America's medical education needs major surgery

January 5, 2012

One of the most important people in your life is your physician. His or her diagnosing and treating you properly can be a matter of life or death.

So, it may be disconcerting to know that doctors are trained mainly, not by master clinical physicians, but by research-focused professors. So it’s not surprising that 100,000 patients a year die because of medical errors, while one in three patients are harmed during a hospital stay.

Professors are better at teaching the cut-and-dried academic science--physics and chemistry, theoretical models, and diagnosis/treatment decision trees--than the messy but critical subjective parts of medicine: When is it worth subjecting a patient to additional testing or treatment? What would motivate a particular patient to eat broccoli instead of bacon cheeseburgers?

Also, professors too often focus on what they like to teach than on what physicians need to know. For example, is requiring every pre-med student to take a year of physics, a year of organic chemistry, and a year of inorganic chemistry worth the student’s time and money? Does requiring such courses weed out students who could become better physicians than students that aced organic chemistry but couldn’t motivate an Olympic athlete?

Each item in the curriculum should be subjected to this test: “If students are required to learn this, is there something more important that will go untaught?”

The more prestigious the medical school, the more likely instruction focuses on academic and research-related material, not on need-to-know clinical practice. That is because universities acquire prestige far more from their research than from their quality of education. Because lesser-known colleges can’t compete with top-tier universities in research, they’re more likely to focus on education. Dr. Molly Cooke, co-author of the Carnegie Foundation’s Educating Physicians: A Call for Reform of Medical School and Residency points to the DeGroote School of Medicine at Canada’s McMaster University, which according to its Web site offers “a unique three-year (rather than the usual four) program based on small-group, problem-based study and an early introduction to the clinical experience.”

Trim the curriculum so it focuses on what’s clinically important, and pre-med and medical education would be both improved and shortened, saving time and money--Currently, the taxpayer spends $9 billion dollars a year merely on residency training.

Another weakness of medical education is that it encourages hubris, according to Cooke. In de-emphasizing the ambiguity and guesswork still necessary in medicine, medical school makes new doctors feel more infallible than they are. Compounding the problem, the arduousness of pre-med programs, medical school, internships and residency create an exaggerated sense of mastery and entitlement. Aspiring physicians must learn mountains of difficult material. But too little of it has significant impact on patient outcomes. If physicians’ self-appraisal were more realistic, they’d work less condescendingly with other members of the health team. Nurses, social workers, and other allied health professionals often have as much to contribute to patient wellness as physicians do. A medical education that inculcates a measure of humility would help physicians understand the field’s current limitations, be more honest with patients and more motivated to contribute their clinical findings to the still adolescent field of medicine.

This brings us to the medical school application and selection process. The selection criteria usually are: GPA (especially in chemistry, biology, and physics,) the Medical College Admission Test (a multiple-choice test of academic science and reasoning), an essay, and volunteer experience. Do those adequately assess a candidate’s potential to be a citizen physician, a good listener or someone who could develop enough of a relationship within 12-minute exams to motivate patients to take medication even though it has side effects?

As part of its selection process, the DeGroote School of Medicine has each candidate proceed through six to eight mini interviews. At each one, the candidate is given a simulated problem. For example, the candidate may have to weigh privacy versus safety when the parents of an HIV-infected child say they don’t want the diagnosis disclosed to his school. Performance during the simulations is much more predictive of interpersonal and communication skills than the conventional interview is.

Alas, the medical school establishment benefits from the status quo, and it has been able to resist change because it controls the oversight entities, for example, the powerful Liaison Committee on Medical Education.

America’s current focus on reforming health care should include the reform of medical education. The innovations proposed here would both reduce cost and improve quality, a hard-to-beat combination, especially when it could save your life.

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