PERSPECTIVES A Consumer/Medical Educator Conference:

New Objectives for the Medical Curriculum

BARBARA J. TURNER, MD, MSEd, FREDRIC D. BURG, MD

The au thors d i s cus s the development and proceedings of a highly structured conference at which 17 representatives from diverse non-medical groups and 14 medical educators from one medical school identified objectives needing grea ter emphasis in the medical curriculum. The confer- e n c e emulated industry's use of consumer advisory panels. Using the nominal group technique, a group process used in business, the non-medical group developed independ- ently a priority list of areas in which physicians might be better e d u c a t e d to s erve society. The m e d i c a l educators then joined the non-medical group to discuss and clarify the c o n c e r n s given highest priority. The authors describe subsequent initiatives by the medical school to address aspec t s of the general concerns raised by the non-medical group. The c o n f e r e n c e represents an approach to seeking input from non-traditional sources in the development of the medical curriculum. Key words, consumers; medical curriculum; humanistic medicine; health care economics; medical e d u c a t i o n c o n f e r e n c e . J G~ I~rr~N MED 1996; 1:323- 327.

TRADITIONALLY, the medical faculty p lans the med- ical school curr iculum to prepare phys ic ians to serve those heal th care needs perce ived by the fac- ulty to be important. Gaps may develop or persist in a reas of the curriculum that a re important to the public-at-large, in part because of fai lure of the faculty to ass ign high priority to them. Society has l imited access to the means of promoting changes in m e d i c a l school cu r r i cu la , e v e n w h e n such changes could produce phys ic ians bet ter p repared to meet the heal th care needs of the community as a whole.

One of the authors (BJT) sugges ted to leaders at the University of Pennsy lvan ia School of Medi- cine that a non-medical group be invited to com- ment on medica l educat ion. The sugges t ion to de- velop a conference to elicit non-medical ideas about the medica l school curr iculum came at a time when the University of Pennsy lvan ia School of Medicine was renewing its efforts to review and revise the medical curriculum. This paper descr ibes the de- velopment and proceedings of the conference and

Received from the University of Pennsylvania Robert Wood Johnson Clinical Scholars Program, the Philadelphia VA Medical Center, and the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Address correspondence and reprint requests to Dr. Turner at her present address: Center for Research in Medical Education and Health Care, Thomas Jefferson University, Jefferson Medical College, College 132, 1025 Walnut Street, Philadelphia, PA 19107.

some of the problems encountered . A summary of curricular init iat ives begun following this confer- ence demons t ra tes efforts made by the School of Medicine to address the concerns of the partici- pants.

PARTICIPANTS

The conference was held in the winter of 1984. The design of the conference had taken shape grad- ual ly over the preceding six months in a ser ies of meet ings with the dean, assoc ia te dean, several faculty members , and other clinical scholars. After the conference was approved by the Dean's Office and the Curriculum Committee, 14 faculty mem- bers ag reed to part icipate; most were full profes- sors and members of the Curriculum Committee.

The non-medical conference par t ic ipants were found through a compl ica ted set of "networks" of medical and non-medical acqua in tances . Potential par t ic ipants were in terviewed in person or by tele- phone. The interviewer descr ibed the ra t ionale for the conference and asked whether the non-medical contact felt p repa red to contribute. Thirty-five such interviews were conducted; 25 of the 35 people in- terviewed were se lec ted and ag reed to part icipate. Because of conflicting commitments, only 17 of the 25 non-medical members a t t ended the conference. All had had occasion, because of their occupat ions or personal contacts, to think about the role of the physic ian in del iver ing medical care and about the heal th care system. The par t ic ipants included cor- porate managers , union and government officials, consumer advocates , theologians, lawyers , faculty members in hea l th professions and l iberal arts, and heal th care researchers . Five of the partici- pants were women and four were members of mi- nority groups.

Before the meeting, all non-medical partici- pants were asked to consider ways in which phy- s icians could be bet ter t ra ined to meet the needs of society. The non-medical group also r ece ived background read ings on medical education, ex- cerpted from the medical school cata log and from mater ia l publ i shed by the American Medical As- sociation, the Associat ion of American Medical Colleges, and the Institute of Medicine.

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324 Turner and Burg, CONSUMER/MEDICAL EDUCATOR CONFERENCE

CONFERENCE FORMAT: NOMINAL GROUP TECHNIQUE

The conference consisted of two sessions. In the morning, the non-medical group met alone to formulate, compare and consolidate their concerns about the training of physicians. In the afternoon, they were joined by the medical educators to ex- amine and clarify the concerns given highest prior- ity.

The quali ty of ideas genera ted by any group depends largely on meet ing techniques that can increase rationality, creativity and participation. Therefore, at tent ion was paid to the selection of the group processes to be used in the conference. Several s trategies for group participation were considered for the morning component of the con- ference: interacting or unstructured groups, "brain- storming," the Delphi technique, and the nominal group technique.

All of these options except the nominal group technique were believed to have d i sadvan tages in accomplishing the goals of the morning meeting. An interacting group risks limiting contributions to only the most vocal or high-status members of the group. Also, the group often focuses on a single train of thought for extended periods of time. 1 As a result, often relatively few ideas are raised and discussed. "Brainstorming" elicits many ideas in a short period of time. But this s t rategy does not in- clude a procedure for clarifying and ranking ideas.

The Delphi technique, pioneered at the Rand Corporation in the 1960s, has been used success- fully by diverse heal th care groups. 2, 3 The tech- nique consists of a series of quest ionnaires used to solicit and collate judgments on a topic. Each succeeding quest ionnaire summarizes and gives feedback on the information derived from earlier responses. It has been es t imated that a minimum of 45 days are required to complete a Delphi proc- ess involving two iterations of quest ionnaires. The Delphi technique would have been a good alter- native if there had been more time to develop the meeting. We might have examined two lists of con- cerns about the medical curriculum, genera ted by separate Delphi processes by the non-medical and medical educator groups.

The nominal group technique was used in this meeting. It is a modification of the "brainstorming" technique and has been widely used by heal th care groups . 4 It w a s d e v e l o p e d as a g roup-process method for bus iness managemen t to promote equal participation in eliciting ideas and es tabl ishing a priority list. The developers of the nominal group technique have sugges ted that it is a useful tool to draw upon consumer ideas. It involves six steps: 1) generat ion of ideas in writing, without discus-

sion, 2) recorded round-robin listing of ideas on a chart, 3) discussion and clarification of each idea on the chart, 4) prel iminary vote on priorities, 5) discussion of the prel iminary vote, and 6) final vote on priorities. 1

Because the nominal group technique per- forms best in groups smaller than ten, the 17 mem- bers of the non-medical group were divided into two groups. A plenary session, held after these groups had completed their task, enabled the non- medical part icipants to compare the two lists of concerns and to vote on a composite priority list. These concerns were grouped into three subject areas, to facili tate the afternoon discussion with the medical educators.

NON-MEDICAL GROUP'S CONCERNS

The final list of concerns produced by the non- medical group is summarized below, in decreasing order of priority:

1. Improve the physic ian-pat ient relationship. Treat the patient as a whole by providing empa- thetic care for both medical and non-medical prob- lems. Include the patient and family in decision- making.

2. Teach a systems approach to heal th care. Promote an unders tand ing of the physician 's role in the system, the resources and structure of the system.

3. Teach about heal th care economics and the interplay of ethics and economics from both a pa- tient's and society's standpoints.

4. Develop skills to facili tate communicat ion with patients and al l ied heal th professions. Teach basic counseling and l istening skills.

5. Include instruction in underemphasized as- pects of medical care: preventive medicine, ger- iatrics, medical ethics, epidemiology.

6. Sustain the physician 's own mental health. 7. Maintain professional credibility. Provide

rigorous medical t raining in order to earn patients ' respect by demonstra t ing competence and profes- sional behavior.

8. Train educators to serve as role models who put into practice the above recommendations.

MEDICAL AND NON-MEDICAL GROUP DISCUSSION

The afternoon meet ing between the non-med- ical and medical educator groups was organized as an interacting group. The purpose of this phase of the meet ing was to promote discussion and clar- ification of the three major a reas of concern raised earlier by the non-medical group. Although limited in its abili ty to promote decision-making, the in-

.JOURNAL OF (3£N£RAL INTERNAL MEDICINE, Volume 1 (Sep/Oct), 1986 325

teracting or unstructured group facili tates a sense of group cohesion and tends to promote generat ion of consensus, i

The afternoon's discussion focused on three priority concerns: the humane physician; the phy- sician in the health care system; and communi- cation skills. One member of the non-medical group made introductory comments about each of these concerns before opening the discussion to the whole group.

The Humane Physician

In present ing the first subject, the humane phy- sician, a minister characterized the ideal physi- c i a n - p a t i e n t r e l a t i o n s h i p as one of f r i end ly collaboration which would enable them to discuss freely a broad range of issues relevant to the pa- tient's whole lifestyle. She expressed the hope that physicians would believe in and foster patients ' abilit ies to part icipate in making decisions perti- nent to their own heal th care.

Other n o n - m e d i c a l pa r t i c i pan t s were con- cerned that the stresses of the current medical ed- ucation process may jeopardize the mental and emotional stabili ty of young physicians, thereby impairing their abili ty to deal effectively with pa- tients. Educators were skeptical, demand ing proof of the a l legat ion that the educat ional process is so stressful that it poses a psychological threat to medical s tudents and residents. In rebuttal, most of the non-medical group members indicated that their concerns were based primarily on their per- sonal experiences with the health care system. They admit ted that they could not cite specific sources in the literature, but contended that they were fa- miliar with studies of the menta l heal th problems of physicians, such as suicide, drug abuse, and divorce. Out of this discussion came the suggest ion that medical school should assume more respon- s ib i l i ty for e s t a b l i s h i n g a d e q u a t e suppor t a n d counseling sys tems for the emotional and menta l development of students.

The Physician In The System

A consumer advocate outlined the non-medical group's discussion regarding the second major topic, the physic ian in the system. She noted the limited extent to which most physicians under- s tand or dea l with the impact of the patient 's care on the family and the community. Such at t i tudes and practices were thought to result, in part, from inadequa te knowledge of the heal th care system. It was sugges ted that in order to practice the art of medicine, the physic ian must unders tand the so- cioeconomic and ethical aspects of society in which he or she practices. Several non-medical partici-

pants indicated that f ragmentat ion of medical care could be d iminished by mobilizing ancil lary heal th personnel and by using new modali t ies such as computers to coordinate patient care.

One medical educator countered that patient care might be more f ragmented if increased re- sponsibili ty were de lega ted to a variety of other heal th care workers. Several non-medical partici- pants replied that the physician, as the "captain" of the interdisciplinary care team, could see to it that pat ients and their families be given ass is tance in many more a reas of need than the physician 's l imited time and training would currently allow. Most of the medical educators present agreed.

The discussion turned to the consequences of economic forces on the heal th care system and on physicians ' medical practices. Both medical and non-medical part icipants were concerned that cur- rent methods of physic ian reimbursement tend to stifle humanis t ic quali t ies in physicians. But sev- eral non-medical representat ives warned that phy- sicians could play a leading role in shaping med- ical care only if they understood the economic underpinnings of the heal th care system.

Communication Skills

A psychologist representing a heal th care re- search organizat ion served as the spokesperson for the third topic, communicat ion skills. These skills were felt to be vital for developing a productive relat ionship with a patient and the family, as well as with other heal th care workers. Two problems cited were physicians ' use of medical jargon and rapid speech. Poor communicat ion was interpreted as signifying a lack of respect for patients.

CHANGES IN THE MEDICAL SCHOOL CURRICULUM

In the year following the conference, the School of Medicine has taken a series of steps to improve the quali ty of its educat ional program, consonant with the concems identified by the consumer group.

1. The Introduction to Medicine course now provides first-year medical s tudents with an op- portunity to consider the psychosocial aspects of medical care. Students interview patients and their relatives, then have debriefing sessions in which both faculty and students discuss the patient 's ill- ness and its effects on both the pat ient 's life and the family. Also, the physician 's roles in all aspects of care are reviewed. The humanist ic aspects of the course have been discussed in the lay press. 5

2. A working group was formed to invest igate the relat ionship be tween physicians and social workers. Representat ives from the School of Social Work, the Hospital Administration, and the School

326 Turner and Burg, CONSUMER/MEDICAL EDUCATOR CONFER, ENCE

of Medicine are identifying ways to encourage greater cooperation between the two disciplines in the delivery of heal th care.

3. The School of Medicine is developing com- puter programs to instruct s tudents in the use of cost-benefit and decision-analysis strategies.

4. A new, 20-session seminar on geriatric care and the quali ty of life is being created in conjunc- tion with the Center for the Study of Aging.

5. A committee to address the issue of the im- paired physician has formed an al l iance with Al- coholics Anonymous of Phi ladelphia which will permit s tudents to part icipate in AA programs. A seminar series to deal with the effects of drugs and alcohol on physicians ' performance has also been developed.

6. A series of workshops has been initiated to improve the teaching skills of medical students and residents. The part icipants discuss methods and problems of teaching, and evaluate their skills in s imulated teaching situations.

DISCUSSION

This conference was predicated on the belief that non-medical individuals can make worthwhile contributions in the analysis and planning of health care issues, such as the preparat ion of medical s tudents to become heal th care providers. Belief in the value of non-medical individuals ' input into heal th care is not new. As early as 1966, Federal legislat ion specifically called for consumer partic- ipation in heal th planning. 6 Consumers p layed a major role in Regional Medical Programs init iated in the 1960s. The government also manda ted that consumers part icipate in developing local contin- uing medical educat ion programs, a process that continued into the next decade. 7 In more recent years, prominent lay persons have addressed sev- eral medical organizations about a reas which, in their opinion, required greater emphas is in both undergradua te and graduate medical education, to better prepare physicians to serve society. 8-1°

Perceiving that the initiatives made in the 1960s to involve consumers in heal th care p lanning have waned, Nowak H and Jensen ~2 recently called for a revival of consumer participation. Nowak proposed that the medical profession follow the example of industry by adopting consumer advisory panels and consumer workshops, to open dialogs between physicians and the lay community.

By inviting a non-medical group to participate in identifying some of the objectives of the medical curriculum, the medical educators became vulner- able to criticism. Differences in opinion and per- spec t ives a rose a m o n g the med ica l educa to r s themselves as well as between the medical and

non-medical groups. Debriefing sessions following the conference revealed that medical educators re- acted to the meet ing in one of two ways, depending upon their prior beliefs about revision of the cur- r iculum. Half of the m e d i c a l group suppor ted s t rengthening the "humanist ic" aspects of medical educat ion and welcomed the non-medical group's input; the other half placed greater emphas is on biomedical aspects of current curriculum and dis- counted the value of the consumer 's suggestions. Those educators who seemed resistant to accepting the validity of the consumer group's suggest ions also quest ioned the extent to which that group's priority list of concerns reflected the interests of the pub l ic -a t - l a rge . The v i ewpo in t s of the med ica l group could not be predicted by their roles as basic scientists or clinical educators.

Prior to the conference, five of the meeting or- ganizers had informally predicted that the con- sumers would raise a different concern as first priority: the high cost of heal th care. Instead, the non-medical group gave the highest priority to the need for physicians to learn to treat pat ients and their families as responsible collaborators in the heal th care system and to foster compassionate approaches to the delivery of medical care. The general nature of this concern has been supported by several large consumer surveys, which report patient satisfaction to be most dependent on the physician's conduct, particularly the extent to which physicians care about their patients.13. 14

The organizers of the meet ing were surprised by the non-medical group's limited concern about the soundness of physicians ' biomedical training. Most non-medical part icipants indicated that, from their rather superficial viewpoints, physicians ap- peared to be well t rained technically. However, the final list of priority concerns did include an item about mainta in ing professional credibility by pro- viding competent medical care.

One of the most rewarding aspects of the meet- ing was the coherence and effectiveness of the col- laboration among the members of the consumer group. The high-quali ty output of the non-medical group justified the t ime-consuming search for con- ference participants. Very few non-medical partic- ipants knew each other prior to the meeting, yet all contributed to clarify and expand on the ideas raised by the group. The structure of the meeting and the powerful influence of the consumers them- selves did not permit dominat ion by the medical educators. Physicians and consumers have been previously reported to collaborate well and to exert equal control in heal th p lanning committees, is

As described in Results, the School of Medicine has, in the year since the conference was held,

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume I (Sep/Oct), 1986 327

addressed aspects of most of the consumer con- cerns. Although the creation of courses and work- ing groups cannot be attributed only to the impact of the conference, it is likely to have acted as one of several important catalysts stimulating educa- tional reform.

The non-medical participants concluded that medical educators should not limit themselves to infusing the curriculum with new subjects and in- novative approaches to medical care. Rather, phy- sicians and society should combat socioeconomic phenomena that reward the physician who ignores the care of the whole patient. The concluding re- marks of the meeting were offered by a lawyer, who drew upon an analogy to the legal profession, which she thought also inhibited caring qualities. She s u g g e s t e d that so lut ions might be found through collaboration with other professions facing similar di lemmas.

The authors give special thanks to the conference participants for devoting their time and energy to this endeavor. They also thank other organizers of the conference: Samuel P. Martin III, MD, Henry W. Riecken, MD, Albert P. Fishman, MD, Edward J. Stemmler, MD, Howard S, Turner, PhD. They are also indebted to Bette Borenstein, PhD, for editing of the manuscript, and to Carol Beauchamp for typing it.

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