• Difficulty in assessing the impact of changes in teaching methods or curriculum (Ludmerer, 1999)

Although much has been written on medical education, future work on the clinical preparation of the workforce should include examining issues related to the education of all health professionals individually and the way they interact with each other. Separation of clinical training programs and dispersed oversight of training programs, especially across the continuum of initial training, graduate training, and continuing development, inhibit the types and magnitude of change in clinical education. For example, various aspects of medical education are affected by the policies of the Liaison Committee on Medical Education, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, 27 residency review committees, the American Board of Medical Specialties and its 24 certifying boards, the Bureau of Health Professions at the Department of Health and Human Services, the American Medical Association, the American Osteopathic Association and its 18 certifying boards, the American Association of Colleges of Osteopathic Medicine, and various professional societies involved in continuing medical education. Similarly, nursing education is influenced by the policies of the American Association of Colleges of Nursing, the National League for Nursing, the American Nurses Credentialing Center, the National Council of State Boards of Nursing, the American Nurses Association, and various specialty nursing societies. Academic health centers and faculty also play a strong role in shaping the education experience of their students. Such diffusion of responsibilities for clinical education makes it difficult to create a vision for health professional education in the 21st century.


If innovative programs are to flourish, they will require regulatory environments that foster innovation in organizational arrangements, staffing and work relationships, and use of technology. The 21st-century health care system described in this report cannot be achieved without substantial change in the current environment of regulation and oversight.

In general, regulation in this country can be characterized as a dense patchwork that is slow to adapt to change. It is dense because there is a forest of laws, regulations, agencies, and accreditation processes through which each care delivery system must navigate at the local, state, and federal levels. It is a patchwork system because the regulatory and accreditation frameworks at the state level are often inconsistent, contradictory, and duplicative, in part because the needs, priorities, and available resources of the states are not equal. And the regulating process is slow in that it is unable to keep pace with changes in health care. The health care delivery system is under great pressure to innovate and change to

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