How should we be training the next generation of doctors?

I have been spending time at an academic medical center lately and I’m noticing some obvious flaws in our method of shaping the doctors of the future.

When I went to medical school I was trained by physicians who were eminent in their areas of specialty and also did some research. They taught in classrooms and as attending physicians when we were working on the wards as doctors in training. I realize now that the clinical attendings who helped us manage our general medical patients actually specialized in some more narrow aspect of medicine, but were smart enough to be able to manage a diverse array of medical problems. I thought they were all amazing and never even entertained the possibility that their knowledge was less than exhaustive. I was also taught by the interns and residents who were themselves in training, though with an MD after their names. I thought that they were both wise and skillful. Perhaps they were. I will never find out now.

Watching the training of medical students this last month, I am appreciative of the skills and scholarship of many of their teaching attendings, but also am noticing that there is a difference between a physician who has spent his or her time entirely at an academic medical institution and a good community physician. The academic physician is nearly forced by the proximity of educational lectures and the demands of teaching to keep current on the recommended treatments for various diseases. They also rely heavily on the expertise of consultants in everything from dermatology to cardiology and gynecology, so don’t necessarily have a good grounding in treating a whole person in the community and circumstances in which that person finds himself. In practice, it would not have been unusual for me to treat someone for their depression, congestive heart failure, obesity, cough and the rash on their legs. In fact, all of these problems were probably connected and required an approach that recognized the other issues.

I was also hanging out in a university hospital’s emergency department some of the time, which was fascinating and sometimes really hard to watch. After saving the patients who required that acutely and sending a subset of them to the wards for admission and further treatment, there were patients who had issues that required a subtle or clever approach, which was not really in the knowledge set of the ER physicians. Not that it necessarily should be, since emergency physicians should really be dealing with emergencies. Still. Many of the patients who use emergency rooms do so because they cannot be refused service there for inability to pay, and they can be seen the day they show up, though they may have to wait many hours. Although their non-emergency problems should be taken care of by doctors in the community, they don’t have doctors in the community, and sometimes, if they do, those doctors are not particularly skillful.

So I think that academic medical centers need physicians who have been in practice to teach medical students. Physicians who have been in practice also need academic medical centers to remind them to keep their knowledge bases updated and give them a reason and a method for doing so. Academic physicians are very intelligent and hard-working, but much of their brain space is taken up with their research projects and many or even most of them have never had to take care of as many patients for as long as those of us in practice have, and so they are not ideally suited to teach medical students how to practice medicine. It would be nice to see some cross pollination between medical schools and non-teaching institutions. Community physicians do act as preceptors for medical students, taking them to clinic and on rounds, but this is just a small fraction of the medical students’ learning and is not coordinated with teaching objectives.

It was probably nearly the same when I was a medical student, but I never noticed, other than realizing when I got out of medical school that there was still lots to learn. One thing that was significantly different when I was in training was that in the third and fourth years of medical school we had very important clinical responsibilities. Without us, patients would have died and residents would have been frantically overworked. We drew bloods, we wrote progress notes, we started IVs, delivered drugs and blood products. We were at the bottom of the food chain, but we were part of it. We were called “scut monkeys” because of the number of menial tasks for which we were responsible for.

Now, medical students have been mostly eliminated from jobs that are vital to patient care. They have restrictions on work hours, which is kind of good and kind of not so good. They can spend all day trying to find learning experiences, but are also seen as kind of a nuisance because they have no really important role. When they get their MDs and become residents, they have all the responsibilities all of a sudden since the medical students don’t help that much. I think I was observing some of the more unpleasant results of burnout in some of the residents as they were deluged with work that they weren’t really prepared to do. Their fatigue impacted attending physicians who were required to do more than they comfortably could handle, thus reducing their ability and willingness to teach.

In some of the hospitals where I have worked consultants or representatives of hospital organizations have come in to identify work processes that are ineffective or inefficient. This is necessary in places that are not heavily subsidized (and academic medical centers are pretty heavily subsidized.) I sense that this focus on efficiency is not necessarily a part of academic hospitals, though my single recent experience is hardly an exhaustive survey.

HealthGrades released a list of the top 5% of hospitals in the U.S. in terms of patient outcomes and patient satisfaction and it is not surprising to me that very few primarily academic medical centers made the list. UC San Francisco is not on the list. Neither is Johns Hopkins, Massachusetts General Hospital, the Brigham and Women’s Hospital or the University of Washington. This may have something to do with the fact that they provide services to very sick and often uninsured patients, but I don’t think that is all of it.

The processes at the university hospital where I have just recently been hanging out are very haphazard compared to other good hospitals in my recent experience. Some well thought out process changes could free up huge amounts of wasted energy in a place like this, which would likely make both residents and attendings have more time for teaching and good patient care. Perhaps medical students could even be brought back into the team as an underutilized labor source.

Janice Boughton is a physician who blogs at Why is American health care so expensive?

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  • Ron Smith

    Apprenticeship is the best way to train physicians.

    My Pediatric residency with the Oklahoma University, Tulsa Medical College had about 7 or 8 full time faculty and about 70 plus clinical faculty doing private practice.

    Half of my patients were their patients whose care I was participating in under the auspices of a clinical faculty. The array of experience from medical schools across the country was invaluable.

    I’m a clinical assistant professor with Mercer Medical College Dept of Pediatrics now for the last two years, and came to be so out of my desire to give back to Pediatrics and young Pediatricians who will someday take my place. This is my 30th year to practice. I was involved in clinical trials of and using Exosurf, the first artificial lung surfactant for premies some 25 plus years ago.

    Despite all this, I have yet to have the first Pediatric resident rotate through my clinic or even any contact from the Dept of Pediatrics.

    If this is representative of the way most clinical Pediatric faculty are viewed, then it is likely there will be fewer and fewer young Pediatricians with a rounded training capable of taking my place on the front line. I can probably practice another ten years, but at some point will have to call it quits.

    I wonder what Pediatrics will look like then?

    Ron Smith, MD
    Pediatrics, McDonough, GA
    www (dot) ronsmithmd (dot) com

    • Daniel

      Do you have any interest in having a resident rotate through your clinic? If so, who should contact whom? Does the Pediatrics Dept have to contact you to find out if you’d be interested in having a resident or student rotate with you? Or do you have to contact the Pediatrics Dept to ask them if they have anyone willing to learn from your experience?

      Not a criticism, just a thought. Although some may have attained their teaching positions by chance, the only way to ensure that you can take part in teaching future physicians is to make the first move.

      • Ron Smith

        Yep, I’ve tried several times to get them to contact me. I was the one who took the initiative to get my paperwork done to apply for the clinical professorship. I don’t get reimbursement and I want to offer what I know. I simply wanted to give back. I’ve been the one to make the first and repeated moves with no response.

        • Daniel

          I wonder what the problem is then. Are you willing to take both medical students and residents? Perhaps someone will see your message and request to see your clinic and rotate with you.

  • Steven Reznick

    We are all the sum of the experiences we have along the way. Each individual teacher has their experiences and strengths and weaknesses they bring to the table. I remember as a PGY3 our attending was a world recognized expert on platelets and coagulation but rather weak in other areas of medicine. He made arrangements for the chief residents to make work rounds with us in the early morning as general medicine supervision and teaching. He used the attending round time to teach us about clotting and platelets and hematology. The eight weeks he attended the chief resident and our team gave him a refresher on general medicine and we received an invaluable lesson on hematology. Shortening the number of years of training lessens these encounters with either academic faculty or community clinicians. Hopefully good programs can balance the exposure. Doing ” scut work” as a student seemed like forced labor but in retrospect we held hands, we made patient contact and we got to see what patients had to endure during an illness and hospital stay. We were part of the ward team and received instruction from the house staff and attending faculty and were expected to write admission notes and progress notes and research topics pertinent to the case. It is a tragedy if this type of experience no longer occurs. Part of the ” scut work” was using the housestaff lab to prepare blood smears and sputum gram stains and do microscopic urine and stool exams while doing simple labs like blood counts, blood glucoses on glucometers.measuring serum and urine ketones while treating diabetic crises.These labs which taught you how the procedure was performed and often produced results you acted on long before the hospital lab had results ready ( diagnosing TB from your smear, diagnosing gram negative pneumonia from your sputum smear) have been shut down by the Joint Commission sighting no oversite by a pathologist as a quality issue. It is a lost art and a knowledge base that allows you to look at a standardized lab report and the strengths and weaknesses of the data presented to you for interpretation. Apprenticeship requires exposure to different types of teachers with different experiences. When you are in medicine you are always learning and always really an apprentice.

  • pmanner

    Actually, academic medical centers are the paradigm for what happens when physicians no longer have any control over medical care. The disconnect between administration/leadership and the rank and file is unprecedented, and results from the belief on the part of the former that the latter are like Kleenex – pull one from the box, trash it, and throw it away, because an identical one is coming up right after.

    The short answer is that academic physicians have all the responsibilities of private practice, with none of the tools to address them. Small wonder that this cascades down to the residents and students!

  • buzzkillerjsmith

    Docs in the community teaching med students. I precept a Univ. of WA med student a half day per week when they’re in school. I like it but it really slows me down. Who’s going to subsidize the community docs for teaching as their productivity goes down? If someone does, count me in.

  • Bob

    As I see stem cells used to “regenerate body parts” I wonder what part most physicians will play in the process, other than taking out the old and implanting the new, which is very precise.
    Other than surgery what else will remain for GP, FP, NP and PA other than prescribing tests and prescriptions for cheap generic drugs, which are the only reason people see them?

  • Allison Falin

    Interestingly, the local university that has the big DNP program has moved more to this model instead of the MSN model that has NPs that work and teach. My professors all held full time jobs at UC and it was apparent because they had up to date knowledge and good examples of real world experiences. We had to find our own clinical sites, which was not difficult for me because I had 16 years of nursing experience in the community and knew enough MDs and NPs to get the best and brightest to work with. What they did get, instead of money, was a ton of CME CE credits for precepting to go towards their license requirement. It is not reimbursement, but the information I gained from them was invaluable and the patients were more than willing to accommodate me and let me learn.

    It does bother me a bit that it appears that the newer DNP programs are looking a lot like the older medical models for instruction. I liked that my courses were taught by working NPs that worked in the field that they were instructing us on. It makes a huge difference in a professor being able to ferret out what is simply “book knowledge” from what is reality and evidence based.