Medical education as a process management problem.

With complaints that new doctors are less prepared for residency and practice than expected, are burdened with debt, and then take even longer to complete their specialty training, the authors ask whether medical education can be designed more effectively. Curriculum redesign and pedagogical reform efforts to date address fragments of medical education-the content of particular courses or clerkships or the way in which the courses or clerkships are conducted. However, these reforms do not typically address the relationships among the various elements, that is, in what order skill sets should be sequenced, how communication should occur between disciplines, and by what mechanisms skills or knowledge should be mastered and assessed by the end of one phase so students are prepared adequately for the next. In failing to address these systems issues, current reform efforts may forgo some opportunities to convey and properly insure greater mastery of knowledge and skills in less time, at less cost. A case study of a typical student's third- and fourth-year clerkships illustrates how focusing only on educational elements leads to the exclusion of opportunities to systemically facilitate the relationships among them. This situation is contrasted with how other demanding, high-tech, knowledge-intensive industries with outstanding operations have learned to achieve superlative performance by managing and designing both the elements and the interactions among them within complex work and learning systems. The authors' exploratory research offers suggestions for medical education reform and frames additional opportunities for further discussion.