Medical Education Retardation

Robert C. Bowman, M.D.

Today's medical students are having a more and more difficult time preparing for careers in medicine, particularly for careers in primary care and service to the underserved.

The loss of the generalist perspective as the basis of all medical education has made it difficult for generalists to train, the survival of departments, programs, and faculty is in question at the current time. Generalism, Generalists, Specialists, and Medical Education
Becoming a doctor is all about practicing medicine. No patient would want to go to a doctor who had not seen a large number of patients with some assurance that the physician has seen their particular problem or need. Students and residents must practice medicine on patients. Unfortunately liability issues have gotten out of hand, making it difficult for students or even residents to actually learn by doing.
Quality medical education, especially in the clinical years, demands a variety of level of supervision depending on the level of training and the individual competence of the learner. Dedicated teachers with dedicated teaching time are a necessity.
This all comes at a time when faculty are teaching students less and less. This has to do with the demands of income generation. Also more and more duties including teaching are being placed on the backs of fewer and fewer remaining faculty. I have seen faculty argue over who had to go teach the residents (in past years).
These isolated incidents are no longer uncommon. This was a major concern of the Millennium Conference on the Clinical Education of Medical Students - Yet, as Kenneth Ludmerer observes in his recent book on the history of American medical education in the 20^th century, Time to Heal, in the 1990s, “for the first time in American history, a conflict appeared between the teachings of medicine and the environment of health care delivery. That conflict has resulted in a degradation in the quality of clinical education and a dramatic reduction in the time faculty spend teaching medical students and medical students spend learning clinical medicine through the experience of caring for patients." The final 2 recommendations of this conference were 9. Development of a “core faculty” of medical educators is an important step toward addressing the problems facing clinical education in a period of increasing pressures on clinical productivity. 10. Better tools need to be developed to evaluate faculty as teachers, with the corollary that excellent teaching should be rewarded appropriately.
Harvard faculty have raised concerns on several occasions with better press coverage than medical education impact. See Boston Globe and Chronicles of Higher Education below:
Use of community physicians for teaching does tend to relieve the pressure on medical school faculty, but community physicians have a whole new set of obstacles for teaching. First, they are often employees facing the demands of employers. Second, they usually do not know their students or residents well and are in a poor position to assess whether the learner is able to take on increasing responsibilities. Third, they often do not know their patients well, especially in urban areas with mobile populations and insurance plans. They face significant liability and confidentiality concerns regarding students and patients. Despite these obstacles, articles by Paul James basically showed equal or better teaching with community faculty, with a trend toward better education increasing with the distance from the academic medical center. see Why a Preceptorship Is Better

Uncertainty is a key obstacle to teaching in the community setting. Community docs are uncertain about how their employer will act if they take the time and effort to really teach, they are uncertain regarding the learner's skills, they do not know how patients will react to learners, and they are uncertain regarding learners and clinical information, billing, roles, and responsibilities. There are so many uncertainties in the above and other situations that the default option is to have the student or resident observe or sit this one out.

Academic family medicine is in the worst situation. Training in family medicine demands the generalist perspective, medical students need a minimum of 6 months in the clinical years to feel comfortable with primary care and only get 3 or 4 months. Family medicine is lower than the lowest on the totem pole in many locations. Faculty in family medicine are encouraged to do research and service more and more with less time for teaching and greater need than ever, academic medical centers are distorted archaic vehicles for family medicine teaching

Sometimes it takes a view from a different perspective to illustrate the above.

Visits to Canada revealed how much liability and our health system impairs the education of medical students and residents.
Familiarity with the preceptorship and longitudinal methods of training at RPAP and rural training tracks exposed the value of having a teacher who teaches for many months or years rather than a new teacher each 2 to 4 weeks as in most medical settings.
Accelerated Models of training in the US have demonstrated the value of a curricula that takes advantage of the largely wasted 4th year of medical school and boosts the learning curve with a steady increase in responsiblity.

Learners must master the basics. If this is delayed until the final year of residency or a fellowship year, then they will be uncomfortable with choices of practice, particularly the demanding inner city and rural practices where they will face a wide variety of challenges without much in the way of resources.

As students, residents, and fellows do less (and faculty) they are more likely to want to do more procedures. The hierarchy of fellows taking from residents from students then insures that there is less and less actual patient contact until later and later in training.

The evidence builds:

Predoc directors in Canada note how Canadian medical students look down upon rotations in the US because they are unable to "do anything" there.
Second career physician notes that there is little substance to his rotations and pursues rural rotation.
Students doing rural rotations with community preceptors rank them above all other 3rd and 4th year experiences in Nebraska and other locations.
Specialized curricula involving rural training such as Minnesota RPAP, Syracuse RMED, rural preceptorships, rated highly by trainees and program directors.

Schools such as Ross University, a Caribbean medical school that fills with medical students unable to get into US schools, may do as well or better in preparation of students, even with the limitations that kept them out of US medical schools. At Ross in the first two years, the faculty are involved only in teaching, and teach 3 classes of students a year. This increases their contact with students, their focus, and their experience. At the usual US medical school, teaching is a few hours or weeks a year. Students face a collection of professors that have varying degrees of devotion to teaching.

Medical students favor lifestyle over money in choice of specialty - who will serve

Note from above:

Sunday's Boston Globe reports that, "Harvard Medical School is struggling to persuade its physicians to teach its students, as doctors seeing more patients to stay afloat financially have less time to educate the next generation of doctors at one of the country's most prestigious medical colleges." The article continues, "Earlier this year at a faculty meeting, Martin, who is generally soft-spoken, let faculty know he was upset about the teaching situation. 'Martin expressed deep and serious frustration at not being able to convince more faculty that teaching responsibilities are the core of a faculty appointment and that faculty have an obligation to carry out their teaching responsibilities,' according to the faculty report of the meeting in February. 'He said efforts to convey this have been largely unsuccessful.' ''

The full article is available at
http://www.boston.com/dailyglobe2/152/nation/Busy_Harvard_doctors_balk_at_teachingP.shtml

More in Chronicles of Higher Education, including information suppressed by the Dean of the Harvard Medical school:

"When I talked to course directors, virtually everyone reported that recruiting faculty to teach was the No. 1 > problem they faced," says David L. Cardozo, a lecturer in neurobiology at Harvard who headed the medical school's Task Force on Faculty Teaching Responsibility. The panel submitted a report in March to the medical school's department chairmen and to its dean, Joseph B. Martin, who declined to release it. Says Mr. Cardozo, "The faculty say they have no time, that there's little financial compensation, and that the time spent teaching doesn't advance their careers." full reference in private files at Faculty Not Teaching

In a message dated 3/30/2004 2:33:23 PM Eastern Standard Time, rbowman@UNMC.EDU writes:

Of all nonmetro visits in the National Ambulatory care study, FP provided 37% and IM provided 24%. As the town size >shrinks, the contribution of IM goes to zero rapidly and FP is the remaining provider. The difference in Nebraska is around a town size of 20 - 25000. Small enough to be considered non-metro, but in reality not much different in terms of workforce.

This really matches my experience. There is a size below which the primary providers of ALL care (not just primary care) in a community are the family physicians (<10K). There is an intermediate population (say 10K to 25K) that can support either a pure FP model or a Peds + IM model (but not both), and at a population of over 25K FP and the Peds/IM modes can co-exist. This probably does not affect communities that don't have hospitals as it is call coverage issues that seem to determine the model.

So, at least for medicine, I might propose:

Rural: vast majority of providers are FP's
Truly rural: the FP's also provide the ER coverage 24/7
Remote: the office has to be equipped to handle trauma as there is no ER within 15 miles.

So PLEASE keep training FP's that can handle ER, OB, ICU and trauma care! If they are not comfortable in those realms, they will not locate in truly rural environments.

Arthur Freeland
Kirksville Missouri

Physician Workforce Studies

For questions or comments rbowman@unmc.edu