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While myriad forces are changing the face of contemporary healthcare, one could argue that nothing will change the way medicine is practiced, more than current advances in technology. Indeed, technology is changing the entire world at a remarkable rate – with mobile phones, music players, emails, databases, laptop computers, and tablets transforming the way we work, play, and relax.
It is axiomatic in medical education that an individual is not a mature physician until having learned to assume full responsibility for the care of patients. Thus, the defining educational principle of residency training is that house officers should assume the responsibility for the management of patients.
A middle-aged man was recently admitted to a Midwest hospital for “refractory congestive heart failure.” He had been followed in the hospital’s out-patient clinic for two years with that diagnosis. Yet, he continued to retain fluid and gain weight, despite optimal treatment for congestive heart failure.
The country has long had too many specialists and subspecialists, so the common wisdom holds. And, the common wisdom continues, the fault lies with the residency system, which overemphasizes specialty medicine and devalues primary care, in flagrant disregard of the nation’s needs.
It was not always that way. Before World War II, medical education practiced birth control with regard to the production of specialists. Roughly 80% of doctors were general practitioners, only 20% specialists. This was because the number of residency positions (which provided the path to specialization) was strictly limited. The overwhelming majority of medical graduates had to take rotating internships, which led to careers in general practice.
After World War II, the growth of specialty medicine could not be contained. The limit on residency positions was removed; residency positions became available to all who wanted them. Hospitals needed more and more residents, as specialty medicine grew and medical care became more technologically complex and scientifically sophisticated. Most medical students were drawn to the specialties, which they found more intellectually exciting and professionally fulfilling than general practice (which in the 1970s became called primary care). The satisfaction of feeling they were in command of their area of practice as an additional draw, as was greater social prestige and higher incomes. By 1960, over 80% of students were choosing careers in specialty medicine — a figure that has not changed through the present.
The transformation of residency training from a privilege to a right embodied the virtues of a democratic free enterprise system, where individuals were free to choose their own careers. In medicine, there were now no restrictions on professional opportunities. Individual hospitals and residency programs sought residents on the basis of their particular service needs and educational interests, while students sought the field that interested them the most. The result was that specialty and subspecialty medicine emerged triumphant, while primary care languished, even after the development of family practice residencies converted primary care into its own specialty.
Radiologist in San Diego CA by Zackstarr. CC BY-SA 3.0 via Wikimedia Commons.
This situation poses a perplexing dilemma for the residency system. More and more doubts have surfaced about whether graduate medical education is producing the types of doctors the country needed. No one doubts that having well-trained specialists is critically important to the nation’s welfare, but fear that graduate medical education has overshot the mark. Ironically, no one knows for sure what the proper mix of specialists and generalists should be. A popular consensus is a 50-50 mix, but that is purely a guess. One thing is clear, however: The sum of individual decisions is not meeting perceived public needs.
At the root of the problem is that fundamental American values conflict with each other. On the one hand, the ascendance of specialty practice service serves as a testimony to the power of American individualism and personal liberty. Hospitals and medical students make decisions on the basis of their own interests, desires, and preferences, not on the basis of national needs. The result is the proliferation of specialty practice to the detriment of primary care. This situation occurs only in the United States, for the rest of the Western world makes centralized decisions to match specialty training with perceived workforce needs. Medical students in other countries are not guaranteed residency positions in a specialty of their choice, or even a specialty residency in the first place.
On the other hand, by not producing the types of doctors the country is thought to need, there is growing concern that graduate medical education is not serving the national interests. This would be a problem for any profession, given the fact that a profession is accountable to the society that supports it and grants it autonomy for the conduct of its work. This poses an especially thorny dilemma for medicine, in view of the large amounts of public money graduate medical education receives. Some medical educators worry that if the profession itself cannot achieve a specialty mix more satisfactory to the public, others will do it for them. Various strategies have been tried — for instance, loan forgiveness or higher compensation for those willing to work in primary care. However, none of these strategies have succeeded — in part because of the professional lure of the specialties, and because of the traditional American reluctance to restrict an individual’s right to make his own career decisions. Thus, the dilemma continues.
Headline image credit: Hospital at Scutari, 1856. Public domain via Wikimedia Commons.
Sir William Osler, the great physician and bibliophile, recommended that his students should have a non-medical bedside library that could be dipped in and out of profitably to create the well rounded physician. Some of the works mentioned by him, for example Religio Medici by Sir Thomas Browne is unlikely to be on most people’s reading lists today. There have been several recent initiatives in medical schools to encourage and promote the role of humanities in the education of tomorrow’s doctors. Literature and cinema has a role to play in making doctors more empathetic and understanding the human condition.
My idiosyncratic choice of books is as follows.
Firstly, I start with a work by the most respected physician of the twentieth century, Sir William Osler himself. The work I choose is Aeqanimitas, published in 1905 and is a collection of essays and addresses to medical students and nurses with essays ranging in title from “Doctor and Nurse,” “Teacher and Student,” “Nurse and Patient,” and “The Student Life”. They are as relevant today as the day they were penned with a prose style combining erudition and mastery of language rarely seen in practicing physicians. Osler was the subject of the great biography, written by the famous neurosurgeon Harvey Cushing, who was to win a Pulitzer prize for his efforts. (I am not including this biography on my list, however.)
Anton Chekhov is included in my list for his shortstories ( he was also a successful playwright). Chekhov was a qualified Russian doctor who practiced throughout his literary career, saying medicine was his lawful wife and literature his mistress. In addition to a cannon of short stories and plays, he was a great letter writer with the letters, written primarily while he traveled to the penal colony in Sakhalin. He was so moved by the inhumanity of the place, that these letters are considered to be some of his best. Chekhov succumbed to tuberculosis and died in 1904, aged only 44 years.
William Somerset Maugham, the great British storyteller was once described by a critic as a first rate writer of the second rank. Maugham suffered from club foot and was educated at the King’s School, Canterbury, and St. Thomas’s hospital, London where he qualified as a doctor. His first novel Liza of Lambeth, published in 1897 describes his student experience of midwifery work among the slums of Lambeth led him to give up medicine and earn a living writing. He became a prolific author of novels, short stories, and plays. His autobiographical novel Of Human Bondage describes his medical student years at St. Thomas’s Hospital. Many of his stories and novels were turned into successful films.
A portrait of W. Somerset Maugham. Public Domain via Wikimedia Commons
Another medical student from the United Guy’s and St. Thomas’s Hospital who never practiced as a doctor ( although he walked the wards of Guy’s Hospital and studied under the distinguished surgeon Astley Cooper), was John Keats, who lived a tragically short life, but became one of the greatest poets of the English language. His first poem “O Solitude,” published in The Examiner in 1816, laid the foundations of his legacy as a great British Romantic poet. Poems the first volume of Keats verse was not initially received with great enthusiasm, but today his legacy as a great poet is undisputed. Keats died, aged 25, of tuberculosis.
Oliver Wendell Holmes, the famous North American nineteenth-century physician, poet and writer, and friend and biographer of Ralph Waldo Emerson, popularized the term “anaesthesia,” and invented the American stereoscope, or 3D picture viewer. Perhaps his best known work is The Autocrat at the Breakfast Table his 1858 work dealing with important philosophical issues about life.
In Britain over a century later, in 1971, the distinguished physician Richard Asher published a fine collection of essays, Richard Asher Talking Sense which showcase his brilliant wit, verbal agility and ability to debunk medical pomposity. His writings went on to influence a subsequent generation of medical writers.
In the United States, another great physician and essayist was Sherwin Nuland, a surgeon whose accessible 1994 work How We Die became one of the twentieth centuries great books on this important topic a discourse on man’s inevitably fate.
Two modern authors next. The popular American writer Michael Crichton was a physician and immunologist before becoming an immensely successful best-selling author of books like Five Patients, The Great Train Robbery, Congo, and Jurassic Park, which was of course turned into a very popular film by the American film director Stephen Spielberg.
Khaled Hosseini the Afghan-born American physician turned writer is a recent joiner of the club of physician-writers, having achieved great fame with his books The Kite Runner and A Thousand Splendid Suns.
I suppose we must finally include Sir Arthur Conan Doyle the Scottish physician and author. His stories of the sleuth Sherlock Holmes have given generations pleasure and entertainment, borne of the sharp eye of the masterful physician in Conan Doyle.
Residency training has always had — and always will have — a dual mission: ensuring the safety of patients treated today by doctors-in-training, and ensuring the safety of patients treated in the future by current trainees once they have entered independent practice.
Surprisingly, these two goals conflict with each other. That is because proper graduate medical education, as I have explained in an earlier essay, requires doctors-in-training to assume responsibility for the management of patients. It is not enough for residents to watch senior physicians evaluate patients, make decisions about diagnosis and therapy, and perform procedures. Rather, trainees must learn to exercise these responsibilities themselves during their residency, lest their first patients in practice become victims of inexperience and inadequate preparation.
For this reason, the needs of today’s patients and those of tomorrow’s are not necessarily the same. Future patients depend on having well prepared doctors who gained extensive independent experience as residents. Their needs are served when inexperienced trainees manage complicated patients or perform major operations today, so once in practice doctors will be able to serve patients maximally. However, today’s patients benefit when they are cared for by the most experienced physicians available. Thus, residency training must consider the safety of both present and future patients. The challenge of achieving this balance has become particularly great during the last generation, as hospitalized patients have become much sicker, hospital stays much shorter, and medical practice ever more powerful and complicated. Mistakes of omission and commission now carry potentially greater consequences.
The key to maximizing the safety of both present and future patients is by providing house officers effective supervision in their work. Many studies have found that closer supervision of residents leads to fewer errors and improved quality of care. One review observed that increased deaths were associated with poor supervision of residents in surgery, anesthesia, emergency medicine, obstetrics, and pediatrics. Another study showed that the impact of better supervision on patient safety was particularly marked with less experienced residents. Despite the contemporary furor surrounding the issue of residents’ work hours, proper supervision has consistently been found to be much more important to ensuring patient safety than house officer fatigue.
We have much to learn about supervisory practices in medical education. However, current evidence suggests that the supervisory relationship is the single most important factor in the effectiveness of supervision. Especially important in this relationship are continuity over time, the supervisor’s skill at discharging oversight responsibilities while preserving sufficient intellectual autonomy for trainees, and the opportunity for both trainees and supervisors to reflect on their work. Other qualities of effective supervision have also been identified. Supervisors need to be clinically competent and knowledgeable and have good teaching and interpersonal skills. The supervising relationship must be flexible so that it changes as trainees gain experience and competence. Residents need clear feedback about their errors; corrections must be conveyed unambiguously so that residents are aware of mistakes and any weaknesses they may have. Helpful supervisory behaviors include giving direct guidance on clinical work, linking theory and practice, joint problem solving, and offering feedback reassurance, and role modeling. Ineffective supervisory behaviors include rigidity, intolerance, lack of empathy, failure to offer support, failure to follow trainees’ concerns, lack of concern with teaching, and overemphasis on the evaluative aspects of supervision.
It should be noted that good clinical supervision, like good teaching, is time-consuming. Many faculty members today find it difficult to provide the time necessary for close supervision and effective teaching because of the pressures they are under to increase their clinical or research “productivity.” For better supervision to flourish, medical schools will have to be willing to place a higher priority on the educational mission than in the past. This will entail a greater institutional willingness to promote clinical-educators, as well as the adaptation of “academies of medical educators,” mission-based budgeting, and other strategies to raise or identify funds to pay for clinical teaching and supervision. If patient safety is the goal, this is an effort worth undertaking.
So the old adage goes. For generations medical educators have uttered this exhortation, based on a perceived increase in the incidence of medical and surgical errors and complications occurring at this time of year, owing to the influx of new medical graduates (interns) into residency programs at teaching hospitals. This phenomenon is known as the “July effect.”
The existence of a July effect is highly plausible. In late June and early July of each year, all interns and residents (physicians in training beyond the internship) are at their most inexperienced. Interns—newly minted MDs fresh out of medical school—have nascent clinical skills. Most interns also have to learn how a new hospital system operates since most of them enter residency programs at hospitals other than the ones they trained at as medical students. At the same time the previous year’s interns and residents take a step up on the training ladder, assuming new duties and responsibilities. Every trainee is in a position of new and increased responsibilities. The widespread concern that these circumstances lead to mistakes is understandable.
Yet, despite considerable consternation, evidence that there is a July effect is surprisingly hard to come by. Numerous studies of medical and surgical trainees have demonstrated no increase in errors or complications in July compared with other times of the year. Many commentators have declared the July effect a myth, or at least highly exaggerated. A few studies have shown the existence of a July effect, but only a slight one—for instance, on the sickest group of heart patients, where even a slight, seemingly inconsequential mistake can have grave consequences. Even here, however, the magnitude of the effect does not appear large, and the studies are highly flawed. Certainly, there is no reason for individuals to avoid seeking medical care in July should they become ill.
That the July effect is so difficult to demonstrate is a tribute to our country’s system of graduate medical education. Every house officer (the generic term for intern and resident) is supervised in his or her work by someone more experienced, even if only a year or two farther along. Faculty members commonly provide more intense supervision in July than at other times of the year. Recent changes in residency training, such as shortening the work hours of house officers and providing them more help with chores, may also help make residency training safer for patients—in July, and throughout the year.
Uncertainty is intrinsic to medical practice. Medical and surgical care, no matter how skillfully executed, inevitably involves risks. It would not be surprising if a small July effect at teaching hospitals does occur, particularly in certain subgroups of critically ill or vulnerable patients, given that house officers are the least experienced. However, the fact that this effect, if present, is small and difficult to measure provides testimony to the strength of graduate medical education in the United States. Indeed, the quality of care at teaching hospitals has consistently been shown to be better than at hospitals without interns and residents. Patients may be assured that their interests will be served at teaching hospitals—in July, and throughout the year.
Kenneth M. Ludmerer is Professor of Medicine and the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine. He is the author of Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, and Learning to Heal: The Development of American Medical Education.
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Image credit: Multiracial medical students wearing lab coats studying in classroom. Photo by goldenKB, iStockphoto.
As a medical student, you are the future of health care. Despite the persistent negativity about the state of health care and the seemingly never-ending health care crisis, you have astutely perceived the benefits of becoming a physician. There is no doubt that health care delivery is unreasonably complex for everyone involved and, as much as political party loyalists insist that this is the fault of the ‘other’ party, the bureaucracy and inefficiencies have endured despite the back-and-forth changing hands of responsibility.
Fortunately, you have seen past the commotion and panic, and steadfastly remained optimistic. There is not a single medical student who ended up where he or she is by accident. The completion of rigorous undergraduate pre-medical prerequisite courses, outstanding grades, and top-notch MCAT scores required for application to medical school only come to those who have a well-thought-out plan, combined with a commitment and perseverance to become physicians. Medical school acceptance is exceedingly competitive, involving a multistep application process starting with preliminary applications, and then progressing to selective invitations for secondary applications and interviews. Academic excellence is the entry point, while interviews serve to distinguish young people who have a passion and a gift for helping humanity. Interviews are granted to few; offers of positions in a medical school class are even fewer.
You have already overcome all of these hurdles and remained focused. You are fortunate to begin your medical education at a time when you can shape the future of the profession. Medical education is becoming more innovative, going beyond traditional approaches to learning. The potential benefits for students are endless. With these advantages, come higher expectations. As a doctor of tomorrow, you will often expect yourself to improve the world around you for your patients.
The direction of health care will certainly improve as your generation of young physicians in training masters the knowledge and proficiencies necessary to become licensed MDs in a few years. The capabilities that will make you a leader are skills that cannot be measured, yet can absolutely be learned. Like many of today’s future doctors, you are likely to find yourself driven to improve the health care options available for patients or to use technology in new ways that have not been thought of before. There has been an increasing trend of physicians playing roles that have not been defined previously.
As a young physician, while you fulfill the requirements for licensing, you may discover that there is more than one way to be a doctor. Some of the ways to be a doctor involve non-clinical work, which typically does not enjoy a well-established path. If you choose to establish experience and find employment in alternative areas besides clinical practice, you will find that you don’t have built in access to guidance and direction. Yet, it is advantageous for you to understand all of the professional opportunities available to you while you embark on the road to becoming physicians. Knowledge is power. Every young doctor ought to appreciate the full array of options after graduation from medical school. This can help set the stage for career satisfaction in the long term. You can attain a career path that is challenging and fulfilling. The results for medicine as a profession will be enhanced when all doctors use their skills and talents in the way that fits best.
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Image credit: Multiracial medical students wearing lab coats studying in classroom. Photo by goldenKB, iStockphoto.
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So the old adage goes. For generations medical educators have uttered this exhortation, based on a perceived increase in the incidence of medical and surgical errors and complications occurring at this time of year, owing to the influx of new medical graduates (interns) into residency programs at teaching hospitals. This phenomenon is known as the “July effect.”
