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Graduate Medical Education Consortia - Continued, 9th Report

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Determining the Content & Assessing the Quality of Medical Education

Undergraduate, graduate and continuing medical education, though in many ways operationally distinct, nonetheless represent a continuum of educational activity. Indeed, "life-long learning" is an attribute that medical educators have long sought to instill at the earliest possible time in their students. Most would agree, too, that medical practice, research and education are inextricably linked, education being the vehicle that translates research into practice both within and across generations. Given this broad context, inherently multilateral organizations such as consortia are ideally situated to bring together the many disparate institutions and groups-medical schools, teaching hospitals, managed care organizations, community training sites, and so on-now required to educate physicians. Continued compartmentalization of the teaching functions of these critical resources can only be counterproductive.

Organizational membership not only presupposes mission but also provides insight into the feasibility of achieving stated goals. A goal to facilitate the transition from medical student to supervised practitioner (resident) makes little sense if medical schools and teaching hospitals are not present. Reshaping residency programs may be an unachievable goal unless hospital executives, deans, clinical service chiefs, and academic department chairs and can all be brought to agreement. A goal to enhance interdisciplinary approaches to health care delivery, makes little sense unless a broad spectrum of health professionals is sitting at the table. Likewise, plans to enhance ambulatory care training in community settings is unlikely to succeed without the active involvement of public health authorities and physicians in practice. Indeed, it is difficult to visualize a quality medical education program in the future that does not involve a variety of different constituencies, that is not collaborative in outlook, and that is not sensitive to the differences between its individual partners.

Medical schools have particular expertise in curriculum development and evaluation, as well as research and scholarly activities. Hospitals and community training sites have particular expertise in the art and practice of medicine, and are required for both undergraduate and graduate medical education. The consortial model would provide for a free interchange of ideas, for resource sharing and for the coordination and strengthening of programs. Already common in university-based or affiliated residency programs, consortia could also extend the incalculable educational and mentoring benefits of different levels of students working closely together to residency programs not presently so endowed. Consortia could also help to translate the full potential of medical student-resident interactions, already so important in the inpatient arena, to the ambulatory care environment as well.

Consortia could also serve as a vehicle to maintain an appropriate balance between education and clinical service--between the resident as "student" and the resident as "employee". This may be particularly important where overlapping, and therefore potentially competitive, health care delivery systems form the operational matrix of a consortium. In such circumstances, the consortium should assume the primary responsibility for delineating just how a common educational mission will interface with the different delivery systems involved.

Given these considerations, it is not surprising that almost all existing consortia include allopathic or osteopathic medical schools. Although some in the medical education community have expressed concern that medical schools (or large academic medical centers) would inevitably dominate consortia, many existing consortia appear to function democratically and in most cases the other partners do not feel dominated by the medical school. Moreover, the majority of the country's allopathic graduate medical education programs already have substantive relationships with the nation's medical schools. In the osteopathic community, similarities have recently been extended and codified by the approval of a new graduate medical education accreditation system that requires all Osteopathic Postdoctoral Training Institutions (essentially consortia of different graduate medical education sites) to contain at least one school of medicine.

Thus, consortia should ensure that the training environment is sufficiently broad to encompass all elements of graduate medical education and, where appropriate, undergraduate medical education as well. Towards this end, the training environment should be carefully evaluated, and enhanced where necessary. Medical professionalism, scientific literacy and a commitment to life long learning are the foundation of medical education, but the curriculum must also provide graduates with the ability to practice effectively in the modern health care environment. Generalism should be fostered, specialist practice and procedural skills enhanced, and the research and educational expertise of the physician workforce assured. The recruitment and promotion of women and minorities should be given attention and the problem of the medically underserved in rural and inner city areas should also be addressed.

A central element of this model is that the consortium, acting collectively, should have overall responsibility for graduate medical education, channeling reform in appropriate directions, even though its individual members will remain the agents of the educational process itself. The model assumes that medical schools will retain primary responsibility for undergraduate medical education, but that consortia, rather than hospitals or any other group, institution or organization involved presently or in the future in training residents, will have primary responsibility for graduate medical education. Such an approach is intended to strengthen and reshape medical education by facilitating interactions between medical schools, hospitals, community teaching sites, managed care organizations, and the like. Mutual interdependence, rather than the dominance of any particular partner, is the goal.

To function in this fashion, consortia must have the authority to reorganize graduate medical education within their local domain. Acting within the guidelines established by the Accreditation Council for Graduate Medical Education and the American Osteopathic Association's Council on Postdoctoral Training (and any other appropriate regulatory agencies), consortia must be able to set standards, to evaluate residency program quality, and to choose to sponsor some residency programs (but not others). Controlling the content of medical education should be the prerogative of the consortium rather than a right of individual partners, and the consortium should assume responsibility for the quality of all graduate medical education programs under its purview.

If consortia, like individual teaching hospitals presently, are to have the authority to reaffirm, and where necessary, remake their product, they must control the "currency" of graduate medical education-residency programs and positions. Present accreditation guidelines dictate that the official sponsoring institution for any residency program has ultimate responsibility for the conduct of that program. If a consortium, rather than any of its individual members, were the official sponsor, the consortium would automatically assume this responsibility. Duly constituted educational consortia are already accepted by both the Accreditation Council for Graduate Medical Education and the American Osteopathic Association's Council on Post- doctoral Training as legitimate graduate medical education sponsors. However, unambiguous policies that would facilitate the transfer of authority from individual institutions and programs to consortia would have to be developed.

Official sponsorship of residency programs by consortia could bring financial benefits as well. Studies of existing consortia have shown that the cost of administering educational programs is lower in consortia that function as the official sponsor of all graduate medical education programs under their purview as opposed to those in which individual members retain control of their own programs. Thus, official sponsorship of residency pro- grams appears to be an important determinant of administrative success. Moreover, an efficient administrative infrastructure will almost certainly also be a critical arbiter of the ability of consortia to advance medical education and reform the physician workforce.

With these considerations in mind, COGME recommends that consortia should:

• Include medical schools and teaching hospitals;

• Include community-based training sites;

• Promote generalism and the competencies required for managed care practice:

• Foster an interdisciplinary approach to health care delivery;

• Have sponsorship authority and responsibility for graduate medical education; and

• Serve as a vehicle for coordinating undergraduate and graduate medical education.