Radical change in doctor training needed

By Anne Barnard, Globe Staff, 12/8/2002


When Daniel Lowenstein was studying medicine at Harvard in the early 1980s,

medical students were so closely involved with hospital care that it wasn't

uncommon for a patient to point to him and say, ''That's my doctor.''



But now, says Lowenstein, who served until this month as Harvard Medical

School's dean for medical education, medical students too often spend their

days trotting along after a parade of residents and specialists, observing

hospital care that is too fast-moving and sophisticated for them to play much

of a role.



''The clinical aspect of medical training is in a state of disarray,'' said

Lowenstein, one of a crowd of medical educators who warn that medicine's

traditional training grounds - hospitals and, to a lesser extent, clinics and

doctors' offices - no longer teach medical students what they need to know to

care for future patients.



Medical educators from Boston to San Francisco agree: After two decades of

dizzying change in health care, hospitals' quick tempo and focus on acute

illness keep medical students from seeing the full picture of medical care,

doctors under financial pressure have less time to teach, and no student can

master the mushrooming amount of knowledge in every specialty.



Now, Harvard is launching the first major rethinking of its medical

curriculum in 20 years. The medical school dean, Dr. Joseph M. Martin, wants

the university to lead what he says will be the most sweeping changes in

American medical education since 1910 - when medical schools established the

first national standards for physician training and licensing and stopped

handing degrees to almost anyone who could pay.



''We need to think about not just an evolution, but a real revolution in the

way we teach,'' Martin said in an interview. ''This is a national problem....

Students, in their critical learning experience at the bedside, find it

increasingly difficult to be able to spend the time with the patient and the

faculty that they need.''

Even faculty at leading universities such as Harvard, Columbia, and Johns

Hopkins describe a common list of frustrations. Shorter hospital stays - less

than two days for nonintensive-care patients at the University of California,

San Francisco, for example - mean that medical students spend less time with

patients. While students may get to close an incision in surgery, they don't

often witness the decision-making process about who needs surgery in the

first place.



Students now spend about a third of their clinical time in doctors' offices,

to learn about managing chronic illness - a growing burden as the population

ages. But the 10-minute patient visits they often see in practice have

nothing to do with the hour-long complete patient histories they have learned

to do in theory.



Harvard's Task Force for a New Curriculum will consider solutions ranging

from letting medical students choose a field earlier - even questioning

whether every doctor needs knowledge of every specialty - to concentrating

teaching duties in the hands of a core group of dedicated educators, rather

than spreading them evenly among a vast clinical faculty. But most observers

agree that one key is to change the financial priorities of academic medical

centers, where education, many faculty say, has become an afterthought.



The problem is rooted in the evolution of medical schools and their

affiliated hospitals. After World War II, research and clinical activities

overtook teaching as the focus of academic medical centers, bringing in the

lion's share of revenues and soaking up most spending. In 1910, tuition

accounted for 70 percent of medical school income; by 1948, that figure had

dropped to 28 percent, and by 1968, it was 7 percent, writes Dr. Kenneth

Ludmerer in ''A Time to Heal,'' a 1999 history of medical education that

helped to launch the current debate.



For years, the rising tide of income from caring for patients essentially

subsidized teaching. Medical faculty volunteered their teaching time, relying

on generous reimbursements from Medicare and private insurers to make up the

lost income. Now that reimbursements have plummeted and most hospitals are in

the red, senior doctors are under pressure to shorten their time with

patients, and teaching duties are increasingly shunted to residents,

themselves harried and fresh out of medical school.

Medical faculty say the problems could threaten the quality of care for

future generations.



''There are concerns across the whole range of what doctors should be

learning, from the ability to establish a caring, productive relationship

with somebody who is scared, in pain, [and] anxious to the physical exam, to

how to participate in the care of a patient with a chronic illness and

support his ability to manage his own care,'' said Dr. Molly Cooke, director

of UCSF's Academy of Medical Educators. ''I don't think we're teaching well

to any of those goals at this point.''



There's little data on how well medical students are learning, partly because

an effective education is hard to measure, medical faculty agreed at a recent

conference on the problem at the New York Academy of Medicine. Two small

studies recently suggested that they are not doing well at traditional

clinical skills: in a 1999 study, students listening to patients' chests

correctly identified 35 percent of lung sounds; in 1997, researchers reported

that of 12 heart sounds, students could identify an average of 2.7. Students

can learn these skills during residency, but in both studies, residents did

little better.



To many medical students, the picture isn't so grim. On Thursday, Sara

Tullis, 26, and Rhondee Benjamin-Johnson, 27, third-year Harvard medical

students, whipped out stethoscopes to listen to a woman's wheezing. Dr.

Nathan Cobb, 32, a second-year resident, challenged them to decipher a

confusing spinal tap reading on a patient with suspected meningitis. And

across Longwood Avenue, Tullis's former roommate, Sarah Valkenburgh, spent

well over half an hour with a patient at the office of Brigham and Women's

Hospital's Dr. Jo Shapiro.



''Avoid spicy foods, try to stay away from caffeine and alcohol,''

Valkenburgh, 25, read from a long list. The patient, Jennifer Farley Smith,

cringed and then started to laugh. ''I can't live without caffeine,'' she




Shapiro had a gentle suggestion: Tell patients it's great if they can follow

just one or two of the ''don'ts'' on the list. ''When you read them this

whole list they just say, `forget it.'''



But too often, these interactions are the exception, not the rule, said

Shapiro, chief of ear, nose, and throat surgery. And when she has a medical

student in her office, she pushes patient appointments past the typical 15-

to 30-minute time slots - forcing her to scramble logistically and

financially. Part of the problem is that while Medicare pays hospitals extra

to train residents, there is no government funding for doctors' offices that

train students.



So medical centers have to solve the problem by reassigning their own funds

and raising funds specifically for education - something they have rarely

done, said Dr. George Thibault, vice chairman for clinical affairs at

Partners, which runs Harvard's largest teaching hospitals.



Thibault dreams of a $100 million endowment for education. The medical school

has already released extra endowment funds, about $4 million annually, to pay

directly for teaching. And the new Academy at Harvard Medical School, which

Thibault directs, has assigned $1 million in new funding to innovative

teaching projects.



Thibault is cochairman of the new task force, which Martin, the dean, is

formally appointing this week. Martin was recently asked to head the

Association of American Medical Colleges' committee to examine the problem




At UCSF, the medical school has wrested back some power from the hospital

departments that control most education, and is paying 20 faculty members up

to $30,000 a year to reserve some of their time for teaching. At the

University of California, Los Angeles, fourth-year students can choose tracks

ranging from family practice to research.



Meanwhile, some medical students see the glass half full. Tullis says the

hospital's fast pace has helped her bond with patients, as with a severely

ill man who confided his secret wish to go out to dinner: ''Sometimes

patients don't want to bother people,'' she said, ''but with a medical

student, they're not as worried.''

Anne Barnard can be reached at abarnard@globe.com.

This story ran on page A1 of the Boston Globe on 12/8/2002.

© Copyright 2002 Globe Newspaper Company. 



JJAMD Note:  This version of the article does not include a side-bar entitled

“Malaise in Medical Education” which reports under the heading Inadequate

Instruction that Medical School faculties are concerned that their students

are dissatisfied with the amount of instruction they are getting key areas,

such as controlling medical costs and prevention of disease.  Percentage of

medical students reporting dissatisfaction in various subject,

1994-1997..Amulatory care 23.9%; Cost Control 52.9%; Disease Prevention

23.7%; Primary Care 13.7%; Team Work 21.9%.