Forward

Medical schools are justifiably sources of civic pride, in no small part because they are the wellspring of the high-quality health care enjoyed by the people whose taxes, tuition payments, and insurance premiums subsidize them. Medical schools have prospered for most of the past century because they had broad public support. And that support is needed now more than ever, as medical education attempts to adapt to significant changes in what students must learn to be good physicians in the 21st century.

This report is designed to enhance our understanding about the nature and extent of those changes. Its findings are both encouraging and unsettling. The good news is that many medical educators are implementing curricular changes that are responsive to the latest advances in biomedical science, to the social and policy sciences relevant to medical practice, to the burden of disease, to the organization and financing of health care, and to the changing demography of the American population.

The unsettling news is that most contemporary curriculum reformers have not yet been able to make necessary changes in the second two years of medical education, when students receive their first intensive education in clinical practice. In the first of two essays that introduce this report, Michael Whitcomb, a senior vice president of the Association of American Medical Colleges, writes that this “lack of innovation . . . is almost certainly due to the fact that many members of the clinical faculty do not believe that changes are needed.” The author of the second introductory essay, Kenneth Ludmerer, agrees with this analysis, as do the authors of most of the case studies that follow the essays. Ludmerer, a professor of internal medicine and history at Washington University, worries that “the approaches described in the case studies are insufficient to prepare the nation’s medical students properly for the practice of medicine in the 21st century.”

We commend the report to persons who have formal responsibility for higher education as well as to medical educators. Members of university governing boards and leaders of the legislative and executive branches of state government should be aware of current achievements and limits of curriculum reform in medical schools and of their potential consequences for American health care.

We also hope that medical educators and persons responsible to the public for higher education will discuss the barriers to reform in the clinical curriculum. Some of these barriers are financial. Others are a result of the reward system in academic medicine. All of them are amenable to change as a result of collaboration among people within and outside medical education. Academic responsibility is the price we must pay for academic freedom.

Finally, we thank the authors of the studies, who are identified below, for drafting and redrafting them against tight deadlines and Drs. Ludmerer and Whitcomb for writing engagingly about controversial conceptual, political, and historical issues that have great practical importance.

Jordan J. Cohen
President
Association of American Medical Colleges

Daniel M. Fox
President
Milbank Memorial Fund