Latest / Health Ethics Podcast / Why Accreditation Matters: Safeguarding Quality in Medical Education

Transcript

Why Accreditation Matters: Safeguarding Quality in Medical Education · Health Ethics Podcast

0:09
Speaker 1: Welcome to Health Ethics, a series of conversations with leading
0:13
Speaker 1: experts about ethical considerations associated with health and healthcare, both
0:17
Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
0:21
Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
0:24
Speaker 1: School of Medicine. This series, like its predecessor, which focused
0:29
Speaker 1: on the COVID nineteen pandemic, relies on the idea that
0:32
Speaker 1: challenging ethical issues are best addressed by folks from diverse
0:36
Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics series
0:41
Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics, philosophy,
0:47
Speaker 1: and the law. Thank you and enjoy the episode.
0:58
Speaker 2: It has my great pleasure to be speaking with Veronica Catonese.
1:02
Speaker 2: Doctor Cattanise received her undergraduate degree from Wellesley, MD from NYU,
1:06
Speaker 2: and MBA from NYU's Stern School of Business. After residency
1:10
Speaker 2: training in internal medicine and a clinical fellowship in endochronology,
1:14
Speaker 2: diabetes and metabolism at NYU, she spent two years as
1:18
Speaker 2: a research fellow at the Joscelyn Diabetes Center of Harvard
1:21
Speaker 2: Medical School. She then returned to NYU as a faculty
1:25
Speaker 2: member in the departments of Medicine and Cell Biology, eventually
1:29
Speaker 2: becoming the school's senior Associate Dean for Education and student Affairs.
1:33
Speaker 2: In two thousand and eight, doctor Cattanie joined the founding
1:37
Speaker 2: team of the Donald and Barbara Zucker School of Medicine
1:40
Speaker 2: at Hofstra Northwell, where she served as Vice Dean, Dean
1:44
Speaker 2: for Academic Affairs, and Principal business Officer. In twenty sixteen,
1:49
Speaker 2: doctor Cantonese assumed the position of Co Secretary of the
1:52
Speaker 2: LCME and Senior Director of Accreditation Services at the Association
1:57
Speaker 2: of American Medical Colleges. Throughout her professional life, she has
2:01
Speaker 2: maintained a visible national profile in academic medicine, having served
2:06
Speaker 2: as President of the American Federation for Medical Research and
2:09
Speaker 2: editor in chief of the Journal of Investigative Medicine. She
2:13
Speaker 2: also has served as a member of the Institute of
2:15
Speaker 2: Medicine's Clinical Research Roundtable and co chair of the Training
2:19
Speaker 2: Subcommittee of the NIH Clinical Research Roadmap Working Group, and
2:24
Speaker 2: chair of the NIH Biotechnology Transfer Study Section. And with
2:28
Speaker 2: that long inter running, thank you so much for joining me.
2:31
Speaker 2: I know that folks, having heard your background, will understand
2:35
Speaker 2: why you're the right person to talk to about ethics
2:38
Speaker 2: and accreditation. So thank you so much.
2:40
Speaker 3: Well, thank you for inviting me, Brian. I look forward
2:42
Speaker 3: to it.
2:44
Speaker 2: So let's go back to basics. Lots of folks who
2:48
Speaker 2: listen to the podcast are interested in health, they're interested
2:50
Speaker 2: in ethics, they're interested in medicine and medical education. Take
2:54
Speaker 2: us a step back. What's accreditation, why is it important?
2:59
Speaker 2: And then tell us how it works in medical education?
3:02
Speaker 3: Okay, perfect, I think you know. A general definition of
3:05
Speaker 3: accreditation really is a process where there's an independent body
3:12
Speaker 3: that officially recognizes an institution or a program because it
3:18
Speaker 3: meets certain established criteria or standards of quality in a
3:25
Speaker 3: particular area. In medicine, the Liaison Committee on Medical Education
3:32
Speaker 3: is the recognized body by the Department of Education for
3:38
Speaker 3: medical education program recognition when those programs are granting the
3:43
Speaker 3: MD degree and are located physically in the US and
3:47
Speaker 3: its territories. The LCME in turn offers the accreditation process
3:55
Speaker 3: to the MD granting programs in our medical school here
4:00
Speaker 3: in the US. So the LCME is both authorized in
4:06
Speaker 3: a sense accredited to do its accreditation, which is then
4:11
Speaker 3: the process of working with schools to assure that they
4:16
Speaker 3: meet the equality standards that are agreed upon really by
4:21
Speaker 3: national stakeholder groups. And it's worth talking about this for
4:25
Speaker 3: a moment too, because the purpose of accreditation from you know,
4:31
Speaker 3: I'm an individual in my perspective, like why bother with this,
4:35
Speaker 3: it is because it is a way of assuring that
4:39
Speaker 3: quality to the different stakeholder groups and those interested parties.
4:44
Speaker 3: They range from the general public to the individual medical students,
4:50
Speaker 3: to the faculty and the staff of the institutions in
4:55
Speaker 3: which those students are training, and then when the students graduate,
5:00
Speaker 3: extends to the postgraduate training community, the residents, for example,
5:05
Speaker 3: out into practice as these individuals who graduate become licensed
5:10
Speaker 3: and become clinical practitioners, and also to the health systems
5:15
Speaker 3: and the health entities in which those individuals will work.
5:19
Speaker 3: So all of those groups have a vested interest in
5:25
Speaker 3: the process and the outcome of accreditation, with the goal
5:30
Speaker 3: at the end really of assuring quality to all of
5:33
Speaker 3: those groups, again most importantly the general public.
5:39
Speaker 2: That's really helpful, and so that it sort of reminds
5:43
Speaker 2: me of some of the LCME visits at our own
5:46
Speaker 2: medical school and writing reports and that fun stuff. So
5:51
Speaker 2: it's important the sort of accreditation is important because it
5:54
Speaker 2: ensures quality, or to the best of everyone's ability, insureance
5:58
Speaker 2: quality for a variety of stakeholders of those who are
6:01
Speaker 2: engaged in the learning, the public. Folks like Meia weren't physicians,
6:05
Speaker 2: but show up to see physicians. We want them well
6:08
Speaker 2: trained and ensure that quality. This makes sense, and so
6:13
Speaker 2: anything in particular for medical education that you think folks
6:16
Speaker 2: should know before we start asking more about the profession
6:19
Speaker 2: and the details, and that.
6:21
Speaker 3: I think that medical education has evolved dramatically over the
6:28
Speaker 3: last I mean, I could probably say over the last
6:30
Speaker 3: three years, but certainly over the last several decades. And
6:34
Speaker 3: one general pattern is that it has become The ways
6:41
Speaker 3: in which students train and the venues in which they
6:44
Speaker 3: train are very, very different from what they were twenty
6:48
Speaker 3: years ago. And that's largely because twenty years ago the
6:53
Speaker 3: medical schools themselves and twenty years ago there probably were
6:57
Speaker 3: around one hundred and twenty right now they're one hundred sixty.
7:00
Speaker 3: But in any case, twenty years ago the medical school
7:05
Speaker 3: was at the center of the academic medicine environment, and
7:11
Speaker 3: the faculty and the students of the medical school did
7:17
Speaker 3: their clinical learning in their clinical training in a variety
7:21
Speaker 3: of different hospitals. What's happened over the last decade or
7:26
Speaker 3: decade and a half is that hospitals themselves have consolidated.
7:32
Speaker 3: There are large health systems now with many hospitals, many
7:37
Speaker 3: ambulatory physician practices associated with them, many different types of
7:44
Speaker 3: healthcare delivery sites. So that the center of the academic
7:50
Speaker 3: medicine community has shifted from the medical school kind of
7:55
Speaker 3: being the trunk of the tree and the hospitals being
7:59
Speaker 3: the branches, to now the health systems and the hospitals
8:03
Speaker 3: being central and very often working collaboratively in the training
8:09
Speaker 3: of multiple of students from multiple medical schools. So there's
8:14
Speaker 3: been a real sort of inversion of the structure. And
8:19
Speaker 3: as part of that, students are training in many different places.
8:23
Speaker 3: They're not training solely in large hospitals as they were before.
8:28
Speaker 3: They're doing much more training in the ambulatory setting. They're
8:31
Speaker 3: doing much more precepted training with individual practitioners who are
8:37
Speaker 3: trained and prepared to do that by the medical school
8:40
Speaker 3: it's faculty themselves. So that has changed a lot, and
8:45
Speaker 3: along with the other change that I would say is
8:49
Speaker 3: probably a little bit older than that, and that is
8:52
Speaker 3: over the last maybe twenty to thirty years, much more
8:56
Speaker 3: emphasis on integrated training. So instead of students learning all
9:02
Speaker 3: of their basic science that they would need from medicine
9:05
Speaker 3: early on in their training, now they're doing more and
9:09
Speaker 3: more clinical basic science and experiential learning from day one,
9:15
Speaker 3: and they're doing that in communities. And as part of that,
9:19
Speaker 3: there is much more awareness of the roles of the
9:25
Speaker 3: individual members of healthcare teams in working with us all
9:30
Speaker 3: as you know, in terms of providing preventive health care,
9:35
Speaker 3: health maintenance, and team based care. And that's changed. That's
9:39
Speaker 3: been a significant change, and you can see that in
9:42
Speaker 3: the evolution of what's expected of schools by like a
9:47
Speaker 3: crediting body like the LCME.
9:51
Speaker 2: That is really really helpful. And I mean the scope
9:56
Speaker 2: of accreditation I picked up because I didn't understand how
9:59
Speaker 2: wide it was for your first answer. Now the complex
10:03
Speaker 2: I'm getting a better feel for the complexity because it's
10:05
Speaker 2: one thing, if I mean, I know, much more was involved.
10:08
Speaker 2: But you show up to a big academic health center
10:11
Speaker 2: with a medical school twenty years ago and you know
10:14
Speaker 2: you sort of you can do your work, But now
10:16
Speaker 2: it seems so diffuse the kinds of things that you
10:19
Speaker 2: have to take into account with accreditation's that's a lot
10:22
Speaker 2: of work.
10:24
Speaker 3: It is, it's a lot of work. And you know,
10:25
Speaker 3: if you look at the standards the way the LCME works,
10:29
Speaker 3: it has twelve standards, and there are all these elements
10:33
Speaker 3: that are connected to them. But the standards, to your point, Brian,
10:36
Speaker 3: they range from topics like how is the medical school
10:41
Speaker 3: and its program organized, what's the governance, what are these
10:44
Speaker 3: relationships with the different training places which are so essential
10:48
Speaker 3: for clinical training. What is the role of the dean
10:53
Speaker 3: in being able to actually influence some of this? And
10:58
Speaker 3: the next level is what is the sort of academic
11:03
Speaker 3: and learning environment structure? What does that look like, both
11:08
Speaker 3: from a nutritious point of view in terms of professionalism
11:12
Speaker 3: and how people interact with each other. How are faculty
11:16
Speaker 3: operating in this system which is quite different, as I
11:20
Speaker 3: described it, from the way it was before. And then
11:23
Speaker 3: of course there is infrastructure, you know, and the financing
11:28
Speaker 3: of this. And the fourth area is the curriculum itself.
11:33
Speaker 3: And then the fifth area is really student services. How
11:37
Speaker 3: are students provided with the the personal counseling, the academic counseling,
11:43
Speaker 3: the career counseling, and all of the necessary parts for
11:49
Speaker 3: their personal development and the professional development. So it really,
11:53
Speaker 3: you know, ranges what the LCMME looks at ranges from
11:57
Speaker 3: the very basics of organizational structure, financial security, and sort
12:03
Speaker 3: of operational pieces to the level of what the students
12:09
Speaker 3: everyday life is like and how the each student can
12:12
Speaker 3: be positioned to be as successful as as they possibly
12:17
Speaker 3: can be in their professional careers.
12:20
Speaker 2: I imagine when accreditation goes well and quality is ensured,
12:26
Speaker 2: I mean, this can only help increase trust between you
12:29
Speaker 2: know it's a little sloppy, but the public end, you know,
12:34
Speaker 2: the h and medicine as a field, and we know
12:37
Speaker 2: that there have been some concerns and issues associated with
12:39
Speaker 2: trustan so this, uh, this is having an external body
12:43
Speaker 2: do this kind of quality check. Yeah, like I said,
12:46
Speaker 2: a lot of work, but sounds exactly right. You mentioned professionalism,
12:50
Speaker 2: and we're interested in this podcast and ethics and professionalism,
12:53
Speaker 2: and so I wanted to turn to a question about professions.
12:56
Speaker 2: So if members of the professional you know, physicians, physicians
13:00
Speaker 2: and training people draw lines and categories differently, But if
13:04
Speaker 2: members of the profession have an obligation to pursue excellence
13:08
Speaker 2: in their craft, let's say and folks have different definitions
13:11
Speaker 2: of profession. I like Alan Buchanan stuff because it's sort
13:14
Speaker 2: of philosophically straightforward. But if you think that's right, if
13:16
Speaker 2: docs should be excellent or try to be excellent, does
13:20
Speaker 2: accreditation help them to discharge that obligation? Do they satisfy
13:25
Speaker 2: this or how might having this kind of quality check
13:30
Speaker 2: help physicians do the kinds of things they need to
13:32
Speaker 2: do well.
13:34
Speaker 3: Great question, Brian, I think you know what your question
13:37
Speaker 3: really gets to. What it is that the accreditor that
13:42
Speaker 3: the LCNE is expecting of its accredited schools in terms
13:49
Speaker 3: of preparation for students and it and it goes far
13:56
Speaker 3: beyond curriculum. So, for example, if you're thinking about what
14:01
Speaker 3: the learning environment is like, there are very specific and
14:06
Speaker 3: explicit recommendations for what should be met in terms of
14:12
Speaker 3: the interchange between students like learners of all kinds and
14:17
Speaker 3: their preceptors and the people who are actually facilitating their learning.
14:21
Speaker 3: There are professionalism attributes that the schools are asked to define,
14:28
Speaker 3: and not only define, but to show how the students
14:32
Speaker 3: are learning and practicing them, how they are learning, to
14:36
Speaker 3: identify them in those that they work with, and perhaps
14:40
Speaker 3: identify when those attributes may be lacking in those that
14:43
Speaker 3: they work with or themselves, and to develop sort of
14:48
Speaker 3: personal improvement plans to work on that. So, in addition
14:53
Speaker 3: to the sort of intellectual development piece which goes which
14:59
Speaker 3: is related more specifically to the sort of biomedical, biosocial
15:06
Speaker 3: and clinical sciences, there is the expectation in several of
15:11
Speaker 3: the LCNME elements that behaviors and attitudes are modeled and
15:17
Speaker 3: that those behaviors and attitudes are practiced by the students
15:22
Speaker 3: and actually are documented in a in a formal way
15:28
Speaker 3: as being achieved before the students graduate. So there are
15:32
Speaker 3: competencies that are associated not only with medical knowledge and
15:36
Speaker 3: patient care, but also with professionalism and how students are
15:43
Speaker 3: prepared to continue to learn after they're out of the
15:49
Speaker 3: of the school setting, so in other words, how they
15:52
Speaker 3: are prepared to learn in a self directed way, how
15:56
Speaker 3: they how they do their own quality assurance, and how
15:59
Speaker 3: they look at the system in which they're working in
16:02
Speaker 3: for quality assurance as well. So all of that is
16:06
Speaker 3: again relatively new and good expansion on what certainly these
16:14
Speaker 3: things were not as prominent when I was in medical school.
16:17
Speaker 2: It's a great deal of work and folks who listen
16:19
Speaker 2: to the podcast regularly may hear in the background some
16:23
Speaker 2: sociological considerations and can go back to our chat with
16:27
Speaker 2: Fred Hafferty, who talked about the hidden curriculum and some
16:30
Speaker 2: of those This is my line, not his, but thinking
16:34
Speaker 2: about the profession of medicine in part as a club
16:38
Speaker 2: or an organization that future physicians might join, right, and
16:42
Speaker 2: so professionalism training join. There are important features which are
16:49
Speaker 2: bars to me, not just in terms of medical science, right,
16:52
Speaker 2: So as a patient when I show up, there can
16:55
Speaker 2: be a physician who knows everything there is to know
16:57
Speaker 2: about X. But if we can't communicate, if I can't
17:00
Speaker 2: understand what's going on, that that's a barrier to optimal care.
17:05
Speaker 2: So it's yeah, I mean, the sort of what goes
17:08
Speaker 2: into accreditation is creditation is a ton I want to
17:13
Speaker 2: move us sort of in the same sort of profession
17:16
Speaker 2: kind of vein, but move us a little bit. Accreditation
17:19
Speaker 2: seems to be an aspect of self governance of a profession.
17:23
Speaker 2: Maybe it is, Maybe it is. I mean it's I
17:26
Speaker 2: think there's interesting features around external bodies serving as quality checks,
17:31
Speaker 2: which sounds great, right, You'll avoid a lot of bias
17:33
Speaker 2: in certain kinds of ways if you know you are
17:35
Speaker 2: not checking or a person isn't checking their own work
17:38
Speaker 2: on the one hand, On another hand, the kinds of
17:42
Speaker 2: expertise which practicing physicians have, you know, they may think
17:47
Speaker 2: with some confidence that they're the best ones to serve
17:50
Speaker 2: as guides. So what's the relationship between accreditation and outside
17:55
Speaker 2: entities the House of Medicine as it's sometimes called, between states, nations, governments.
18:01
Speaker 2: I mean, there's a lot of stakeholders here, right, So
18:04
Speaker 2: that's a huge question.
18:06
Speaker 3: Help, so you could expand and expand before, you know,
18:10
Speaker 3: before we talk about that, I think it's probably worthwhile
18:14
Speaker 3: to speak for just a moment about you know, I
18:17
Speaker 3: mentioned that this is an independent body, but didn't really
18:20
Speaker 3: talk about the fact that this is an independent body
18:24
Speaker 3: of peers that are doing this. So the way they
18:27
Speaker 3: LCME works is it is a panel of twenty one
18:33
Speaker 3: individuals and of those twenty one, seventeen of them are
18:38
Speaker 3: deans or very senior faculty members in accredited medical schools.
18:44
Speaker 3: Two are medical students in their final year of training,
18:49
Speaker 3: and two are public members, and everyone is voting members.
18:56
Speaker 3: The students are there for their final year of training,
18:58
Speaker 3: but the public members and a professor members are there
19:02
Speaker 3: if they choose for two three year terms, so there's
19:06
Speaker 3: a component of peer review in the accreditation process. Then
19:12
Speaker 3: to move to kind of the next level or the
19:15
Speaker 3: next orbital out from what you've described, Brian. The LCMME
19:20
Speaker 3: in turn is involved with the assurance to the graduate
19:29
Speaker 3: medical education programs that graduates of the medical schools are
19:34
Speaker 3: capable and have been sort of sealed of approval for
19:39
Speaker 3: graduation and ready for and competent to be residents. So
19:44
Speaker 3: from the external bodies, the Accreditation Council of Graduate Medical Education,
19:49
Speaker 3: they're the ones who are who accredit the residency programs
19:53
Speaker 3: require that MD students in the United States graduate from
19:59
Speaker 3: an LCMB accredited school. So that's one layer of connection.
20:04
Speaker 3: The other is that the in order for an individual
20:08
Speaker 3: to become licensed and credentials, there are a couple of
20:12
Speaker 3: steps that have to happen. The first is the sort
20:15
Speaker 3: of examination part of that, and that is done by
20:18
Speaker 3: the US Medical Licensing Examination through the National Board of
20:24
Speaker 3: Medical Examiners, and they in turn require that students or
20:29
Speaker 3: in MD programs in the United States are in LCMIA
20:33
Speaker 3: accredited programs. That's another way of ensuring that is to
20:37
Speaker 3: go through each step of this that that quality is
20:41
Speaker 3: being upheld. The other piece there is with the licensing boards.
20:46
Speaker 3: The state licensing boards routinely ask whether the individuals who
20:51
Speaker 3: are being licensed have graduated from LCMME accredited schools in
20:56
Speaker 3: the United States. So that's how the other pieces of
21:01
Speaker 3: the House of Medicine, if you will, become involved in
21:04
Speaker 3: this in what is hopefully a continuing and continuous process
21:11
Speaker 3: of quality assurance across the continuum from medical education learning
21:19
Speaker 3: to you know, beginnings of practice and residency and out
21:23
Speaker 3: into the continuing medical education world for licensed physitions.
21:28
Speaker 2: So with that background, I mean, that's all House of
21:30
Speaker 2: Medicine stuff, which is great because physicians are embedded within communities,
21:36
Speaker 2: and you talk before about training in communities, the role
21:41
Speaker 2: of sort of local government, states, nations. How what are
21:48
Speaker 2: the interactions with those stakeholders. And I say that before
21:51
Speaker 2: I move into ask about the lcn sort of changing
21:57
Speaker 2: some or eliminating some accreditation features. So what's relationship between
22:01
Speaker 2: get the House of Madison and the state or the
22:05
Speaker 2: US government. You know?
22:07
Speaker 3: The as for one one relationship is as we said,
22:11
Speaker 3: for the for the LCME, it is authorized by the
22:14
Speaker 3: Department of Education, does the The Department of Education has
22:23
Speaker 3: two types of authorization. When it accredits, it can accredit
22:29
Speaker 3: an institution, which is the way it would a credit,
22:32
Speaker 3: say my medical school to give the degree. And that's
22:38
Speaker 3: a separate accreditation piece. That is the accreditation that is
22:44
Speaker 3: associated with the ability of this school to offer federal
22:51
Speaker 3: funds for its students. Got that's separate from the l
22:56
Speaker 3: CME accreditation, which is called programmatic rather than institutional accreditation.
23:02
Speaker 3: So the LCMEME is not involved at all in in
23:07
Speaker 3: the eligibility for federal funds. It is actually involved only
23:14
Speaker 3: in the authorization of the program itself that leads to
23:20
Speaker 3: the MD degree. So that's one piece. So the direct
23:24
Speaker 3: relationship between the LCMEME and the federal government, for example,
23:30
Speaker 3: in terms of federal funding of higher education is one
23:36
Speaker 3: step removed. Then that relationship would be for an institutional accreditor.
23:42
Speaker 3: And you know an example of an institutional creditor, you know,
23:45
Speaker 3: for our area, Brian is like Middle States, there are
23:48
Speaker 3: several you know, throughout the throughout the country, there's probably
23:51
Speaker 3: six or seven of them, although there may be more coming.
23:55
Speaker 3: But so the one thing that I will say is
24:00
Speaker 3: that the schools themselves obviously are especially state schools are
24:08
Speaker 3: very dependent on state funding. And all of our medical schools,
24:13
Speaker 3: to one degree or another, whether it's directly for medical
24:17
Speaker 3: education or whether it's for research, are involved with federal
24:22
Speaker 3: funds as well. The LCME isn't directly involved in that.
24:27
Speaker 3: But and this leads to, I think where your questions
24:31
Speaker 3: will come. What has been happening over the last and
24:35
Speaker 3: this started about three years ago. This is this is
24:38
Speaker 3: not new. This did not happen six months ago. We
24:43
Speaker 3: were starting to hear from more and more of our
24:47
Speaker 3: colleagues in schools in various states that state legislation was
24:55
Speaker 3: was asking them to do or not do things that
25:00
Speaker 3: were inconsistent with the expectations that the LCME had. And
25:08
Speaker 3: this started, I mean we started actually in one of
25:13
Speaker 3: our southern states, probably again two and a half years ago,
25:18
Speaker 3: and what the kinds of restrictions that were being talked
25:22
Speaker 3: about were predominantly focused on one of the lcme's elements,
25:28
Speaker 3: which was Element three point three, which was diversity programs
25:33
Speaker 3: in partnerships. And it's important to say something about what
25:37
Speaker 3: that element was about and is about, and the element
25:44
Speaker 3: itself expected certain things of LCME accredited schools on the
25:51
Speaker 3: highest level, it expected the schools to have identified they're
25:58
Speaker 3: all mission appropriate diversity categories for students, faculty, and senior
26:06
Speaker 3: administrative staff. And mission appropriate meaning given their culture, given
26:12
Speaker 3: their location, given where they were, and what they could do,
26:17
Speaker 3: how were they for what categories? Perhaps were they best
26:22
Speaker 3: positioned to promote a healthcare workforce that really was as
26:28
Speaker 3: diverse as possible. So as you can imagine, if you
26:33
Speaker 3: were a school in in North Dakota, you might be
26:38
Speaker 3: able to to develop and devote to resources perhaps in
26:44
Speaker 3: working with the Native American population, to increase the number
26:49
Speaker 3: of students sort of coming up through the lower phases
26:53
Speaker 3: of education up until the higher stages of education, and
26:57
Speaker 3: to recruit perhaps individuals of that particular category. If you
27:02
Speaker 3: were in the middle of Manhattan, or if you were
27:06
Speaker 3: in the middle of Chicago, then your diversity categories may
27:11
Speaker 3: be different and many For some schools those were based
27:14
Speaker 3: on race and ethnicity. For other schools, especially schools in
27:19
Speaker 3: the Midwest, that were based on rural upbringing, perhaps with
27:24
Speaker 3: the idea of really trying to increase the likelihood of
27:31
Speaker 3: enhancing the number and the quality of healthcare professionals in
27:36
Speaker 3: rural areas. So the LCN said, you decide what those
27:41
Speaker 3: categories are and do everything that you can to recruit
27:47
Speaker 3: and retain within those categories. And starting about even before,
27:53
Speaker 3: about three years ago, it became very clear that it
27:56
Speaker 3: was difficult for schools to capture this information for faculty
28:03
Speaker 3: and senior administrative staff for a number of reasons. For
28:08
Speaker 3: many cases, human resources would not release the data in
28:11
Speaker 3: that way, so a schools really couldn't capture it and
28:14
Speaker 3: other things. The other reason relates, Brian to something we
28:17
Speaker 3: said at the very beginning, and that is that as
28:22
Speaker 3: the health systems grew and they were bringing in more
28:26
Speaker 3: and more practices, more and more smaller hospitals, the physicians
28:31
Speaker 3: associated with those often became faculty members of one of
28:38
Speaker 3: the schools that were associated with that health system. So
28:42
Speaker 3: the faculty recruitment was driven primarily by healthcare delivery unit expansion.
28:52
Speaker 3: It wasn't driven primarily by a school saying we need
28:56
Speaker 3: a faculty member in physiology, so we are going to design,
29:00
Speaker 3: you know, a search process for this. Yes, some of
29:03
Speaker 3: that was happening, but those numbers were tiny compared to
29:08
Speaker 3: the numbers of individuals that were brought onto the faculty
29:12
Speaker 3: because they were part of a hospital system or a
29:15
Speaker 3: practice that became part of the academic health center in
29:20
Speaker 3: which those students were training. So those numbers didn't make
29:26
Speaker 3: any sense, and so the LCME decided that it wasn't
29:30
Speaker 3: reasonable to expect schools to collect that. So another little
29:35
Speaker 3: piece of that Element three point three sort of was
29:39
Speaker 3: carved away. What happened in two and a half years
29:45
Speaker 3: ago and really became a very very clear and prominence
29:51
Speaker 3: about four months ago, was that certain states had very
29:56
Speaker 3: very clear legislation that was threatening the the entire ability
30:02
Speaker 3: of schools to meet what was expected by Element three
30:06
Speaker 3: point three. So specifically it was Arkansas that was the
30:14
Speaker 3: sort of proximal cause of the lcm's decision. This was
30:18
Speaker 3: in March, I believe, there was a piece of legislation
30:21
Speaker 3: called the Access Act, and among many many other things
30:25
Speaker 3: in here, it prohibited any school, including medical schools, from
30:32
Speaker 3: collecting and or sharing any information related to the diversity
30:40
Speaker 3: of its student population or any other population. So the
30:45
Speaker 3: LFCME has always promised its schools two things, and one
30:52
Speaker 3: was that it would have the same expectations for all
30:57
Speaker 3: schools and not have different bars are different levels of
31:02
Speaker 3: expectation for different schools because this is a national thing,
31:06
Speaker 3: and again it's a national guarantee, if you will, so
31:10
Speaker 3: that there would be one set of expectations for all programs.
31:15
Speaker 3: And the second was that they would never do anything
31:18
Speaker 3: or require something that would put the school in the
31:22
Speaker 3: crosshairs of its local government, state government, national government, you
31:28
Speaker 3: name it. And this act, which was on the books
31:33
Speaker 3: passed as opposed to an executive warner or something that
31:37
Speaker 3: was threatened, was very clearly going to make it impossible
31:42
Speaker 3: for the state schools, for example, in that state, to
31:45
Speaker 3: be able to comply. And that underlied the lc and
31:50
Speaker 3: these decision, you know, those two principles, not going to
31:54
Speaker 3: have different standards for different schools and not going to
31:58
Speaker 3: do anything that is going to compromise your ability to
32:04
Speaker 3: both meet the lcme's expectations and meet the requirements of
32:10
Speaker 3: for example, state law. And I could tell you that
32:14
Speaker 3: that was a really tough decision for that twenty one
32:18
Speaker 3: member group that I mentioned before, the LCME, a lot
32:22
Speaker 3: of discussion, a lot of hand ringing, and a lot
32:26
Speaker 3: of sadness, quite frankly, and at the same time, it's
32:32
Speaker 3: important to remember that schools that can continue to do
32:36
Speaker 3: that can absolutely continue to do that. The LCME is
32:40
Speaker 3: not going to hold schools to that expectation. But that
32:45
Speaker 3: doesn't mean that there is that there is any sense
32:49
Speaker 3: that somehow doing this is prohibited by the LCME, just
32:53
Speaker 3: just the opposite.
32:55
Speaker 2: I mean, I have loads of questions. We only have
32:57
Speaker 2: so much time. There's a I mean, there's something I
32:59
Speaker 2: think ethically appropriate. You can't hold folks to act on
33:06
Speaker 2: certain kinds of information if they don't have it, or
33:08
Speaker 2: if you know, if you can't report or assess or
33:11
Speaker 2: check the information. It's we always find about attendance policies
33:15
Speaker 2: right and schools across the board. And if you can't
33:17
Speaker 2: tell who's in the room, you can't require folks to
33:20
Speaker 2: be in there. This sounds right now, sort of intuitively right,
33:24
Speaker 2: it's and we talked about this in COVID and different
33:26
Speaker 2: kinds of situations. But I mean the there's I think
33:32
Speaker 2: interesting questions around the relationship between national and local, and
33:37
Speaker 2: I appreciate the consistency. Right, So, as a patient, I
33:40
Speaker 2: walk in and I know you know much more now
33:42
Speaker 2: that I've spoken with you, but I know the quality
33:44
Speaker 2: check covers you know, the US as a whole. But
33:48
Speaker 2: as you mentioned before, medical schools. It seems like a
33:51
Speaker 2: really local right the three point three was connect it
33:55
Speaker 2: would act differently or be realized differently in one state
34:00
Speaker 2: opposed to another based on the local community considerations. And
34:04
Speaker 2: so maybe there's some space for difference there. And I
34:08
Speaker 2: appreciate there's the l c ME is you know, sort
34:12
Speaker 2: of sort of happy with these efforts continuing. It's be well,
34:16
Speaker 2: let me ask you this way, what if Arkansas changes
34:19
Speaker 2: it's or someone else changes their law and now it's
34:22
Speaker 2: possible for the l cm or it's possible for schools
34:27
Speaker 2: to report the information in certain kinds of ways, would
34:29
Speaker 2: three point three be back on the table sort of?
34:33
Speaker 2: And it can be about this can be about something
34:35
Speaker 2: else that sort of How do how do you think
34:37
Speaker 2: about change because you have to be a responsive to
34:41
Speaker 2: different local constituencies.
34:44
Speaker 3: That's a really good question, Brian.
34:46
Speaker 2: I you know that.
34:47
Speaker 3: I'm glad you brought up the first part about the
34:51
Speaker 3: you know, Arkansas law. If it was a law, that's
34:56
Speaker 3: the problem for that was the problem for the LCMME.
34:59
Speaker 3: You know, if this were a piece of legislation that
35:04
Speaker 3: was being discussed, and I can tell you there are
35:07
Speaker 3: probably a hundred of them that are being discussed in
35:10
Speaker 3: different states right now. But this was on the books,
35:13
Speaker 3: so in order for it would have to be there'd
35:16
Speaker 3: have to be a lawsuit, it would have to get
35:18
Speaker 3: turned overturned. And that is why that had more of
35:24
Speaker 3: weight with the LCMME than an executive order might have.
35:30
Speaker 3: Well put it that way, now, the world is constantly changing.
35:37
Speaker 3: If the world changes back, shall we say, and there
35:42
Speaker 3: is absolutely no reason that the LCME would not consider,
35:48
Speaker 3: you know, reinstating something like this. I do think that
35:51
Speaker 3: there is some potential maneuverability with the idea of pathway
36:00
Speaker 3: programs and and you know, because there I think the
36:05
Speaker 3: link to community and to things that stretch beyond medical
36:11
Speaker 3: education per se that that you know, stretch beyond missions
36:16
Speaker 3: to medical school and stuff like that, which really tends,
36:19
Speaker 3: I think to be the flash points for most of
36:24
Speaker 3: what we've been hearing about. It would be hard, you
36:27
Speaker 3: would think, to argue, for example, if you were in
36:31
Speaker 3: a state with vast rural needs, to say that a
36:38
Speaker 3: program that would be focused on bringing up through the
36:46
Speaker 3: education and through exposure not only to students but actually
36:50
Speaker 3: to parents to get you know, the idea of more
36:54
Speaker 3: participation in healthcare from that particular group. And again, it
36:59
Speaker 3: can be based on geography, it can be based on
37:01
Speaker 3: race and ethnicity, it can be based on socioeconomic status.
37:07
Speaker 3: You know, I will emphasize that the LCN schools used
37:14
Speaker 3: all of those categories. They didn't use all of them
37:16
Speaker 3: in any one's school even but the California schools had
37:22
Speaker 3: been prohibited for a long time from using race and
37:27
Speaker 3: ethnicity in their recruitment for medical students, and yet many
37:33
Speaker 3: of the state schools had been very successful in having
37:38
Speaker 3: a student population that had that was diverse in terms
37:42
Speaker 3: of backgrounds in all kinds of ways. So the ability
37:48
Speaker 3: to continue forward without necessarily defining your categories in terms
37:57
Speaker 3: of race and ethnicity has always been that has been
38:02
Speaker 3: a problem for schools. Now largely because of their legal counsel.
38:09
Speaker 3: They're saying that these are sorry. You know, so there's
38:11
Speaker 3: all kinds of stuff saying that is that is happening,
38:15
Speaker 3: and you know, again it's it's beyond your mind or
38:20
Speaker 3: the lcme's ability to what's the word be very clear
38:27
Speaker 3: about the ways in which words sometimes are being used
38:33
Speaker 3: as catalysts for reactions without much thinking about what the
38:38
Speaker 3: purpose of those words actually happens to be.
38:43
Speaker 2: That's a point well taken, and for uh brings me
38:47
Speaker 2: to one of my usual soapboxes, which I think medical
38:51
Speaker 2: students should study more philosophy. But that's a whole different conversation.
38:54
Speaker 2: It's I mean, it's terrifically interesting because the lcme right,
38:58
Speaker 2: you're really interested in the programs, right, And this was
39:01
Speaker 2: really helpful talking about the programs and in allowing which
39:04
Speaker 2: sounds exactly right, allowing schools with particular missions to realize
39:09
Speaker 2: those missions how they have to in light of where
39:11
Speaker 2: they are. And there's interesting working ethics and sort of
39:13
Speaker 2: obligations given.
39:14
Speaker 1: Location and all that.
39:16
Speaker 2: And so I imagine accreditation and maybe certain kinds of
39:20
Speaker 2: assessments in the future will be more challenging, maybe open
39:25
Speaker 2: up opportunities for creativity, because I know the medical school
39:28
Speaker 2: I teach at, which of course is the best medical
39:30
Speaker 2: school in the world, Hackensack Marine In School of Medicine,
39:32
Speaker 2: is really interested in the local community, in care for
39:37
Speaker 2: patients in New Jersey, and so medical students who are
39:39
Speaker 2: really interested in that, right, I mean, this is part
39:41
Speaker 2: of the mission inability to it may require creativity to
39:47
Speaker 2: assess that in certain kinds of ways. And to just
39:51
Speaker 2: help and make sure that the school is living up
39:53
Speaker 2: to its mission. So that's I mean, it's it's sort
39:58
Speaker 2: of in the backdrop, and the longer history is much
40:01
Speaker 2: better because occasionally when I see headlines, you know, your
40:03
Speaker 2: eyes are pulled toward certain things and think, you know,
40:06
Speaker 2: recency bias and all of that. But given the research
40:10
Speaker 2: that suggests serven shows that patients often have better outcomes
40:15
Speaker 2: when they identify in certain ways with the practitioner, I
40:18
Speaker 2: imagine that was on the mind of folks as they
40:20
Speaker 2: considered three point three and whether they keep it or
40:23
Speaker 2: not and raises Yeah, I mean, it's just I think
40:26
Speaker 2: it more creativity will be needed to sort of train
40:31
Speaker 2: future physicians to provide optimal patient care.
40:34
Speaker 3: Yeah, I think. You know, it's important to realize too
40:37
Speaker 3: that the two things. One is that the school themselves,
40:43
Speaker 3: with their mission in mind, certainly have access to the
40:48
Speaker 3: information and the data to show that they are accomplishing
40:54
Speaker 3: what they're set out to accomplish. In my internal means,
40:58
Speaker 3: whether the me is looking at me. Teamy never looked
41:02
Speaker 3: at that specifically anyway. You know, it said set this
41:05
Speaker 3: up for yourself, do the best you can. What we
41:08
Speaker 3: want to be able to support or to get behind.
41:13
Speaker 3: Is the idea that each school can sort of personalize
41:18
Speaker 3: its approach so that it can selectively best deploy its
41:23
Speaker 3: resources to contribute this to the national landscape, you know,
41:28
Speaker 3: and and then hopefully, because there are so many schools
41:33
Speaker 3: contributing in a different way by trying to have their
41:38
Speaker 3: missions and their recruitments and their delivery and their contact
41:42
Speaker 3: with the community is aligned that nationally, that gives a
41:47
Speaker 3: broader picture. And the other thing was that from an
41:51
Speaker 3: education perspective, there is clearly and will continue to be
41:58
Speaker 3: an expectation from the lc and me that students, regardless
42:03
Speaker 3: of who they are or where they're from, are prepared
42:07
Speaker 3: to be able to take care of and work both
42:11
Speaker 3: in a preventive way and as a healthcare interventionist way
42:15
Speaker 3: with people with all different backgrounds. And so the ability,
42:20
Speaker 3: the educational piece of that is wrapped into the lcnb's
42:26
Speaker 3: expectations as well. Is it possible that the terminology we
42:31
Speaker 3: talked about words and how people sometimes focus on words,
42:35
Speaker 3: the terminology may change, that concept will remain and it'll
42:40
Speaker 3: be there very prominently in what the LCNB expects. So
42:44
Speaker 3: the training and focus on the importance of this and
42:49
Speaker 3: training is not coming out.
42:52
Speaker 2: RNNI, thanks so much for the time to day. I
42:54
Speaker 2: have a load of other questions. I'm sorry, but I
42:56
Speaker 2: see I see the clock, So I mean and I
42:59
Speaker 2: think this was extremely helpful. We got into the weeds,
43:01
Speaker 2: which I really enjoyed on some accreditation questions and issues,
43:06
Speaker 2: and I think it's really important, maybe now more than ever,
43:09
Speaker 2: or maybe not. People probably say that every couple of
43:11
Speaker 2: decades or so, but for folks to be able to
43:13
Speaker 2: understand how quality is ensured, and I think this leads
43:17
Speaker 2: to greater trust and all sorts of positive things. So
43:21
Speaker 2: I'll get you let you out on this last question
43:24
Speaker 2: for folks who found this really interesting. Anything you're doing, writing,
43:29
Speaker 2: speaking at, anything that you're that's sort of upcoming for
43:32
Speaker 2: you that you think folks should know about, well.
43:36
Speaker 3: I think you know, we do an awful lot of
43:39
Speaker 3: speaking to different constituent groups, like within medicine. But what
43:43
Speaker 3: we do have a public website, and on our public
43:47
Speaker 3: website it's LCME dot org. There is a horizontal navigation
43:52
Speaker 3: bar that talks about strategic visioning and the kinds of
43:56
Speaker 3: things that the LCME is thinking about going forward. So
44:00
Speaker 3: we welcome you know, people to access that. And the
44:05
Speaker 3: other piece there too is you know, also available on
44:09
Speaker 3: that website are the standards and the elements and you
44:13
Speaker 3: and they're there for the last three years, so you
44:16
Speaker 3: can actually see the evolution of of some of this.
44:20
Speaker 3: So that's what I would say from a general perspective,
44:24
Speaker 3: and for those people who do have touch points within
44:28
Speaker 3: the medical sort of education community, we do is actually
44:34
Speaker 3: even more. We also on our website there is a
44:39
Speaker 3: we have monthly webinars that are devote you know, devoted
44:43
Speaker 3: to different topics and themes, and the PDFs of those
44:47
Speaker 3: slides are posted on the public website as well, so
44:51
Speaker 3: there may be information there that is of interest in
44:55
Speaker 3: different areas and different topics.
44:58
Speaker 2: That's great and we'll make sure to thank to all
45:00
Speaker 2: of that on our show page. Ronnie, thank you so
45:03
Speaker 2: much for the time. Everyone, Thanks for listening. I've been
45:05
Speaker 2: speaking with doctor Veronica Cattonese about all things accreditation, ethics
45:10
Speaker 2: and medical education. Thanks so much, Ronnie, I appreciate it, Okay,
45:14
Speaker 2: but bye, thank you.
45:14
Speaker 1: Series is a production of the Health Ethics Lab, and
45:17
Speaker 1: I am grateful to colleagues in the Department of Medical Sciences.
45:20
Speaker 1: The IHS Library and the Hackensack Ready In the School
45:23
Speaker 1: of Medicine for making this collaboration possible. To learn more
45:27
Speaker 1: about our work or to engage with the series content,
45:30
Speaker 1: reach out to me Brian Pilkington at Brian dot Pilkington
45:34
Speaker 1: at HMH and dot org.