Friday, June 15, 2012

Medical Education on the Brink: 62 years of Front-Line Observations and Opinions

From an harshly worded editorial published in the Texas Heart Institute Journal by Herbert L Fred, MD, MACP this month entitled "Medical Education on the Brink: 62 Years of Front-line Observations and Opinions*:"
"Over the sixty-two years that this report covers, medical education has moved its focus from the patient to the laboratory and now 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."  Many of these limited-work-hour trained individuals cannot take an adequate history, perform a reliable physical examination, create a sound management plan, or communicate effectively.  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 the American people actually receive are worlds apart.  Consequently, those of us in medical education have a major obligation and responsibility to close that gap."
Dr. Fred offers the following solutions:
"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 nothin but dissappointment, 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 hours.

In place of the existing mandate, we could (and should) revert to the unlimited work-hour system that has 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."
I think Dr. Fred has hit the nail on the head, but while he beautifully articulates what more senior physicians have observed over the past ten to twenty years, I think that unless there are rewards to physicians for their long hours from family, there will be very little going back to the days of old.  Doctors of tomorrow have accepted lower wages in exchage for a more balanced life-style.  Since payments to physicians are not likely to increase in the years ahead thanks to health care reform, I see no incentive for younger doctors to accept longer residency work hours any longer, even if program directors demand them.

It IS sad to see the deterioration the skills Dr. Fred mentions in our younger doctors.  But I find the younger doctors who have completed training are still eager to learn.  Educators of today should stop expecting doctors of tomorrow to learn everything in their three or four years of residency training with "unlimited hours."  The availability of information online is incredible and I would suggest that medical educators would better serve doctors of tomorrow by teaching (and showing) them how to continuously think critically about their patients and published studies.  Even more important they should learn an even more important skill: to learn how NOT to say "I don't know" but rather "I don't know but I'll look it up."   Sure we should turn from computers and lean more on our patients as educators- after all they still are, and will continue to be - our very best teachers.  But if we use computers as a useful tool rather than a crutch, our patients and students will be better for it in the long run.



Fred, Herbert L. "Medical Education on the Brink: 62 years of Front-Line Observations and Opinions." Texas Heart Institute Journal Vol 39, No. 3, June 2012, pp 322-329. (Contents here).

*I regret that the publication is not yet online and because of copyright restrictions, I hesitate to publish the entire work here.


Jay said...


Coupled with the devaluation of the medical education process is a rise in pervasiveness and power of the physician extender.

It's not hard to see a crossing point in the very near future in which the PA/NP impact and power exceeds that of the traditional physician, especially in the non-procedural based specialities.

Given the growing similarity in their training, experience and skills, PA/NPs may look fairly similar to MDs at the bedside to our patients who are already being conditioned to accept their care without complaint.

Hospital employers and healthcare payers looking for ways to reduce cost will increasingly shift business to the extenders, reducing the MD role to that of a manager (of which there will be a limited number of jobs).

Lots of money is saved. Quality is preserved.

Everybody is happy, except for the lifestyle oriented MD who just got maneuvered out of a job.

The days of assuming that having a MD degree alone ensures a solid career future may be in jeopardy. Do you think the new generation sees this??


Thomas Nielsen said...

I read this editorial and found it very interesting. Stupidly I threw out the journal.

Since then this article has become a source of discussion in our group. I'd like a copy again.

Unfortunately the web site does not appear to have pdfs of editorials.

Anyone have a pdf or a scanned copy?

DrWes said...


Send your email to me at wes - at - medtees dot com and I'll send you a pdf copy of the article.

Darrell said...

Sounds an awful lot like this:

I've been beating this drum for more than 10 years and have been uniformly vilified.