Let's Heal Ourselves

As a trainee on the brink of the fellow-to-faculty transition, perhaps I am particularly reflective about the issues raised by Kenneth Ludmerer's newest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. This exhaustive history of graduate medical education inspired me to feel nostalgic—partly for a past I never experienced, but mostly for the transformative 8-year educational period of my own career that is quickly drawing to a close. Reading the book also helped me place my training in perspective. It left me feeling reassured that my experience as a resident and fellow has truly prepared me for my profession, and cautiously optimistic that our ever-changing system of graduate medical education will continue to produce outstanding physicians.

From the first chapter Ludmerer articulates themes that echo throughout the history of physicians' education after medical school, and still resonate today. More than a century ago, he teaches us, there was an increasing trend toward physician specialization, due in part to the rapidity of advances in medical science. Although residency training at the time was a privilege rather than a professional requirement, house officers served as both providers of patient care and performers of menial tasks. With each successive decade, patient complexity increased and hospital length of stay grew shorter. Combine these changes with the mounting external requirements for documentation, and residents' workloads became ever more clerical and less clinical. Readers will realize, however, that the conflict between education and service is not a product of the 80-hour workweek; rather, it is inherent in graduate medical education. Similarly, achieving the proper balance of autonomy and supervision, finding time for clinical investigation, and learning to deal with sleep deprivation have always challenged house staff and their mentors. Although conditions and circumstances have changed over time, Ludmerer illustrates that resident education is not different from other aspects of society—history repeats itself.

That history contains lessons as well. Meticulously researched, Let Me Heal is sprinkled with anecdotes that serve as fables, each with a moral for today's generation. For example, Ludmerer tells the story of a Johns Hopkins surgical resident who told the revered Dr Halsted that his patient was doing well, when in fact he had not examined him. Actually, the patient was not doing well, and Halsted summarily dismissed the resident “not for failing to visit the patient, but for saying he had.” Other than the fact that it involves Halsted, there is nothing terribly remarkable about that event. Honesty, including admitting one's own mistakes, remains a central tenet of medical training. Through similar tales, Ludmerer uses the founding fathers of graduate medical education (Osler, Cushing, Christian, Stead, Moore) to remind current trainees and their teachers that the fundamental principles endure: call for help, know why you do something, be intellectually curious, know when not to operate. Although the role of the house officer has evolved, the moral groundwork of medicine remains constant.

Ludmerer shows us that certain issues and challenges in graduate medical education are not unique to our time, yet he certainly does not claim that the current system is not broken, nor does he advocate that we embrace the status quo. Indeed, even in the sections of Let Me Heal that seem to stagnate in repetitive detail, readers feel the constant undertow of residents' diminishing roles in caring for their patients. With each major shift in the health care system—the elimination of wards, the introduction of Medicare, the societal focus on patient safety, the enforcement of resident duty hours—house officer autonomy has suffered, and the residents' clinical role has diminished. The cumulative effect of these systemic changes has been a gradual erosion of the importance of trainees in patient care. Although residents remain a necessary part of the workflow, they are now superfluous to many aspects of patient care. Ludmerer convincingly guides his readers through this slow but steady process of “marginalization.” By the book's last chapter, it was easy to understand how graduate medical education has been swept along by the tide of external forces, and it was refreshing to read Ludmerer's call for internal leadership to seize opportunities for change.

Ludmerer places the blame for the deterioration of resident education squarely on the medical profession itself. I suspect this was a conscious choice—by not shifting responsibility, he reminds his readers that we ourselves control the destinies of our training programs. However, I also believe that giving patients and lawyers a free pass leaves integral pieces out of the puzzle. Ludmerer suggests that as tests and treatments became more available and faculty became less involved, residents stopped thinking critically and instead ordered everything they could. “Patients, once concerned that doctors could not do enough to keep them alive, now began to worry that doctors might do too much,” Ludmerer writes. Perhaps this was true in the 1960s, but this conservative mindset is not one I have encountered in many patients. Granted, I have been fortunate to train at 2 institutions that are particularly cost-conscious and outcomes-driven, but it seems a stretch to explain the culture of excess in medicine as the result of residents who fail to consider the indications for tests. Patients and families often demand “everything,” especially at the end of life, even when physicians take the time to have nuanced discussions about questionable benefits or futility. When these expectations are considered in the context of the medicolegal climate, the problems are compounded. The term “defensive medicine” is not mentioned in Let Me Heal until late in the last chapter. Although Ludmerer deserves credit for focusing responsibility internally, his failure to address the powerful influences of American culture, such as patient demands and the ever-present specter of litigation, appears a relative weakness.

Let Me Heal gets to the heart of another crucial issue: heightened generational tension. Although there has always been a tendency for senior faculty to regard trainees as “soft,” the more recent reforms seem to have prompted increasingly disgruntled faculty to turn their anger toward their younger colleagues. Residents are both compelled to comply with new policies and simultaneously criticized for doing so. For the most part Ludmerer avoids participating in judgmental generational stereotypes. In fact, he seems to reserve his censure for disengaged faculty. With the first several chapters focusing on the profound influence of now-legendary medical educators, the absence of influential mentors is conspicuous later in the book. Admittedly, today's outstanding faculty members have not yet achieved the folklore status bestowed with time, nor are modern anecdotes injected with the apocrypha of memories. However, Ludmerer makes quite apparent that medical education today lacks giants. For me, that is both the most lamentable and the most inspiring message of Let Me Heal.

Still 2 months before its official conclusion, I reflect fondly on my training. Of course, I could have done more and seen more, but I hope this remains true even at the end of my career. Ultimately I learned timeless lessons, gained invaluable experiences, and crossed paths with some exceptional mentors. “Years or decades later, doctors often wax eloquently about the wonders of their years as house officers,” Ludmerer writes. “What they are really saying, however, is that they love medicine and are grateful to their residency for having prepared them for their calling—not that every moment was perfect.” We cannot make graduate medical education perfect, but, precisely because we love medicine, we should work together to preserve its integrity. I hope Ludmerer's Let Me Heal inspires us all to do so.