The quality of health care depends on many things, but certainly medical education is uniquely significant. Following four years of medical school, the additional years of internship, residency, and fellowship are not simply a time for acquiring the latest insights into the nature and treatment of disease. This is when fledgling doctors imbibe the values and priorities of the medical profession from the attending physicians who mentor them. If attendings have no time to mentor the doctors they are presumably training, the quality of doctors who emerge from such a system will suffer. And if the priority of an academic medical center is to increase profits rather than care for patients, patients will also suffer, first at the hospitals associated with these centers and later as patients of the doctors who trained there. The decline in the residency system for training doctors is the subject of Kenneth M. Ludmerer’s Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
From mentorship to profits
Sir William Osler established his ideal of medical training at Johns Hopkins Hospital in the 1890s. The guiding principle was that doctors should learn to care for patients under the close supervision of highly experienced attending physicians. Right up to WWII, the highest priority of teaching hospitals remained education. Faculty members formed intense mentorships with their students, often lasting a lifetime. Lara Goitein, in an essay/review of Let Me Heal, writes:
There was a strong moral dimension to this system. Ludmerer writes that “house officers [residents and fellows] learned that medicine is a calling, that altruism is central to being a true medical professional, and that the ideal practitioner placed the welfare of his patients above all else.” Commercialism was antithetical to teaching hospitals in the era of education. “Teaching hospitals regularly acknowledged that they served the public,” writes Ludmerer, “and they competed with each other to be the best, not the biggest or most profitable.”
Today there is little time for mentorship.
The Oslerian ideal of faculty and residents forming close relationships and thinking together about each patient is in trouble. Instead, residents, with little supervision, are struggling to keep up with staggering workloads, and have little time or energy left for learning. Attending physicians, for their part, are often too occupied with their own research and clinical practices—often in labs and offices outside of the hospital—to pay much attention to the house officers.
Key to the change in US medical education is the goal of being the “most profitable.” In the postwar period, investments in science and medicine increased. The National Institute of Health directed large sums of money into research at academic medical centers. The creation of Medicare and Medicaid in 1965 accelerated the growth of medical insurance and greatly increased hospital admissions. In the quarter century after 1965, the revenues of academic medical centers increased by nearly 200%. What doctors learned in their post-graduate medical education was not how to care for patients, but how to increase the profits of hospitals.
The implications for patients
In the 1980s, health insurers changed the way they reimbursed hospitals. Instead of “fee-for-service” payments for such things as individual consultations, tests, and treatments, hospitals received a “prospective payment,” a fixed amount that varied with the diagnosis. If the patient’s hospital stay was shorter than anticipated, the cost was lower, and the hospital could keep the difference. This gave hospitals a strong financial incentive to get patients in and out as quickly as possible. Between 1971 and 2011, the average length of stay in US hospitals decreased from sixteen days to five.
Of course, if a patient’s stay was longer than anticipated, the hospital lost money. Clinical revenues actually slowed following the introduction of the new system of reimbursement. In response, hospitals attempted to increase their bargaining power with insurers by increasing their size and the number of patients they served. They merged with or acquired other hospitals and attempted to attract as many paying patients as they could. To increase revenues, they also developed profitable relationships with the pharmaceutical industry, biotech companies, and medical device manufacturers.
The implications for doctors
The mentoring relationship between faculty and students virtually disappeared. Faculty responsibilities changed from teaching to managing a large organization. They were paid based on their ability to generate profits, not for teaching. “[T]he surest way not to receive tenure in a clinical department was to win an award for teaching,” Ludmerer writes
In addition to losing their mentors, doctors in training had to deal with the new pace of care created by the rapid turnover of patients. Partly to compensate for reduced face time with patients, there was a huge increase in the number and complexity of tests performed. The increased patient load meant there was much more to do and less time in which to do it. “The result was that by the 1990s, many house officers felt they were providing care on a production line that had sped wildly out of control,” writes Goitein. Commenting on her own training in the 1990’s: “The sheer number and complexity of my patients was nearly overwhelming—and I was worried that at best, they were not getting the care they had a right to expect, and at worst, that they were not safe.”
Ludmerer on how this increased pace impacted patient care:
The patient volume was too high, the turnover of patients too great, and time simply in too short supply. Interns and residents in every specialty often experienced panic and anxiety as they struggled to care for far more patients than time reasonably permitted. The only way that they could cope with the high patient load was by cutting corners.
The pace of patient care contributed to increased costs. Overtesting — a significant driver of health care costs — began as a survival technique for residents. By the end of their training it had become a habit, “ingrained as a style of practice.”
Doing more in less time: The reduction of residency hours
Not surprisingly under these conditions, a 1999 Institute of Medicine report documented an unacceptably high rate of deaths from medical errors. The response of the Accreditation Council for Graduate Medical Education was to mandate a reduction in the number of hours residents could work (80 hours or less per week, 24 hours or less in a shift). But this only made things worse. Goitein writes:
[T]he narrow focus on work hours reflected a fundamental misunderstanding of the nature of residents’ work. … In the absence of accompanying changes in workload, the regulations meant that residents had to accomplish the same work in less time—leaving even less time for education or thorough patient care. …
“In the mad rush to limit resident work hours,” Ludmerer writes, “the importance of the learning environment was generally overlooked, as if nothing else mattered but the amount of time at work.” What really mattered was the loss of teachers and mentors, and the loss of time for education and thorough, considered care of patients. And what also mattered was that, increasingly, residents trained in an environment where money seemed to talk more loudly than traditional professional values.
Whither the priorities of the medical profession
At academic medical centers, traditional professional values morphed into the pursuit of profit. Ludmerer points out how readily those in positions of authority sacrificed patient care and the training of doctors once they encountered the temptations of financial gain.
As the pressures to increase the throughput of patients grew stronger, professional leaders did little to counteract the tide…. Academic leaders, faculty members, clinical departments, medical schools, and teaching hospitals…benefited too much from the enhanced revenues they received for succumbing to the forces to increase throughput. They followed the money, resting content with the status quo as long as clinical revenues and their own pay continued to grow, even if graduate medical education and patient care might have suffered in the process.
What’s needed is a restoration of quality teaching time and quality patient care. “This may sound overstated,” Goitein writes, “but the stakes are indeed high: doctors are only as good as their training.” And patients only receive the quality of care for which their doctors are trained.
The decline in the quality of US medical education is something all of us should care about. Ideally, Ludmerer’s book would be widely read and appreciated and would contribute to much needed change. He has identified the problem. Unfortunately, he has also documented how fundamentally ingrained that problem is.
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The esteem of the medical profession: Then and now
The Dreams of the Founders of Family Medicine
Is a liberal arts education good preparation for being a doctor?
Image source: Hurley Medical Center
Kenneth M. Ludmerer (2014), Let Me Heal: The Opportunity to Preserve Excellence in American Medicine
Lara Goitein, Training Young Doctors: The Current Crisis, The New York Review of Books, June 4, 2015, pp 60 – 62