jfa1928lWhen Laennec invented the stethoscope in 1816 and physicians no longer had to put their ear to the patient’s breast, health care delivery changed. Asepsis, effective treatments for syphilis, and other breakthroughs soon followed.  By 1910, medical education needed to move on as well.

Scientific breakthroughs had altered the values held by the public and the medical profession: clinical and laboratory research had exposed the irrationality of “heroic” treatments (such as blistering, bleeding, and purging) and had proven the therapeutic efficacy and rational scientific basis of modern practices, such as antiseptic surgery, vaccination, and public sanitation. Most of the public and virtually all physicians now believed in the superiority of scientific medicine

Medical education underwent a transformation that lasted until very recently. The first two years were heavily influenced by science and the medical students were taught, not by physicians but by “basic scientists” whose training was in anatomy, histology, biochemistry, physiology, and other “hard sciences.” Students were then allowed access to patients, with whom they would presumably spend the rest of their lives.

Does it work today? The LCME, the board that governs the majority of the medical schools in this country, looked at just that (report found here).  The good news: Doctors trained under this system are knowledgeable and technically proficient in providing care for acute disease; they wish to do what is best for their patients; and  patients respect them as credible sources of information.

The bad news? Again to paraphrase from the report:

  • Physicians are not prepared to evaluate the care they provide in their own practices and to use the results to improve patient safety and the quality of care provided.
  • Physicians are generally not prepared to be advocates for patients on issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession.
  • Physicians often lose altruism and qualities of caring as they proceed through training and enter the practice environment.
  • Because of their training, physicians find it difficult to deal with the inevitable uncertainty arising from incomplete or conflicting information. Additionally, they are not typically prepared to convey their uncertainty when interacting with patients and colleagues.
  • Many physicians are not prepared to utilize information technology to assist in information acquisition and management.
  • Physicians are trained to be autonomous. This can be a barrier to providing patient-centered care, where patient values and desires are an integral part of shared decision-making. The expectation of autonomy diminishes the ability of physicians to act as team players with other physicians and other health professionals.
  • Physicians are not prepared to participate in ethical and political discussions about the allocation of health care resources, which are not limitless.
  • Graduates do not acquire skills in cultural competence/awareness and to recognize that some patients may have health literacy issues.

So, what’s the problem, you say? Teach the science and teach the humanism (like having chocolate and peanut butter together). The limiting factor is time and the explosion of factoids that are considered “vital” for a physician to know. Or, to put it another way by someone who thinks things are just fine:

Increasing emphasis on apprenticeship-based education and increased focus on the non-medical knowledge competencies inevitably will be at the expense of rigorous training in the basic sciences if the existing number of hours available for teaching are maintained.

In addition, the teaching of the lacking humanism skills will require another type of medical education specialist, one much more skilled in communication than in versed in scientific discovery. The basic scientist may be on the way out when it comes to educating physicians. The article referenced above is a plea for not allowing the science education of our nascent physicians to be diminished. The author expresses concern that though care may improve and patients may be more satisfied, we as a profession and our society may be poorer as a result. I would argue the system begun in the 1910s has left us with an expensive and not very effective care delivery platform and is destined for failure. I would also argue that we must improve the value (cost, quality, and efficiency) of our clinical care, a challenge that will require all physicians to be versed in the skills identified above as lacking. We need to teach smarter. If we do not, we may be seen as upholding our scientific standards as we bankrupt our society.

Advertisements