency calls anew for a close look at medical training. Since Flexner's original recommendations, the field of health care has changed dramatically, though the way new M.D.s are taught has not.

The authors found several weaknesses in the current system:

• Inflexible, excessively long training
• Overly focused on inpatient clinical experience
• Poor connections between formal knowledge and experiential learning
• Inadequate opportunities to work with patients over time

At Boston University, a group of medical educators has formed a journal club to respond to the critiques in the new report. The state of graduate medical education has improved since 1910, but the centennial provides a symbolic opportunity to update the curriculum.