RIP Osler: Teaching Young Doctors to Avoid Original Thought
I’ve spoken to many residents who are interested in our Interventional Orthopedics Fellowship in Regenerative Medicine. Interestingly, many tell stories of having to fight to get the type of educational experiences they want and need to pursue the career of their dreams. Now a new book, entitled “Let Me Heal” by Ludmerer and an excellent NYT review bring the problem into focus – we’re teaching young doctors to avoid original thought.
The review by Lara Goitein is a must read for any patient who laments that their doctor doesn’t pay enough time and attention to them and/or who knows things are being missed. Starting with a wonderful description of the golden age of medical education when Sir William Osler (a demigod of American medicine) established the concept of medical “residents” who lived at the hospital to be trained, Goitein describes a world of physician led medical innovation which has been swept away. If you watch the TV show “The Knick“, which is also about this era of rapid medical innovation where older physicians were encouraged to mentor young physicians and innovate in the process, you can experience what no longer exists in medicine. Not only has high volume healthcare hurt medical education by replacing physician thinking with algorithms, this has also caused us to mint new doctors who have become automatons. By teaching young doctors to avoid original thought, we also destroy their ability to innovate. How did we get here?
From the review:
“The implications for the public are profound. Nearly anyone admitted to a teaching hospital—and these are the most prestigious hospitals in the country—can expect to be cared for by residents and fellows. Whether house officers are well trained and, most important, whether they have the time to provide good care are crucial.”
During the Golden age of medical education:
“There was a strong moral dimension to this system. Ludmerer writes that “house officers 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.”
Regarding the modern medical-industrial complex:
“In 1980, Arnold Relman wrote a landmark article in The New England Journal of Medicine, warning of the emergence of a “medical-industrial complex.”
In the golden era of medical care “With few exceptions, members of the faculty did not patent medical discoveries or accept gifts from industry…”
“The cozy relationship with industry was in large part enabled by the Bayh–Dole Act of 1980, which permitted academic medical centers to patent NIH -funded discoveries. (Publicly funded discoveries had previously not been patentable.) Academic medical centers can then license these discoveries exclusively to private companies in return for royalties. The public therefore pays for many innovations twice: first by funding the research, and second by buying the products for whatever the market will bear. According to data mandated by the Physician Payments Sunshine Act, medical device and drug companies paid teaching hospitals more than $315 million during the last five months of 2013 for research funding, royalties, grants, gifts, and facility rentals.”
“…increasingly, residents trained in an environment where money seemed to talk more loudly than traditional professional values. (This is all too clear to a resident when his attending physician spends minimal time teaching or caring for their patients, but has the time to take numerous paid speaking engagements as a consultant for Pfizer, or to develop a start-up company in collaboration with Syntonix.)”
“For example, many teaching hospitals provide their residents with “protocols” (often in the form of flow diagrams, or prewritten orders for tests and treatments) for common problems such as chest pain, pneumonia, heart failure, and stroke. While protocols may make residents more efficient and provide a basic safety check, they also devalue innovation and individual initiative, and discourage thoughtful consideration of unusual or unique features of individual patients. As Ludmerer points out, while standardization may impose a floor on performance, it may also impose a ceiling.”
The upshot? We’ve lost something very important to society in the creation of the modern medical-industrial complex (what I also often refer to as the Pharma-University Industrial complex). First we’ve lost the idea that we should educate our doctors to be independent thinkers. In fact, over the past few years, through new changes to Medicare payment, doctors are now financially rewarded by maximizing the use of government mandated treatment algorithms. Who do you think creates those guidelines? University professors on the dole from big Pharma (see above). How did we get there? Read the review and the new book. Why can’t you get the care you need? Your doctor has been trained to follow a script, we’re teaching young doctors to avoid original thought, not figure out what’s really wrong with you!