What's the Work?

Let Me Heal: The Opportunity to Preserve Excellence in American Medicine is the third (but, one hopes, not the final) volume in a history of medical education in America by Kenneth Ludmerer, the unchallenged doyen of this essential area of scholarship.

His two previous volumes are titled Learning to Heal (1996), which examined the structure, content, evolution, and purpose of medical education in America from its beginnings to the 1920s, and Time to Heal (1999), which described the years from the 1920s to 1994, the span he considers to cover both the rise and subsequent gradual fall of academic medicine's finest teaching, research, and scholarship.

The title of his newest work is, I believe, a supplication to those agencies (the Accreditation Council for Graduate Medical Education and specialty certifying boards) now “in charge” of 21st-century resident education, to decrease the imposition on teaching medical hospitals of more rules, regulations, and mandatory content that, in their accumulating requirements, take residents away from actual patient interaction. He also appeals in his title for a respite from the concurrent gradual erosion of patient-centeredness and faculty engagement with residents. These have resulted from the commercial business environment of “rapid throughput” care and an increasing dominance of procedures and diagnostic-therapeutic technology over the past several decades. The focus on procedures and technology brings in money, but it concurrently diminishes faculty time with residents and impedes the physician-in-training from seeing himself or herself as a principal diagnostic and therapeutic instrument.

Ludmerer, both an accomplished historian and a clinically active physician-teacher attending to patients, writes his latest book in his habitually engaging style, a mélange of evidentiary scholarship and personal experiences and opinions by residents, their faculty, and program directors. His text is rich in stories, and his “footnotes” (which I enjoyed very much) are a combination of published references, memorable anecdotes, and supplemental commentary to his text.

His conviction is that the residency, as he says in his preface to Let Me Heal, is the “dominant formative influence” in the making of a physician. The genesis of Let Me Heal began in earnest, as he tells it, when he was a member of the Institute of Medicine's Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. It seemed to him too simple a solution to a set of far more complex environmental influences than those arising from resident physical fatigue. This simplified focus might not only divert attention away from, but even augment, more dire changes in the educational environment of residents by requiring them to “get the work done” in less time and, concurrently, causing them to lose the sense of “ownership” and responsibility for their patients, already threatened by the pressures of rapid throughput.

Ludmerer's concern about this issue reminded me of a particularly conscientious and empathetic senior medical resident I spoke to as he was in the process of admitting a man to our General Medicine Ward team. He said he had been paged by the discharge planner within minutes of his arrival at the patient's bedside. She wanted him to tell her when the patient could be discharged. She went on to say that, since the patient was indigent, my resident should just “get the work done” and get the patient out of the hospital, as quickly as possible.

He then asked me the essential question: “What is the work?”

In my academic university teaching hospital, as well as many (most?) others, the pressure on faculty to spend more and more time doing procedures (which bring in the most money) is very great. We have even created a promotional ladder especially for them, in which their RVUs (Relative Value Units)—how much money they bring in—are prominently listed as part of the merit packages submitted for their advancement in a certain type of professorship: I call it the “Clinical-Profiteer Series,” not necessarily in reference to profit obtained by the physicians, but that gained by the hospital. Faculty teachers are often so burdened by their assigned tasks in research, procedures, or other clinical care that they have little time to spend chatting with residents and students. Similarly, residents and students have little time to talk with one another, their faculty, or their patients. The formulaic documentation imposed by the electronic health record (designed principally for billing, not patient care, and diagnosis-centered rather than patient-centered) results in far more resident time spent on the computer than spent with the patients themselves. Mandated specific curricula and endless evaluations also proliferate, and both teachers and learners are consumed by these tasks—a form of “in vitro” education that further reduces “in vivo” time spent with patients.

It is in the final chapter of this book where, in my opinion, the many gems in Ludmerer's Triple Crown of books on American medical education shine brightest. In chapter 13 he proposes, based on his wisdom and scholarship, the ways we must try to address the difficult task of redesigning medical education in the 21st century such that we may teach both the science and the human art of medicine as inextricably bound together, as they are in our ancient promise to serve the suffering.

In a way, now is, perhaps, the best of times to do this. I strongly believe that our physicians-in-training are up to the task: They chose to go to medical school when others—including some physicians—tried to discourage them from doing so. They were told they would go deeply into debt, sacrifice time with their families, sleep very little, work very hard, and be servants of the system instead of masters of their craft. And they came nevertheless. They are potentially the best of us, and we who are their teachers must help them be, and do, their best, for our patients' sake.