Defending Education

Academic medicine is like a tripod, standing on three legs. One leg is patient care, one is research, and one is education. Over the course of the twentieth century, the emphasis placed on each of these missions changed. In recent years, education has become the short leg of the tripod. More and more attention and resources have been devoted to patient care and research, and education has languished. This is a dangerous situation, in part because it threatens to destabilize both medicine and the healthcare system. If the profession of medicine and the healthcare of our society are to flourish, we need well-educated physicians.

These changes are admirably documented by Kenneth Ludmerer in his 1999 book, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. He presents a scholarly examination of the major trends in US medical education during the century, as well as a critique of the effects of managed care on medical education. Ludmerer traces out the historical forces that have placed medical education at risk, and provides insights into the remedies that will be necessary to restore education to its proper stature in the culture of our medical schools.

To appreciate what happened in the twentieth century, it is important to know what medical education looked like in the nineteenth century. Ludmerer reminds us that US medical education looked quite different then. Medical schools were proprietary organizations, meaning that they operated for a profit. A typical course of study consisted of two 14-week courses of lecturers, the second merely reprising the first. To get into medical school, it was only necessary to be able to afford the tuition. Many matriculating students were illiterate. Patient care was not part of the curriculum. As a result, patients often suffered when graduates began "practicing" medicine.

Abraham Flexner's 1910 report, Medical Education in the United States and Canada, spurred significant changes. Flexner called for radical reforms, including basing all medical education in universities, which he believed would provide the resources necessary to learn the scientific foundations of medical practice. Of greater concern to Flexner than the basic medical sciences,however, was clinical care. Many universities-based medical schools were doing an adequate job of teaching sciences such as anatomy, physiology, and pathology. At virtually none, however, were medical students learning well how to care for patients. Flexner argued that students had to make the transition from a passive role listening to lectures to an active role actually helping to care for the sick.

The only way, Flexner argued, that students could learn how to care for patients was by caring for patients. They needed to do it themselves, not merely hear others talk about it or watch others do it. To do this, medical schools needed to be based in teaching hospitals. Flexner cited as his model the fledgling Johns Hopkins University School of Medicine, which had been founded several years after the Johns Hopkins Hospital in Baltimore. Hopkins was the site where luminaries such as the three Williams, William Osler, William Halstead, and William Welch had introduced such contemporary staples of medical education as medical student clerkships and postgraduate training through internships and residencies. By allying medical schools and hospitals, Flexner argued, medical students would receive a robust education that truly prepared them to provide excellent care to the sick.

American medicine embraced Flexner's advice. The proprietary schools were rapidly replaced by four-year, university-based medical schools that evenly divided the curriculum between basic medical sciences and clinical experiences.

This was the heyday of education in US medical schools. True to their status as schools, medical schools treated education as their principal mission, to which patient care and research were subordinated. Patient care and research were important, but education was the defining mission. Community hospitals could provide patient care, and biomedical research could be carried out in the basic science departments of universities and by research institutes and private industry, but only medical schools could produce physicians. The primacy of education among the missions of US medical schools lasted at least until World War II.

In the two decades that followed World War II, the focus of US medical schools shifted toward research. There was huge growth in the funding of research, and many faculty members began to think of themselves less as teachers of future physicians than as investigators expanding biomedical knowledge. Research became the most prestigious track on which a faculty member could be promoted and receive tenure. Medical schools and their deans began to keep score less by the quality of education they offered and more by the quality of their research and the size of their research budgets.

Beginning in 1965, another sea change began. As part of president Lyndon Johnson's Great Society initiatives, the legislation establishing Medicare and Medicaid was passed. Suddenly the charity care that medical schools had traditionally provided as a way to educate the medical students became a viable source of revenue in its own right. Moreover, research was generating new and expensive healthcare technologies, such as the CT scanner. As the US healthcare budget mushroomed, medical schools began to shift their focus from research to patient care. In the early 1960s, Ludmerer notes, medical schools derived only about six percent of their income from the private practice of medicine. The social contract between medical schools and their communities meant that the medical schools would care for the poor in exchange for training the next generation of physicians. Poor patients would get free care, and medical students and residents would have "clinical material" to learn to practice medicine.

Beginning in the 1960s, this changed radically. Tens of millions of indigent patients were converted into paying patients, and healthcare as a business began to explode. Patient care,which formerly generated only 6% of US medical school revenues, soon grew to over 50%, substantially exceeding both research and education. With the increase in revenues, the size of medical school faculties mushroomed as well. Between 1965 and 1990,the full-time faculty of US medical schools increased from about 17,000 to about 75,000. The typical medical school budget, which had been about $20 million, grew to over $200 million.

This great expansion in US medical schools was driven by something very much like the private practice of medicine. Traditionally, medical school faculty members saw only enough patients to permit high-quality teaching. Patient care was an academic endeavor, focused on educating medical students and residents. With time,however, medical school faculty members became less and less distinguishable from physicians in a multispecialty group practice. Medical school professors increasingly saw themselves as private practitioners of medicine, attempting to see more patients in order to generate more clinical revenue. As the emphasis on clinical productivity increased, the time and energy available for education decreased. Medical students and residents tend to slow down clinical work, leading many faculty members to begin to practice in settings where education is de-emphasized, and in some cases excluding medical students and residents from the practice. What happened to research? In 1965 about six percent of US healthcare dollars went into research. Today, that number is closer to three percent.

As the scholarly faculty became a clinical faculty, another important change pushed healthcare and medical schools toward a managed care model. The people who pay for healthcare, including private insurers, government, and ultimately, employers and patients, became increasingly concerned about annual double-digit increases in the cost of healthcare. Between 1965 and 1995, healthcare costs rose from 3.5% of US gross domestic product, a level that had obtained for most of the century, to more than 14%. Alarmed by this trend, employers and patients began searching for ways to constrain and perhaps even reverse this trend. Managed care seemed a promising option.

In the old fee-for-service system of healthcare payment, hospitals and physicians were compensated in proportion to what they charged. Thus the marginal revenue of providing an additional unit of service to a patient was positive. The more services a hospital or physician provided, the more revenue they generated. This system appeared to some analysts to provide an incentive toward overutilization, and thus to drive up healthcare costs. What could be done?

Some analysts suggested capitation as the solution. In a capitated payment system, providers are paid a fixed amount per covered patient, regardless of the amount of service they provided. It was like starting the day with a fixed amount of money to care for a fixed number of patients, and then taking money out of that pot as services were provided. This renders the marginal revenue of each additional service negative. Instead of rewarding providers for providing services, capitation in effect rewarded providers for reducing costs. For the first time since the introduction of Medicare and Medicaid, providers could actually lose money if they performed an additional procedure or kept the patient in the hospital an additional day.

Traditionally, payers had been willing to pay a premium for care delivered in teaching hospitals, in order to subsidize the education of future physicians. Everyone knew that teaching medical students and residents compromised efficiency somewhat, which increased the costs of care in teaching hospitals by about 30% compared to private hospitals. Every hour a medical school faculty member devotes to teaching is an hour taken away from patient care. Thus a medical school faculty member can see fewer patients in a day than a colleague in private practice. With the intense cost-cutting focus of managed care, however, payers became less willing to subsidize that inefficiency, and they began to cut back on the premium they paid teaching hospitals.

Suddenly, teaching hospitals could no longer compete effectively for their principal source of revenue, payments for clinical care. To reverse this trend, medical schools discovered that they had to increase the clinical productivity of their faculty members. Medical school faculty members had already begun to resemble private practitioners, but now they found themselves forced to compete directly with the most efficient private practitioners in their communities.

Ludmerer points out that the American Association of Medical Colleges defines the productivity of medical school faculty according to the income they generate. A busy cosmetic surgeon who never publishes a paper or teaches a medical student or resident appears to be many times as productive, and thus many times as valuable to the school, as a pediatrician or general internist who spends most of the day teaching.

This change in medical school revenues was paralleled by a change in the kind of care teaching hospitals delivered, with implications for the quality of education they offer. Ludmerer points out that in the 1960s, patients stayed in the hospital on average ten days, and a busy night for a house officer was three or four admissions to the hospital. By the 1990s, patients stayed on average only three or four days, and a busy night meant admitting ten or more patients. Patients no longer came into the hospital to be diagnosed and then got worked up and treated. Instead, they were diagnosed as outpatients and then admitted for as short a time as possible to receive therapy. As soon as they could be discharged, they were sent home to recover.

The teaching hospital became more and more of a revolving door, and medical students and residents enjoyed less and less time to get to know their patients. The hospital increasingly resembled an assembly line, and the house officer became an admission and discharge machine. Ludmerer notes that the academic hospital whose hallmark had once been careful deliberation and attention to detail was replaced by a commercial enterprise whose principal mission was to get the patient out of the hospital as quickly as possible.

These changes took a toll on the resources necessary for medical education, including both money and time. In terms of money, medical schools were able, for a time, to cross-subsidize their educational missions from the clinical missions. The premiums for clinical care in teaching hospitals helped underwrite the costs of education. As those premiums disappeared, however, it became increasingly difficult to excite medical school administrators about teaching. Teaching medicine, which had once been the medical school's reason for being, became a financial liability.

Medical school faculty members who could once support their salaries through part-time clinical practice found themselves under increasing pressure to devote all their time to patient care. Ludmerer warns that medical education is returning to the proprietary model that Flexner decried at the beginning of the century. The fast pace of contemporary clinical work threatens to marginalize medical students and residents. If we are not careful, they will once again become largely passive observers of healthcare, rather than active participants in it. The focus on clinical productivity tends to diminish both the frequency and intensity of educational interactions. The demands of clinical throughput sweep aside opportunities for hands-on experience, and student learning suffers. We can attempt to implement high-tech substitutes, but from Flexner's point of view, there is no substitute for learning by doing. Medicine cannot be learned at a distance. Not only is formal teaching under threat, but the opportunity for faculty members to serve as advisors, mentors, and role models is also suffering.

Ludmerer criticizes managed care as grounded in false assumptions about human biology. For one thing, the practice of medicine requires more than a science of health and disease. It also requires artfulness in negotiating with uncertainty. In particular cases, we cannot be certain that we have the right diagnosis or that we are prescribing the right therapy. If we attempt to provide medical care according to the same model we use for fast food, we will undermine the trust on which a sound patient-physician relationship needs to be based.

Without that trust, both patient care, and the education of future physicians who need to experience it firsthand, will suffer. If every patient arrived with a complete diagnosis and plan for therapy, then increasing throughput in our hospitals and clinics would not be a problem. But if that were the case, we would not need doctors, either. Because it is not the case, increases in throughput have been achieved at the price of diminished quality, which is harming both patients and students.

Is the practice of medicine a business? What if it is not? What if willing patients should never be subjected to tests and procedures, whether they can afford them or not, unless they are really indicated? Conversely, is it acceptable to withhold indicated medical care from patients merely because the payer would like to save some money? In each of these situations, we are purveying a defective model of medicine. If this is what the managed care prescription entails, then the therapy is worse than the disease of rising costs it is meant to treat.

Above all, we must ensure that our system of medical education, including our 126 US medical schools, never ceases to serve the purpose for which it was created in the first place: to educate future physicians. Short-term cost savings are not worth it if they require us to jeopardize the long-term quality of our medical practitioners. Education is a core mission, perhaps the core mission, of academic medicine, on which the future of all of medicine depends.

Producing bad doctors lies in no one's long-term interest. Instead, we need to recognize the necessary ingredients of high-quality education and determine what sacrifices need to be made to provide them. We need to attract top-notch medical school faculty members, and to do so we need to make sure that we do not expect our faculty to work just as hard clinically for less money than their colleagues in private practice. We need to ensure that we provide them the opportunity to excel as academic physicians, including the academic missions of education and research.

Academic medicine needs to take the lead in developing quality and cost-effectiveness indicators, not only in patient care but in research and education. People recognize the harm that managed care has wrought on the academic missions, but we are not as equipped as we should be to assess those problems. High-quality assessments of educational outcomes are crucial.

How do we know whether medical students and residents are being well prepared to excel as physicians, and can we track changes in the quality of that preparation over time? How can we demonstrate whether we are sacrificing quality to price? How do we know that our curricula are adding genuine value to healthcare? What really comes out of the time students and residents spend with faculty members, and how can we make that time even more beneficial?

How can we show the courage of our convictions, and stand up for the profession and the patients we serve when we see quality of care compromised? It is bad for medicine if physicians are seen to be caught up in internecine turf battles, protecting our own wallets. As long as we appear to be acting from self-interest, our efforts to establish performance criteria will be regarded with suspicion. Instead we must strive genuinely to deserve the respect and trust that we once took for granted. We must rededicate ourselves to the core academic values that are the reason for being of our medical schools.

Ultimately, medical education can only thrive when the larger healthcare system reflects high-quality learning as a priority. We can indoctrinate students about the importance of patience and circumspection, but if they see us cutting corners and throwing caution to the wind, they will learn what we do, not what we say. We need to instill in our students and residents a clear vision of what excellence in medicine looks like, so they go into practice with their internal compasses pointing in the right direction.

But medical schools alone cannot reform the healthcare system. The best we can do is seek to regain our status as the conscience of medicine, and to reestablish our moral voice as society's healthcare prophets. If we are going to excel at these missions, we need to enter the public debate with unclouded vision and clear consciences. Nothing less will work if education is to regain its rightful place as the reason for being of our medical schools.

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