Medical education has become an assembly line

January 10, 2000

A medical historians new book says that in the mad scramble to stay afloat, academic medical centers are shortchanging young doctors.

Medical education has become an assembly line

A medical historian's new book says that in the mad scrambleto stay afloat, academic medical centers are shortchanging young doctors.

An interview with Kenneth M. Ludmerer, MD

In 1910, the landmark Flexner Report triggered a revolution in medicaleducation. It exposed the folly of the era's proprietary medical schools,where students did little more than attend lectures, often of dubious content.What mattered most was the student's ability to write a tuition check.

From that point on, medical education fully embraced the modern universitymodel advocated by reformer Abraham Flexner. Medical students and residentsnot only trained to be scientists, but learned by doing, even if it meantsuturing a patient at 2 am. Universities tapped various revenue streamsto subsidize this costly enterprise.

Today, managed care has set off a second revolution in medical education.Together with government budget cuts, it threatens to erase the gains ofthe first one. So says medical historian Kenneth M. Ludmerer, a professorof internal medicine at Washington University School of Medicine in St.Louis. In his book, Time to Heal: American Medical Education fromthe Turn of the Century to the Era of Managed Care, Ludmerer arguesthat academic medical centers, forced to compete—and desperate to survive—ina bottom-line marketplace, have become high-volume patient factories. Heconcludes that the assembly line robs medical education of a precious commodity:the time that trainees need to learn, and faculty to teach.

Ludmerer's diagnosis of the ills besetting medical education, and hisprescription for a cure, have earned Time to Heal high praise fromthe medical and academic communities. Midwest Editor Robert Lowes recentlyasked Ludmerer to elaborate on the dangers of this second revolution.

Q: You describe how today's teaching hospitals are obsessed with "throughput"—treatingas many patients as possible to make up for lower reimbursements and reducedgovernment subsidies. How has this affected trainees?

A: When I was a resident in the 1970s, it was a busy night whenI admitted four patients. Today, residents routinely admit eight to 10 patientsper night. Adding to this hectic mix, most patients are now discharged afterthree or four days. Thirty years ago, the average length of stay for internalmedicine patients was 12 to 14 days.

So there's less time to think about each patient's problems. When hospitalstays were longer, you had more opportunities to read about your patient'sillness in the library, ask a faculty member to confirm a diagnosis, orjust talk about a biochemical principle or ethical question raised by acase. Those opportunities are rarer now.

A longer hospital stay also allowed trainees to follow the course ofa disease. Today, patients are sometimes hustled out before all their testresults come in, just for the sake of freeing up a bed.

Q: How has the faster pace of inpatient care affected medical schoolfaculty?

A: Managed care is pressuring them to see more and more patientsjust to keep the medical school solvent. So they have less time for teachingand research. It used to be that after morning rounds, faculty could visita hospital ward and have relaxed conversations with house staff and students.Now they're forced to go back to the office and see their own patients.

Q: You describe residents as becoming mere workup machines and dispositionarrangers. Can you talk about this in more detail?

A: More admissions per night means more paperwork. Every new patientneeds a history, examination, lab studies, and orders. Plus, you have toplan his discharge. Where will he go? What medicines will he need? Willhome therapy be required? Have you dictated notes to the private practitionerwho referred the patient? Do you want to bring in a social worker? All thispreparatory work is tedious and time-consuming.

Residents have to think about discharging the patient almost from themoment he walks in. It leads to what I call medical myopia: focusing onthe chief complaint, and giving short shrift to everything else. Mrs. Jones,for example, is admitted with chest pain. Lab tests show that she's alsosuffering from severe anemia. A few years ago, this news would have excitedhouse officers and students. They had just discovered an important problem.It was in their power to institute meaningful therapy.

But today, working up the patient's anemia diagnosis would extend thehospital stay. Besides, this disease has been relegated to outpatient care.So the resident discharges Mrs. Jones with a note saying that the doctorwho sees her on an outpatient basis should deal with the anemia. I worrythat because we're not encouraging trainees to be thorough, Mrs. Jones'anemia will slip through the cracks.

Q: How else has the growth in outpatient care altered medical education?

A: Residents and medical students don't see the breadth of illnessthat they used to. Years ago, we frequently admitted patients with hyperthyroidism.Now that's encountered mostly in the doctor's office.

Likewise, patients with abdominal pain of unknown etiology were sometimesfound to need cholecystectomy. This workup now occurs on an outpatient basis.The result is that the surgical resident often meets the patient for thefirst time when the patient is on the operating table. The trainee learnsthe technical procedure, but doesn't develop the clinical judgment neededto decide whether the patient needs surgery in the first place.

Q: Not surprisingly, medical schools and residency programs have movedtrainees into ambulatory settings. Is this a positive development?

A: Outpatient education is important, but as with inpatient education,time is the essential ingredient. And we're losing the time to heal andeducate in the outpatient setting, too.

Teaching slows down patient care. That's why teaching hospitals havea hard time competing with community hospitals. The average internal medicineresident needs 45 minutes to an hour to see a new patient. If patients arebeing churned through a doctor's office every eight to 10 minutes, that'shardly enough time for education to occur.

I came across one Southern medical school that speaks proudly of puttingthird-year students in the offices of local primary care doctors. It soundsgreat, in theory, but students told me that one of the doctors sees 60 patientsa day. The students have very little opportunity to do anything other thanwatch. When they do work up a patient themselves, the physician says, "Okay,fine," in a matter of minutes.

This approach violates every principle of good medical education. Studentsneed to be active learners, and faculty need to supervise them appropriately.For that matter, many primary care doctors who are added to medical schoolfaculties are valued more for patient referrals than for any discernibleteaching or research ability.

Q: Given the time crunch you describe, are we producing doctors deficientin basic skills?

A: This hasn't been well-studied, but based on impressions andanecdotes, I would answer Yes. There's been a marked deterioration in historytaking and physical exams. Medical educators have been heard to say, "Youwon't believe what my resident missed."

I find that my students and house officers are generally very good. Theycan give you a competent differential diagnosis of splenomegaly and discusshow to manage such a patient. But what they're not good at is actually detectingan enlarged spleen.

This problem of eroded clinical skills is older than managed care. Alot of it has to do with the irony of our recent technological progress.As lab tests and diagnostic imaging have become more sophisticated, thedoctor's patient-examination skills have tended to atrophy. Managed carehas exacerbated this slippage, because trainees have less time to learnhow to perform a physical exam, and faculty have less time to teach it.

Q: The Flexner Report spelled the doom of proprietary medical schools.Why do you say that the proprietary system is re-emerging?

A: It's returning in the sense that many schools today are asmuch money-driven as academics-driven. The proprietary medical schools ofthe 19th and early 20th centuries were places where teaching and researchwere done on the fly because faculty members, who owned the schools, spentmost of their time seeing patients. That's primarily how they earned theirincome. It would be a mistake to say that we've regressed to the pre-Flexnerera, but we've begun moving in that direction. Today's preoccupation withincome is turning medical schools away from their central purpose—educationand research. The learning environment is eroding.

Q: How can we get medical education back on the right track?

A: First of all, please don't interpret Time to Heal asan endorsement of everything that preceded managed care. Medical educationdid very well under fee-for-service, but that system failed to contain costs.Managed care is a response to a health care system that became too expensive.However, we need to maintain the quality of medical education and patientcare, too—and that requires two things.

One, we must provide medical schools and their teaching hospitals withgenerous, consistent funding. Research and education aren't profit-makingactivities; they require external support. But should this support be federal?Or should it come from private insurance companies? We have to work thisout in the political arena.

Two, we must recognize that medical education can't be done in a hurry.And yes, teaching slows down patient care. We need a financing system thattakes this reality into account.

To earn public support, we in medical education have to do a better jobof deserving it. That requires producing the kinds of doctors that societyneeds, in terms of both specialty mix and the ability to practice cost-effective,preventive medicine. Our academic medical centers need to operate more efficientlyand live within their means. And although we should pay faculty well, wemust ask: Should faculty earn as much as private practitioners? That's whatsome of us have come to expect in the past 20 years. But we may not be ableto maintain this parity.

Most important, medical educators must stand up for high-quality care—somethingwe haven't done often enough. We need to demonstrate that we're placingthe interests of society before our own.

Robert Lowes. Medical education has become an assembly line.

Medical Economics