Medical Education on the Brink

To the Editor:

I read with delight the editorial by Dr. Herbert Fred, “Medical Education on the Brink: 62 Years of Front-Line Observations and Opinions.”¹ Dr. Fred explained in great detail the major changes that are taking place in medicine today. I have explained to the medical students who take a rotation with me, and to the young physicians who spend a month at a time seeing patients with me, that it is absolutely necessary for physicians to sit down, get an appropriate history from the patients, and then perform a complete examination. We were once taught that, in 90% to 95% of patients, the diagnosis can be made from a complete medical history even before one does the examination. Unfortunately, insurance companies and the government employ “hired guns” (some of them, our colleagues) to decide when and how treatment should be allocated. In part, this is ostensibly to conserve money, but it changes the way in which medicine is practiced.

It was decided that residents can spend only a certain number of hours in training per day. This means that they are not exposed to follow-up with patients, which in turn hinders teaching and learning. When this policy went into effect, my questions were, “What happens when that doctor-in-training actually goes into practice? Does he cut off his telephone at night because he has already served for a certain number of hours during the day? And may he therefore neglect his patients and their follow-up?” Now, questions are arising as to whether this was a good provision to apply toward residency training.

We, as physicians, have allowed our profession to be degraded by equality. An editorial in Endocrine Today ² by Dr. Richard Dolinar emphasizes the degrading of physicians. As he pointed out, we used to be called “doctor,” and now we are lumped into a group of “care providers.” As a medical dinosaur,³ I well remember making rounds in years past. The ward clerk (now called the ward secretary) had my charts ready, and the nurse would make rounds with me and be knowledgeable about the care that each patient should receive. In contrast, when I was making rounds not too long ago, a chart was not readily available in the chart rack. I asked the ward secretary if she knew where the chart was. She pointed her finger and said, “Look over there.” Nurses are now too busy to make rounds because they are sitting at a computer, entering data.

Today, everything is “protocol.” Postoperatively, when patients are seen by a physical therapist, they are taken through a regimented process—whether they are 20 or 80 years old. The 20-year-old might be able to get out of bed and walk, whereas the 80-year-old might only be able to sit on the side of the bed flexing his legs, at least on the first day. If the patient does not follow the therapist's instructions, a note is written in the chart that the patient refused therapy. Several months ago, I was amazed to see a sign at the nurses' station that said, “Do not disturb the nurses between 7:00 and 7:30 AM.” This meant that the nurses were in nurses' report and did not want to be disturbed. Does the patient really come first?

Our societies and governing bodies need to understand that a physician is part of a profession. In this profession, the patient is number one, the doctor needs to practice good medicine, and the training programs need to make sense in the real world of medicine. These programs can certainly include meaningful innovations in medicine for the benefit of the patient, but we should not discard the fundamental training of our young physicians. They need to make judgments on the basis of their training in anatomy, physiology, pathology, and biochemistry so that they can make logical decisions about the diagnosis and care of a patient.

We need more physicians like Dr. Fred to write more articles about the integrity and practice of medicine.

Stanley J. Zimmerman, MD, FACE
The Zimmerman Medical Clinic, Houston, Texas