As I look around the medical landscape in the spring of 2012, there is not a lot out there to engender confidence. There have been darker days I’m sure, but none with the sense of foreboding that is pervasive amongst many physicians these days. There are three movements in particular that seem to presage a 3-pronged attack, as it were, on the physician of today. Each taken separately may not have much significance, but taken together could spell the end of the physician model as currently constituted. This post will focus on the first development as outlined in a recent article from the Journal of the American Medical Association this past week.
The article, by Ezekiel Emanuel and Victor Fuchs, proposes decreases in the time spent in pre-medical school training, medical school, and residency programs. I am not going to speak to the first two items on the list (as decreased time spent in these endeavors may have merit), but the proposal to drop a year from primary care residency programs is at least short-sided and likely detrimental to the trainee and his/her patients when the resident leaves the program. As the article states, “The third year of internal medicine or pediatric residencies or the research year in surgical specialties could be eliminated without compromising the clinical quality of trainees.” Also, “the third year is not essential to ensure competent physicians. This residency year is mainly engaged in supervising and teaching interns, in taking electives, or in some cases conducting research.”
In my experience, the time spent supervising and teaching interns was one of the most valuable aspects of my training. Emanuel and Fuchs infer that much of what is seen in residency is rote and repetitive in nature, as “changing the structure of training would force medical leaders to eliminate unnecessary and repetitious material…” Again, in my experience, there was and continues to be great value in the necessary repetition of cases and workups. I didn’t learn how to manage a new diabetic in DKA on the first go round, and I suspect that even after the fourth or fifth time I was still learning the nuances of the illness. Likewise for the training of interns; there is much to be said for the educational value of teaching someone else. It served as an acute learning tool for me; one had to be on their game every day in morning report, on rounds and while on call to be able to answer the questions that would invariably come up. Most of what I learned as a pediatric resident was during my second and third years of training. There would have been a large gap in my knowledge and competence had the third year been scuttled.
What might be the reasons behind such a proposal to decrease residency time? Emanuel and Fuchs state that this shortened time frame would
- “enable physicians to recognize their limitations as well as their competencies; (as I stated above, one less year of training certainly would have enabled me to find my limitations quicker once out in practice…I’m not sure this is helpful to patient care)
- “enable physicians to use evidence more effectively to improve care; (laudable on its face but could be construed as a call to encourage physicians to not individualize patient care and force a “one size fits all” approach to medicine)
- “enable physicians to become comfortable with group decision making, standardization of practices (see second bullet point above), task shifting to non-physician providers, and outcomes measurement.” (this might be the crux of the issue, to take doctors down a notch and remove them from their traditional role as the ultimate authoritative decision maker in the health care team. If they feel less confident in their training and skills then they may be more likely to look towards a team approach that may have other motives (think financial) than what is best for that specific patient.)
Looking at the broader picture, what does this mean for medical education in the future? What I suspect is going to happen is that medical school and residency training will be further and further shortened until the line between a doctor and an advanced practice nurse is so blurred as to not be distinguishable whatsoever. I also suspect this has been the agenda all along of those who will be paying for medical care in the future under a single payer system. Cheaper medical costs, but at what cost?