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chapter 3
THE ACADEMIC HEALTH CENTER
AS REFORMER:
A
THE EDUCATION ROLE
The forces described in Chapter 2 demand a change in the approaches
and attributes of clinical education in the 21st century. Demographic
changes, technological and scientific advances, and continued cost pres-
sures necessitate a reexamination of how health professionals are prepared
for practice. The committee finds the following:
· AHCs have played a major role in the education of health profes-
sionals, successfully teaching the latest procedures and interventions for
relieving the symptoms and suffering of sick patients. They have empha-
sized in particular the education of physicians at the undergraduate and
graduate levels, relying on the hospital's inpatient and outpatient settings as
primary training sites.
· The AHC role in education for the 21st century will require more
than the direct training of health professionals. AHCs will be expected to
demonstrate leadership in the design and development of educational ap-
proaches for health professionals throughout the continuum of education.
Doing so will require much more than curricular reform, requiring consid-
eration of how the clinical settings in which students are trained reinforces
the attributes desired of health professionals in the 21st century.
· All teaching environments will need to provide a sound base of
knowledge that includes not only the emerging sciences, such as genomics,
but also the social, behavioral, and other sciences that are important to
45
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46 ACADEMIC HEALTH CENTERS
improving health. Providing a broad-based scientific and humanistic foun-
dation will require that all teaching environments reexamine the content,
methods, and approaches used at all levels of clinical education, including
undergraduate, graduate, and continuing education.
· As part of their education role, AHCs need to work with educators
and other resources within their parent universities to develop the evidence
base for clinical education so that the approaches used will be based on
sound educational principles that improve understanding of the quality of
clinical education.
As university-affiliated, academic organizations, AHCs need to take a
leadership role in meeting these challenges. The first section of this chapter
examines the need for new approaches to clinical education to provide the
new skills required for the health care workforce of the future. This is
followed by a discussion of the factors that affect the ability of AHCs to
reform clinical education. The final section describes some implications for
the future.
NEED FOR NEW APPROACHES TO PROVIDE NEW SKILLS
As noted above, the trends and developments described in Chapter 2
will create a different set of expectations for practice and require different
types of skills from health professionals. Shifting patient needs, the evolving
science of medicine, and changes in the organization and financing of care
will all affect how health professionals should be prepared for practice.
Health professionals trained today can be expected to reach their peak of
practice around 2040, a health environment that is sure to be very different
from that of today.
There is no question that additional skills will be required. For ex-
ample, the greater understanding of the mechanisms of disease that will be
possible with genetic and other scientific advances will improve diagnosis
and treatment, but also make them more complex. Analysis of disease at
the molecular level will move diagnosis to that level as well (Pollard, 2002).
Clinicians will require skills in differentiating genetic, other, and combined
sources of illness. This requirement will alter the skills needed for diagnosis;
moreover, treatments will have to be individualized to accommodate ex-
pected responses to treatment given a patient's genetic profile. These skills
will not be demanded only of specialists; genetics will also redefine how
primary care and preventive medicine are practiced. Changes in the organi-
zation and financing of care will require that health professionals demon-
strate safe, efficient, and effective practice styles. Changing patient needs
will necessitate increased emphasis on skills required to manage chronic
conditions, including, for example, understanding the course of illness and
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AHC AS A REFORMER: THE EDUCATION ROLE 47
the patient's experience outside the hospital, with a focus on prevention,
behavioral change, and maximizing of functioning.
The education of health professionals for future practice involves more
than identifying needed skills, however. In health care, students learn
through a combination of classroom experience and supervised clinical
practice. In fact, the bulk of health professions training is in the latter
venue. Although the situation is changing, the first 2 years of medical
school are focused most heavily on learning the basic sciences in a class-
room setting. The last 2 years consist of clinical rotations, followed by at
least 3 years of residency, also in a clinical setting. Therefore, the clinical
experience represents about 70 percent of medical training. In nursing, it is
estimated that about 50 percent of training for baccalaureate-prepared
registered nurses is in clinical settings, and the proportion increases with
advanced training (Helen Bednash, personal communication, Jan. 10,
2003). The clinical learning environment, sometimes referred to as the
informal curriculum, communicates values, culture, personal development,
priorities, and the language of the field to students (Accreditation Council
for Graduate Medical Education, 2002). It influences their relationships
with each other and with patients.
To prepare health professionals for practice in the coming decades,
therefore, the clinical experience must be addressed. It is not enough to say
what should be taught to students; it is also necessary to consider the
context in which it is taught and the approaches used, and how knowledge,
skills, and attitudes are both acquired and taught. A focus on skills consid-
ers the competencies required of students at the conclusion of a training
program, while a focus on the clinical experience considers the "competen-
cies" or capabilities of the training program itself, focusing on what is
conveyed, and how, during the clinical experience.
As noted in Chapter 2, the changing environment of health care will
have at least three consequences that can be expected to affect the educa-
tion of health professionals. First, patients will exert more influence over
their care decisions, both because they will bear the costs of care and
because they will be faced with making more choices as technology expands
treatment options. Second, there will be increased calls to measure and
manage care as costs increase in the face of concerns about quality and
access and as information technology makes it more feasible to do so.
Third, improving health will require a broader view in which the discover-
ies of science and the new biology combine with those of the social and
behavioral sciences to affect the determinants of health and illness.
Given these trends and directions, the committee identifies three ap-
proaches that will need to be considered by all training programs in the
coming decades: interdisciplinary approaches that ensure a broader view of
health, tools and methods for managing information, and training in
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48 ACADEMIC HEALTH CENTERS
nonhospital settings. Each is briefly discussed below. It should be noted
that although some progress is being made toward implementing these
approaches, current educational programs are focused at the departmental
and discipline-specific levels; as a result, varied levels of commitment and
resources are devoted to such approaches, even within a single AHC. Sig-
nificant advances in health professions education will require a clear com-
mitment and adequate resources across the entire AHC.
Interdisciplinary Approaches and a Broader View of Health
Interdisciplinary education occurs when "faculty learn, work and teach
together" (Gelmon, 1996, p. 218) to prepare students to work as a team
driven by the health needs of patients and the goal of providing the services
necessary to improve health to the extent possible (Bulger, 2000; Gelmon,
1996). Interdisciplinary education involves more than simply defining the
roles of various clinicians (Osterweis, 2001). Health professionals that are
well prepared for practice in the 21st century will collaborate across depart-
ments and disciplines, and even settings of care, to meet patients' needs.
The term "interdisciplinary" as used here refers to the involvement of
different disciplines, such as medicine, nursing, and pharmacy; the term is
not used to denote different specialties within a single discipline, such as
internal medicine, cardiology, and endocrinology. The notion of interdisci-
plinary education will assume increasing significance in the future. For
example, the needs of people with chronic conditions (who, as noted in
Chapter 2, represent a growing proportion of the population) cannot be
met by any single health professional. Similarly, applying the latest bio-
medical advances will increasingly require the expertise of specialized health
professionals, such as genetic counselors. Additionally, if patients are ex-
pected to be more accountable for maintaining their health and to assume
responsibility for self-care in managing chronic conditions, they also need
to be recognized as a key member of the health care team. Yet team interac-
tions in practice often fall short of expectations, in part as a result of
current approaches in clinical education that emphasize hierarchy, indi-
vidual decision making, and the organization of work around professional
roles rather than patient needs (Institute of Medicine, 2001b). Indeed, the
implementation of more interdisciplinary educational approaches will
require a level of cooperation that has rarely been demonstrated. As one
observer notes, interdisciplinary training is a "goal often espoused but
rarely pursued" (LeRoy, 1994, p.337).
As suggested above, clinical education in the 21st century will also need
to take a broader view of medicine and health, with greater emphasis on
understanding the social, behavioral, cultural, and environmental factors
that influence health and disease in addition to understanding the biological
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AHC AS A REFORMER: THE EDUCATION ROLE 49
basis of disease (LeRoy, 1994; Josiah Macy, Jr. Foundation, 1999; Young
and Coffman, 1998). Developing this understanding will in turn require
that biomedical science be better integrated with a patient- and population-
based approach that addresses the determinants of disease and health, and
places greater emphasis on prevention (LeRoy, 1994) and the identification
of risk factors and how to mitigate them.
The focus on the biomedical basis of disease that characterizes the
current model for clinical education assumes that ill health is fully ex-
plained by disease, so that the core of medical science is the diagnosis and
treatment of disease (Cassell, 1999). American medicine, however, is being
asked to move beyond this model to address issues related to population
health, resource allocation, new means for caring for chronic disease, and
the management of health information, all areas in which physicians have
traditionally not been trained (Schneider and Eisenberg, 1998). Medical
schools in particular are believed to produce physicians well equipped to
deal with specific organ systems or pathologies, but ill equipped to deal
with the behavioral causes of chronic diseases or the social context of illness
(Cantor et al., 1993). According to one survey of young physicians, fewer
than half reported receiving excellent or good preparation in coordinating
patient care with community services, providing cost-effective care, or man-
aging the needs of the frail elderly (Cantor et al., 1993). Nursing tends to be
more oriented toward health promotion and disease prevention. Advanced-
practice nurses in particular are focused on establishing knowledge partner-
ships with their patients, educating them about their conditions, and engag-
ing them in illness prevention and health promotion (Mundinger, 2002).
There are a number of barriers to conducting interdisciplinary educa-
tion, including turf battles, academic credit, recognition of faculty, and
scheduling (Gelmon, 1996; Osterweis, 2001). Each college, even each de-
partment, guards its own curriculum, and bringing different students to-
gether can be viewed as virtually impossible (Kaufman, 1999). The differ-
ing academic schedules of schools can also create a significant obstacle
(Osterweis, 2001). Although 60 AHCs have identified an individual with
responsibility for interdisciplinary education, only about a dozen have es-
tablished significant activities in this area; most of the latter are public and
community-based, have multiple health professional schools, and fall under
the broad jurisdiction of an AHC leader (Osterweis, 2001).
Another potential barrier is that faculty may have neither the skills nor
the incentives to pursue interdisciplinary approaches to education. Faculty
who themselves have not been trained through interdisciplinary approaches
may find it difficult to teach that way and be unable to undertake the
educational innovations required to implement such approaches. More-
over, interdisciplinary education is not as strongly rewarded as the efforts
of independent scientists working in their laboratories. A concern is that
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50 ACADEMIC HEALTH CENTERS
students are not being taught explicitly to work in interdisciplinary teams,
but implicitly through the work environment (Conway-Welch, 2002;
Larson, 2001), which often has not fostered the types of positive, construc-
tive interactions desired across the disciplines. Strengthening efforts to im-
prove the health of patients and populations will necessitate the develop-
ment of new educational models.
Conducting rounds with students in multiple disciplines is one ap-
proach used for encouraging interdisciplinary interactions, but this ap-
proach becomes more difficult to implement as hospital stays shorten. It
may be relatively easy to design interdisciplinary education for the class-
room, but doing so becomes more difficult in a clinical setting, especially as
training diversifies into nonhospital clinical sites. Interdisciplinary ap-
proaches also become more difficult to implement when attempted across
settings of care. For example, there may be opportunities to foster interdis-
ciplinary training between doctors and nurses in a hospital, but it is less
clear how to bring public health into the training model. Some have recom-
mended that public health training be incorporated into medical and nurs-
ing schools and that schools of medicine and nursing partner with schools
of public health to develop interdisciplinary and joint programs (Institute of
Medicine, 2003c). Examples of improved public health training for medical
students can be found at Duke University, the University of California at
San Francisco, and the University of Southern California (Institute of Medi-
cine, 2003c).
Information Management
Health professionals will need to be prepared to manage information
so they can deal with a constantly growing evidence base, serve as an
information resource, support decision making by patients, and measure
care so they can manage it effectively.
Technological and biomedical advances are expanding the evidence
base for health and medical care exponentially. The number of clinical
trials published in the literature grew from approximately 1,000 in 1966 to
more than 10,000 in 1996, with half that growth experienced in more
recent years (Chassin, 1998). This growth in information, which will only
intensify in the future, will challenge traditional approaches to educating
health professionals. Some have even suggested that the traditional empha-
sis on a core of knowledge is questionable in light of the expansiveness and
dynamic nature of the science base (Weed and Weed, 1999). Rather than
the traditional approach based on teaching facts, students should be pre-
pared for the types of problem solving they will face in practice (Weed,
1981).
Health professionals will have to know how to obtain and manage new
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AHC AS A REFORMER: THE EDUCATION ROLE 51
knowledge as it continually emerges. The concept of evidence-based prac-
tice is that a clinical problem is defined, and published evidence is obtained,
appraised, synthesized, and applied to the problem (Welch and Lurie, 2000).
However, there are virtually an unlimited number of clinical strategies, and
resources for evaluation are limited. Educators need to teach the evidence
where it is certain, and students need to learn to how to obtain and apply
evidence as it develops, as well as how to make clinical decisions when the
evidence is absent or weak (Welch and Lurie, 2000).
The increasing complexity of disease and expanding treatment options
will require that health professionals be able to serve as an information
resource for their patients. Health professionals will need to bridge the gap
between the evidence base and patient knowledge, evaluating the evidence
and turning it into information that can be explained to patients so their
preferences can be expressed. They will need to synthesize, explain, and
interpret information to support patient decisions and self-management. In
some cases, the health professional's primary role may be serving as an
information consultant and resource to guide and support decision making
by more informed patients, rather than performing a clinical intervention.
There is some evidence that patients whose informational needs are not
adequately met are likely to make more visits and use more resources in
their care (Mundinger, 2002). Indeed, some have suggested that this infor-
mation role is one of the most important therapies provided to patients,
with health professionals serving as coach and adviser to support patients'
increased direction over their care (Schneider, 2002). This role should be
incorporated into the education of all health professionals, but also rein-
forced through interdisciplinary training that recognizes the varying contri-
butions different team members can make to a patient's care.
The increasing costs of care and concerns about the quality of care will
result in growing demands to measure and manage care. The management
of information must include a focus on measuring care so it can be continu-
ously improved. Research, patient care, and therefore health professions
education will become increasingly reliant on evaluative disciplines, such as
clinical epidemiology, informatics, health services research, outcomes analy-
sis, and value management (Detmer, 1997; Wennberg, 2002).
Managing information to the extent that will also be required in the
future cannot be done without more-advanced information systems to ac-
quire and manage the level of information that will be needed for practice.
Part of delivering state-of-the-art care in the future will be the use of clinical
and other information systems. Students will need to be prepared to use
information technology as a more central component of health care. Clini-
cal education programs that fail to incorporate state-of-the-art information
systems into their training will be unable to prepare students for practice
today, let alone tomorrow.
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52 ACADEMIC HEALTH CENTERS
Nonhospital Training Experiences
To prepare health professionals to deliver care in the 21st century,
education should correspond to care delivery. The majority of care is deliv-
ered to patients in noninpatient and nonhospital settings. Nearly a billion
ambulatory visits were made in 1999, compared with 32 million hospital-
izations (Eberhardt, 2001). Ambulatory care as discussed here refers not
only to hospital outpatient departments, but also to offices, community
health centers, managed care organizations, public health departments,
long-term care facilities, and even patients' homes. Any location where care
is delivered should be considered a potential training site.
The predominant model of education today, especially for physicians,
consists of training in the inpatient setting, delivering tertiary care. The
advantage of hospital-based training is that students can learn from the
most challenging and difficult cases. Hospitals that see a larger volume of
similar patients (e.g., cardiology or cancer patients) are also more likely to
demonstrate higher-quality care in that field, which is desirable to teach
(Institute of Medicine, 2001b). In addition, seeing patients who are admit-
ted for ambulatory-sensitive conditions or for certain chronic conditions
should give students an opportunity to learn what factors contributed to
the condition so they can not only treat the symptoms but also consider
how patients might be able to avoid such hospitalizations in the future. It is
easier to conduct education in the inpatient setting because the acute prob-
lems seen are more readily specified, and therefore, the educational content
is easier to define (Showstack, 1999). Finally, inpatient settings offer a
cluster of faculty, other students, and an infrastructure to oversee the edu-
cational process.
The inpatient model for clinical education will be increasingly ineffec-
tive in the coming decades, however. The rate of hospital admissions has
been declining; lengths of stay are becoming shorter; many diagnostic prob-
lems are being handled outside the hospital; patients in hospitals have the
most complex conditions and therefore present a relatively narrow spec-
trum of diseases; and the sicker patients admitted require increasingly tech-
nical care (Kassirer, 1996; Goroll et al., 2001). These trends give the learner
less time to establish a relationship with the patient and to understand the
multiple medical, social, psychological, and other factors that affect not
only the course of disease, but also the individual's health and well-being. A
short hospital stay provides a poor learning opportunity to understand the
influence of behavioral and social factors on health or to foster shared
decision making (Ewan, 1985). Furthermore, most patients admitted elec-
tively to the hospital have been worked up prior to admission, so they
arrive not only with a chief complaint, but also with the results of diagnos-
tic and laboratory tests, and sometimes, a diagnosis. The intellectual chal-
lenge to the learner is incomplete, and the learning opportunity is affected.
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AHC AS A REFORMER: THE EDUCATION ROLE 53
Training in the inpatient setting, therefore, does not sufficiently prepare
health professionals for practice or provide adequate exposure to alterna-
tive settings of care. A survey of young physicians revealed that more than
half believed there was too little training in physician offices, organized care
settings (e.g., health maintenance organizations), or long-term care facilities
(Cantor et al., 1993). People with chronic illness that is managed effectively
may often avoid hospitalization for the condition altogether. Even more
care can be expected to move out of the inpatient setting as biomedical
advances affect when an illness is identified and how it is treated. Finally, in
the marketplace, there is a trend toward the provision of nonspecialized
care in community hospitals and other settings; specialty care is becoming
more concentrated in AHCs (The Commonwealth Fund Task Force on
Academic Health Centers, 2000). As AHCs become relatively more focused
on specialty care and caring for patients with specialized needs, they be-
come less able to prepare health professionals for everyday practice. It has
been estimated that, on average each month, less than 1 person in 1,000 is
admitted to an AHC (Green et al., 2001).
There has been some progress in increasing the amount of training
provided in ambulatory settings; however, the majority of ambulatory train-
ing remains within hospitals, and only a small proportion takes place in
nonhospital settings. Primary care physicians can be expected to practice
predominantly in nonhospital settings, and they undergo about two-thirds
of their training in ambulatory settings; however, only about one-quarter of
their training is provided in community settings and about one-tenth is in
managed care settings (Brotherton et al., 2000). Among nonprimary care
residents, just over one-third of training is in ambulatory settings, but only
about 6 percent is in community settings and about 6 percent in managed
care settings (Brotherton et al., 2000). Furthermore, the proportion of train-
ing time in nonhospital ambulatory settings (community and managed care
settings) showed a decline between 1997 and 1999--a trend in the wrong
direction.
Among undergraduate medical education programs, teaching in outpa-
tient settings in required clinical clerkships occupied one-third or more of
the time in primary care program areas compared with one-quarter or less
in nonprimary care program areas (Barzansky and Etzel, 2001). On the
other hand, between 1984 and 1994, the percentage of all medical students
who participated in one or more clerkships increased from just under half
to almost three-quarters, and the average number of weeks in ambulatory
settings increased as well (The Commonwealth Fund Task Force on Aca-
demic Health Centers, 2002).
Baccalaureate nursing programs are also offering more opportunities
for clinical training in noninstitutional community settings, including visit-
ing nurse agencies, home care, schools, and hospices (National Advisory
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54 ACADEMIC HEALTH CENTERS
Council on Nurse Education and Practice, 1996). To a lesser extent, train-
ing is also provided in such settings as nursing centers, senior citizen cen-
ters, and homeless shelters.
Shifting training to ambulatory settings involves more than simply
moving or adding training slots. Ambulatory settings will not provide a
good learning environment without additional preparation. As a learning
environment, they can be unpredictable in terms of the types of patients
seen, limited in terms of continuity of care, and variable across sites (Irby,
1995). Short patient visits can make it difficult to provide the observation
and feedback needed for teaching (Bowen and Irby, 2002). There is also
concern that students in ambulatory settings may lose the conferences,
faculty, and general educational surroundings offered by the institutional
environment (Kassirer, 1996). Indeed, students rate the quality of their
instruction in ambulatory settings lower than that in inpatient settings (The
Commonwealth Fund Task Force on Academic Health Centers, 2002).
FACTORS THAT AFFECT THE ABILITY OF AHCS
TO REFORM EDUCATION
The preceding discussion is not intended to imply that clinical curricula
have been static over time. Indeed, there are many examples of efforts
aimed at accomplishing the very types of changes outlined above (Associa-
tion of American Medical Colleges and the Milbank Memorial Fund, 2000;
The Commonwealth Fund Task Force on Academic Health Centers, 2002).
The Association of Academic Medical Centers recently launched the Insti-
tute for Improvement in Medical Education to examine ways to improve
medical education curricula, reform the clinical education of medical stu-
dents and residents, enhance public health education in medical schools,
promote professionalism during medical education, engage in international
medical education activities, and better meet the need for continued profes-
sional development of physicians once they enter practice (Association of
American Medical Colleges, 2003a). And more than half of medical schools
(58 percent) reported having a major curriculum review or change under
way in 2001 (Barzansky and Etzel, 2001).
Many examples of changes in health professions education can be found
at individual AHCs. In one example described at the committee's January
2002 workshop, Hundert (2002) described reforms in the medical educa-
tion curriculum at the University of Rochester1 through which the clinical
and basic sciences are interwoven throughout the 4-year curriculum. He
highlighted a course called Mastering Medical Information that is taught in
1Dr. Hundert has since joined Case Western Reserve University.
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AHC AS A REFORMER: THE EDUCATION ROLE 55
the first 4 weeks and last 2 weeks of the first year, in which students learn
how to access and navigate through information, gaining skills in data
analysis, biostatistics, and epidemiology. Another unique element of the
curriculum is a 1-month clerkship in the fourth year called Community
Health Improvement. Several years ago, the University of Rochester added
a fourth mission to its portfolio--to make Rochester, New York, "the
healthiest city in America." The content of the clerkship is determined by
the health department's assessment of local health needs, and varies from
providing the pneumococcal vaccine in nursing homes to working with
teenagers to get them to quit smoking. The academic content of the clerk-
ship is focused on public health and epidemiology.
The Undergraduate Medical Education for the 21st Century (UME-
21) program was a 5-year national demonstration project funded in Octo-
ber 1997 by the Health Resources and Services Administration and admin-
istered by the American Association of Colleges of Osteopathic Medicine
(2003). Eighteen schools were funded to initiate curricular innovations in
undergraduate medical education aimed at supporting graduates in prac-
ticing high-quality, population-based, cost-effective medicine while main-
taining a commitment to care of the individual.2 The areas addressed in the
reforms included health systems finance and organization; the practice of
evidenced based medicine, with emphasis on population health; health
care ethics; patientprovider relationships and communication skills; lead-
ership and interdisciplinary teamwork; quality measurement and improve-
ment; systems-based care; medical informatics; and wellness and disease
prevention.
At the graduate level, the Accreditation Council for Graduate Medical
Education (ACGME) has led a major undertaking to move its accreditation
processes toward assessment of competencies or outcomes of the education
process (Batalden et al., 2002). Six areas of competency are identified:
patient care, medical knowledge, practice-based learning and improvement,
professionalism, interpersonal skills and communication, and systems-based
practice. These six areas will be used to guide residency program directors
in curricular development and residency program requirements as defined
by the residency review committees. The American Board of Medical Spe-
2The medical schools involved are Dartmouth, University of California at San Francisco,
University of Miami, University of Nebraska, University of Pennsylvania, University of Pitts-
burgh, University of Wisconsin, Wayne State University, Case Western Reserve, Eastern Vir-
ginia University, Jefferson Medical College of Thomas Jefferson University, Medical College
of Pennsylvania-Hahnemann, University of Connecticut, University of Kentucky, University
of Massachusetts, University of Minnesota, University of New Mexico, and University of
North Carolina at Chapel Hill.
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56 ACADEMIC HEALTH CENTERS
cialties (ABMS), the organization for certifying boards of practicing physi-
cians, has accepted these same competencies, thus offering the potential for
coordination and reinforcement of skills at the levels of graduate and con-
tinuing education.
Nursing educators also have recognized the need for reform in nursing
education. The National Advisory Council on Nurse Education and Prac-
tice (1996) has recognized the changing nature and responsibilities of regis-
tered nurses. Registered nurses will be asked to manage care along a con-
tinuum, work in interdisciplinary teams, integrate clinical knowledge with
knowledge of community resources, adapt to changing technologies, dem-
onstrate an ability to communicate, and analyze data. Also recognized is
the need to prepare the registered nurse workforce more adequately in the
use of nursing informatics to support clinical decision making, consumer
education, and interactions with other providers (National Advisory Coun-
cil on Nurse Education and Practice, 1997).
Specific programs to support change have also been undertaken. For
example, the American Association of Colleges of Nursing (2002a) has
undertaken a major initiative to support gerontology curriculum develop-
ment, with support from The John A. Hartford Foundation of New York.
Objectives include redesign of existing gerontology curriculum, faculty de-
velopment, design of innovative clinical experiences, and development of
new leaders in geriatric practice. The grant will assist nursing schools in
adapting their gerontology curriculum and clinical experiences at both the
graduate and undergraduate levels. The expectation is that newly identified
competencies will be incorporated into advanced-practice nursing programs
and will lead to the development of models of excellence for adoption by
the broader nursing education community.
The progress made to date reflects the determination of those directing
educational programs, who face a number of obstacles in trying to move
clinical education forward. Even when AHCs agree with the goals de-
scribed in this report, a number of factors affect their ability to implement
educational reform. The first of these relates to the accreditation and over-
sight of education programs. Program requirements should support move-
ment toward the attributes desired for clinical education in the 21st cen-
tury. The second factor relates to faculty development and organization. If
students are to have different educational experiences, faculty must be
prepared to impart those experiences. The third factor relates to the weak
evidence base for clinical education, which makes it difficult to know which
changes will have a positive effect on student preparation for practice. The
fourth factor relates to financing. Methods of financing for all AHC roles
are discussed in Chapter 6, but here we consider the effect of financing on
the design of educational programs.
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AHC AS A REFORMER: THE EDUCATION ROLE 57
Oversight of Education Programs
It is estimated that more than 50 groups are involved in the over-
sight of undergraduate and graduate training programs in the health profes-
sions (Gelmon et al., 1999). Some of these groups are identified in Box 3-1.
The list intentionally includes the accrediting group for programs in health
administration. Although the focus of this chapter is on clinical education,
the challenges described also face administrators in terms of both their own
education and their support for reform efforts in clinical education. Fur-
thermore, clinicians ought to have knowledge of administrative issues, so it
is important to consider programs in health administration when looking at
coordination across disciplines.
Continuing education requirements are overseen by yet other groups.
Accreditation of continuing medical education programs is offered by the
Accreditation Council for Continuing Medical Education. The American
Osteopathic Association has a separate council for continuing education.
The American Nurses Credentialing Center of the American Nurses Asso-
ciation administers the association's credentialing programs, providing both
accreditation of continuing education programs and certification for spe-
cialty nursing practice. Unlike undergraduate and graduate training, which
have clearly defined requirements, requirements for continuing education
vary within disciplines. Some physician specialty boards require continuing
medical education hours to maintain specialty certification, whereas other
have no such requirement (Federation of State Medical Boards, 2002).
The proliferation of oversight groups has serious implications for re-
forming the education of health professionals. There has been a tendency
toward expansion in recent years as more specialties have been recognized,
a phenomenon that tends to increase subspecialties (as they seek recogni-
tion) and extends the length and cost of training (LeRoy, 1994). However,
the approaches proposed in this report are not discipline specific, but apply
to everyone. As a result, it may be necessary to ask 50-plus groups to amend
their standards. For example, achieving a goal such as interdisciplinary
education would require not only that each group make changes, but also
that the groups work together in making those changes. That is likely to be
a time-consuming process, and it is not clear that there is a mechanism for
the purpose.
Coordination across the continuum of education is also poor. Coordi-
nation of oversight of education has been called fragmented and duplica-
tive (Gelmon, 1996). Responsibilities for undergraduate, graduate, and
continuing education reside for the most part in separate organizations
(Enarson and Burg, 1992). As a result, accreditation divorces residency
training programs from professional schools (Hanft, 1988). Feedback loops
between the levels of education could improve all. For example, if one of
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BOX 3-1
A Sample of Accrediting Organizations for
Health Professions Education
Oversight of health professions training occurs through a combination of public
and private regulatory activities. A variety of private agencies accredit the educa-
tion programs for undergraduate, graduate, and continuing education. Accredited
programs are eligible to receive public funds to support their activities. Individuals
who complete such programs are then eligible to receive a license to practice from
a state, or after graduate training and thereafter, to sit for certification or recertifica-
tion. These processes are interrelated educationally in that education programs
are expected to prepare health professionals to pass licensure exams, and licen-
sure exams are intended to reflect expectations for practice as defined in the
scope-of-practice laws (Safriet, 1994). In general, the purposes of these functions
are to ensure minimum levels of quality and to protect consumers through assur-
ance of compliance with established standards of quality. It is also hoped that
these processes offer the programs and individuals being evaluated an opportuni-
ty for self-evaluation and improvement (Gelmon et al., 1999).
The U.S. Department of Education "recognizes" private organizations that car-
ry out education accreditation. In the case of nurse education, the U.S. Depart-
ment of Education may recognize a state agency to accredit programs. On behalf
of the U.S. Department of Education, accreditation agencies may also be recog-
nized by the Council on Higher Education Accreditation (see www.ed.gov/offices/
OPE/accreditation). Accreditation is applied to entire institutions and/or individual
programs, departments, or schools of a larger institution.
Undergraduate allopathic medical education: Accreditation of allopathic medical
schools is overseen by the Liaison Committee on Medical Education (LCME). The
majority of its membership is from the American Medical Association and Associ-
ation of American Medical Colleges, but students and the public are represented
as well. Substantive changes in LCME's standards must be approved by the Coun-
cil of Medical Education of the American Medical Association and the Executive
Council of the Association of American Medical Colleges (see www.lcme.org).
Graduate allopathic medical education: Accreditation of graduate medical educa-
tion is overseen by the Accreditation Council for Graduate Medical Education
(ACGME) for allopathic education, an umbrella organization with membership from
five organizations: the American Board of Medical Specialties, the American Hos-
pital Association, the American Medical Association, the Association of American
Medical Colleges, and the Council of Medical Specialty Societies. ACGME accred-
its residency programs through its residency review committees. There is a resi-
dency review committee for each specialty board that sets the standards and
guidelines by which a residency program will receive accreditation (see
www.acgme.org).
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Osteopathic undergraduate and graduate medical education: The American Os-
teopathic Association (AOA) is the accrediting agency for osteopathic medicine.
The AOA Bureau of Professional Coordination coordinates accreditation across
the continuum of education through several councils. The Council on Predoctoral
Education focuses on undergraduate medical education. The Council on Postdoc-
toral Training focuses on internships, residencies, preceptorships, and other post-
graduate medical education programs. The Council on Continuing Medical Educa-
tion approves programs and credits for continuing medical education. The Council
on International Osteopathic Medical Education and Affairs address international
training concerns. Osteopathic graduate training is organized around community-
based training consortia, known as Osteopathic Postdoctoral Training Institutions.
These consortia consist of at least one medical school accredited by AOA and
several hospitals that are accredited by AOA's Bureau of Health Facilities' Accred-
itation (see www.aacom.org)
Nursing education: Accreditation of nursing programs is provided by two groups.
One is the National League for Nursing Accrediting Commission (NLNAC), an in-
dependent entity within the National League for Nursing. NLNAC accredits all types
of nursing programs, from the diploma through the doctoral level (National League
for Nursing Accreditation Commission, 2001). The other is the Commission on
Collegiate Nursing Education (CCNE), established by the American Association of
Colleges of Nursing. CCNE focuses only on nursing programs in universities and
4-year colleges (American Association of Colleges of Nursing, 2002c), providing
accreditation services for programs at the baccalaureate and graduate degree lev-
els. Accreditation for programs for nurse practitioners is also becoming standard-
ized, although four different groups will have unique certifying exams (Phillips et
al., 2002).
Public health education: Schools of public health, community health education pro-
grams, and community health/preventive medicine programs are accredited by the
Council on Education for Public Health (Council on Education for Public Health,
2002). The Council is a private, nonprofit organization with two members: the
American Public Health Association and the Association of Schools of Public
Health. The primary professional degree is the Master of Public Health (MPH), but
other master's and doctoral degrees are offered as well.
Health Administration: The Accrediting Commission on Education for Health Ser-
vices Administration (ACEHSA) is the organization authorized by the U.S. Depart-
ment of Education to accredit master's level health administration programs in the
United States and Canada. Graduate programs in health care administration are
housed in various schools and departments on university campuses. These pro-
grams are found in schools of business, medicine, public health, public administra-
tion, and allied health sciences, as well as schools of graduate studies. The de-
grees awarded by these programs include MA, MBA, MHA, MHSA, MPH, MS, and
others (Accrediting Commission on Education for Health Services Administration,
2001).
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60 ACADEMIC HEALTH CENTERS
the purposes of continuing education is to supplement areas in which
undergraduate or graduate training has been deficient (Waxman and
Kimball, 1999), such information should be provided systematically to
those education programs so the deficiencies can be addressed. The current
fragmentation inhibits these interactions. A recent Institute of Medicine
report (2003a) calls on all education oversight organizations (accrediting,
licensing, and certifying bodies) to work together to revise their standards.
Faculty Development and Organization
The school and its faculty are the strongest influences on the design of
curriculum and students' educational experiences. Accrediting groups de-
fine standards for the structure, performance, and/or functions of the
schools, but do not prescribe specific courses or educational experiences.
The latter is the responsibility of each school as it designs its own curricu-
lum within the guidelines of the pertinent oversight bodies. Even with a
bounty of standards, it is known that schools vary in terms of emphasis,
resources, costs, size, centralized or decentralized curriculum, frequency of
curricular change, and other factors.
Faculty are being asked to assume new duties in areas in which they
may not be adequately prepared to teach the next generation. Faculty teach-
ing today may themselves not have been trained in nonhospital settings,
computer-based systems, or interdisciplinary approaches to care (Wilkerson
and Irby, 1998). They may not have learned how to develop curricula,
evaluate students, or manage educational programs (Gelmon, 1996). Most
medical teaching occurs through one-on-one encounters between physician
and patient, reflecting the comfort level and expertise of many faculty
(Kaufman, 1999). As a result, faculty may be unsure about their own skills
for implementing aspects of a new curriculum (Sachdeva, 2000). Being a
knowledgeable clinician (or basic scientist) does not necessarily translate to
being an effective teacher.
There are also concerns about the availability of faculty in terms of
both supply and time. As noted earlier, teaching faculty are under pressure
to see patients and conduct research, leaving little time for teaching (The
Commonwealth Fund Task Force on Academic Health Centers, 2002;
Ludmerer, 1999). Although this concern is often voiced about medical
faculty, it has been suggested that as nursing practice plans develop, a
similar pattern will ensue. Nursing faculty will also face constraints on time
for teaching as the pressure to see patients and raise revenue increases
(Conway-Welch, 2002). Furthermore, particularly in nursing, there are con-
cerns about the adequacy of the supply of faculty (American Association of
Colleges of Nursing, 2002b; Association of Academic Health Centers,
2002).
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AHC AS A REFORMER: THE EDUCATION ROLE 61
The pressures on faculty preparation and time are likely to intensify as
training is expanded to encompass a range of sites. More faculty with more-
varied backgrounds could enhance the educational experience for students
but could also result in even greater variability in student training. Faculty
development will be needed to ensure that the faculty available at all train-
ing sites are prepared to teach students effectively (Weed, 1981; Griner and
Danoff, 2000). Some have suggested using a smaller, full-time faculty
(Hanft, 1988), perhaps moving with the students rather than the clinicians
in each site taking on faculty duties.
In medical schools, the decentralized structure of faculty with powerful
department chairs is viewed as a force that can inhibit educational innova-
tion (Cantor et al., 1991; Regan-Smith, 1998; Petersdorf and Turner, 1995).
Faculty identify predominantly with their own department and focus on
training in their own discipline, hindering a broad, integrated view of clini-
cal education. The strong departmental structure can also make it difficult
to incorporate broad-based education courses that are not departmentally
defined; for example, population health or "evaluative" sciences, such as
biostatistics or epidemiology. Some schools have moved toward a more
centralized curriculum to overcome the problems of a departmentally orga-
nized model, and although improvements are seen in terms of curricular
reform, they also tend to raise costs because of the increased time needed
for faculty coordination (Reynolds et al., 1995).
Weak Evidence Base
The evidence base for clinical education is not as strong as it should be
to support the reforms described in this chapter. Better information is
needed on the effectiveness of various teaching approaches for clinicians,
on how principles of adult education can be applied appropriately to clini-
cal education, on what types of teaching technologies are most effective and
under what circumstances, on the characteristics associated with high-qual-
ity clinical education, and on the cost of training various health profession-
als. Good quality measures in clinical education do not currently exist
(Blumenthal and Bass, 2001).
The Cochrane Collaboration has been working for many years to de-
velop the evidence base for clinical care, but there is no comparable re-
source for the evidence base in clinical education. When the Cochrane
Collaboration attempted to conduct a systematic review of educational
interventions for teaching evidence-based medicine, only one article was
found that met their criteria for inclusion (Hatala and Guyatt, 2002).
Two relatively new groups are making such an effort at developing an
evidence base. The Campbell Collaboration (formally established in 2000)
prepares and maintains systematic reviews of the effects of social and
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62 ACADEMIC HEALTH CENTERS
education policies and practices (see www.campbellcollaboration.org). For
example, a systematic review is being prepared for problem-based learning
for health professionals (Davies and Boruch, 2001). The second group,
Best Evidence Medical Education, is a collaboration of individuals and
organizations committed to the dissemination of information to people
involved in medical education; the production of systematic reviews of
medical education; and the creation of a culture of best-evidence medical
education among teachers, institutions, and national bodies (see www.
bemecollaboration.org). The group has been meeting since 1999. Both
groups are international, with a strong European representation.
There is also a lack of information on the actual cost of education
programs and its relationship to the quality of education (Henderson, 2000).
Spending patterns for public funds are known, but how much training costs
is not understood. Medicare payment per resident is known to vary, but it
is believed to reflect historical accounting practices rather than true differ-
ences in the cost or quality of programs (Young and Coffman, 1998). Many
schools have not budgeted systematically for clinical education (The Com-
monwealth Fund Task Force on Academic Health Centers, 2002). Because
current information is so poor, it is difficult to estimate the costs for educa-
tional reform or identify areas in which savings might occur (The Common-
wealth Fund Task Force on Academic Health Centers, 2002). For example,
costs might be incurred to implement computer-based instruction, but could
reduce faculty time in some areas.
Financing
As discussed in more detail in Chapter 6, current financing methods for
clinical education are not viewed as being supportive of the types of changes
advocated in this report (LeRoy, 1994). The current methods have encour-
aged increases in the number, size, and duration of residency programs
(Henderson, 1999, 2000) and programs for the training of specialists in
tertiary settings (Young and Coffman, 1998). These methods have also
hindered training in nonhospital settings (Henderson, 2000). Moreover,
funding is not linked to any workforce goals, whether they be the types of
changes described here or other goals related to the supply and mix of the
output of the programs.
Interdisciplinary training is also discouraged by variation in how the
education of different professions is supported. When Medicare began,
educational costs for nursing and allied health professionals were allowable
expenses for hospitals. Since 1965, however, many hospital-based training
programs have been eliminated. For example, in 1965, 80 percent of train-
ing programs for registered nurses were in hospital-operated programs;
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AHC AS A REFORMER: THE EDUCATION ROLE 63
today the figure is only 7 percent (Medicare Payment Advisory Commis-
sion, 2001). Medicare currently supports diploma nursing programs, pro-
grams for nurse anesthetists, and training for allied health professionals
that are hospital-based programs. About one-half of hospitals with resi-
dency training programs also receive money for nursing and allied health
training (Medicare Payment Advisory Commission, 2001). However, AHCs
offer few hospital-based training programs, so the training support pro-
vided for medicine and that for nursing and allied health are going to
different organizations, discouraging an interdisciplinary perspective. An-
other difference is that services provided jointly by a medical resident and
supervising physician may be reimbursed, whereas the same is not true for
other students. Therefore, nonmedical students do not offer the same ad-
vantages in cost recovery to the hospital sponsoring a training program; the
result, again, is an emphasis on medicine.
IMPLICATIONS FOR THE FUTURE
There have been many calls for reform of clinical education, especially
medical education. A recent Institute of Medicine report (2003a) urges an
overhaul in health professions education. Likewise, in their survey of medi-
cal school deans, Cantor, et al. (1991) found that 68 percent believed
fundamental change was needed in medical education. This was true for
their own institutions, as well as for medical education overall. Petersdorf
and Turner (1995, p. 541) report that the education given to students is
"dated and arcane" and not in tune with societal needs. In interpreting their
survey of young physicians, Cantor et al. (1993, p. 1035) find that "while
medical training has remained largely unchanged, the demands placed on
practicing physicians have changed dramatically." At a workshop spon-
sored by the committee during the course of this study, Hundert (2002)
described the current process of medical education as one that can "take
altruistic other-oriented people and turn them into bitter cynics, in four
short years."
The current curriculum is perceived as overcrowded and relying too
much on memorization of facts, and the changes implemented have not
altered the underlying experience of educators and students (Regan-Smith,
1998). Current processes of education are too static and passive and do not
focus sufficiently on teaching students how to solve real, everyday problems
and measure the effectiveness of interventions through such sciences as
epidemiology, informatics, health services research, and outcomes analysis
(Detmer 1997). The fundamental approach to clinical education has not
changed since 1910, or as some have observed, there has been "reform
without change" (Christakis, 1995, p. 710). Others have gone so far as to
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64 ACADEMIC HEALTH CENTERS
suggest that the current model of education is so mismatched with today's
complex health care environment that a "drastic overhaul" is needed
(Chassin, 1998, p. 579).
AHCs will need to provide leadership in effecting the broad educa-
tional reforms required to prepare health professionals to meet the needs of
the 21st century health system. Most educational reform to date has taken
the approach of overlaying courses on the existing curriculum and struc-
ture. The result has been the overcrowded curriculum noted earlier, wide
variation across programs, and poor progress in some areas. What is needed
is more comprehensive and fundamental reform of the educational experi-
ence that spans the continuum of education and recognizes the shifting
roles and responsibilities among health professionals, along with the inter-
actions of those shifts.
In taking up this challenge, AHCs will need to work more closely with
their parent universities, using the academic and interdisciplinary resources
available. Schools of education should be consulted in the development of
educational methodology. Coordination of basic science and social science
courses in the university should be explored in an effort to streamline the
education process and foster interactions among faculty at different schools.
Interdisciplinary approaches should work in both directions. University
students in engineering or computational biology should have the opportu-
nity to conduct work at the AHC; exposure to such work could interest
them in applying their much-needed skills to health care. Similarly, students
at the AHC should be encouraged to explore the resources available
throughout the university, such as at a business or law school.
Public policy also needs to support changes in education that respond
to changes in health care. Policy makers need to consider how financing
methods can support both short- and long-term changes in clinical educa-
tion. Innovative approaches are especially needed in implementing methods
to support interdisciplinary education, and to provide training in informa-
tion management, as well as in developing nonhospital training sites.
Representative terms from entire chapter:
clinical education
