http://www.aamc.org/newsroom/pressrel/2005/051106.htm

Washington, D.C., November 6, 2005 - AAMC (Association of American Medical Colleges) President Jordan J. Cohen, M.D., delivered the following address today at the association's Annual Meeting:
"As you know, the theme of this year's meeting is Beyond Boundaries. And, like any good theme, this one works on many different levels. Taken literally, it obviously evokes medicine's increasing globalization, as just detailed so eloquently by Lynn Eckhert.
On another level, it reminds us of the boundaries of courage and creativity crossed by our colleagues in Louisiana, Mississippi and Texas as they grapple with the horrific catastrophe unleashed by Hurricanes Katrina and Rita. And closer to home, it acknowledges that the AAMC is about to cross a boundary of its own as it identifies a new president.
The time seems right, therefore, to consider some of the challenges the new president and his or her team will face-the work ahead, if you will. Judging by the array of unanticipated issues that surfaced on my 12-year watch, it would be foolhardy to be too prescriptive about the work that lies ahead.
After all, who could have predicted the doubling of the NIH's budget, or the achievement-finally-of gender parity among medical students? Who could have foreseen the sudden collapse of the Clinton health care plan, or the legal challenge to the Match? The acutely threatening PATH audits, or the overnight crash of AMCAS, the electronic medical school application service? And certainly, none of us was prepared for the public outcry triggered by the tragic death of Jesse Gelsinger.
The one certainty we can count on in the future is that unexpected events will continue to occur and will command attention. But some of the work ahead can be specified with reasonable assurance. An obvious example is the work the AAMC must continue to do to support the multiple needs of its many constituencies.
Equally important in my view, the AAMC must continue to serve as a principled voice of leadership for American medicine. Indeed, given our challenging times, opportunities for raising that leadership voice are likely to be many.

Today, as I deliver my final annual meeting address, I would draw your attention to five present and future challenges for which a strong AAMC voice will be especially important.
Challenge number 1 is to increase the racial and ethnic diversity of the medical profession.
As medical educators, our core obligation is to prepare a future physician workforce that is optimally equipped to address America's health care needs. As our country becomes increasingly multiracial and multicultural, racial and ethnic disparities in health and health care remain major blights on our system-and on our profession.
Increasing the racial and ethnic diversity in the medical school classroom and in the physician workforce is essential to eliminating those disparities.
As you all know, just two short years ago, higher education surmounted a serious challenge when the Supreme Court barely upheld the legality of using narrowly tailored affirmative action in admissions.
The deciding vote was cast by Justice Sandra Day O'Connor, who, in writing the majority decision, expressed her expectation that '25 years from now, the use of racial preferences will no longer be necessary.'
So, the legal clock is ticking, and could even speed up depending on the future make-up of the Supreme Court. In whatever time remains, medical schools must not only redouble their efforts to identify qualified minority candidates in the existing applicant pool, they also must do everything in their power to advance the academic preparedness of underrepresented minority students and to increase their interest in medicine as a career.
To fail in this effort would be to fail in one of our most sacred obligations-serving the health care needs of all Americans. I have no doubt that the AAMC will continue to play its part in this effort, but the real work ahead must be done by you and your colleagues.
Those institutions that participated in the AAMC's Health Professions Partnership Initiative have provided important guidance for that work. This initiative, a nine-year effort funded by the Robert Wood Johnson and the W. K. Kellogg foundations, produced several successful models for strengthening the educational pipeline through close working relationships between academic medical centers and regional K-12 and college collaborators.
But no matter how hard we try, we can only do so much by ourselves to solve this problem. Medical schools and teaching hospitals also must use their considerable moral suasion to convince society at large of its stake in closing medicine's unconscionable diversity gap.
To reach the long-term goal of a medical profession that looks more like America, we must forge an effective alliance with the public to address the deep-seated societal ills that lie at the root of the problem.
Challenge number 2 is to lead the transformation of the health care system.
Wouldn't it be nice if medical schools and teaching hospitals operated more like law schools and moot courts-that is, in a safe, sequestered academic enclave, insulated from the vicissitudes of the real world and free to contemplate an idealized version of reality? But, as we know all too well, we are anything but insulated from reality.
And the reality confronting us is becoming increasingly dysfunctional as our healthcare system becomes increasingly obsolete.
Obsolete systems, like the one we've inherited, cannot be 'fixed'. It is not 'broken,' as commonly thought, it is an outmoded, archaic legacy system that must be replaced. Mike Johns from Emory suggested that I use the following analogy to characterize the futility of trying to fix an outmoded system rather than discarding it and designing one capable of meeting new expectations and new realities.
He said, imagine trying to fix a model 'T' Ford so that it could fly. You could put in a larger, more powerful engine, take off the fenders, strap on wings, and put on a pair of aviator goggles. But you still couldn't get the damn thing off the ground!
So it is with the legacy healthcare system we've inherited-a fragmented, uncoordinated, fee-for-service conglomeration that tolerates wide variations in practice by excessively autonomous providers and that repeatedly fails to provide many patients with the right care at the right time. Such a system cannot hope to address the health needs of a new era characterized, among other things, by:

• An overwhelming burden of chronic illness
• Unprecedented complexity and specialization
• Major system failures undermining patient safety
• Inexorable increases in health care costs, and
• Demands for greater accountability, reliability and quality.

Like that Model T Ford, we could tinker endlessly with our current health care system, trying to make it work for an entirely different set of needs than the one it was originally designed to address. Or, we could get to work building a new one.
Doing so, however, will not be easy. Neither the Congress, nor state governments, nor insurance companies, nor employers, nor even the invisible hand of the market is likely to catalyze the needed transformation in a timely way.
Our best hope, in my opinion, is for academic medical centers to take the lead in establishing integrated and accountable models, prototypical of the system of the future. Many AAMC constituents,

• with their organized faculty practice plans,
• their hospital networks,
• their community physician referral bases,
• their IT infrastructure,
• and their loyal patients, already have the ingredients necessary for a nascent system of the future.

Aggregating these ingredients into robust demonstration projects, preferably in collaboration with other regional academic centers, could illustrate in real time the multiple advantages of a system designed explicitly and prospectively to deal with the realities of today.
To help catalyze this transformation, the AAMC's new Institute for Improving Clinical Care is working with medical schools, teaching hospitals, and clinical faculties to mount innovative solutions designed to get the healthcare delivery system off the ground so it can truly fly.
A prime example is the institute's Academic Chronic Care Collaborative, in which 22 of our member institutions are embedding evidence-based techniques for managing patients with chronic illnesses into their complex learning and research environments. I long to see the AAMC catalyze scores of similar efforts across the full spectrum of our clinical activities.
Challenge number 3 is to strengthen the continuum of medical education.
The AAMC's principal strategic commitment is to be the champion of medical education. Over the past decade or two, that commitment has kept us running very hard to keep pace with a fast moving scene.
Indeed, you and your colleagues across the country have been responsible for implementing the most profound changes in the content and processes of medical education since Flexner's time. And I'm proud to say that the AAMC has been on the leading edge of many of those changes.
But much, much more must be done to truly align medical education, in all three of its interlocking phases, with the rapidly evolving scientific underpinnings of medicine, as well as with the public's growing expectations of physicians.
Much of the work ahead was outlined in the 2004 report of the AAMC's Ad Hoc Dean's Committee, entitled 'Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States.' This watershed report, which I hope you all have read, identified multiple opportunities for significant improvements across the entire continuum of medical education.
For the undergraduate phase, the report underscored the need to establish a strong foundation in the biomedical sciences, and an understanding of the relevance of those sciences to clinical practice.
It called for focusing more effort on the clinical education of students; for creating a better balance among in-patient, ambulatory, and community-based experiences; and for incorporating more interdisciplinary curricular arrangements.
For graduate medical education, the report recommended greater institutional accountability, a reduction in non-educational service demands, and better alignment of residency curricula with what practicing physicians actually do.
But perhaps the report's most demanding challenge was in the area of continuing medical education, where it identified an urgent need to shift from the current paradigm of predominately passive, lecture-based learning toward one that is based on active, self-directed, practiced-based formats.
Indeed, the ultimate goal is to tie CME directly to an assessment of individual physician performance, identifying specific areas for improvement, crafting appropriate educational interventions, and documenting whether the doctor's practice actually gets better as a result.
Recognizing the central role that our faculties play in CME, both in programs sponsored by medical schools and in those sponsored by other organizations, the AAMC is in a unique position to exert forceful leadership in transforming the country's CME system into a true quality improvement enterprise.
As intended, the recommendations of the dean's report for all three segments of the medical education continuum have provided the framework for several important strategic initiatives of the AAMC's Institute for Improving Medical Education.
The institute's purpose is to catalyze innovation within our constituent institutions and, equally important, within the broader framework of accreditation, licensure and certification that overarches the entire medical education enterprise. The AAMC can certainly help, but the hard work ahead-and there's a lot of it-must be done by all of you.
Challenge number 4 is to uphold the integrity of research and assure the safety of human research subjects.
Nothing we do defines our ethics and our commitment to public welfare more than how we conduct research. Indeed, the general level of public trust in medical schools and teaching hospitals is, in large measure, the direct result of our reputation for scientific integrity.
We must recognize that the very nature of modern medical research poses many new threats to scientific integrity and, of even more concern, to the safety of human subjects involved in clinical research.
The work ahead in this arena is certain to be even more challenging than it has been in the past. The increasingly important partnerships between academe and industry, while unquestionably accelerating the translation of discovery into useful products and services, will continue to raise the specter of pernicious conflicts of interest.
We dare not allow those conflicts to undermine the public's trust in our integrity.
But preserving public trust in our research mission requires much more than monitoring and managing conflicts of interest. Ensuring the responsible conduct of research also requires that institutions remain mindful of the need to uphold the highest standards of research integrity, even in the most routine functions of basic and clinical investigation.
As our research enterprise becomes more complex, more dispersed, and more collaborative, maintaining rigorous adherence to standards of ethical conduct will be an evermore-demanding challenge.
I'm extremely proud that the AAMC has been such a strong advocate for the responsible conduct of research. Over the past decade, the association has spawned multiple activities in support of our constituents' efforts to maintain the highest standards in this critical arena, including:

• our Taskforce on Financial Conflicts of Interest in Clinical Research
• our sponsorship of AAHRPP -- the Association for the Accreditation of Human Research Protection Programs
• our cooperative agreement with the Office of Research Integrity to foster the responsible conduct of research among our member institutions, and
• our recent Conference on the Integrity of Reporting of Clinical Research Studies, which culminated in a set of demanding principles endorsed overwhelmingly by the AAMC Executive Council and now being promulgated widely.

These and related efforts are prime examples of the value of a professional association dedicated to public welfare and mindful of the overriding importance of public trust. In the work ahead, the AAMC must continue to play a prominent role in safeguarding that trust.
Challenge number 5 is to enlarge the capacity of LCME-accredited medical schools.
As Yogi Berra is famously credited with saying, 'prediction is a risky business, especially about the future.' Nowhere is that adage more apt than in trying to predict our country's future need for physicians.
As I'm sure you all remember, the AAMC, along with most other national organizations, announced with great fanfare less than a decade ago that the U.S. was heading for a huge surplus of physicians.
The assumptions underlying that prediction seemed altogether reasonable at the time-namely, that closed panel HMOs would soon become the dominant mode of healthcare delivery. Since that model uses far fewer physicians than the open-ended, fee-for-service model, we and many others surmised that the U.S. would soon be awash in an abundance of doctors. How quickly things change!
The consensus now is that present trends will soon culminate in a significant shortage of physicians. Workforce gurus now point to the fact that our population is increasing substantially, is growing older, and is using more healthcare services. In the meantime, the overall supply of physicians is barely increasing at all.
Moreover, physicians as a group are growing older even faster than the U.S. population, while younger physicians are choosing to work shorter hours. Convinced that these trends are unstoppable, the AAMC this past February called for an expansion of medical school and GME capacity by some 15 percent over the next 10 years.
Will this be enough? Is 15 percent the right number? Who knows? What we do know is that a 15 percent increase in our graduates will add only about 2500 new MDs to the workforce each year, and only after many years in the pipeline, at that.
Close monitoring of the physician supply and demand will be essential to recalibrate our target, if needed. Should current trends continue, even more doctors may be called for. Alternatively, should the healthcare delivery system be refashioned along more rational lines, fewer may be needed.
Fortunately, the AAMC's new Center for Workforce Studies, which is already making significant contributions to our understanding of this complex issue, is positioned to play a key role in helping us keep tabs on future trends.

But there is much more at stake for us in this arena than just getting the overall number right. We need, as a community, to have a serious discussion about the nature of the educational pipeline that produces our nation's doctors.

Let me ask you a question:
What fraction of the physicians emerging from ACGME-accredited training programs and joining the practitioner workforce each year do you think are graduates of LCME-accredited medical schools?
The answer may surprise you. It certainly surprised me. The answer is 64 percent-less than two thirds.
As Lynn Eckhert noted a few moments ago, of the some 24,000 individuals who funnel through the GME pathway toward independent practice each year, more than one third-over 8,500 individuals-have received their undergraduate medical education from somewhere other than an LCME-accredited school.
To be specific, about 2,700 are graduates of osteopathic medical schools, some 1,300 are U.S. citizen graduates of foreign medical schools, largely in the Caribbean, and well over 4,500 are non-U.S. citizens who attended a wide variety of schools abroad.
As you may know, all the other suppliers of U.S. physicians-the osteopathic schools, the for-profit offshore schools, and many other foreign schools-also see a U.S. doctor shortage on the horizon, and they are rapidly expanding their capacity even as we speak. Five new osteopathic schools have opened in the past 10 years and several more are on the drawing board.
Even more arresting, no fewer than 15 off-shore schools have opened their doors over the same 10-year period and those already in existence are increasing their capacity dramatically. India, and perhaps other foreign countries, see a lucrative export market for physicians and are cranking up their already sizable medical education apparatus.
Hence, if current projections prove accurate-that our health care system will demand and be able to assimilate many more doctors over the next few decades-we could be facing an unwelcomed reality. When considered against the far more dramatic expansion occurring in the non-LCME world, our modest expansion plans could result in our corner of the medical profession becoming a minority presence.
Is this a cause for concern? I certainly think it is. To think otherwise would imply that ACGME training provides graduates of non-LCME schools with all the benefits our students obtain as undergraduates-that by the time residents finish their training, any differences that existed on entry to GME are no longer evident. I just don't believe that.

I think our model of undergraduate medical education offers the public something of special value-that it equips our students with a set of critically important, foundational capabilities and attitudes that the current format of GME does not and cannot provide.
Even if you think otherwise, consider the ethical questions raised by our reliance on foreign schools to educate so many of our country's doctors. Can we, in good conscience, continue to recruit so many highly educated professionals from developing countries who clearly need them much more than we do?
A recent United Nations report captured this issue in its headline: 'Health care brain drain threatens to overwhelm developing world.'
Last week's New England Journal of Medicine echoed that threat and documented its magnitude.
And there is yet another ethical question raised by our current reliance on foreign schools. What is our obligation to qualified American citizens who aspire to become doctors? Rather than consign so many of them to schools in the Caribbean, don't we have a civic responsibility to open our doors to more students who can meet our standards?
Given the need to ensure that the preponderance of tomorrow's doctors are educated in LCME-accredited medical schools, and the need to face up to the ethical implications of a global medical brain drain, I've come to the conclusion that we should begin thinking seriously about expanding our capacity, not by 15 percent, but by something more like 30 percent, or 5,000 additional MDs each year.
Considering the large gap between the number of students we now graduate each year and the much larger number of GME slots that exist, an expansion of this magnitude would still leave room for over 1,000 graduates of foreign schools each year, even if an expanded physician workforce turned out to be unneeded and GME capacity were not increased at all--which seems highly unlikely.
Increasing U.S. medical school capacity by 5,000 students per class is a tall order, to be sure, but not impossible. Consider this scenario: an average increase of 30 students per class for each of our current 125 schools would get us three-quarters of the way to this goal.
Just eight new schools with an average class size of 150 would take us the rest of the way. Our analysis shows that there are plenty of qualified applicants already available. Using MCAT scores as a rough indicator, we could accept 30 percent more students from the current pool and still have an entering class with an average total MCAT score above 26.
So, there you have it, five sizable challenges for which a strong AAMC voice will be vitally important in the work ahead.
1. Increase the racial and ethnic diversity of the medical profession
2. Lead the transformation of the health care system
3. Strengthen the continuum of medical education
4. Uphold the integrity of research and assure the safety of human research subjects
5. Enlarge the capacity of LCME accredited schools
Grappling with these challenges undoubtedly will consume time and effort far beyond the boundary of my tenure at the AAMC. And, for that reason, I hesitate to add still another challenge to this list.
But there is one more I feel compelled to articulate, a challenge that is arguably more important than any other and that drives to the core of what medical education and medical educators are all about.
What is our fundamental job, anyway? What existential purpose are medical educators charged to fulfill?
The reflex answer is that we are charged to impart the information and the skills needed by the next generation of physicians so that they will know and will be able to do what is necessary to help their patients.
Pretty straight forward. And indeed we spend a lot of time talking and planning and implementing educational programs to be sure they include the scientific information and the clinical skills we deem essential for our students to master.
But is that all? Does the profession of medicine only require its members to know and to do what patients need? My answer, and I hope yours, is 'no, not by a long shot.'
Possessing the requisite scientific knowledge and the technical and clinical skills are obviously necessary for every physician, but they are not, and they have never been, sufficient for a doctor who purports to be a true professional.
What's essential, in addition to those attributes, goes by many names: character, integrity, honor, moral fiber.
The physician professional is defined not only by what he or she must know and do, but most importantly by a profound sense of what the physician must be.
Without wanting to be overly dramatic, I believe one of the most serious threats to Americans' future health is the real possibility that physicians will fail to hold fast to what they must be to fulfill their oath as professionals.
In an era of increasingly complex, costly, even dangerous health care services, the legitimate needs and expectations of patients can be fully served only if physicians consistently act on their own volition-following their deep-seated moral compass-to subordinate their self-interest in deference to their patients' best interest.
In my view, no laws, no regulations, no watchdog government agency, no fine print in an insurance contract can serve patients'-and the public's-interest as well as physicians who are honor bound to uphold the principles and responsibilities of professionalism.
My friends, I know-and you know-that the learning environments in which our students acquire their identities as physicians are too often failing to properly calibrate their professional compass.
Students emulate what we do, not what we say. And what we too often do is patently unprofessional. Every time we

• demean a nurse,
• disrespect a patient,
• harass a student,
• exploit a resident,
• overbill for services,
• fudge data to gain a favorable journal review,
• permit commercial interests to bias educational offerings,
• shill for a pharmaceutical company,
• or do anything that would embarrass us if published on the front page of a newspaper, we chip away at the character we profess to cherish among the learners in our midst.

We do an excellent job, in my estimation, of preparing our students to know and to do what patients need. But we are not doing nearly enough to honor the legacy of Hippocrates, of Maimonides, of William Osler, of ******* Weld Peabody, nor of the pantheon of virtuous physicians who honed our timeless values.
We must do more as stewards of that legacy to develop, not undermine, our students' character; to fortify the idealism that motivated them to choose medicine in the first place; to strengthen their moral fiber by conscious, conspicuous, and conscientious role modeling; in other words, to prepare them to be professionals.
Remember, we can't change what we don't measure. So, I urge you to look hard at your learning environments, at your hidden curriculum, at the cultural norms at work in your institutions. Find ways to measure and document what you see. Use that data to inform the changes you wish to make to transform whatever crucibles of cynicism you find into cradles of professionalism. Doing so will ensure that the work ahead continues to be guided by physicians with a trustworthy moral compass.
Let me conclude by expressing my deepest conviction-that our country's medical schools and teaching hospitals are among the most treasured institutions in the world. And that you and your colleagues are the jewels that make those treasured institutions so valuable.
I thank you for listening to my annual sermons from this privileged bully pulpit and, most especially, for the honor of serving as president of your association for the past 12 years."
-----------------------------------------
consult with Ross AHHHHHHHHHHHHHHHHH