Natural Partners for Educational Reform

Jordan Cohen, M.D.


Association of American Medical Colleges

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By now most medical educators have reconciled themselves to the widespread perception that our country needs more generalist physicians and fewer specialists and subspecialists. Disagreements remain about precisely how much of a shift will be required in the mix of specialty choices made by our students to bridge the gap, but virtually everyone acknowledges the need for some correction in the current pattern.

In some quarters, the required shift in the “products” of medical education has been lamented in the belief-altogether misguided I think-that a more balanced emphasis on educating generalists somehow portends a retreat from our traditional commitment to science-based education. Many who hold this view believe that a career as a generalist physician is less intellectually demanding than a career as a highly focused specialist and hence, conclude that less of a basic science foundation is required. Proponents of this view fear that medical schools that respond to the call for more generalist physicians will perforce reduce the curriculum time and emphasis devoted to the basic sciences and will be loosening their standards as they consign all their students to a less rigorous educational program. This line of thinking has led some basic science chairs and other faculty leaders to resist efforts to commit their schools to the goal of increasing the fraction of their graduates who elect generalist careers, as advocated by the AAMC and numerous other organizations.

Is there any truth to this point of view? Quite obviously, I think not.

First, a commitment by the academic medicine community to produce more generalist physicians does not entail any deviation whatsoever from the longstanding educational goal of the undergraduate years, as reinforced in the GPEP report: to focus on the general professional education of the physician, thereby preparing those awarded the MD degree for any career path they might choose. The task of medical schools has always been to graduate such undifferentiated “proto-generalists,? capable of succeeding in any residency training program because they have had a firm foundation in basic sciences, in basic clinical reasoning, and in basic clinical skills. We have never before questioned the necessity of a science-based education to meet this task and there is certainly no reason to do so now.

Second, as the miracle of molecular medicine continue to revolutionize medical practice at an ever more dizzying pace, the ability of generalist physicians to orchestrate the clinical care of their patients in a cost-effective and intelligent way will almost certainly track with their understanding of the fundamental scientific principles underlying those miracles.

Third, the generalist physicians’ most prized clinical skill is arguably the ability to make decisions under uncertainty. A future characterized by resource constraints, with limited access to consultants and expensive testing, means that generalists must rely even more heavily than now on deductive reasoning rooted firmly in their knowledge of the basic sciences. Thus, far from reducing the academic rigor required of undergraduate medical education, educating the future generalist will place an even higher premium than in the past on a thorough grounding in all of the classic sciences basic to medicine.

Fourth, the new competencies required of the generalist physician in a reformed health care system mean that our students must acquire a foundation in the basic sciences that is not only deeper but broader than that now established in most schools. Among these new competencies are management of large databases, quantitative decision making, leadership of health care teams, evaluation and utilization of clinical outcomes data, effective functioning in large administrative structures, and the ability to take full responsibility for the care of a defined population. Equipping our students optimally to meet these new challenges will require a firm foundation in the basics of information science, the theoretical underpinnings of decision analysis, the fundamentals of group dynamics, the principles and methods of clinical epidemiology, the essentials of organizational behavior and the elements of population-based science.

Seizing on the critical and expanded role for the basic sciences in the education of the generalist physician, basic science faculty can take the lead in redesigning the curriculum for all students to bring about many long-sought reforms. For example, by picking up the generalist gauntlet, those responsible for the early years of the medical school curriculum could engineer a fundamental reorganization of the classic basic science offerings. Now is the time to create visionary interdisciplinary course, to purge the curriculum of unnecessary redundancy, to rivet home the revolutionizing principles of the biomedical sciences, to introduce illustrative and motivational clinical material, and to deride fact grubbing and acclaim problem solving and self-directed learning. Similarly, now would seem to be an ideal moment to convince curriculum committees to assign meaningful curriculum space in the “clinical” years for more targeted and indisputably relevant basic science offerings designed to amplify and particularize the principles laid out in the “basic science” years.

For all of these reasons, I urge our basic science faculties to view not with disdain but with unbridled relish the prevailing accent on educating more generalist physicians~ Abundant opportunities are in the offing to strengthen the basic science curriculum with the conviction that students will grasp not only the inherent beauty of the sciences but also the relevance of “that stuff’ to their future success.

(Reprinted from Academic Medicine, 69: 640, 1994)