graduation-cap“How ready are medical students for the clinical practice of medicine?”

This was the question addressed by the landmark 1910 Flexner Report from the Carnegie Foundation for the Advancement of Teaching. Back in the early 1900’s, residency training did not exist yet, and students entered clinical practice immediately after graduation from medical school. The quality of medical training varied significantly with alarming deficiencies in many medical schools. An independent, nonprofessional organization was commissioned to report about the situation in order to pressure the public to reform medical school education.

This organization was the Carnegie Foundation for the Advancement of Teaching, led by Abraham Flexner. The result was the creation of laws that required physicians to have completed a defined set of educational experiences before starting their clinical practice.

100th year anniversary of flexner report

The year 2010 marks the 100th year anniversary of the Flexner Report. Because there will certainly be many journal articles reflecting back to the original report in the upcoming months, I thought I’d read a little more about it. This is a review of a commentary by Academic Medicine’s editor-in-chief, Dr. Michael Whitcombe. I met him several years ago at SAEM’s national meeting when he gave an inspiring talk about educational research. An articulate visionary.

Unlike in 1910, current trainees must now also complete residency training after medical school before entering clinical practice. If updated, the revised Flexner report would focus instead on graduate medical education (GME) instead of undergraduate medical education (UME).

So, how ready are our residents for the clinical practice of medicine today?

Unfortunately, not so ready.

The Institute of Medicine and various articles in JAMA have documented this. Their conclusions are that GME needs a significant overhaul so that graduating residents can consistently provide high-quality medical care of our country’s citizens. Unfortunately (1) identifying the problem and (2) making recommendations for change doesn’t magically make change happen. Many regulatory bodies are stuck in how they currently practice the business and management of GME. Traditions are understandably difficult to change.

Confounding the picture even more is that each specialty has its own set of regulatory bodies which also have significant say over how their residents should be trained. In Emergency Medicine, some of the key players are the American Board of Emergency Medicine (ABEM), the EM Residency Review Committee (RRC), and the Council of Residency Directors in EM (CORD).

On paper, the solution might seem easy. The Accreditation Council for Graduate Medical Education (ACGME), which oversees the accreditation of all GME training programs, should make an overarching top-down change. The decree- Make residency training better. But no, things can’t be that easy. As it currently stands, the ACGME has given the individual RRCs (each represents a medical specialty) to come up with the specialty-specific training standards. I support this philosophy because EM physicians on the EM-RRC know the nuances of EM training more than a non-EM physician in the ACGME office. Unfortunately, this adds another layer of complexity and creates an impasse for a blanket change across specialties.

In the commentary, Dr. Whitcombe summarizes some proposed ideas. Several revolve around some form of licensure demonstrating competency (a.k.a. “stamp of approval”) before graduating from residency.

My thoughts

Personally, I don’t think that the idea of having a standardized, exit exam licensure is going to work. Are we going to impose yet another standardized test on our trainees, knowing that it poorly measures the multifaceted complexities of clinical competency and medical decision making?

I think the responsibility lies somewhere on the shoulders of the ACGME and individual RRCs.

My crazy idea

Here’s a crazy outside-the-box thought. If JAMA published several papers (see references below) documenting survey results that new practicing physicians feel inadequately trained in particular aspects of medicine, why can’t we use these survey tools annually during residency training? We should be addressing and assessing clinical competency throughout residency and not just before they graduate. Each resident would perform a honest self-assessment of his/her competencies (or lack thereof) in various areas.

Inevitably, different trainees will have different deficiencies, even within the same residency program. This means that the curriculum should shift towards a new model – a learner-centric model. This would involve annual custom-tailoring of each trainee’s clinical experiences and other learning opportunities, based on their subjective or objective deficiencies. I would get rid of a large portion of the weekly conference lectures (passive learning where everyone gets taught the same topics whether they knew them already or not) in exchange for more personalized, active-learning networks.

There are obvious down-sides to my idea.

  • Education is placed directly at odds with clinical service. For instance, a resident may need to do an elective in bedside ultrasonography. This may require pulling them off of an Emergency Department rotation. That leaves a gap in clinical coverage in the ED. This translates to more dollars needed by the department to ensure adequate clinical coverage. Asking for more money for the sake education is always a touchy subject.
  • Because each resident has a customized personalized curriculum, lots of faculty and administrative time will be needed to ensure each resident’s success. This is a resource-intensive endeavor.
  • This is an operational and scheduling nightmare.

Hey, I said I had a radical idea. I didn’t say that I could operationalize it. I look forward to following the upcoming papers addressing the 100th year anniversary of the Flexner Report.

Whitcomb ME. Flexner redux 2010: Graduate medical education in the United States. Academic Medicine. 2009; 84:1476-8.

JAMA references

  1. Wiest FC, Ferris TG, Gokhale M, et al. Preparedness of internal medicine and family practice residents for treating common conditions. JAMA. 2002;288:2609 –2614.
  2. Blumenthal D, Gokhale M, Campbell EG, Weissman JS. Preparedness for practice. Reports of graduating residents at academic health centers. JAMA. 2001;286:1027–1034.
  3. Cantor JC, Baker LC, Hughes RG. Preparedness for practice: Young physicians views of their professional education. JAMA. 1993;270:1035–1040.


Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD