opinion

100 years after Flexner, AMA is still a force in med ed

A message to all physicians from AMA President 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 Feb. 1, 2010.

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Over these last seven months, I have received many letters, e-mails and texts from people who identify themselves as physicians and whose messages suggest that the AMA doesn't do anything for them.

It's a sad irony that they are unaware that their ability simply to practice medicine acceptable to the public is due to the role the American Medical Association has played for 163 years in medical education standards. It is a role that the AMA continues to play today.

In fact, one of the two driving forces behind the AMA's creation in 1847 was the need for a common code of medical ethics and standards for medical education across the United States.

Among the AMA's first acts was to create the Committee on Medical Education (which later became the Council on Medical Education), and it soon produced a set of standards to evaluate medical schools.

But it was not until the Carnegie Foundation for the Advancement of Teaching funded Abraham Flexner with a grant to travel with the secretary of the AMA Council on Medical Education to the 155 medical schools then in existence that medical education moved to the forefront of America's public health agenda.

The project resulted in Flexner's famous report, "Medical Education in the United States and Canada," which became a catalyst for an historic shift in thinking.

The report, published in 1910, had five key findings. Flexner and the AMA learned that the medical education system churned out an overproduction of uneducated and ill-trained medical practitioners, who in general practiced with "an absolute disregard for the public welfare and without any serious thought of the interests of the public."

Flexner noted that there were five times as many U.S. physicians in proportion to population than in European nations such as Germany.

What drove this oversupply was a large number of commercial schools whose mission was profit, not education. For these diploma mills, the expense of setting up a laboratory to aid didactic instruction took away from the bottom line, and the quality of education suffered as a result.

These schools' defense, that even an inadequately funded medical school served a purpose by offering an opportunity for disadvantaged individuals to attend, was soundly and correctly rejected as a bogus argument.

Another key finding was that a hospital run under complete educational control is as necessary to medical school training as a chemistry lab or a pathology course. Trustees of hospitals, public or private, should open hospital wards to teaching, with the only condition that the universities secure sufficient funds to employ teachers dedicated to clinical science.

In his report, Flexner noted that the articulation of medical education must be coordinated within the general system of education.

At the time, it was noted that in the eastern and central parts of the United States, entry into medical school would articulate well after the second year of college. In the southern states, which trailed in the development of extensive secondary education, articulation with a four-year high school education was found to be a reasonable starting point.

I note this as the concerns build over calls to extend postgraduate education for additional years, to the point that one is in one's mid-to-late 30s before being able to open or join a clinical practice.

Revisiting early-entry programs into medical education might be something that would justify the return on investment of medical education. The result would be a longer period of clinical practice for physicians, which would benefit patients.

Our AMA Council on Medical Education continues to accredit medical education in the U.S. and Canada in partnership with the Assn. of American Medical Colleges through the Liaison Committee on Medical Education. The cost to accredit programs leading to the medical degree is split between the AAMC and the AMA.

Physicians who have MD degrees obtained from LCME-accredited programs but say the AMA has done nothing for them are wrong. As Theodore Roosevelt said, it is the professional's obligation to belong to the organization that defines your profession. Regretfully, many physicians in America with medical degrees from domestic medical schools ignore that obligation.

One hundred years after Flexner, medical education standards continue to evolve.

The AMA's Initiative to Transform Medical Education and the Innovative Strategies for Transforming the Education of Physicians are two projects that the AMA's Council on Medical Education is actively pursuing.

When Flexner produced his report, women were a rare presence in medical education. Now, a hundred years later, Susan Bailey, MD, from Texas, is the chair of the AMA Council on Medical Education.

The current AMA board chair, Rebecca Patchin, MD, is a former CME chair.

The AMA is part of every physician's life who obtained a MD degree, entered an Accreditation Council for Graduate Medical Education residency program or received AMA-Physician's Recognition Award credit.

It is another tangible example of how the AMA helps doctors help patients by ensuring the highest medical education standards. This protects the public from those who wish to expand their scope of practice through legislation and regulation, instead of a quality education.

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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