Medical Education

It strikes me that I have written very little here about an issue that concerns me very much, and that is the training of physicians. I haven't consciously avoided the subject but perhaps I've been reticent because of adverse conditioning -- I find that physicians tend not to like it when non-members criticize their fraternity hazing rituals. Well, I'm over that.

This is a large subject to which more than one major journal is devoted, (Acedemic Medicine is the top one), and general and specialty journals also frequently publish relevant research. My direct pesonal experience consists of a few years teaching a section of a course for first-year students on medical professionalism -- which means everything that isn't biomedical science, including medical ethics, sociology, economics, communication and relationships with patients, and oh yeah, that little tiny subject called public health. I also frequently precept combined M.D./M.P.H. students doing internships in public health, and first year students who are assigned special projects.

Well, the school cancelled the course, because the students complained that it didn't help prepare them to pass the boards and they didn't have time to write papers about ethics while they were trying to pass the anatomy final and learn all the cytokines. Medical professionalism is a large and growing concern at medical schools, they talk about it incessantly, but they don't actually do anything about it. The biomedical science that students are required to study just keeps growing, and now it's almost impossible to keep the undergraduate program to four years. (Medical students are called "undergraduates," even though they have bachelor's degrees, because medical training continues after receipt of the M.D.) Classroom learning does include some training in interviewing, physical examination, and other clinical skills, but it's mostly rote and unreflective. Most of what doctors learn that isn't biomedical science is acquired through apprenticeship.

And there's the problem. Nobody is in charge. How a young physician learns to interpret his or her role; to interact with colleagues, other professionals and patients; to value money, prestige, and service to humanity; to view the place of the physician and medicine within society and in relation to patients; all depend on the role models she or he happens to encounter and the existing culture of the institutiosn where she or he comes to work as a clerk and resident. There is no committee, dean or hospital president who exerts substantial control over the training of physicians. Senior attending physicians who precept students and residents don't have the slightest interest in having anybody tell them what to do, and their students have little or no formal support to help them process and critically evaluate the experiences they have with mentors. It's a self-perpetuating system that is susceptible only to very broad shaping (such as recent moves to limit residents' work hours), with very little individual accountability.

So, that's a very general introduction to the situation. In the future, I'll talk about specific problems that arise from the system we have now.