The Proper Care and Feeding of Student Physicians
“If the purpose for learning is to score well on a test, we’ve lost sight of the real reason for learning.”
– Jeannine Fulbright
I am both impressed and distressed at how the training of physicians has changed since I finished medical school in 1978. In some ways it is so much better, as some parts of the old system certainly had to go. But in some ways I wonder if we haven’t lost our way and are becoming faster and more efficient at taking brilliant young caring individuals who are entering the medical field for all of the “right” reasons down the wrong path.
To some extent, our health does depend on the advice received from our medical professionals. It is a comment on our society that seven out of 10 Americans over the age of 20 are taking at least one prescription medication. You might think that this would be a great thing for young physicians who are entering a career that will most likely lead to financial security for them. But a recent report in Academic Medicine[i]. indicates that not only are medical students more disillusioned than their age matched cohort of college graduates, but they’re more frustrated and likely to burn out as well. Perhaps that’s saying the same thing.
Perhaps my addled brain really doesn’t remember how tough medical school was, but I really don’t remember the pressure and paranoia and true emotional distress that I see on the faces of today’s medical students. College students choose medicine because they care about people and want to make a difference. But I believe something is happening to the 80,000 medical graduates each year that is sucking much of, not only the idealism, but the driving purpose they once had for getting into medicine, out of these wonderful, if idealistic, individuals.
For one thing the volume of material has increased exponentially. When I was in medical school the immunization schedule up to the age of 18 would fit handily on a 4X6 Index card. Today it is an Excel spreadsheet. Today’s medical students know more about biochemical pathways, mechanisms of action, the genetic basis for disease, and alternative pathways to care that have ever before been the case in medical training. I believe the medical schools are doing a great job in selecting candidates who are motivated, can do the work, and are training them accordingly. The medical schools have a dilemma: they need to get their students to a point where they understand the material and can pass the boards. But to some extent their education is complete only if the medical students are passing the boards at a sufficiently high rate. There certainly are times when advances in medicine are not given as much time as might be desirable in the medical school curriculum in an effort to simplify the curriculum and not confuse students when it comes to taking board exams.
But I believe that it’s too easy to blame the burnout of young physicians on the intensity and complexity of their studies. There is certainly there an ominous cloud of uncertainty overhanging the future of the profession of medicine. Old ways are changing rapidly, as they should. Methods of reimbursement and a growing need to spend more and more time documenting in order to provide malpractice protection are nearly universal concerns among practicing physicians. Many physicians resent having been subtly coerced into becoming data gatherers for epidemiologists. Most of us are aggravated really by artificial barriers to care imposed by third-parties to that care. It is fascinating how the elephant in the room, the insurance company, has managed to drive a wedge between the physician and his patient. Medical educators and students alike need to acknowledge this fact and proactively plan for the effect that it is having on the minds and hearts of young physicians. What are we asking these young physicians to really do? What can we do to make sure that they continue to see the joy and value the medical profession can provide?
I think finding ways to enhance creativity and even playfulness are going to be needed. Today’s medical school graduates won’t finish their careers, if all goes well, until the year 2060 or beyond. No one that I know can tell me exactly will happen to healthcare in 2016. One thing is clear: as much as my generation of physicians has had to adapt, it will be nothing compared to what is required of today’s physicians-in-training.
We regularly have students and residents at various levels of training in our office. I think this is extremely valuable. It is unbelievable to me that during all of my medical education I spent zero hours in a physician’s office and had no experience with the continuity of care that I value so highly today. It is more important for students to see the big picture of where they’re heading and how their subject matter may have practical application as they begin and continue their practice of medicine. This may help keep at bay some of the angst I see in young students who are solely preparing for what the next exam may bring. I hope it doesn’t become a rare, to the point of extinction, phenomenon that medical students care about each other, reach out to those that are struggling, and yet maintain the highest degree of integrity when it comes to testing and demonstrating competence in the subject matter of their chosen profession. I applaud those schools that have a mechanism in place to reach out to those students who are struggling with confusion, discouragement and who, in the maze of testing and grades, begin to lose sight of their goals and passion. Medical school is tough on relationships, finances, and the student’s both mental and physical health. No one truly understands how tough it is better than the students themselves. I think it’s important to appreciate that. I also think it’s important that we not make striving for great grades and acing exams more important than providing an environment that promotes caring for each other.
We, who are mentors, have a valuable role in continuing to demonstrate to those who will take our place the true value and honor that being a physician represents. Yes, we have an EMR. Yes, we have patient registries and track and follow overdue health maintenance. Yes, we have a website and a social media presence. Yes, we have extended hours and continue to go to the hospital to be there at the bedside when some of life’s most precarious medical events take place. But what’s really valuable to patients, and what the students who follow us on rotation get to understand, is the magic that happens when the door is closed and a caring physician looks into the eyes of his patient, closes the computer, and asks, “Okay. Tell me what happened.”
[i] Dyrbye, L. N., et al. (2014). "Burnout Among U.S. Medical Students, Residents, and Early Career Physicians Relative to the General U.S. Population." Academic Medicine 89(3): 443-451 410.1097