The digital ink was barely dry on our most recent post about manipulating the training of American physicians to make them perfect Renaissance men and women, when an article was published on the topic in JAMA by the brother of President Obama’s former White House Chief of Staff, Ezekiel J. Emanuel, MD PhD, and Victor R. Fuchs, PhD.
In our last post we described how the Association of American Medical Colleges (AAMC) recently decided to de-emphasize the sections addressing scientific knowledge in the Medical College Admissions Test (MCAT). Instead of stodgy old biology, chemistry and statistics, the new test would emphasize psychology, ethics, cultural studies and philosophy in an effort to make physicians of the future less scientifically skilled, but more sensitive to the needs and feelings of patients and families. We then examined yet another proposal to make physicians even more intellectually diverse by requiring them to be able to explain their medical bills to patients, again by shifting time and educational efforts from medical science to medical finance.
Against this setting Drs. Emanuel and Fuchs seem to think that we’re not doing nearly enough to dumb down and shortchange the medical training of those who will be doing our cardiac catheterizations and brain surgeries.
We don’t have full-text access to JAMA, but we do have access to a short blog piece that The Washington Post published on their proposal. The post quotes the JAMA article thus:
“Why is medical school 4 years in length? The answer probably has to do with the Flexner Report’s recommendation in 1910 for 2 years of preclinical science training followed by 2 years of clinical training. Yet most physicians could be trained in significantly less time. Since 1997, the University of Pennsylvania has only 1 years of preclinical science training.
The important patient care skills can be obtained in less than 2 years of clinical training. The medical school at Harvard University requires students to complete only 15 months of clinical rotations….This change would be consistent with the increasing emphasis on individualized instruction and assessing students on core competencies rather than on time served. Consistent with this proposal, Texas Tech School of Medicine as well as 2 Canadian medical schools now offer 3-year programs.”
The Post then goes on to report that:
“Emanuel and Fuchs suggest reducing doctors’ training time by 30 percent, from 14 to 10 years. That would create space to train more doctors, they argue, while also reducing physicians’ debt burdens. It could also have the effect of driving down American doctors’ salaries, which are double that of doctors in most other countries, but often justified because of the profession’s expensive training costs here.”
It should therefore be no surprise that while the JAMA article is entitled: “Shortening Medical Training by 30%”, the blog entry in the Washington Post is called: “One way to cut health care costs: Cut medical training”.
Let’s take a moment to summarize:
- We know from our last post about carefully crafting the politically correct physician, that the American public (or at least the AAMC) wants us to be admitting medical students who know less about science, and more about cultural awareness, empathy and ethics. This is presumably so that patients feel better about being denied care that might have helped them had their doctors only known what was wrong with them and how to treat it.
- Other folks have proposed substituting training in healthcare cost accounting and finance for clinical medical training early in the residency process.
- Drs. Emanuel and Fuchs have now decided that, once admitted to medical school, medical students are learning far more than they need to know about things like anatomy, biochemistry, pharmacology, microbiology, biostatistics, neurobiology, histology and other things that would only come in handy if one were to eventually want to diagnose and treat physical and mental diseases.
- Meanwhile, the Accreditation Council for Graduate Medical Education (ACGME) has implemented restrictions on the number of hours medical and surgical residents may work each week. Although these restrictions were imposed for the laudable purpose of ensuring that physicians-in-training weren’t so tired that they would make lots of mistakes, they inevitably reduce the total amount of time that medical residents spend seeing patients, discussing cases and generally learning the very serious business of being a doctor. Any weakness in one’s medical school training will be amplified by having less time to make up the difference while undergoing on-the-job-training.
- As if that weren’t enough, poorly conceived, poorly executed electronic medical records have turned medical residency training from an educational experience into something more akin to secretarial school. Attending physicians – the older and wiser doctors who have traditionally walked the wards and clinics with residents to show them the ropes of clinical care – now hold back for fear of taking too much time from their keyboard duties. For a flavor what residency training has become in an era where administration and documentation has become more important and time-consuming than either patient care or medical education, we highly recommend this article by Michael B. Edmond, MD, MPH, MPA, and an attending physician and mentor to medical residents for over 20 years:
“Those of you who trained in the last century, as I did, will recall that the team room was the nerve center for managing the group of patients to whom you were assigned. It was a hub of activity that contained a large table where the housestaff reviewed thick paper charts, wrote their history and physicals, ate meals, and all the while shared the stories of their lives and their patients’ illnesses. It was strewn with EKGs, x-rays, photocopies of journal articles stained with coffee, and a worn edition of Harrison’s Textbook of Internal Medicine. You could walk into the team room at any time and immediately sense activity, observing multiple interactions among residents, students, and attending physicians.
Now, fast-forward to the modern-day team room: It still has a table, which if not physically then certainly figuratively much smaller and generally devoid of clutter. All of the action now occurs in the periphery of the room at a bank of computers where the housestaff sit nearly all of their working hours facing the wall. The room is silent except for the rhythmic clicking of multiple keyboards…
Before enforcement of the 80-hour workweek rule, residents would simply work longer in response to any unforeseen event, such as a patient’s sudden deterioration, or a planned event that took longer than expected. Part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients. However, the ability to stretch the day to accommodate the complexities of care has ended, and strict departure times have clearly added to the stress that our current house officers face daily….
I feel guilty if I ask the residents questions about themselves or what they did over the weekend as they type (and they are always typing), because I’m distracting them and using precious time. So I find that I don’t know them very well as people, and I suspect that they don’t know each other very well, either… One of my colleagues, a master clinician and superb attending physician, says that he now feels guilty when he attempts to teach, because he can see the look of fright in the residents’ eyes as they wonder how the teaching session will impact their time.”
Incredible. That we should create and maintain a system that makes attending physicians feel guilty for taking the time needed to pass on their unique and precious knowledge. Simply incredible.
Yet amidst all of these demands culturally sensitive non-scientists who are trained faster and cheaper (solely so that the resulting doctors can be paid less), there has been absolutely no change in the level of expertise or performance expected of these same physicians by the public, by payers, by the legal system, or by the literally dozens of certifying and regulatory boards that now roam the nation. The medical malpractice system – and clinical perfection demanded by its attorneys and juries – has not changed in 30 years. Medical specialty boards pursue profits by filling their certification exams with needless trivia. The federally mandated RBRVS payment system and scores of Medicare and Medicaid rules and regulations manage to suck up hours of time and money, add new “pay for performance” requirements and mandate the use of awkward and even defective electronic medical record systems, all while reducing net physician each year since the mid-1990s.
How can one country possibly be so schizophrenic, or unrealistic, about the investment it wishes to make in its physicians and the standards to which it wants them held? And why on earth is the nation’s political leadership so obsessed with slashing physician income, when literally trillions of dollars are being wasted on administrative complexity and a host of other non-productive uses? The money is just not there.
Let’s do a quick calculation. There are about 800,000 clinically active physicians in the U.S. Let’s say that each one is paid an average of $300,000. (This is an absurdly high estimate. The true weighted average is nowhere near that amount. Many doctors don’t even have gross practice revenues that total that amount.) Simple multiplication tells us that total amount of money directed toward American doctors each year is $240 billion. Total U.S. healthcare spending in 2009 was $2.5 trillion, an order of magnitude greater than all physician income combined. Even if every doctor in the country were forced to work for free as slaves, total medical expenses would drop by less than 10%.
Short of some actual mental illness, what would explain this sort of behavior? Doctors are supposed to be experts on healthcare science and the management of disease. Who will benefit from making them less expert, less trained and less experienced, all in the name of conformity, saving money, cultural values and software-mediated regimentation? The most plausible answer is anyone who wishes to transform physicians from independent, scientifically informed advocates for patients, into relatively uninformed followers-of-guidelines. Doctors following federally mandated guidelines for screening, diagnosing and treating patients don’t need to know any science; they just need to do what they’re told.
The end result may or may not be best for any given patient (perhaps you or a member of your family), but it will be less expense for Medicare, Medicaid and your private insurance company to have their doctors follow guidelines than to customize care. Meanwhile given the lack of progress in reforming the world of medical malpractice liability, the blame for whatever happens continues to rest with the physician him/herself. After all, he or she is the board-certified “expert”.
Well. At least they were experts…