Medical Education on the Brink

Blessed is the physician who takes a good history, looks keenly at his patient and thinks a bit.

–Walter C. Alvarez (1884–1978)

Figure. Clockwise from top left: 1) Barton Childs in a laboratory similar to the student labs of the time. Harriet Lane Home, 1964. Image courtesy of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions. 2) William MacCallum with students in autopsy room, 1937. Image courtesy of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions. 3) Maxwell Wintrobe making bedside rounds with his house staff in 1944. Image courtesy of the Special Collections Department, J. Willard Marriott Library, University of Utah. 4) Students and house officers in a medical library, 1950.

Medical education has been a passion of mine for more than 60 years. Consequently, I have devoted my entire professional career to full-time teaching. To date, I have mentored several thousand medical students and house officers and have been intimately involved in the care of many of their patients. As a result, I have received numerous local, state, and national teaching awards, including a citation from former president Ronald Reagan. In 2002, my former trainees established The Herb Fred Medical Society, Inc., honoring me for 50 years of bedside teaching. I have served, and continue to serve, as a visiting professor or invited lecturer at academic institutions around the world. And at each of those locations, I have always interacted up close and in depth with the trainees and teachers there.

On the basis of the evidence cited above, I feel qualified to comment authoritatively and critically on the striking changes in medical education that have occurred during my watch. So in this report, I will chronicle those changes and recommend specific moves to make medical education relevant to our evolving healthcare system. Keep in mind that my observations and opinions do not necessarily apply to every teaching program in the land. Nor do they stem from, or relate to, any particular teaching faculty or student body.

The Patient-Centered, High-Touch Years: 1950–1975

When I entered medical school in 1950, the high-touch medicine of Osler and Peabody was standard, and it remained so for the next 2½ decades. High-touch medicine stressed the power of obtaining a good medical history, the advantage of performing a good physical examination, and the merit of critically evaluating the information derived therefrom.¹ Only after these steps had been completed were laboratory tests and other investigative procedures given thought. Then, if deemed necessary, further studies were selected to substantiate, not to generate, the clinical impression. This diagnostic approach was hammered home every day in almost every teaching institution in America. But only those who received such training can ever fully understand and appreciate its virtues.

These high-touch years had other laudable features as well. Trainees, faculty members, and practitioners all viewed medicine as a 24/7/365 calling in which the patient was the master and the doctor was the servant. Commitment, compassion, hard work, self-pride, devotion to duty, respect for authority, strict accountability, disciplined behavior, professionalism, and pursuit of excellence were the norm. Faulty performance was not tolerated, and any deviation from the norm prompted quick corrective measures. Because contracts often consisted of a handshake and a spoken pledge to work diligently, trainees who lacked commitment, honesty, or sufficient competence were easily dismissed on the spot or at the end of the academic year. And with the pyramid system of advancement, only the most skilled of the group survived the yearly cut.

The physical diagnosis course was a crucial part of the curriculum, and it always received the attention and support that it deserved. Only senior faculty members did the teaching, and the practice models were real patients with real physical abnormalities. Lectures played little or no role.

Students and interns in most programs were on call every day and every other night.² At Johns Hopkins Hospital, however, medical and surgical interns were always on call, and except for a 1- to 2-week scheduled vacation, they never had a day off throughout the year. The medical interns at Duke University also worked every day and night but did get 1½ days off every other weekend. Despite such draconian work requirements, positions in these programs were among the hardest of any in the country to secure.

In small “student labs” set up on all teaching units, students and interns performed basic laboratory studies, such as the complete blood count with differential, a urinalysis, and a stool guaiac test. These seemingly menial tasks—usually called “scut work”—taught trainees the importance of accountability and the factors that can influence test results. More important, that scut work brought the trainees into repeated physical contact with their patients, which strengthened the patient–doctor bond.

Early in this period, there were no intensive care units. So trainees learned to monitor their patients with God-given technology—their own eyes, ears, nose, hands, heart, and brain! And they managed any and all types of illnesses in that manner, often spending much of the day and night at, or close to, the bedside of the critically ill. Those frequent trips to the bedside gave the trainees invaluable insight into the pathophysiology and natural history of acute disease.

Work rounds, sometimes referred to as patient rounds, consisted of 1 resident, 2 interns, the charge nurse, and a portable rack containing all of the inpatient medical records. Students were excluded. Those rounds always took place at the bedside, where every day of the week each patient underwent a brief history and physical examination related to the illness for which he or she had been admitted. At the same time, one of the house officers, usually the resident, scrutinized the patient's hospital record for missing data, illegible notes, disorganized inserts, and other common deficiencies. A sloppy record indicated a sloppy doctor.

House officers occasionally were discussants at Grand Rounds. This assignment compelled them to spend long hours in the medical library searching the stacks for pertinent articles on their topic. From this process, they learned what it takes to research a subject thoroughly, how to read with discrimination, how to be critical of what one reads, and how to give a formal presentation before a discerning audience.

They also prepared vigorously for teaching rounds, which took place 5 times a week—4 with an attending physician and 1 with the department chair. The attending and chair served simply as consultants who offered their opinions and recommendations in a handwritten note in the patient's record. Responsibility for managing the patient—including all decision-making and order-writing—rested solely with the intern and resident on the case.

Presentations of cases at teaching rounds had to be well organized and free of rambling and redundancy. If they weren't, the presenter earned a harsh reprimand. After the case presentation, the group went to the patient's bedside, where the attending or chair demonstrated the art of speaking with and examining the patient.

Autopsies were common, took place at all hours of the day or night, and served as the ultimate teacher. Consequently, attendance at these sessions was mandatory for all students and house officers. The attending physician or department chair who had consulted on the case ordinarily attended as well.

Most trainees were unmarried, and only about 5% of medical students were women. Both situations, of course, have changed substantially. Nowadays, most trainees are married, and about half of the medical students are women.

Throughout these days of patient-centered medical training, there was a strong sense of camaraderie among the students and house officers. Although the work was hard, the hours long, and the pressures constant, trainees firmly believed that being a doctor was a privilege. So their spirits remained high, and they had fun. When their training ended, they were well prepared to render patient care of high quality.

The Laboratory-Centered, High-Tech Years: 1975–2003

When modern medical technology first became available in the early to mid-1970s, it revolutionized the way we taught and practiced medicine. Suddenly, we had gadgets and devices that enabled us to establish diagnoses with unprecedented speed, accuracy, and safety. Within a decade, ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) had gained enormous popularity among physicians worldwide. The reason was obvious. Ordering these tests took little of the physician's time, required no particular expertise, demanded no discriminative thought, and was a convenient and easy way to obtain a lot of useful information quickly.³ In fact, physicians didn't even have to see their patients before ordering these tests. And because CT in particular gave such comprehensive findings, physicians began using it in place of the history and physical examination.

But with the good came the bad. This high-tech diagnostic approach shifted focus from the patient to the laboratory and sacrificed to a large extent the very core of doctoring—humanism. It also gave rise to a new malady that slowly pervaded and subsequently engulfed our profession. I first called attention to this malady in 1978.⁴ Later, after the manifestations had become distinct, I named it “technologic tenesmus”—the uncontrollable urge to rely on sophisticated medical gadgetry for diagnosis.⁵

Technologic tenesmus was insidious in onset, highly contagious, and rapidly addictive. Particularly susceptible were the ill-trained and ill-informed, together with those who were looking for shortcuts, fearing litigation, or lacking self-confidence. Unaware of their affliction, the victims became tools of the laboratory—shackled to the routine of using advanced medical technology to formulate rather than to substantiate their clinical impressions. Their approach was haphazard, time-consuming, unduly expensive, and sometimes dangerous.

This overreliance on technologic advances crippled physicians' use of their minds and 5 sensory faculties to make diagnoses. Jumping from the patient's chief complaint to a host of tests and procedures became almost standard and took much of the fun and challenge out of medicine. It depersonalized the patient–doctor relationship and essentially eliminated the individuality of patient care. Unfortunately, medical school faculties seemingly failed to recognize this problem and did little or nothing to halt its growth. As a result, high-tech laboratory medicine became the only type to which trainees were routinely exposed. So whatever clinical skills the trainees might have developed were destined to deteriorate.

In skipping or curtailing the history-taking and physical examination, the high-tech approach weakened the patient–doctor bond or prevented it from ever forming. It also promoted laziness, both physical and mental. Characteristic of the mental inertia was the inability or unwillingness to think for one's self. This herd mentality adversely affected all aspects of patient care, especially correct decision-making and effective communication. It also dampened requisite curiosity and impeded self-education.⁶ The overall result was inarguable—the inappropriate, indiscriminate, and inexcusable use of technology.

The emergence of the AIDS epidemic in the early 1980s eliminated any possibility of putting a damper on technologic tenesmus. The complex nature of AIDS created diagnostic and therapeutic challenges never before encountered by the medical profession. In the attempt to meet those challenges, physicians turned early and often to every available investigative tool, including computed tomography and subsequently magnetic resonance imaging.

With so much emphasis on diagnostic software and hardware, everything mentioned in the patient-centered years took on a different light. Mediocrity gradually replaced excellence as the norm. Pride, hard work, accountability, and devotion to duty began to slide. The physical diagnosis course started using hired actors and simulation devices as practice models,^7,8 junior faculty and residents as course instructors, and lectures as the main source of information.

Interns began taking call every 4th to 5th night, and toward the end of these years, student laboratories had disappeared along with the opportunity to perform routine laboratory work. Patient rounds now included the students but excluded the charge nurse. The rounds typically took place in the hallway outside the patient's room. Talking with and examining each patient were no longer routine. The really sick patients were admitted to intensive care units where machines and nurses did the monitoring. House officers rarely discussed topics at Grand Rounds. Autopsies became infrequent. Computers began appearing throughout the hospital, and visits to the medical library by students and house staff steadily decreased.

Three developments in particular adversely affected medical education. One was the loss through death or retirement of senior teachers from the preceding patient-centered years. The faculty members who replaced them were much younger, much less experienced, and had been trained in the laboratory-centered years. Consequently, they could teach only what they had been taught—laboratory-centered medicine. Furthermore, they functioned as decision-makers for patient management, taking that role away from the house officers to whom it rightfully belonged.

The 2nd serious drawback occurred about halfway through this period, when the structure and function of emergency rooms around the country began to change. In 1989, Emergency Medicine became an independent specialty and departments of Emergency Medicine soon became part of most medical schools. As a consequence, the supervision of patient care in emergency rooms switched from surgeons and internists to specialists in emergency medicine, who advocated rapid patient triage. Shortly thereafter, admissions to the teaching services increased substantially, placing hospital beds at a premium and forcing premature patient turnover, often without a clear-cut diagnosis or follow-up plan.

Many of these admissions involved individuals who were not very sick and could have been managed easily and safely as outpatients. Other patients, however, did deserve admission but were extensively investigated and treated for a wide variety of ills before being transferred to the teaching service. This practice robbed the ward teams of the opportunity to make their own diagnostic and therapeutic decisions and to observe firsthand the pathophysiology and natural history of disease. Regrettably, the teaching faculties made little or no effort to halt or slow down this unnecessary, inappropriate, and anti-educational pre-admission activity. So the practice gained impetus and stands today as a major detriment to medical education.

The 3rd adverse development emerged when health maintenance organizations (HMOs), with their insistence on maximizing “throughput,” began forcing physicians to process patients in assembly-line fashion at ever-accelerating rates of speed for the lowest amount of pay.⁹ This system of healthcare delivery was bad because it really served no one but the HMOs, leaving patients short-changed and doctors dissatisfied, with little or no time for teaching and learning. Unfortunately, this practice grew and is evident today in the clinics and hospitals of nearly every teaching institution.

These years left 2 strong memories—the demise of high-touch medicine and the rise of high-tech medicine. Accordingly, in 1983, I wrote the following: “The day could come when physicians per se will no longer be necessary. In their place will be the ultimate gimmick—a convenience store computer that takes care of your medical needs and tells your fortune, all for a quarter.”¹⁰ That statement might still be relevant someday.

The Doctor-Centered, Limited-Work-Hour Years: 2003–Present

In 2003, when medical education was already in trouble, the Accreditation Council for Graduate Medical Education (ACGME) added insult to injury. Believing that sleep deprivation and physical fatigue in physicians led to harmful medical errors, the ACGME acted to protect patient safety by mandating strict work-hour limits across all training programs, regardless of specialty.¹¹ That stunning mandate launched a new period of medical education in which the focus now rests primarily on the comfort of the doctor in training.

Duty hours for all interns and residents were limited initially to 80 per week, averaged over a 4-week period. In addition, all interns and residents had to leave the hospital within 30 hours of starting a shift, no matter how sick their patients were. House officers also had to have 1 day completely free of duty every week. Then, on 1 July 2011, further restrictions took effect, including duty periods for interns and residents limited to 16 hours and 28 hours, respectively.¹² Currently, the interns and residents must leave the hospital when these duty periods end. In 2013, the next accreditation system will not only continue to emphasize these work-hour limits but will begin a phased implementation of new, more complex, and broader program requirements.¹³

So far, a large body of evidence indicates that duty-hour limits have neither improved nor worsened quality of care and patient safety.^14-17 However, as anyone could have predicted, the marked reduction in work hours has improved the physical well-being of house officers.^18,19

I believe that the ACGME's mandate is the worst thing that has ever happened to medical education because it

• Effectively eliminates at least 1 month per year of on-duty supervised experience. This has led to a proposed extension of the training period.²⁰

• Negatively affects faculty members, nurses, and medical students, as well as residents and patients.²¹

• Prevents residents from observing firsthand the natural history of acute disease.

• Discourages the hard work that has always been a characteristic of the medical profession.

• Interrupts the continuity of patient care and lessens patient satisfaction.^22,23

• Decreases resident ownership of patients.²³

• Requires handoffs that inherently foster errors in patient care.^23,24

• Weakens the patient–doctor bond or prevents it from ever forming.

• Creates extra work for an already overworked teaching faculty who now must render the patient care that the “at-home, off-duty” house officers should be rendering.

• Switches the focus of program directors from resident education to resident work hours.

• Is a major factor in the burnout of some program directors.^{25 *}

• Increases the overall expense of medical education by necessitating additional personnel to monitor and maintain duty-hour compliance and by requiring substitute providers to fill the resultant gaps in patient care.²⁶

• Sets up the potential for wrongdoing when residents work longer than the allowable limits. In that situation, the “guilty” residents—either on their own or because of pressure from peers or the teaching faculty—can protect themselves from rebuke and their programs from probation by tacitly adjusting their work records to indicate compliance.^**

• Poses complex compliance problems for some programs (for example, internal medicine and neurologic surgery) and no real problems for other programs (for example, dermatology and pathology).

• Shortens the time available for residents to teach interns and students.²⁷

• Places primary emphasis on the well-being of the doctor rather than on the well-being of the patient!

In addition to the work-hour limits, cultural changes in our society have had a major impact on medical education. Many of the norms of 50 years ago have largely disappeared: especially hard work, accountability, and respect for authority. People at all levels—including many medical students, house officers, and faculty members—are satisfied with mediocrity, which is the only norm they really know.

Although today's trainees are as bright as any in the past, they clearly are different in a number of important ways. When compared as a group with trainees from the patient-centered years, they view our profession more as a shift job than as a calling, consider their training a right rather than a privilege, have a weaker work ethic, show less respect for authority and less intellectual curiosity, dislike being held accountable, are not as disciplined, demonstrate less pride, and depend on cell phones for communication and computers for “library” research. Some of them, in fact, have never been in a medical library or observed an autopsy.

Today's teaching faculties also differ from those of 50 years ago. The current teachers are younger on average with less teaching experience and weaker bedside skills. And because money for education is so tight these days,^26,28–30 medical schools force the clinical faculty to spend more and more time caring for patients who can pay their bills and less and less time caring for medical students and house officers. As a consequence, trainees are left to fend for themselves in their quest for competence, unaware of how much better their lot could be and should be.³¹

Another matter merits exposure. Nowadays, there is widespread fear among program directors that if even one student or house officer were to work beyond the mandated limits or were to register some complaint with the residency review committee, the program might be placed on probation or jeopardized in some other way. So there is a strong tendency to coddle the trainees. This means demanding little from them, turning a cheek to those with a bad attitude or poor work ethic, putting up with those who show outright clinical incompetence, and tolerating those guilty of misconduct, disrespect, or dishonesty. Some directors seem to forget that their primary responsibility is to educate, not placate, trainees, and that coddling does nothing but comfort the weak and penalize those who welcome demands, thrive under pressure, and prefer to be challenged and to work hard.

Equally disturbing, if not worse, is the difficulty of firing bad residents. The process entails so much paperwork and requires so many legal twists and turns that it isn't attempted often and rarely proves successful.

Finally, I would like to make 2 other points. One concerns the large number of foreign medical graduates entering our training programs. On arrival, these graduates generally show clinical skills superior to those of their American counterparts. I attribute this superiority to a relative lack of technology in their home countries, which requires them to depend on a good history and physical examination to construct a clinical impression. But it doesn't take long for their clinical skills to deteriorate as these foreign graduates adjust to our high-tech environment.

The other point involves the greatly expanded, indiscriminate use of advanced technology. As an example, consider echocardiography. For many, if not most, house officers these days, an echocardiogram is part of the physical examination. In reality, this procedure is the only way for them to evaluate the heart reliably. But they are just partly at fault for such a shameful deficiency. The bigger fault rests with the teaching faculty who spend little or no time at the bedside with the house officers and who rarely, if ever, emphasize the cost of an echocardiogram (usually about $2,000) or of any other test for that matter. In fact, I find that most teaching faculties and trainees know almost nothing about the cost of what they order and do not realize that the most expensive piece of medical technology is their pen.^32,33

The Bottom Line

Over the 62 years that this report covers, medical education has moved its focus from the patient to the laboratory and now to the doctor. As a result, we currently have a training system that is doctor-centered, technology-driven, computer-dependent, algorithm-loving, and Internet-based. And thanks in large part to the ACGME, we are exchanging sleep-deprived, competent healers for a growing number of “wide-awake technicians.”³⁴ Many of these limited-work-hour trained individuals cannot take an adequate medical history, perform a reliable physical examination, create a sound management plan, or communicate effectively.³⁵ Therefore, they don't deserve the image of competence that their training certificates convey.

So it all boils down to this: The kind of health care that American medicine is capable of providing and the kind that the American people actually receive are worlds apart.²⁰ Consequently, those of us in medical education have a major obligation and responsibility to help close that gap.

Closing the Gap

As I have tried to show in this report, many of today's medical graduates are not adequately prepared to meet contemporary expectations and responsibilities. In addition, they are not equipped to deal effectively with the rapidly changing patterns of health care and private practice.^33,36 If medical educators stand idly by, content with the status quo, no type of healthcare reform can succeed. So we must put forth the necessary energy and creativity to make medical education relevant to our evolving healthcare system. In that regard, I recommend 3 basic moves, each a requisite for closing the aforementioned gap.

First, we must abolish the ACGME mandate on work-hour limits. When discussing the mandate with program directors in medicine and surgery around the country, I hear nothing but disappointment, dissatisfaction, and disgust—my sentiments exactly. Therefore, given its previously listed drawbacks, coupled with its unproven benefits to patient outcomes despite 9 years of intense evaluation, the time has come for program directors to unite and overthrow the mandate. Getting rid of it, however, will be difficult and will require strong professional leadership and solid support from the public, which at present favors the limited work hours.³⁷

In place of the existing mandate, we could (and should) revert to the unlimited work-hour system that served all disciplines well for 100 years. Or we could select program directors from each specialty to devise a work-hour system best suited for and limited to their particular discipline. Either move would be a great step in the right direction, because the existing mandate is our biggest obstacle to producing competent physicians.

The 2nd gap-closing move requires major changes in the curriculum of medical schools and postgraduate training programs. Many medical educators have recognized this need and have offered various ways to meet it.33,36,38–53 A comprehensive listing and analysis of all such offerings are beyond the intent and scope of this presentation. One such offering, however, deserves special attention here.

In August 2009, the Johns Hopkins University School of Medicine implemented a completely new, meticulously planned, and superbly constructed 4-year curriculum called “Genes to Society” (GTS). At the same time, it opened an ultramodern, $50-million building dedicated solely to medical student education and providing the updated facilities that the novel curriculum would require. A major goal of GTS is to reframe the context of health and illness more broadly, encouraging medical students to explore the biological properties of an individual's health in the light of a larger integrated system that includes social, cultural, psychological, and environmental variables. The curriculum also emphasizes collaboration among students and faculty at all levels. A description of GTS's 5-year planning process and details of its structure and content are available elsewhere.³⁸ Having recently toured the new education building and discussed GTS with the faculty in charge, I view this innovative Hopkins model as an exemplar of excellence for other medical schools to emulate, much as its counterpart did for the Flexner Report a century ago.^54,55

My final recommended move is to raise the bar of performance in all training programs to a distinctly higher level, with excellence as the perpetual goal. In that regard, my mentor, Maxwell Myer Wintrobe, often said, “No matter how good of a job we do, we could always do a better one.” Those words have motivated me throughout my professional career and could motivate anyone else who wishes to improve, including program directors, teachers, and trainees.

Once excellence has been re-established as the norm, all members of every training program—teachers and trainees alike—will be held to the same high standards. Specifically, everyone will be accountable; incompetence will not be tolerated; trainees will not be coddled; everyone will be cost-conscious^32,56,57; circumspection will prevail when ordering sophisticated technologic procedures; hard work and devotion to duty will be expected; the patient–doctor bond will become preeminent again; and punctuality, respect for authority, and professionalism will be the rule. And medicine will resume its role as a calling, with the patient as the master and the doctor as the servant.⁵⁸