Darrell G. Kirch

The importance of anatomy in health professions education and the shortage of qualified educators.

The current shortage of faculty qualified to teach anatomy in U.S. medical schools is reversible. Sufficient numbers of individuals are in the pipeline to provide a future cadre of well-trained faculty members educating students in gross anatomy. The challenge is to realign departmental, institutional, and federal training grant priorities and resources, creating incentives for graduate students, postdoctoral fellows, and faculty members to stay the course and become the teachers needed to educate the next generation of health professionals. These strategies include (but are not limited to) team-teaching gross anatomy, thereby distributing the time commitments of a laboratory-based course more widely within a department; funds made available from the administration of medical schools to allow postdoctoral fellows to participate in teaching and providing compensation for the research activities; using “mission-based budgeting” to specifically compensate for faculty teaching time; and, finally, re-instituting federally funded training grants that solved this same teaching crisis in the not-too-distant past.

The future-oriented department chair.

The authors describe the current dilemma facing academic health centers (AHCs) as they recruit department chairs. In the past, leaders at AHCs predominantly were concerned with fulfilling the esteemed tripartite missions of patient care, research, and education. Today, their time and energy are occupied by a different set of tasks that have a distinct business orientation, including winning contracts, enhancing revenue, reducing costs, recruiting and managing a diverse workforce, and dealing with consumer satisfaction and marketing. New visions and strategies must be developed—requiring different dimensions of leadership. The authors offer concrete recommendations for recruiting, retaining, and sustaining department chairs, and argue that a deliberative, thoughtful process of engaging chair candidates should begin by focusing on the candidates’ values as a first priority. Candidates who most clearly share organizational values should then be engaged in an iterative process of developing a shared vision, resulting in a letter of agreement that explicitly states the mutual expectations and commitments of both the organization and the candidate. Once department chairs are in place, ongoing development through leadership training, mentoring, and other investments help to retain and sustain them.

Reinventing the Academic Health Center

Academic health centers have faced well-documented internal and external challenges over the last decade, putting pressure on organizational leaders to develop new strategies to improve performance while simultaneously addressing employee morale, patient satisfaction, educational outcomes, and research growth. In the aftermath of a failed merger, new leaders of The Pennsylvania State University College of Medicine and Milton S. Hershey Medical Center encountered a climate of readiness for a transformational change. In a case study of this process, nine critical success factors are described that contributed to significant performance improvement: performing a campus-wide cultural assessment and acting decisively on the results; making values explicit and active in everyday decisions; aligning corporate structure and governance to unify the academic enterprise and health system; aligning the next tier of administrative structure and function; fostering collaboration and accountability—the creation of unified campus teams; articulating a succinct, highly focused, and compelling vision and strategic plan; using the tools of mission-based management to realign resources; focusing leadership recruitment on organizational fit; and “growing your own” through broad-based leadership development. Outcomes assessment data for academic, research, and clinical performance showed significant gains between 2000 and 2004. Organizational transformation as a result of the nine factors is possible in other institutional settings and can facilitate a focus on crucial quality initiatives.

Confronting the Complexity of the Physician Workforce Equation

THE UNITED STATES IS A NATION IN WHICH 47 MILlion citizens have no health insurance, more than 16% of the country’s gross domestic product is spent on rapidly increasing health costs, and stark disparities exist in health care access, exemplified by 20% of the population currently residing in federally designated health professional shortage areas. These formidable challenges have led to renewed interest in reforming the health care system while engendering intense debate among policy makers and politicians. One area of increasing focus has been the current and future size of the US physician workforce. If the health care system’s purpose is to provide quality care and appropriate access to care, a critical factor is to have an adequate supply of well-educated providers. Although physicians are not the only professionals providing health services, they are a key component of the overall health care workforce. Therefore, determining the number of physicians necessary to meet current and future US needs has become a critical question. The debate regarding this question, however, is at risk of becoming overly simplistic and polarized.

Changing The Culture In Medical Education To Teach Patient Safety

In 1999 a seminal Institute of Medicine report estimated that preventable medical errors accounted for 44,000-98,000 patient deaths annually in U.S. hospitals. In response to this problem, the nations medical schools, teaching hospitals, and health systems recognized that achieving greater patient safety requires more than a brief course in an already crowded medical school curriculum. It requires a fundamental culture change across all phases of medical education. This includes graduate medical education, which is already teaching the next generation of physicians to approach patient safety in a new way. In this paper the authors explore five factors critical to transforming the culture for patient safety and reflect on one real-world example at the University of North Carolina School of Medicine.

Selecting tomorrow's physicians: the key to the future health care workforce.

Recent U.S. health care reform efforts have focused on three main goals: improving health care for individuals, improving population health, and lowering costs. Physicians, who traditionally have practiced with considerable autonomy, will be required to become members of the team-based patient care models necessary to achieve these goals. In this perspective, the authors assert that medical school admissions, the selection of the future physician workforce, is a key component of health care reform. They review the historical context for medical school admission processes, which have placed a premium on grades and standardized test scores, and examine how admission practices are undergoing fundamental changes in order to select physicians with both the academic and interpersonal and intrapersonal competencies necessary to operate in the health care system of the future. The authors describe how new techniques, such as holistic review and multiple mini-interviews, are contributing to the shift toward competency-based medical education. Innovations underway at the Association of American Medical Colleges to transform medical school admissions also are explored. The authors conclude by arguing that although the admission process has great potential to transform the future health care workforce, major overhauls of the health care payment and delivery systems must be achieved alongside innovations in health professions education to truly transform the U.S. health care system.

Transforming Admissions: The Gateway to Medicine

IN THIS ISSUE OF JAMA, A STUDY BY EVA AND COLleagues describes the multiple mini-interview (MMI) process pioneered at McMaster University and its association with students’ national licensing examination scores. The MMI is based on sequential structured interviews, with a series of tasks analogous to the objective structured clinical examination. The authors found that students who were accepted by McMaster based on their MMI results and other application data scored higher on Canadian licensing examinations than students who were not accepted by McMaster but attended other medical schools. The MMI appears to be an effective technique for probing dimensions ranging from applicants’ responses to novel situations to their reactions to an ethical conflict. The adoption of the MMI by more schools also may increase the diversity of medical student personal attributes, which may lead to increased opportunity for student professional growth, increased specialty distribution, and improved patient care. The MMI is one important, relatively new tool that medical schools have developed as part of an admissions process known as holistic review, a “flexible, highly individualized process by which balanced consideration is given to the multiple ways in which applicants may prepare for and succeed as medical students and doctors.” The goal of holistic review is 3-fold: to assess applicants’ academic readiness; to gauge their intrapersonal and interpersonal competencies, such as integrity and compassion; and to promote diversity in the student body. Ultimately, the hope is that medical schools’ use of holistic review and a competency-based admissions process will better enable identification of students who have the greatest potential to be the physicians of the future. Traditional admissions processes have placed considerable weight on measures of academic readiness, such as Medical College Admission Test (MCAT) examination scores and grade point averages, when deciding which applicants to interview. Although MCAT scores are a reliable predictor of academic success in the first 2 years of medical school, they are not strongly correlated with later outcomes in medical school or practice. Nevertheless, MCAT scores appeal to admissions committees because they allow for easy comparison of applicants from different undergraduate schools. Although academic credentials have an important place in medical school admissions, there is increasing recognition that overreliance on measures of academic readiness may eliminate some applicants who could become excellent future physicians. As a result, medical schools are moving toward a broader view of medical school readiness that emphasizes the competencies applicants have demonstrated in addition to their academic credentials. This change is essential to identify future physicians with the skills and knowledge to manage illness in the 21st century. For example, in the last 40 years, the largest contributors to increased life expectancy in the United States are reduced tobacco consumption and increased levels of exercise, both of which are behaviors linked to disease prevention. To prevent and treat disease in the future, physicians must have cognitive and behavioral competencies. The new MCAT examination, beginning in 2015, will shift toward a broader definition of academic readiness. The new MCAT will achieve this by including a new section on behavioral and social science content and by revising the current verbal section to test the way examinees reason through text excerpted from books, journals, and magazines across a variety of disciplines, including ethics and philosophy, cross-cultural studies, population health, and other subjects. Although robust measures of academic readiness will remain important, admissions interviews continue to offer a key opportunity for schools to gauge the second dimension of holistic review: interpersonal and intrapersonal competencies, ie, the personal characteristics required of physicians to practice patient-centered care. In assessing competencies, such as oral communication or resilience and adaptability, a variety of approaches are emerging, including assessment centers to evaluate medical school candidates’ personal and interpersonal attributes, situationbased judgment tests, and hybrids of these interview approaches. The movement toward competency-based ad-

Qualities of the medical school dean: insights from the literature.

Purpose To review the literature and resources for professional development of medical school executives in order to identify the characteristics proposed as relevant to medical school deanship. Method In 2006, the authors conducted a PubMed search using the key words leadership, dean, medical school, and academic medical center to identify relevant publications since 1995. Articles were excluded that that did not address the roles and responsibilities of the North American medical school dean. Articles gleaned through review of materials from relevant executive development programs and interviews with leaders involved in these programs were added. Results Both management skills (e.g., institutional assessment, strategic planning, financial stewardship, recruitment and retention of talent) and leadership skills (e.g., visioning, maximizing values, building constituency) are commonly cited as important deans of contemporary medical schools. Key content knowledge (e.g., academic medical center governance, expectations of clinicians and scientists, process of medical education) and certain attitudes (e.g., commitment to the success of others, appreciation of institutional culture) are also noted to be valuable qualities for medical school deans. Conclusions The literature review identifies a number of areas of knowledge and skill consistently affirmed by scholars as important to success for medical school deans. These characteristics can provide a basic foundation for needs assessment and professional development activities of academic medical executives preparing for and entering medical school deanships, and they can also provide insight to those charged with selecting their next dean.

Interprofessionalism: Educating to meet patient needs.

Interprofessional teams in health care are showing promise in achieving the triple aim—providing better care for the individual patient, reducing costs, and improving population health. To complement current changes in health care delivery in the United States, there is a growing consensus among health professions educators that students should be trained in interprofessional models prior to entering clinical practice. Current interprofessional education (IPE) efforts in anatomy education are producing positive results in enhancing professional respect, collaboration, and teamwork among health professions students. In spite of existing structural and cultural barriers to IPE, health professions educators must continue to lead and grow IPE efforts as a critical component to improving the health of our nation. Anat Sci Educ 8: 296–298.

The challenge of promoting professionalism through medical ethics and humanities education.

Given recent emphasis on professionalism training in medical schools by accrediting organizations, medical ethics and humanities educators need to develop a comprehensive understanding of this emphasis. To achieve this, the Project to Rebalance and Integrate Medical Education (PRIME) II Workshop (May 2011) enlisted representatives of the three major accreditation organizations to join with a national expert panel of medical educators in ethics, history, literature, and the visual arts. PRIME II faculty engaged in a dialogue on the future of professionalism in medical education. The authors present three overarching themes that resulted from the PRIME II discussions: transformation, question everything, and unity of vision and purpose.The first theme highlights that education toward professionalism requires transformational change, whereby medical ethics and humanities educators would make explicit the centrality of professionalism to the formation of physicians. The second theme emphasizes that the flourishing of professionalism must be based on first addressing the dysfunctional aspects of the current system of health care delivery and financing that undermine the goals of medical education. The third theme focuses on how ethics and humanities educators must have unity of vision and purpose in order to collaborate and identify how their disciplines advance professionalism. These themes should help shape discussions of the future of medical ethics and humanities teaching.The authors argue that improvement of the ethics and humanities-based knowledge, skills, and conduct that fosters professionalism should enhance patient care and be evaluated for its distinctive contributions to educational processes aimed at producing this outcome.