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Journal of Graduate Medical Education logoLink to Journal of Graduate Medical Education
. 2014 Sep;6(3):437–450. doi: 10.4300/JGME-06-03-17

SPECIAL BOOK REVIEW

PMCID: PMC4535206
J Grad Med Educ. 2014 Sep;6(3):437–450.

Mapping the Terrain of Graduate Medical Education: A Patient's Perspective

Helen Haskell 1

Kenneth Ludmerer's Let Me Heal: The Opportunity to Preserve Excellence in American Medicine is an absorbing book that transports the reader through the evolution of physician education over 2 centuries. The discourse on the topic is much needed. Writing in spare and elegant prose, Ludmerer traces the concept of American graduate medical education from its antecedents in the unpaid apprenticeships of the 18th century to the institutionalized, heavily taxpayer-supported residencies of today. For nonphysicians, the book shines a light on a mysterious world and answers questions many did not even know needed to be asked.

Several leitmotifs define Ludmerer's perspective on his topic. Chief among these are the intrinsic contradictions that he identifies as keeping the medical residency in a state of constant tension. One of these is the inherent conflict between medical education and the economic exploitation of residents, a dynamic that Ludmerer calls the “fundamental fault line” of the residency system. A second is the tension between medical education and patient safety, potentially the central issue in the eyes of the public, but one that has been surprisingly muted over the years.

These 2 themes are closely related. The recurring debate of recent decades has centered on resident duty hours, with the controversy framed as need for sleep versus the concept of continuity of care and learning. Yet, the primacy of the duty hours issue is in some ways curious. As Ludmerer points out, it has never really been the main concern in terms of patient care. The pivotal Libby Zion case in New York and the ensuing Bell Report that laid the basis for state and, much later, national duty hour restrictions were at least as concerned with the problem of resident supervision as the work hours that made them famous. Patient activists, too, have traditionally focused on resident supervision and the fear of “ghost surgery.” But fatigue has been the issue that resonated with the public, perhaps because it is both easier to understand and fundamentally less alarming. The result has been an emphasis on 1 aspect of the problem that may have worked to the detriment of more comprehensive approaches.

Intertwined with this is the conflict between adequate resident supervision and the idea of allowing residents to develop the ability to act autonomously. In the urban charity wards where the modern residency system developed, resident physicians were given almost complete autonomy. As medicine has become more complex and faster paced, the near impossibility of doing this safely has emerged. Yet, the concomitant adjustments are not always being made. At the same time, the concept of supervision as what Ludmerer calls an “underutilized” educational tool—the idea that a learner needs a teacher—has eroded, leading to a confusion of independence with education.

Implicit in his analysis is the idea of the corrosive effect of the profit motive on both learning and the concept of professionalism. Ludmerer harkens back to the mid-20th century, when legendary medical educators interacted closely with students and patients; when residents had the time to follow the clinical course of patients throughout a hospital stay; and when academics—and not just medical ones—disdained the idea of money as a yardstick of success. Yet, even in this golden age the ideals did not carry over into resident supervision: Ludmerer quotes Yale Professor Thomas Duffy as reflecting on his residency as “a form of training that plunged young physicians into waters far above their heads.” Ludmerer sees this as exacerbated in recent years by financial motivations that have led to work compression rather than work relief in response to resident duty hour restrictions. This increased workload in an already arduous occupation has far-reaching implications in its effect on both patient care and resident attitudes: reduced compassion, reduced intellectual curiosity, a task-oriented approach to work, loss of diagnostic and other decision-making skills, and a default to overtesting and overtreatment in the absence of time to reflect and research.

Ludmerer is concerned that inflexible policies on duty hours contribute to a culture in which it is considered permissible for residents to lie about hours worked, and he worries about the moral message this sends to young people who should be learning professionalism. But this is only part of a deeper problem of transparency that dates back to the demise of the charity wards: the silence surrounding the role of residents in patient care. In the early days of the residency, charity patients agreed to participate in medical education in return for free and needed care; whatever drawbacks there may have been, the bargain was explicit and the benefit to the patient clear. For modern patients, the exchange is hidden and the benefit often may not exist at all. This is the deception that so outraged Sidney Zion when he realized the circumstances behind the death of his daughter Libby in 1984: Patients are not cared for by the physicians they believe they have hired.

This financial and ethical jerry-rigging of a system that was meant to operate in a very different world results in strikingly different realities for patients and professionals. Program directors worry about loss of professionalism in young physicians, while patients, if aware of the residency system at all, worry about inexperienced physicians and surgeons and ill-informed decisions that may cause harm. Faculty worries about the loss of continuity of care, while patients for the most part haven't a clue as to the identity of the parade of people streaming in and out of their rooms. Above all, when the inevitable errors occur, vital information is often withheld from the patient, with complicity from the institution. These are the issues that should raise concerns as a threat to professionalism: the unstated encouragement to be less than candid about one's role in the patient's care, the denial of time to do a job thoroughly and thoughtfully, the acquiescence in the abdication of responsibility toward those who have placed trust in their providers.

Ludmerer ends his book with a thoughtful and inspiring discussion of the role of graduate medical education in the 21st century mission of health care reform. He lays out a series of sensible and humane prescriptions, including suggestions for reducing workload, improving supervision, providing faculty with time to be involved with their residents' work, and creating a culture in which residents do not fear asking for help. He points out the irony of the fact that diagnostic accuracy, the basis of good medicine, is still not included in safety and quality criteria, and that the need for not just competent, but highly competent clinicians, is largely omitted from the safety and quality agenda.

To Ludmerer, the interrelationship between residency training and the delivery of medical care is at the core of health care renewal, and the key to that should lie in the molding of skills of decision making, observing, and communicating. It should be the mission of graduate medical education to produce physicians who can, in Ludmerer's words, “think, solve problems, decipher unknowns, manage complexity, and care about their patients.” As no one needs to tell the readers of this journal, medical residency is the crucible in which the attitudes, skills, standards, and aspirations of generations of physicians are formed; and as medical education goes, so goes the state of health care.

J Grad Med Educ. 2014 Sep;6(3):437–450.

The Residency and the Hospital: The Consequences of Codependency

Muriel R Gillick 1

In the final decades of the 19th century, the American general hospital served as a social welfare institution for the poor as often as it served as a medical institution for the sick: It provided food, warmth, and cleanliness to the impoverished, along with splints and dressing changes to the injured.1 To the extent that hospitals did offer medical treatment, they catered to the “worthy poor,” composed of the urban working class, many of them recent immigrants, a group whose illness was attributed to misfortune rather than to immoral behavior.2 Anyone with even modest resources preferred to stay at home for medical care, and the vast majority of them did. After all, most of the available medical treatment could easily be provided at home, assuming the patient had a home, his own bed, enough to eat, and a caregiver. The stethoscope and the thermometer were the only medical instruments in widespread use, and although anesthesia had been introduced in the 1840s, routine surgery would have to await the development of aseptic technique in the 1880s. X-rays did not arrive on the scene until 1896, and only 6 therapeutic agents (such as medications, vaccines, and hormones) were commonly used in 1913, compared with 35 in 1943. Given that the hospital was not the site of most medical care, it was not the most obvious candidate to serve as the home for graduate medical education. Yet it was during this period that the hospital and advanced medical education became intimately and inextricably intertwined, with enduring and portentous implications, as Kenneth Ludmerer describes in his comprehensive and insightful book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.

The hospital was not the only available option for graduate medical education at the end of the 19th century. Young physicians, as well as medical students, had long sought clinical experience through apprenticeships to practicing physicians. The hospital dispensary, which would evolve into the outpatient clinic, was another site for educating the graduates of America's medical schools. But it was the hospital that prevailed, in no small measure because of the inspiring example set by Johns Hopkins University in Baltimore, Maryland, as well as by the convenience of a ready supply of cases. The critical step was the adoption by the Johns Hopkins Hospital of the German model of the scientific clinician when it opened its doors in 1899. In Germany, the medical capital of the world, physicians were steeped in both bedside medicine and in biologic science, and they were expected to become clinical investigators, applying one to the other. Pioneers at Hopkins, such as William Osler (in medicine) and William Halsted (in surgery), were enamored of the German system, and chose to build residency programs in its image. Crucial to the choice of the hospital as the primary teaching site was also the large concentration of charity patients, patients felt to be deserving of medical care, provided they submitted to the indignities of serving as teaching material. Just as hospital physicians (the 19th century counterpart of today's attending physicians) saw their role as stewards of the lower classes—and benefited from the opportunity to advance their careers by the experience and connections afforded by a hospital practice—so, too, did the newly defined interns and residents.1 And so began the fateful linkage between the hospital and the residency, marked as Ludmerer delineates so well, by an ongoing tension between the service needs of hospitals and the educational needs of young physicians.

The codependence of hospitals and residency programs has had profound consequences for American health care. For example, today, when much of the disease burden is in the form of chronic illness, residency education continues to focus on acute medical problems, largely because moving residency training out of the hospital and into the outpatient setting has proved challenging. Tying residency to the hospital, a “total institution” traditionally structured to accommodate the needs of physicians rather than patients,3 is arguably antithetical to physicians-in-training mastering “patient-centered care,” the contemporary model of optimal care.4 Although both hospital and residency programs are affected by scientific advances and dominant societal trends—the Civil Rights movement, feminism, and consumerism are 3 that Ludmerer addresses—the overwhelming reality is that the hospital and the residency, like a binary solar system in which the 2 stars revolve around a common center of gravity, exert a strong influence on each other.

One of the earliest changes in the hospital that produced corresponding modifications in the residency was the growth in patient acuity. With advances in medicine between the wars, hospitals shed their safety net role and became exclusively medical institutions, leading to an increase in the proportion of sick patients. And because hospitals now had something to offer middle-class patients as well as the poor—in 1928, a physician at Massachusetts General Hospital commented that for the first time, acutely ill patients were better off in the hospital than at home—the volume of admissions rose as well. To care for so many sick people, hospitals turned increasingly to residents, abandoning the pyramidal system in which only a handful of interns were allowed to stay on for a second or third year of training. The multiyear residency became the norm and, no longer restricted to the best and the brightest, evolved away from the scientific investigator model and toward a more strictly clinical experience.

After World War II, another seismic shift in hospitals had a dramatic impact on residency training. The demand for hospital care accelerated further, due in part to the rapid pace of medical discoveries and in part to the rise in private health insurance. During the war, employers circumvented existing wage controls by negotiating an exemption for fringe benefits. As a result, employer-provided health insurance flourished, quickly becoming the norm and making hospital care affordable for many more patients.5 To absorb the influx of patients but also to benefit from the revenue they brought, the hospital arranged with insurers to allow payment for services rendered by residents to “private” patients who had insurance but whose physician was not on the medical staff, spelling the end of the “indigent ward.” The collapse of the rigid divide between charity patients (who were taken care of by residents) and private patients (who were not) ushered in a new era. No longer would the demeaning treatment of ward patients be tolerated. No longer would the role of residents include improving the “character” of patients; henceforth, residency was all about healing.

Perhaps the greatest change for the hospital—with important implications for residency training—was the introduction of Medicare in 1965. The program affected hospitals by requiring segregated wards to be abandoned as a condition for receiving Medicare payments; the integration of the hospital nudged residents into treating their patients of color respectfully. In addition, Medicare provided an enormous financial boost to hospitals through its direct subsidy of graduate medical education (by paying the salaries of residents and teaching faculty) and its indirect subsidy (by offering a higher reimbursement to teaching hospitals to account for the increased complexity of illness and longer length of stay compared with community hospitals). The funds kept the teaching hospital solvent, but at a price: Because salaries for residents were tied to the care they provided for hospitalized patients, off-campus ambulatory training was not covered. Allowing residents to learn how to care for patients in a private physician's office or in an HMO was problematic; residency programs would instead teach residents greater and greater technologic proficiency through exposure to continuous bedside hemodialysis, intra-aortic balloon pumps, and the like—techniques most would never use after graduation.

Just as the hospital influenced the residency, so too did the residency influence the hospital, although residency programs were always the smaller star in the binary system. One of the major ways that residency affected the hospital was through the “power of the pen,” the control exercised by residents over the ordering of tests and procedures (now supplanted by the click as electronic order entry replaces the traditional pen and paper). Because residents were learners, because they were expected to be exceptionally thorough, they were encouraged to be profligate in their test-ordering. With MRI scans and PET scans, endoscopies and echocardiograms all paid for by third-party payers, there was little attempt to rein in the resident's proclivity for greater certainty through more testing. Such behavior increased the cost of medical care, affected the physician's behavior after entering clinical practice, and put residents and hospitals on a technological treadmill.

Let Me Heal makes clear that as graduate medical education goes, so goes American health care: Well-trained physicians, steeped in a culture of scientific medicine and dedicated to patients, are essential for the public's health. Allowing the commercialization of health care to seep into the fabric of residency training, Ludmerer cautions, will have a perfidious effect. The solution to the problem, the historical narrative suggests, will require modifications in the structure of residency programs, but that will not be possible without simultaneously reforming the institution with which residencies are tightly linked: the general hospital.

Footnotes

Editors’ Note: The following pages feature a series of invited reviews of Kenneth Ludmerer’s newest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, the third work by the noted author and historian examining American medical education. Let Me Heal traces the history of resident education over more than a century, ending with present day accomplishments and challenges. Authors include US and international medical educators, residents, a designated institutional official, and a patient. Collectively, they examine Ludmerer’s work in the context of their experience with the medical education system, some with nostalgia, some critically, echoing the author’s quote at the beginning of the final chapter: “. . . the residency system had never experienced a ‘golden era.’ Each generation coped with the medical and cultural challenges of its own age.” We at the Journal of Graduate Medical Education consider this book an invaluable contribution to the field and encourage everyone involved with residency training to read it.

References

  • 1.Rosenberg C. The Care of Strangers: The Rise of America's Hospital System. New York, NY: Basic Books; 1987. p. 112. [Google Scholar]
  • 2.Rosner D. Health care for the “truly needy”: nineteenth-century origins of the concept. Milbank Mem Fund Q Health Soc. 1982;60:355–385. [PubMed] [Google Scholar]
  • 3.Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York, NY: Doubleday; 1961. [Google Scholar]
  • 4.Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013. [PubMed] [Google Scholar]
  • 5.Rothman D. Beginnings Count: The Technological Imperative in American Health Care. New York, NY: Oxford University Press; 1997. [Google Scholar]
J Grad Med Educ. 2014 Sep;6(3):437–450.

The Heroic Odyssey of Graduate Medical Education

Patrick Brunett 1

It's 1895 and you are a house officer at the storied Johns Hopkins Hospital. You share cramped and dilapidated living quarters with 3 other interns. The food is awful and the paint is peeling. It is your third night on call this week, and you have not left the hospital in nearly a month. You remind yourself that, as rough as these conditions are, you feel blessed by the excellent teaching you are receiving from the staff physicians, and know that your counterparts at the hospital across town have it a lot worse. You grab a short nap after taking your seventh admission of the night on the charity ward, a 38-year-old woman with shortness of breath. Your careful percussion of her chest wall shows enlargement of her heart border, and the auscultative skills you learned from the resident, a year ahead of you in his training, reveals a subtle diastolic murmur. You and your cohort of single, white male interns are looking forward to rounding later this morning with Dr William Osler.

Fast forward to 2014. You are well rested after your obligatory 10 hours off, but are worried about your sick 8-year-old, who is home from school today with your spouse. Payments on your student loans, which amount to just shy of $200,000, started 6 months ago. You take sign-out on 24 patients from the night float resident, 10 of whom you will need to discharge later today but none of whom you are familiar with. Your clinical decisions, and the fate of your new patients, rely on the input from countless consultants who are nowhere in sight. Nor are their consult notes, which will not be completed and accessible in the electronic health record until early this afternoon. You have little faith in your attending helping you complete your workload. She is notoriously late to rounds and is usually grumpy about the latest mandate from hospital administration to shorten her patients' lengths of stay in the hospital.

The dichotomous picture of resident life described above is a slightly exaggerated version of that portrayed by Kenneth Ludmerer in his latest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. He has masterfully assembled a compendium of personal narratives, reflections, and scholarly works from hundreds of original sources that provide a living history of graduate medical education (GME) over the past 140 years—an odyssey replete with struggle, controversy, and change, both evolutionary and cataclysmic. He offers his keen reflections on the current and future state of GME, with strategies on how to preserve and regain excellence in medical training.

At its inception, residency training fulfilled a variety of needs, depending on the hospital and the trainee. It often existed in an apprenticeship model, providing a bridge to clinical practice for individual trainees and a cheap labor force for hospitals. In the late 19th century, Johns Hopkins Hospital, under the influence of Sir William Osler and others, created the modern model of residency with which we are familiar today. Rather than primarily offering supplemental training necessary for the independent practice of medicine, house officers at Johns Hopkins, Peter Bent Brigham Hospital, Massachusetts General Hospital, and other facilities comprised a hand-selected group of the best graduates from an elite group of medical schools. Newly graduated physicians at top schools were often recruited to train at their own affiliated hospitals, as the quality of their medical education was viewed as superior to the education of other candidates from lesser schools. Institutions offered mentorship, guidance, and one-on-one training from nationally recognized experts in modern medicine. The overarching goal was to provide an environment in which residents could engage in scholarship, reflection, and in-depth learning. It was in essence a training camp for future leaders in health care, and not solely for the acquisition of specific skills and knowledge.

A true community of healers was the result. Residents lived and worked in an invigorating atmosphere of inquiry, scholarship, and shared purpose, and were likened to monks in a monastery. Indeed, the description of intellectual life at these elite hospitals seems idyllic and almost too good to be true, and Ludmerer warns against romanticizing the learning environments of the past. The concept of work-life balance as we know it today did not exist. Instead, scientific rigor, thoroughness, and self-sacrifice ruled the day. Perfectionism and delayed gratification were the ethics code. Interns often did not see the outside of the hospital for weeks on end. House officers were forbidden to marry or begin families until their training was completed. Most of the work of direct patient care was provided by interns, with long hours and high degrees of responsibility from the beginning of their training. Residents in their second year and beyond enjoyed only slightly more freedom as they assumed greater leadership and teaching roles.

Stark as the differences may be between the daily lives of past house officers and present-day residents, many of the hardships, challenges, and systemic flaws in how we train residents remain the same today. Now, as then, residents make up much of the health care workforce in training hospitals. The perpetual tension between service and education still exists, and many feel residents continue to be exploited for their labor by the health care system. The question of whether residents are in fact students, employees, or both remains unanswered. The debate over the role of generalists and specialists in the provision of care endures, and the rise of specialty care that began in the 1950s continues unabated. How much autonomy should junior trainees be given, and how fast? Who should oversee their care? Should patients be exposed to potential risks in the name of education, and if not, what can be done to assure both patient safety and robust resident training?

To answer these and other questions, Ludmerer takes us on an absorbing journey from the early beginnings of GME, through the 20th century and its subsequent reforms and upheaval, to the rapidly changing system we know today. The scientific, social, and economic forces driving this transformation are well described. For example, the rapidly expanding body of scientific and medical knowledge in the late 19th and early 20th centuries meant that new and effective medical treatments became available. Patients were now being hospitalized and treated for more complex and heretofore untreatable conditions. The subsequent debate over the definition of a specialist led to the advent of national specialty boards, which Ludmerer describes as “the second great reform of medical education” after the Flexner report in 1910. This and other forces resulted in specialty boards and other national organizations assuming greater influence over graduate medical training. Rather than being the domain of the medical school, GME was now firmly entrenched within the clinical infrastructure of the hospital. This led to the standardization (and, in many cases, extension) of the length of graduate medical training.

In my view Ludmerer is an optimist, yet he is skeptical about many of the reforms we are familiar with today. He carefully dissects the forces leading to the duty hour restrictions currently imposed on GME programs and their trainees. For example, the recommendations stemming from the Libby Zion case had far more to do with the need for greater resident supervision by faculty than they did with resident fatigue and duty hours. (The residents involved in this notorious case, he points out, had in fact just returned from vacation and were presumably well rested!) Restrictive duty hour rules, he proposes, have led to an increased number of handoffs and a resultant loss of continuity of care and attention to detail that threatens to increase the frequency of clinical mistakes made by residents rather than reduce it.

With an eye to the future, Ludmerer correctly asserts that the fate of residents and the training they receive are dependent on the fate of our health care delivery system. That fate is far from secure. Ludmerer shines a light on the economic forces that threaten the quality of GME. The advent of diagnosis-related groups and the growing emphasis on throughput, clinical productivity, and cost containment have resulted in a system that diminishes the value of education over other missions. Such an arrangement helps marginalize residents within a system they cannot control, and it threatens to reduce residency to vocational training. He distinguishes between “fast medicine”—shorter lengths of stay, rapid turnover, quick decision making, and expeditious care when needed—and “slow medicine”—delivered at the bedside at a human pace allowing physicians to bond with their patients in rewarding and salutary relationships.

Ludmerer offers a clear road map for managing the current and future challenges to GME. He unapologetically calls for revision of the current duty hour structure—particularly the “24 plus 4” model that forces residents to abruptly leave the hospital—as out of synch with patient needs. Given that there is no demonstrated link between physician fatigue and medical errors, he posits that flexibility around duty hours would align the clinical requirements of patient care with the educational goals of residents and fellows, without sacrificing safety or the 80-hour workweek. Limiting the number of patients assigned to residents, he suggests, would allow a return to a more deliberative, reflective, and thorough consideration of patients' presenting complaints and their context. His prescription calls for innovative care team models and more support staff that could help unburden residents from the tasks that do not pertain to their level of education, or the skills needed for future practice. Improved models for supervision by senior faculty, including department chairs and other institutional leaders, would recapture the added dimension of professional identity development that GME was intended to provide. Although Ludmerer remains a strong proponent of safe and effective care delivery, he suggests that the surest guarantee of achieving the quality of clinical outcomes is a knowledgeable, skillful, and well-trained physician workforce. Another critical aspect of quality care is the stewardship of resources, manifested by the thoughtful use of diagnostic tests and procedures, and, just as important, knowing when not to perform a test or procedure. Finally, he suggests that residents be included in helping to define and enact remedies to the challenges that face them during their training.

Let Me Heal provides an invaluable primer on the foundations, history, and advancement of GME in the United States. Ludmerer's comprehensive and readable exposition, supported by innumerable references and footnotes, should be required reading for all program and institutional leaders in GME. We are clearly in the midst of an evolution—some would say a revolution—in the way we educate and train our physicians. Ludmerer's book helps put the current upheaval in perspective.

J Grad Med Educ. 2014 Sep;6(3):437–450.

Our House: A Resident Perspective

Sarah Dotters-Katz 1

As a resident, I am always being encouraged to read more. Read this chapter. Read that journal article. Read the new practice bulletin. Rarely is there time to read for fun. Like potential space, the time for nonwork reading isn't there until you create it. When asked to review Kenneth Ludmerer's Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, part of me rebelled: Why would I want to read more about medicine—isn't that what I eat, sleep, and breathe? However, the history major in me triumphed: Wouldn't it be interesting to learn about my roots, especially as I am personally transitioning from the completion of a graduate medical education program to a subspecialty training program?

I was not disappointed. Starting from the early eras of medicine in the United States, this book provides an in-depth chronicle of how residency evolved into what it is today. Ludmerer contends that national events and their associated social themes were the main context that drove the development of graduate medical education over time. To further this theory, he employs an interplay between primary and secondary sources. The quotes from residents about day-to-day life, their mentors, and the residency process really bring the book to life. These quotes are then balanced by more recent insights into those eras, which provide a broader perspective. As the pace of medicine accelerated over the last 50 years, so effectively does the pace of the book, which makes it fun to read as well.

On a micro level, there are a few entertaining aspects that make this book worth reading. First, we hear the voices of real individuals, known better as “giants of medicine” from the operations, procedures, and examination findings named after them. Second, the etiology of the term “house officers” is explained, which brings the term to life. Also, the portrayal of residents as being a family since the onset of graduate medical education allowed me to feel part of something much larger. However, as a resident, my favorite theme in this book is the service versus education balance, something that we still struggle with today. It is fascinating to discover this is not a new issue, but one that residents and faculty alike have grappled with in different ways since the formal training of physicians began. Finally, another storyline that emerges effectively in this book is the concept of academic faculty, physicians who are dedicated to teaching. Using multiple adoring and respectful quotes from their students, a series of remarkable individuals are highlighted. We can all identify with these descriptions and note the many similarities between these past individuals and today's most effective mentors. Ludmerer illustrates the development of the academic physician as a crucial element in physician education, which evolves over time and becomes essential to the success of resident education.

The depth and thoroughness of the book are impressive. However, it is so comprehensive that it serves as more of a reference or encyclopedia than an easy weekend or airplane read. This was disappointing to me because although the history of residency is a valuable and interesting topic to residents and attendings, in this format it is too long and too dense to be easily digestible for the busy trainee or clinician. Also, as a woman in medicine, I wish more pages were devoted to medical education for women and underrepresented minorities. There is a small section that describes the integration of women and minorities into mainstream residency programs, which made me much more curious about the specific pathways these individuals pursued previously. Finally, most of the examples used in the book refer to medicine and surgery. There are minimal entries or histories that refer to pediatrics, obstetrics and gynecology, or psychiatry. Thus, although interesting, the appeal to a wider audience may be somewhat limited.

For the nonmedical reader with an interest in medicine, this book highlights central themes in the development of academic medicine and graduate medical education. Ludmerer describes this subject matter in an understandable and illustrative way that resonates with medical and nonmedical people alike. With grace and style this book tells a complicated story in a clear and thorough manner. Overall, both the history major and the resident in me were content. I gained a new sense of the true nature of the legacy I have inherited, and a sense of belonging to something bigger and more important than a single individual.

J Grad Med Educ. 2014 Sep;6(3):437–450.

What's the Work?

Faith T Fitzgerald 1

Let Me Heal: The Opportunity to Preserve Excellence in American Medicine is the third (but, one hopes, not the final) volume in a history of medical education in America by Kenneth Ludmerer, the unchallenged doyen of this essential area of scholarship.

His two previous volumes are titled Learning to Heal (1996), which examined the structure, content, evolution, and purpose of medical education in America from its beginnings to the 1920s, and Time to Heal (1999), which described the years from the 1920s to 1994, the span he considers to cover both the rise and subsequent gradual fall of academic medicine's finest teaching, research, and scholarship.

The title of his newest work is, I believe, a supplication to those agencies (the Accreditation Council for Graduate Medical Education and specialty certifying boards) now “in charge” of 21st-century resident education, to decrease the imposition on teaching medical hospitals of more rules, regulations, and mandatory content that, in their accumulating requirements, take residents away from actual patient interaction. He also appeals in his title for a respite from the concurrent gradual erosion of patient-centeredness and faculty engagement with residents. These have resulted from the commercial business environment of “rapid throughput” care and an increasing dominance of procedures and diagnostic-therapeutic technology over the past several decades. The focus on procedures and technology brings in money, but it concurrently diminishes faculty time with residents and impedes the physician-in-training from seeing himself or herself as a principal diagnostic and therapeutic instrument.

Ludmerer, both an accomplished historian and a clinically active physician-teacher attending to patients, writes his latest book in his habitually engaging style, a mélange of evidentiary scholarship and personal experiences and opinions by residents, their faculty, and program directors. His text is rich in stories, and his “footnotes” (which I enjoyed very much) are a combination of published references, memorable anecdotes, and supplemental commentary to his text.

His conviction is that the residency, as he says in his preface to Let Me Heal, is the “dominant formative influence” in the making of a physician. The genesis of Let Me Heal began in earnest, as he tells it, when he was a member of the Institute of Medicine's Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. It seemed to him too simple a solution to a set of far more complex environmental influences than those arising from resident physical fatigue. This simplified focus might not only divert attention away from, but even augment, more dire changes in the educational environment of residents by requiring them to “get the work done” in less time and, concurrently, causing them to lose the sense of “ownership” and responsibility for their patients, already threatened by the pressures of rapid throughput.

Ludmerer's concern about this issue reminded me of a particularly conscientious and empathetic senior medical resident I spoke to as he was in the process of admitting a man to our General Medicine Ward team. He said he had been paged by the discharge planner within minutes of his arrival at the patient's bedside. She wanted him to tell her when the patient could be discharged. She went on to say that, since the patient was indigent, my resident should just “get the work done” and get the patient out of the hospital, as quickly as possible.

He then asked me the essential question: “What is the work?”

In my academic university teaching hospital, as well as many (most?) others, the pressure on faculty to spend more and more time doing procedures (which bring in the most money) is very great. We have even created a promotional ladder especially for them, in which their RVUs (Relative Value Units)—how much money they bring in—are prominently listed as part of the merit packages submitted for their advancement in a certain type of professorship: I call it the “Clinical-Profiteer Series,” not necessarily in reference to profit obtained by the physicians, but that gained by the hospital. Faculty teachers are often so burdened by their assigned tasks in research, procedures, or other clinical care that they have little time to spend chatting with residents and students. Similarly, residents and students have little time to talk with one another, their faculty, or their patients. The formulaic documentation imposed by the electronic health record (designed principally for billing, not patient care, and diagnosis-centered rather than patient-centered) results in far more resident time spent on the computer than spent with the patients themselves. Mandated specific curricula and endless evaluations also proliferate, and both teachers and learners are consumed by these tasks—a form of “in vitro” education that further reduces “in vivo” time spent with patients.

It is in the final chapter of this book where, in my opinion, the many gems in Ludmerer's Triple Crown of books on American medical education shine brightest. In chapter 13 he proposes, based on his wisdom and scholarship, the ways we must try to address the difficult task of redesigning medical education in the 21st century such that we may teach both the science and the human art of medicine as inextricably bound together, as they are in our ancient promise to serve the suffering.

In a way, now is, perhaps, the best of times to do this. I strongly believe that our physicians-in-training are up to the task: They chose to go to medical school when others—including some physicians—tried to discourage them from doing so. They were told they would go deeply into debt, sacrifice time with their families, sleep very little, work very hard, and be servants of the system instead of masters of their craft. And they came nevertheless. They are potentially the best of us, and we who are their teachers must help them be, and do, their best, for our patients' sake.

J Grad Med Educ. 2014 Sep;6(3):437–450.

Training Residents in the United States: Past, Present, and What's Next

Geert Blijham 1

In 1979, I became hematology/oncology fellow in the Department of Developmental Therapeutics at the world-famous MD Anderson Cancer Center in Houston, Texas. I had almost finished my residency in internal medicine at the Academic Hospital Maastricht in the Netherlands, and with curiosity and anxiety I looked forward to my new working and training environment. It turned out to be a once-in-a-lifetime experience. There were 6 patients per fellow (rather than 12 as a resident in Holland), daily rounds by the attending physician (rather than once a week), rounds on Saturday and Sunday (rather than having the weekend off), and patients calling 7 days a week, 24 hours a day (rather than “out of the hospital” meaning “no patient contact”). And, most important to me, a department chair with a never-ending ability to ask difficult questions, to address the “why” more than the “what.” After all, in 1965 Emil J. Freireich was the coinventor of the first curative treatment for children with acute leukemia. For him, and consequently for all faculty in the department, today's patient care was the laboratory for the patient care of tomorrow. This fellowship experience has stayed with me for all my professional life.

Where was I in the succession of “tectonic shifts” in residency training that Kenneth Ludmerer describes in his fascinating book Let Me Heal: The Opportunity to Preserve Excellence in American Medicine? In short, I benefited from the profound changes in working conditions that, as he describes, characterized the 1960s and 1970s. Residents and fellows did not have to be monks anymore; I received a salary and was entitled to a private life, albeit with less privacy than I was accustomed to. Moreover, I did not suffer from the upcoming shift toward what Ludmerer calls “the high throughput era,” in which the day of admission was in fact the first day of discharge. The patient load was actually rather low, and there was enough time for reflection and study. Within 1 year I had submitted an abstract on prognostic factors in chronic myeloid leukemia blast crisis and had presented at the Annual Meeting of the American Society of Clinical Oncology about the first patients with testicular cancer treated with stem cell transplantation. Training and science were still in balance, at least in the fellowship phase, on the way toward Board eligibility, which, as Ludmerer points out, was the phase most resistant to the pressures of production.

This brief summary of my own experience resonates with a major theme of Let Me Heal: the constant drift away from the early “Hopkins” days, where “students” rather than “employees” were taught by eminent clinicians how to think rather than how to act, and toward the “9-to-5” house officers for whom the mastery of skills and techniques is most important.

Ludmerer certainly recognizes there are problems associated with working more than 100 hours a week, and having an educational system that looks inward rather than taking aspects of society into account. But his word processor becomes enthusiastic when he writes about Osler and Halsted, Stead and Beeson, the full dedication of residents to the well-being of their patients, and residents becoming not only expert medical specialists but also clinical scientists.

Let Me Heal is very well written and touches on virtually every aspect of the graduate training of physicians in the United States. But it is not applicable only to the United States: almost all of these aspects are recognizable to those engaged in the education of medical specialists in Western Europe, albeit with some differences. In the Netherlands, in the early 1990s we reduced the working hours of residents to 48 hours per week and did so, I believe, without any deterioration to the quality of training or patient care. We even introduced part-time training programs, which allow female residents to combine starting a family with continuing medical training. To me, Ludmerer's fascination with the 80-hour workweek, or with the resident being allowed to stay 4 or more hours after a busy night shift, seems to be inspired more by romanticism and nostalgia than by facts. In contrast to his opinion, I would assert that neither professionalism (that is, serving the interests of the profession) nor the interests of patients are at risk when residents are treated as normal human beings.

About 20 years ago in the Netherlands we embarked on a system in which the resident spends time in both an academic hospital and a community hospital. Before that time, academic hospitals and community hospitals offered separate programs. On paper these programs may look very much alike (duration, rotations through inpatient and outpatient departments, a required number of procedures), but in reality there were considerable differences in the number of patients per resident, the intensity of supervision, and, most importantly, patient mix. Academic and community hospitals are different working places, yet both offer valuable training experiences.

Being only trained in an academic setting may sound more attractive, but it may leave the resident with the erroneous impression that rare diseases are the most common ones in the world. The resident may lack typical practice experiences that form the daily life of most medical specialists. Let Me Heal does not delve into this issue of exposure to both academic and nonacademic institutions.

Let Me Heal is the book of a historian describing the rise and fall of the very successful American residency system. In the last chapter, Ludmerer introduces interesting thoughts about how to adapt this system to the realities of today's health care without losing its inherent good qualities. Here I sense that a thorough discussion about the relationship between generalist and superspecialist educations, both in terms of competencies and regulation of numbers, would add to his work. Ludmerer makes the point that changes in residency training and changes in health care are closely related. Part of the problem with the current residency system in the United States is due to general problems in health care: the emphasis on more rather than less, the persisting view that a patient's death is a medical failure, and confusion about what professionalism really means. I sense that Ludmerer is concerned that such messages are reinforced through residency training. In a way, the health care system and the residency system hold each other hostage.

When I left MD Anderson to return to the Netherlands, I asked my attending physician about his experience supervising me. He said, “We said so often no.” I took that as a compliment, knowing that some of my cancer patients, after honestly and openly discussing the pros and cons of a new treatment in the final stage of their disease, ultimately declined treatment. I was fortunate to get my education in hematology and oncology in an environment that allowed me independence, and at the same time let me be inspired by excellent clinicians and scientists. Let Me Heal provides us with a deep insight in how this successful residency system has been developed and maintained, despite threats from the world around it.

J Grad Med Educ. 2014 Sep;6(3):437–450.

Let's Heal Ourselves

Meredith J Sorensen 1

As a trainee on the brink of the fellow-to-faculty transition, perhaps I am particularly reflective about the issues raised by Kenneth Ludmerer's newest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. This exhaustive history of graduate medical education inspired me to feel nostalgic—partly for a past I never experienced, but mostly for the transformative 8-year educational period of my own career that is quickly drawing to a close. Reading the book also helped me place my training in perspective. It left me feeling reassured that my experience as a resident and fellow has truly prepared me for my profession, and cautiously optimistic that our ever-changing system of graduate medical education will continue to produce outstanding physicians.

From the first chapter Ludmerer articulates themes that echo throughout the history of physicians' education after medical school, and still resonate today. More than a century ago, he teaches us, there was an increasing trend toward physician specialization, due in part to the rapidity of advances in medical science. Although residency training at the time was a privilege rather than a professional requirement, house officers served as both providers of patient care and performers of menial tasks. With each successive decade, patient complexity increased and hospital length of stay grew shorter. Combine these changes with the mounting external requirements for documentation, and residents' workloads became ever more clerical and less clinical. Readers will realize, however, that the conflict between education and service is not a product of the 80-hour workweek; rather, it is inherent in graduate medical education. Similarly, achieving the proper balance of autonomy and supervision, finding time for clinical investigation, and learning to deal with sleep deprivation have always challenged house staff and their mentors. Although conditions and circumstances have changed over time, Ludmerer illustrates that resident education is not different from other aspects of society—history repeats itself.

That history contains lessons as well. Meticulously researched, Let Me Heal is sprinkled with anecdotes that serve as fables, each with a moral for today's generation. For example, Ludmerer tells the story of a Johns Hopkins surgical resident who told the revered Dr Halsted that his patient was doing well, when in fact he had not examined him. Actually, the patient was not doing well, and Halsted summarily dismissed the resident “not for failing to visit the patient, but for saying he had.” Other than the fact that it involves Halsted, there is nothing terribly remarkable about that event. Honesty, including admitting one's own mistakes, remains a central tenet of medical training. Through similar tales, Ludmerer uses the founding fathers of graduate medical education (Osler, Cushing, Christian, Stead, Moore) to remind current trainees and their teachers that the fundamental principles endure: call for help, know why you do something, be intellectually curious, know when not to operate. Although the role of the house officer has evolved, the moral groundwork of medicine remains constant.

Ludmerer shows us that certain issues and challenges in graduate medical education are not unique to our time, yet he certainly does not claim that the current system is not broken, nor does he advocate that we embrace the status quo. Indeed, even in the sections of Let Me Heal that seem to stagnate in repetitive detail, readers feel the constant undertow of residents' diminishing roles in caring for their patients. With each major shift in the health care system—the elimination of wards, the introduction of Medicare, the societal focus on patient safety, the enforcement of resident duty hours—house officer autonomy has suffered, and the residents' clinical role has diminished. The cumulative effect of these systemic changes has been a gradual erosion of the importance of trainees in patient care. Although residents remain a necessary part of the workflow, they are now superfluous to many aspects of patient care. Ludmerer convincingly guides his readers through this slow but steady process of “marginalization.” By the book's last chapter, it was easy to understand how graduate medical education has been swept along by the tide of external forces, and it was refreshing to read Ludmerer's call for internal leadership to seize opportunities for change.

Ludmerer places the blame for the deterioration of resident education squarely on the medical profession itself. I suspect this was a conscious choice—by not shifting responsibility, he reminds his readers that we ourselves control the destinies of our training programs. However, I also believe that giving patients and lawyers a free pass leaves integral pieces out of the puzzle. Ludmerer suggests that as tests and treatments became more available and faculty became less involved, residents stopped thinking critically and instead ordered everything they could. “Patients, once concerned that doctors could not do enough to keep them alive, now began to worry that doctors might do too much,” Ludmerer writes. Perhaps this was true in the 1960s, but this conservative mindset is not one I have encountered in many patients. Granted, I have been fortunate to train at 2 institutions that are particularly cost-conscious and outcomes-driven, but it seems a stretch to explain the culture of excess in medicine as the result of residents who fail to consider the indications for tests. Patients and families often demand “everything,” especially at the end of life, even when physicians take the time to have nuanced discussions about questionable benefits or futility. When these expectations are considered in the context of the medicolegal climate, the problems are compounded. The term “defensive medicine” is not mentioned in Let Me Heal until late in the last chapter. Although Ludmerer deserves credit for focusing responsibility internally, his failure to address the powerful influences of American culture, such as patient demands and the ever-present specter of litigation, appears a relative weakness.

Let Me Heal gets to the heart of another crucial issue: heightened generational tension. Although there has always been a tendency for senior faculty to regard trainees as “soft,” the more recent reforms seem to have prompted increasingly disgruntled faculty to turn their anger toward their younger colleagues. Residents are both compelled to comply with new policies and simultaneously criticized for doing so. For the most part Ludmerer avoids participating in judgmental generational stereotypes. In fact, he seems to reserve his censure for disengaged faculty. With the first several chapters focusing on the profound influence of now-legendary medical educators, the absence of influential mentors is conspicuous later in the book. Admittedly, today's outstanding faculty members have not yet achieved the folklore status bestowed with time, nor are modern anecdotes injected with the apocrypha of memories. However, Ludmerer makes quite apparent that medical education today lacks giants. For me, that is both the most lamentable and the most inspiring message of Let Me Heal.

Still 2 months before its official conclusion, I reflect fondly on my training. Of course, I could have done more and seen more, but I hope this remains true even at the end of my career. Ultimately I learned timeless lessons, gained invaluable experiences, and crossed paths with some exceptional mentors. “Years or decades later, doctors often wax eloquently about the wonders of their years as house officers,” Ludmerer writes. “What they are really saying, however, is that they love medicine and are grateful to their residency for having prepared them for their calling—not that every moment was perfect.” We cannot make graduate medical education perfect, but, precisely because we love medicine, we should work together to preserve its integrity. I hope Ludmerer's Let Me Heal inspires us all to do so.

Articles from Journal of Graduate Medical Education are provided here courtesy of Accreditation Council for Graduate Medical Education

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