ANOTHER CENTURY OF “REFORM WITHOUT CHANGE?”

“And the seasons, they go round and round

And the painted ponies go up and down

We’re captive on a carousel of time”

(Joni Mitchell 1970)

The 1910 Flexner report is credited with beginning the modern era of medical education.¹ Since that time, a regular calliope of calls for changes in the way that medical students are selected and educated has been heard. Yet authors such as Bloom^2,3 and Christakis⁴ have noted that these calls for reform are ‘remarkably consistent,’ with perennial themes and similar recommendations. Whitehead⁵ likens this revolving pattern to a carousel, observing that “medical educators were regularly returning with fresh and un-remembering minds, to the same concerns.”

What are the reasons that the same “ponies go up and down;” and is the current wave of curricular reforms likely to yield any different results? Will proposed reforms overcome the resistance to fundamental change that has so far stymied the reformers’ stated desires to achieve a system of medical education to better serve the needs of the public? One source of resistance to real change was pointedly cited by Bloom: “The scientific mission of academic medicine has crowded out its social responsibility to train for society’s most basic health-care delivery needs.”

Comprehensive reviews of curricular reform by Christakis⁴ and Whitehead⁵ found similar conclusions, emphasizing the need for increased generalist training and concerns about overspecialization. In the 1990s, curricular reform efforts funded by the Health Resources Services Administration and private foundations enthusiastically initiated novel curricular changes. Academic institutions watched a transient increase in medical student selection of generalist disciplines. The failure of a concurrent systemic reimbursement reform contributed to another decline in student interest in primary care.⁶

New reports promote novel efforts to reshape the health care workforce for the 21st century.^7,8 Coupled with a parallel wave of curricular revision, what factors offer hope that academic institutions will go beyond focus on the oft-recommended goals of selecting the right medical students, providing a more suitable curriculum through more suitable methods, and encouraging a professional identity that is immune to the hidden curriculum? This hidden curriculum, including what Funkenstein⁹ called “the ideology of the era,” has obstructed the most idealistic of curriculum planners’ intent to influence students’ perception of generalism and the relevance of population needs to their particular specialty choice.

What is required to hold academic medical centers accountable for preparing a workforce capable of improving population health? How much of the hidden curriculum and influential “ideology of the era” can academic medical centers control?

Surveys suggest that most (53% in 2011 and 65% in 2012) chairs of academic departments of family medicine are being asked to lead health care delivery innovations. Family medicine educators across the country are emphasizing patient-focused team-based learning, incorporating cost/value issues and practice-based quality improvement projects into medical student experiences. Departments of family medicine are leading unique public health initiatives and demonstrating the value of primary care physicians’ role in improving the health of the public. Is this enough? Or will academic institutions continue to “impute novelty” to curricular issues and continue to avoid examining factors linking resistance to change with the continued struggle to prepare a health care workforce best suited to address the health needs of our citizens?

• © 2013 Annals of Family Medicine, Inc.