Leadership education for medical students - educating medical students in medical care administration

Medical practice and education have gone through abrupt, and at times traumatic, changes in the past 25 years. These changes in practice have even come to involve academic medicine in such areas as: capitation contracts, HMO-sponsored graduate and potentially undergraduate medical education, hospital acquisition of medical practices to assure a primary care base, insurance and hospital alliances, and entrepreneurial schemes for research and medical services marketing. Through all of this, the education of medical students and residents has remained relatively unchanged.

In 1992, the Association of American Medical Colleges (AAMC) proposed changes in undergraduate and graduate medical education to encourage an increase in the number of generalist physicians.[1] The recommendations included turning back the tide of subspecialist education to increase the number of generalists to approximately 50 percent of private practicing physicians from the current level of approximately 30 percent.

As a policy statement, the AAMC advocated that a majority of graduating students be committed to generalist careers of family practice, general internal medicine, or general pediatrics. These recommendations were made to the medical schools and residency programs throughout the U.S. in response to the perceived need of society for well-trained generalists to care for patients and to coordinate their care in a complex medical world.

In June 1994, the AAMC defined the "Roles for Medical Education in Health Care Reform, by requesting again that generalist medical education be encouraged through generalist faculty development, teaching in ambulatory care sites, and teaching cost-effective diagnosis and treatment. Managed care organizations were suggested as a means of teaching health promotion and disease prevention.[2]

The assurance of generalist competence through residency training and continuing medical education was also encouraged. These recommendations were made, in part, because large numbers of graduating medical students had perceived that their educational experience was deficient in some of these basic areas. Surveys of medical school and residency graduates showed areas of concern which, when combined with reported frustrations of private practitioners, could serve to direct further change in how we educate practitioners.

Medical school graduates polled

In the 1993 and 1994 AAMC Medical School Graduation Questionnaire, which probed into multiple areas of the medical education process, more than 12,000 responses of graduating medical students revealed two surveyed areas that are of interest and concern.[3,4] The first involves medical school experience and curriculum. The graduating students were asked to evaluate their experience in the 41 areas of instruction received during medical school. They rated their exposure as either excessive, appropriate, or inadequate. Table I shows the results of the 1993 and 1994 graduating classes' assessment of where their instruction had been inadequate. Of the 11 areas where at least 50 percent felt that they had received inadequate training, six of these either involved the practice of medicine or were directly related to the health care reform process. Practice management was the topic area where most students felt inadequately trained.

TABLE 1 MEDICAL SCHOOL EXPERIENCE

                                      Percent of students rating
                                      experience as inadequate

    Area of Learning                       1993       1994

1) Practice management                     76.3       77.5
2) Utilization review and quality
   assurance                               73.3       73.1
3) Cost effective medical practice         68.0       62.1
4) Medical care cost control               68.0       61.9
5) Medical social economics                64.2       61.0
6) Nutrition                               63.2       62.6
7) Family/domestic violence                59.9       56.3
8) Legal medicine                          59.0       56.9
9) Rehabilitation                          57.3       58.0
10) Research techniques                    54.5       53.6
11) Literature analysis skills             54.2       52.7

- Association of American Medical Colleges

Medical science, disease recognition, and patient care are all covered well in medical school. However, postponing practice management, socioeconomics, legal medicine, or leadership training will not prepare students to become effective leaders in the changing health care landscape. Too much is to be gained - or too much could be lost - not to address the needs of future practitioners so that they may become able leaders in the business side of medicine, as well as in patient care.

Recommendations

National Medical Societies

1. Support should be given to developing generalist physician training as proposed by the Association of American Medical Colleges. This will help relieve the pressure on medically underserved areas in the U.S., encourage cost-effective medical care, and enhance the promotion of health and disease prevention. Additionally, this will help to maintain the physician autonomy in the medical community, as these services can best be provided by well-trained generalist physicians. 2. Training should be fostered in practice management, legal medicine, methods of assessing quality assurance, and the physician's role in directing utilization review with the patients, welfare in mind. The focus should be on the standards of medical practice and training physicians who will be guided by those standards. Even in a managed care environment, the patients, needs and physician professional autonomy can, and should, be maintained. 3. Faculty development in medical business should be encouraged so that appropriate and effective teaching, research, and leadership can come from the medical school and residency program faculties.

Medical schools

1. Teaching medical business practices should be established within the medical school either within the existing departments or through the establishment of a new department, to train the students and perhaps t he faculty. Alternatively, an alliance with the school of business for such professional teaching could be arranged. 2. First and second year medical students should be required to explore such topics as the future of medicine, managed care, malpractice, management, marketing, and personal finance. An elective in the first and second years in practice management could also be a valuable experience. 3. Third and fourth year students should address such topics as utilization review, quality assurance, medical records, professional compensation, negotiation, burnout, and stress reduction. Administrative medicine, as an elective rotation either at the medical school or in the hospital setting, could serve as a springboard for future professional activities. 4. Graduate medical management training opportunities should be introduced, such as the MBA or MPH programs. The American College of Physician Executives has more than 11,000 members and approximately 10 percent hold a master's degree in either business administration or public health. ACPE, along with its members, could be a resource to the medical school for mentors and also as a teaching resource.

Residency

1. Requirements for medical management training during residency should be established in all programs. Perhaps the Family Practice Residency requirement for practice management could be used as a model for other programs. 2. Faculty n embers should be provided with opportunities for professional development in the business of medicine so that they may become better teachers and researchers in this field. 3. Topics that would be appropriately considered during a residency would include cost-effective health care, patient satisfaction, personnel management, medical staff relations, finance of a medical practice, and continuing medical educational excellence following completion of residency training. 4. The residency program should become a resource to previous graduates, and also to members of the community at large, in practice management by such activities as sponsoring continuing medical education courses or inviting specialized faculty into the residency program for training and educational programs.

Conclusion

There are already many opportunities available for practicing physicians to develop expertise in the business of medicine. These educational programs should perhaps be expanded to include opportunities for interested practitioners to receive training of a practical nature in centers where medical administration is currently at an excellent level. We should also encourage those with an aptitude and an interest in medical leadership to pursue training and employment where they may be able to have an impact on the how medicine is practiced both locally and nationally.

These recommendations will require a major shift in what is considered to be appropriate for the education of medical students and, in some cases, residency physicians. It will take a great deal of effort on the part of administration and faculty to find time and willing teachers to be able to accomplish this task. It will require the medical profession to be more cohesive, as many of these topics involve multiple professional disciplines. This may require an individual from one discipline to have an important function within the boundary of another faculty of the medical school or university at large.

Academic medicine should rise to the challenge of providing training in these areas considered "deficient," so that others outside of our medical discipline do not become, by default, our medical managers. These areas of "less value" in medical education should now find utility in preparing individuals for a more rewarding practice of medicine and hopefully should help our profession retain more control over its future.

References

[1.] AAMC policy on the generalist physician. Acad Med 1993;68:1-6. [2.] Roles for medical education in health care reform. Acad Med 1994;69:512-515. [3.] 1993 Medical School Graduation Questionnaire. Association of American Medical Colleges. [4.] 1994 Medical School Graduation Questionnaire. Association of American Medical Colleges. [5.] Shea, J.A., Frenkel, E.P., and Webster, G.G. Training and practice activities of hematology and medical oncology diplomates. Arch Intern Med 1990;150:145-148. [6.] Cantor, J.C., Baker, L.C., and Hughes, R.G. Preparedness for Practice. Young physicians, view of their professional education. JAMA 1993;270:1035-1040. [7.] Royo, M.L. Saultz, J.W., Wartman, S.A. and Dewitt, T.G. Defining the generalist physician's training. JAMA 1994;271:1449-1504. [8.] Linney, B.J. Changes in the Practice of Medicine. Physician Executive 1993;19:59-63. [9.] O'Connor, S.J., and Lanning, J.A. The End of Autonomy? Reflections on the Post Professional Physicians. Health Care Manage Rev 1992;17:63-72. [10.] Cox, K. What Doctors Need to Know. A Note on Professional Performance. Med J August, 1992;157:764-768.

COPYRIGHT 1996 American College of Physician Executives
COPYRIGHT 2004 Gale Group