AMA and medical education: 100 years of progress

A message to all physicians from the chair of the AMA Board of Trustees, J. James Rohack, MD.

By J. James Rohack, MDis senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05. Posted Aug. 2, 2004.

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Before the creation of the American Medical Association in 1847, physicians in North America were more like tradesmen than professionals, splitting their time between mixing and selling medicines and cutting hair.

The AMA was formed in great part to counter this lack of professionalism, and one of the AMA's earliest missions was to establish and uphold the highest standards of medical education and training -- a tradition that continues today.

At the time of the American Revolution, however, only about 10% of the doctors in the original 13 colonies had any formal medical education. Even physicians who did have so-called training didn't necessarily have much to offer their patients.

In those days, and even later, getting into medical school was easy -- and so was getting out. Typically, medical schools required applicants to have a high school diploma and to pay a fee. But for some schools, the fee was the only requirement. Standards for graduation were also slack. In many schools, students did not get grades and took few examinations. The standard course of study lasted 16 to 20 weeks and consisted primarily of lectures, with little interaction between the student and patients.

The AMA's founder, Dr. Nathan Davis, understood that the bedrock of any profession is education. Thus, the first committee ever created by the American Medical Association was a Committee on Medical Education. But the AMA had not yet established formal working relations with the growing number of state and county medical societies. Thus, the standards suggested by the AMA committee remained largely theoretical, since physicians were licensed under state, not federal, law.

This situation persisted until 100 years ago, when the AMA created the Council on Medical Education with the full support of the newly formed Federation of Medicine.

The council began working in earnest right away. In 1905, it published the first edition of "Education Standards for Medical Schools." These standards included a premedical school education requirement, a five-year training period for medical students (including a one-year internship) and interaction with patients at the bedside.

The next year, the AMA Council on Medical Education, under its first chair, Dr. Arthur Bevan, inspected all 160 medical schools in the United States. Only half of all these schools met the council's standards. Clearly, further steps were needed -- and they were taken.

With the encouragement of the AMA council, the Carnegie Foundation provided funds to one of its staff researchers, Abraham Flexner, so he could inspect America's medical schools firsthand. Accompanied by AMA Council Secretary Dr. Nathan Coldwell, Flexner traveled the nation and eventually produced his seminal report, "Medical Education in the United States and Canada," in 1910.

The Flexner Report, as it is commonly known, reinforced what the council had found in 1905. Flexner wrote, "... these establishments -- for the most part, they can be called schools or institutions only by courtesy -- were frequently set up regardless of opportunity or need. Wherever and whenever the roster of untitled practitioners rose above a half dozen, a medical school was likely at any moment to be precipitated."

Flexner's report triggered massive reform in the American medical education system. But the work of the AMA Council on Medical Education was far from over, and it continued its standard-setting and inspections. In 1912, it conducted the first survey of hospitals for the training of interns. In 1919, it established and published the "Essentials for Approved Internships." In 1927, it began approving residency programs. In 1934, it began approving examining boards for the certification of specialists.

Today, the Council on Medical Education continues to accredit programs leading to the medical degree in the United States and Canada. It does so through the Liaison Committee on Medical Education, which was created in 1942 along with the Assn. of American Medical Colleges. Today, the AMA fully funds half of the LCME accreditation activities, with no charge to medical schools. Thus the perception that the AMA does not support academic medicine is not true.

The AMA Council on Medical Education has continued its involvement in standard setting, working to ensure that physicians uphold the highest educational standards throughout their professional lives. In 1981, it helped to create the Accreditation Council on Graduate Medical Education and the Accreditation Council on Continuing Medical Education, and it continues to be involved in both groups today. In fact, the coin of the realm for continuing professional development is the AMA Physician Recognition Award. This award system was created in 1968, and the council continues to oversee it.

The AMA Council on Medical Education also continues to be a catalyst for change in the standards of our medical profession. These standards define who we are as physicians and protect our patients from those who would provide medical care without appropriate education or training.

What's more, thanks to the work of the AMA and the council, physicians -- not bureaucrats or legislators -- establish standards for our profession. We earn the right to practice medicine by adhering to these standards, which include a rigorous formal education and ongoing training.

It is regrettable that all physicians do not understand the valuable role the AMA plays in professional standard-setting, and how the AMA's work enables us to call ourselves physicians, and to do so with pride -- and without undue governmental interference.

Perhaps the next time you see a colleague who is not an AMA member and asks why doctors should join, you might remind them that without the high medical education standards established and upheld by our AMA, we would still be part-time barbers.

J. James Rohack, MD is senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05.

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