Chat transcript: Educating future doctors

September 7, 1999
Web posted at: 10:19 a.m. EDT (1419 GMT)

(CNN) -- The following is an edited transcript of our September 3, 1999, chat on medical education. Our guests were Dr. Richard Glass, interim co-editor of the Journal of the American Medical Association, and Dr. Harry Jonas, assistant vice president for medical education at the American Medical Association. CNN Interactive provided typists for both guests.

Chat Moderator: Welcome, Dr. Glass!

Dr. Glass: Thank you!

Question from markp: Why is the medical school curriculum changing without the research to support the changes?

Dr. Glass: Much of the change in specific curriculum content is supported by research. The emphasis on various specialties in medical school depends upon changes that are occurring in the practice of those specialties. For example, there tends to be increased amounts of time spent on family medicine. That reflects the increased emphasis on primary care in the United States.

Question from Brian: Do you support an increase in the teaching of nutrition and preventive medicine in U.S. medical schools? Currently only 25 percent of U.S. medical schools offer nutrition as a required course. It seems that number should be much higher.

Dr. Glass: Yes, I do support that. There has been some progress in that regard, but we need to do more. There was a previous question about research supporting the curriculum, and this is one area where that certainly applies. In the past, there was not nearly as much scientific information about nutrition as there is now.

The medical school curriculum does need to increase the amount of time and effort devoted to that topic.

Question from apd: Why isn't there more training on how to deal with things like HMOs in the medical school curriculum?

Dr. Glass: Many schools have started to increase their attention to that topic, and the settings in which students are taught also may be part of managed care. That is a fairly recent development in health care in the United States, so that is an area in which the curriculum is changing.

Question from AAAS: Do you believe that medical schools should emphasize more research training than they currently do?

Dr. Glass: One problem area that has been documented is that physicians are less involved in doing research, possibly because of the increased difficulty in obtaining funding for research.

Certainly, all medical students and physicians need to learn how to evaluate research and to use research findings to improve their practices. This is an area that certainly should be taught in medical school.

Question from McGill: We read the recent story about the fact that not enough medical schools offer education programs in dealing with patients and smoking cessation. As students at McGill, we would like to know how we would develop a program, and how you see this as fitting into the current medical curriculum.

Dr. Glass: I'm glad that the medical students want to pursue this issue, because we know that tobacco use is the largest single cause of preventable death in the developed world.

I hope the students will approach their dean or curriculum committee with their interest and concern; tell them about the article in JAMA to support their concern.

Question from Brian: Regarding nutrition, with increased demands on medical faculty for curriculum time, what medical society is best suited to spearhead an enhanced nutrition and preventive medicine emphasis in U.S. medical schools? Who will drive home a message to U.S. medical schools that preventive medicine is cost effective?

Dr. Glass: In most schools, there is a department of preventive medicine that should be a major supporter of that point of view. Nutrition crosses many areas of medicine, which may partly explain why it has been neglected in the curriculum. I think that is a good question that also indicates a part of what the problem has been.

Question from apd: What reasons can you give for the decrease in applicants to medical school in the past few years?

Dr. Glass: We don't know the answer to that for sure, but there has certainly been a great deal of publicity about the current difficulties and frustrations that physicians are facing in dealing with managed care.

It seems likely that those concerns could partly explain why fewer people may be eager to make the sacrifices in time, energy and money that are necessary to undertake medical school training.

Question from Shaun: How do you think distance learning via the Internet will play a role in adding important training to the medical curriculum?

Dr. Glass: In response to a previous question, I mentioned that learning to evaluate research and evidence is an essential aspect now of medical training and practicing medicine. The Internet opens up many possibilities in being able to access the medical literature; students and physicians can look for evidence to answer important medical questions about diagnosis and treatment.

Question from Allen: What is your opinion on the considerable number of internationally trained physicians in practice here ?

Dr. Glass: There have been several studies of that issue, which is a vexing one, considering that even though the number of applicants to medical school is decreasing, there are a large number of international medical graduates practicing in the United States. Many of them are excellent physicians who provide great care for their patients, but there have been concerns that the number may be too large in relationship to the number of graduates of U.S. medical schools. That issue requires further careful evaluation.

Question from Allen: In terms of research involvement, would you agree that current curricula in medical schools do not offer enough training for most to establish independent research ?

Dr. Glass: There are some programs that enable students to obtain both an M.D. degree and a Ph.D. degree in an area of science. Those are often called "medical scientist" training programs. Outside of those programs, it is true that it may be difficult for students to find adequate time to do research, given the press for time in the curriculum.

Certainly, involvement in an area of research teaches many things beyond the specific topic of the research. I agree that having some time available to learn and do research, or at least participate in an ongoing research program with a faculty member, can be very valuable.

Question from kwando: What steps, if any, are medical schools taking to increase ethnic and cultural diversity as we approach the new millennium?

Dr. Glass: The review paper published in the September 1 issue of JAMA surveyed the studies that have been published about that. It found 17 studies that met certain quality criteria and concluded that only limited information is available on this very important subject. My impression is that many medical schools have become more sensitive to this issue and are including it in their supervision of medical students, but it does appear that more attention needs to be paid to this very important aspect of the patient-physician relationship.

Question from futuredoc: To what extent do you see medical informatics becoming a part of the medical school curriculum in the next 10 years?

Dr. Glass: I think it will be a very important topic in the curriculum, probably crossing over other topic and specialty areas, because learning how to access and analyze information is so important, and often so difficult.

Learning how to do that better in order to provide good care and also to document the care that is provided will become increasingly important.

Question from Brian: If you could change one aspect of the medical education curriculum or process, what would you choose to change, and why?

Dr. Glass: That is a very interesting question, and of course one tends to react to it subjectively. I think emphasizing the ability to integrate scientific data in order to provide technically excellent care on the one hand and having the appropriate personal care and concern for patients on the other hand is what probably needs to be emphasized in all areas of medicine. Sometimes this is modeled and taught well, but sometimes not. I would hope that could achieve increasing emphasis in medical schools.

Question from Shaun: Many schools seem to hold back from fitting another subject into their full curriculum. How can faculty be convinced that something should be taken out of the curriculum to make room for smoking cessation training?

Dr. Glass: Very good question. It is true that people tend to hold on to what they are already doing, which makes change difficult. For this particular topic, the evidence of the importance of smoking cessation for people's health is so strong that it is one area that clearly needs to have appropriate emphasis in the formal curriculum as well as informal supervision and teaching by residents and attending physicians. This is one place where the evidence should help to produce some change, although I recognize that such changes are difficult if people feel like they have to give up something.

Question from Michael : The health care system seems to be changing very quickly in the United States (such as the recent development of HMOs). How are medical schools keeping up with these changes? Could you also address the use of computers by doctors and hospitals?

Dr. Glass: I'll take the second part first. There is increasing use of computers for many aspects of physician activity in hospitals, including ordering and obtaining lab results and ordering medications. Because of that, almost all physicians practicing in hospitals need basic computer literacy now. The rapid changes in medical practice have been difficult for both practicing physicians and medical schools to keep up with, and some of the changes have not been positive.

For example, often the amount of time that can be spent with an individual patient has decreased in managed care programs because of an emphasis on efficiency. To some extent, the doctors' and students' need to become more efficient begins to harm the patient-physician relationship. If it harms the ability to provide good care, then it should be resisted. These changes have been very difficult for practicing doctors, for medical schools and medical students.

Question from MD2B: In a recent court decision from the state of Michigan, the U.S. Medical Licensing Examination was allowed to NOT recognize the existence of learning disabilities/processing deficits in medical students and thus did not have to grant testing accommodations to those students. What is the position of the AMA regarding these students?

Dr. Glass: I'm not familiar with the case, and I really can't speak for the AMA about that.

Question from Maitre: How much of the current difficulties and frustrations that physicians face are the result of the fact that a medical cartel has maintained a very limited pool of physicians for the last 75 years and dramatically escalated their pay compared to anyone with comparable education in the sciences or engineering?

Dr. Glass: I don't agree with the supposition. In fact, some studies thought that there is an oversupply of physicians in the United States.

Chat Moderator: Thank you, Dr. Glass, for joining us. Dr. Jonas will be joining us next.

Dr. Glass: Thank you, and goodbye.

Chat Moderator: Welcome, Dr. Jonas of the AMA!

Dr. Jonas: Hello, everyone. I'm glad to join you. I'm sorry I'm late!

Question from Shaun: For important addictions (like smoking cessation training) that need to be made to an already bulging medical curriculum, do you think that distance learning will be a viable option for training students and physicians adequately to incorporate it into their practices?

Dr. Jonas: I think distance learning will be very much a part of the techniques that we use in medical education in the future. It will be used to teach medical students, residents and doctors in practice.

Question from Greg: The limited number of medical school spots makes application very competitive. Can you tell us if there will be an increase or decrease in the number of available U.S. medical school seats in the next 20 years and what kind of impact this will have on the acceptance rate?

Dr. Jonas: The number of applicants to medical schools runs in cycles. Right now we are in a down cycle. There are almost 5 percent fewer applicants this year; if the applicant pool falls further, some have concern that we won't be selecting the most academically talented students.

There is a debate going on in this country about the number of physicians we need. The nation has more physicians per 100,000 population than any other developed country in the world. I don't see a dramatic change in the number of U.S. medical school positions in the next decade.

Question from Maitre: In other equally important areas such as dentistry and mental health, time pressure on practitioners isn't handled by rationing, but by increasing the number of practitioners. Why doesn't the U.S. medical establishment allow this for physicians?

Dr. Jonas: If you look at the number of physicians in the United States that has occurred over the last 20 years, the number has increased dramatically. We have more physicians per 100,000 population than any other country.

We also allow a large number of foreign medical school graduates to enter our system of medical education. A large percentage of them stay in the United States to practice. We have been running surveys of resident physicians finishing their training about difficulties they have had in finding jobs.

Question from AAAS: What initiatives has the AMA taken in the world of e-publishing? I was thinking in terms of something like "Science's Next Wave," which focuses on the career development of young scientists, e.g. medical students, in an electronic forum (www.nextwave.org). I believe this is a valiant effort that should be replicated or enhanced by the AMA.

Dr. Jonas: We have published that information in the Journal of the American Medical Association. At the present time, the AMA is looking at that the same way the National Institutes of Health is and many other agencies are. There is no doubt that we are going to have more scientific information in the future through the electronic media.

Question from Maitre: In the early 1900s, the AMA and AAMC closed so many medical schools that the ratio of physicians to patients was unchanged from 1910 to 1963, expressly to inflate physician wages. How do you justify the current high wages of physicians in an era of skyrocketing medical costs?

Dr. Jonas: If you look at the number of medical schools we had in this country in the early part of this century, we had hundreds. Most of them were of very poor quality. We referred to many of them as diploma mills, and the Flexner report of 1910 set the groundwork for higher standards in medical education.

Prior to that time, if you were American and wanted a good medical education, you went to Europe. Today, our standards for medical education are the best in the world; many foreign citizens who want medical training now come to the United States.

There is no question of the fact that if we overproduce physicians, we may have a problem. That issue needs to be looked at and monitored carefully.

Question from pham: What about international medical schools wanting to open branches in the United States?

Dr. Jonas: The answer to your question really depends on state law about licensure of educational institutions. If a medical school wishes to establish itself in the United States, and wants accreditation by the LCME, which is the national accrediting body, it is eligible to apply for accreditation if it is licensed or incorporated in the United States.

Graduates of schools that have foreign charters are treated like all other international medical graduates. They must first be certified by the ECFMG, which is the Educational Commission for Foreign Medical Graduates, and then they must pass all three steps of the United States medical licensing examination -- the same examination that is given to graduates of U.S. accredited schools.

Question from MH: Do schools teach practice management skills? I am an M.D. since 1977 and had no such training "back then."

Dr. Jonas: That's a good question. When I was a medical school dean, I was often asked by the graduates, 'Why didn't you teach me more about how to manage a practice?' In response, we instituted a course in practice management for medical students. It was an elective course; few if any medical students came because they were so busy studying the many required courses that are important in the first years of medical school.

We re-evaluated the teaching of practice management skills and placed it later in the resident cycle for residents who very much appreciate that kind of training.

Question from MD2B: As a medical student in the New York metropolitan area, I want to mention that when I applied to medical school several years ago, applications were their highest ever. In retrospect, a decrease in the number of applications was inevitable. I think it profoundly unfair to look at this year's first-year students and think they are intellectually inferior to my class, or any previous class.

Dr. Jonas: The trend for applicants has changed considerably since the year you applied. We continue now to see a decline in applicants, so that we may be headed back toward the situation we were in the early 1980s, when we had the lowest number of applicants in history. There are many complicated reasons why applicant numbers to medical schools change as they do.

I think prospective applicants are concerned today about the very high cost of a medical education, the large debts that many medical school graduates have, and whether or not the present practice environment allows them to have professional autonomy rather than functioning as an employee.

Question from stream: Do you think that education for doctors should be paid for by the government?

Dr. Jonas: Education for doctors is paid for in other countries of the world. It has never been paid for in the United States, although there are many federal loan programs and scholarship programs that help to underwrite the costs.

I think the No. 1 challenge facing medical educators today is to look at how we can reduce the cost of a medical education. The cost has gotten out of hand; the debt burden of many medical school graduates today approaches unconscionable levels. Whether or not we ever get more governmental support for medical education will be determined in the political climate.

Chat Moderator: Thank you, Dr. Jonas, for joining us today.

Dr. Jonas: Thank you for the opportunity to participate. Medical education has been a big part of my life for many years, and I hope to continue to see continued interest in this subject.

My office has much information pertaining to your questions, so please don't hesitate to contact us. You may want to look at the LCME Web site, http://www.lcme.org. Thank you.