US medical education is in moral crisis

We recently discussed the plight of young medical faculty.  It appears that their plight is even worse than we imagined.

Recently, an abstract was presented at the Annual  Conference on Research in Medical Education at the Annual Meeting of the Association of American Medical Colleges, in a session entitled, “Your Career is More than Your Specialty.”

The authors described a large survey, of over 5000 faculty at 26 US nationally representative medical schools, done as part of the National Initiative on Gender, Culture, and Leadership in Medicine (known as C ‐ Change) project.  The overall response rate was good (53%).

Here are the striking results:

51% agreed that ‘the administration is only interested in me for the revenue I generate’; 31%; that ‘the culture of my institution discourages altruism’; 31%, that other people have taken credit for my work’; and 30% that ‘I am reluctant to express my opinion for fear of negative consequences.’ Half perceived that the institution does not value teaching and 27% that it does not reward clinical excellence; Over half disagreed with the statement that their own values are aligned with those of the institution. Also, 30% had seriously considered leaving academic medicine and 46% their own institution, both in the prior year.

These results show that US medical education is in moral crisis, and probably close to catastrophe.  These results should provoke shame and outrage, and cause widespread discussion. On the other hand, it is remarkable that they were allowed to see the light of day at all, given the persistent strength of the anechoic effect.  Pololi and colleagues obviously never got the message that one is never ever supposed to discuss such things in public.

Instead of being about discovery and dissemination of knowledge, the fundamental mission of education, a majority of large sample of faculty surveyed says American medical schools are about making money.  Instead of putting teaching first, half of the faculty said their institutions explicitly do not value teaching. Instead of supporting free speech, free enquiry, and academic, a significant minority of faculty say that are afraid to speak out.

It is no wonder that nearly half of the faculty are considering leaving.

On Health Care Renewal, we have discussed evidence, mostly anecdotal, about the rot within the foundations of medicine and health care. Now it appears that the rot is so severe that the whole edifice is about to fall down.

Our foolish transformation of the calling and profession of medicine into a business at a time when businesses were taken over by the arrogance, greed, unscrupulousness, and amorality that lead to the global financial collapse will surely also lead to a global health care collapse if something is not done very soon.

We need a new effort much bigger than but at least as influential as the Flexner Report to re-imagine academic medicine again as valuing teaching, learning, research and patient care, while regarding its financing only as the means to reach those ends.

The Carnegie Foundation sponsored the original Flexner Report, and the Rockefeller Foundation then hired Dr Flexner to reform medical education. Will anyone or any organization have the courage to sponsor a new, bigger, and likely much more contentious effort?

Meanwhile, the academic leaders who have personally profited from and colluded with the transformation of the system into one that is only in it for the money should resign. The few remaining leaders will need to draw upon all their honesty, integrity, knowledge, and determination to rebuild the system.

Finally, shame on all of us for letting us get to this place.

Roy Poses is an internal medicine physician who blogs at Health Care Renewal.

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  • stitch

    It’s time to take medicine back from the administrators, across the board and not just in education.

  • IVF-MD

    These are good points and ones that many people in academic medicine already knew or suspected.

    This begs the question. Are monopolies good or bad? Suppose a group of caring concerned doctors wanted to break free from the established medical-education monopoly and set up their own alternative medical school, free of the current academic bureaucracy and free to set their curriculum to be different from the current censored, money-centered, non-altruistic, internally back-stabbing status quo (I got these descriptors directly from the article survey).

    Why hasn’t this been tried? It’s not for lack of willing volunteers. I have reason to believe there are many well-intentioned doctors who are willing to participate in such a noble project if it weren’t for the potential harsh punishments. There are monopoly protections in place blocking anybody outside the current system from trying this.

    Aren’t monopolies bad, especially in something so important as medical education? I’m curious who agrees or disagrees.

  • Dr. J

    The people in control of medical education are often misguided. I work in a community hospital emergency dept. and a couple of years ago the local medical school ‘informed’ us that we would be taking medical students for emerg rotations. There was no attempt to ask us, it was just assumed we would do as we were told.
    Whatever, the medical students are fun and we work hard to make it a good experience for them. We definitely loose money by having them there but no one is too fussed about it. Every year we have to re apply for credentials to teach these students through the university.
    This year instead of stamping my paperwork I was called in for a meeting, which meant I had to drive in to the city and listen to the head of the academic emerg dept. tell me how disappointing my lack of research and publications was and how I needed to remedy this if I hoped to continue teaching ‘his’ students (for free, and imposed).
    Now I work in a community ED because I don’t really want to deal with the business of academic posturing. I like teaching, and I even got a teaching award for my efforts. That being said it is hard to be an enthusiastic teacher when the all important medical school behaves like this.
    I suspsct this is a pretty wide spread problem, in Canada where I work basically any hospital of any size now has learners of one type or another. Instead of support from the big medical schools it seems that the more common mode of interaction is to criticize for not being large urban academic centres.

  • Futuredocs

    It’s more than a moral crisis, its a financial one too. As long as academic medical centers are big businesses, they respond to economic incentives and the bottom line. Unfortunately, teaching is not well paid and clinical care pays well only for certain pts. We need to change the incentives to see a dramatic change – reports can only go so far. For example, much of what Flexner said is still true today.

  • soloFP

    I found that the first two years of medical school required lots of self taught information to do well on the Step 1 of the boards. During the clerkships, most of us would not have survived Step 2 of the boards without board review books. Much of medical school is simply survival and self study. Much of the clinical behavior and one up man ship that was in the clinicals would not pass muster in the real world. I would wager that most med school physician faculty could not survive in the real world. Most docs would not be happy with the 50% pay cut in academia.

  • Afraid

    “Meanwhile, the academic leaders who have personally profited from and colluded with the transformation of the system into one that is only in it for the money should resign.”

    As if these captains of industry care a wit about this or what anyone else says. They will not go quietly into the night. Indeed they will fight tooth and nail to keep their status.

    The egyptian method makes an awful lot of sense to me if the support for overthrowing the current regime in some hospital chains is large. That however is the point, how widespread is the support for change, how many are willing to stand up and be counted? How many instead have been coopted?

    Count noses and I think you’ll be surprised.

    Not enough I’ll wager.

  • medical blog

    Wow. I’ve been out to academia so long I had no idea it is so messed up. The med students I see seem pretty well based in both values and academics.

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