As clinical medical education moves from the hallowed halls of hospital academia to the real world of office-based practice, major changes have occurred that go beyond simply the location of training. As Irby points out (p 246), the goals of community-based education are clear and focus on the types of medical problems and the type of environment in which the trainee is most likely to practice in the future. The shift to the community has forced medical schools to rely heavily on community-based doctors to deliver a large part of the clinical curriculum. The timing couldn't be worse, given the increased demand on physicians' time. Yet, as Vath and colleagues (p 242) explain, physicians have always volunteered to teach primarily because they like it—they like the challenge, getting to know trainees, and the feeling that they are in some way paying back the system for their own education.
How are things going in the trenches? Not wonderfully. One of the most common complaints I hear from medical students concerns the anger and bitterness that they hear from physicians in the community. These angry doctors come in all shapes and sizes. They are young and old, male and female, and specialists and generalists. They are angry that they don't have the time to teach students in the manner they would like. They are angry that the practice of medicine is controlled by bean counters with little interest or understanding of the art of medicine. Simply put, they are just angry that medicine has changed remarkably. Many of these angry doctors are planning to retire early. Others have begrudgingly accepted that the practice of medicine has changed, and they are “doing time” until they can “get out.” But the advice they all pass on to students is that the students have made a huge mistake, and they should “get out while you can.”
Where does that leave the students? Have they entered a dying profession? We think not (as evidenced by the January 2001 edition of wjm on physician well-being). Times are most certainly changing, and many of the students' complaints are accurate. But when all is said and done, it is still a profession where physicians go home at night (albeit at a later time than in the recent past) and feel good about what they accomplish. Whether it be talking with a new mom about breast-feeding, diagnosing a new case of diabetes and educating the patient about the disease, putting a pin in an elderly man's hip, or dealing with a patient in the terminal stages of cancer, physicians do their best to apply the science and art they have learned. Are we obliged to make everything sound rosy for students? Of course not! The students need to hear the negatives, but these negatives need to be placed alongside the positive. Students need to hear the problems with “the system” and be given opportunities to discuss solutions. Ignoring these problems or forbidding physicians from talking openly with students about their unhappiness is in no one's best interest. Medical students are the future; they need to be educated about the realities of practice as well as the science and art of medicine and to be given an opportunity to lead us all to brighter pastures.