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Getting Rid of Patients: Contradictions in the Socialization of Physicians.

Getting Rid of Patients: Contradictions in the Socialization of Physicians

"To cover the vast field of medicine in four years is an impossible task. We can only instill principles, put the student in the right path, give him methods, teach him how to study, and early to discern between essentials and non-essentials." That could have been written by a medical school professor in 1987. In fact, it was written by William Osler in 1899.

Kenneth Ludmerer's fine book Learning to Heal, the source of this quotation, tells how medical education in America changed between 1870 and 1925. In 1870 medical education in proprietary school was unscientific, didactic, and lax. By 1925, the university medical school and teaching hospital had arrived. Moreover, attitudes about medical education that persist to this day had taken root. The central belief held that scientific experimentation was the key to medical progress. Since scientific discoveries would continue to proliferate, students had to learn to discover and assimilate new information. Merely absorbing information was futile, since tomorrow's discoveries would quickly render it obsolete. Ludmerer recounts the fascinating story of these historical changes with great clarity and insight. Both a physician and a historian, he combines careful research on new primary sources with a broad appreciation of the social and intellectual background of the Progressive era.

The Progressive Era

During this period, visionary and forceful medical reformers dramatically changed American medical education. Men like Charles Eliot of Harvard and William Welch and William Osler of Johns Hopkins were inspired by German experimental medical science. This scientific outlook led to discoveries like the germ theory, vaccines against rabies and typhoid, antitoxins for diphtheria and tetanus, the therapeutic use of thyroid extract, and new diagnostic tests.

The reformers introduced physiology, bacteriology, and pharmacology and replaced lectures with laboratory studies and clinical teaching. Their philosophy of education found its most articulate statement a generation later in the writings of John Dewey and the progressive education movement. This educational philosophy still dominates medical education. A 1984 report by the Association of American Medical Colleges, founded in 1890 as part of the Progressive reforms, reiterated that students must be taught how to learn independently, so that they can keep pace with new medical information.

To implement these goals, the reformers developed new institutions. Medical schools became integral parts of universities. Teaching hospitals were established under the control of the medical schools. The career pathway of the full-time clinician-researcher in academic medicine was established. These academic researchers took control of the medical profession from clinical practitioners. Unprecedented fund raising drives financed construction of new laboratories and hospitals. Proprietary medical schools, which were not affiliated with universities, had weak clinical teaching; concerned with making money rather than with research, they did not survive this period of reform. Ultimately, state licensing boards standardized these reforms through licensure requirements.

Ludmerer debunks many myths about medical education, and argues that the importance of the Flexner Report and the American Medical Association in these medical reforms has been overstated. For example, many important changes had already occurred before the Flexner report was published in 1910, and the movement would have achieved its goals even if the report had not been written. Furthermore, educational reforms were not motivated by the medical profession's desire to improve its economic and social position, as is usually assumed, but by the educational philosophy of academic leaders.

Ludmerer recognizes that the medical reformers did not always achieve their ideals. Particularly for average students, medical education still entails rote memorization rather than critical thinking. In general, however, Ludmerer focuses on the leaders and ideologies that inspired reforms, not on the impact of those reforms.

The Modern Hospital

The sociologist Terry Mizrahi, in her book, Getting Rid of Patients, examines contemporary clinical education. In her role as interviewer and participant-observer, she argues that interns and residents desire above all to get rid of their patients, to transfer their care to someone else. Overworked and stressed house officers regard their mainly indigent patients as social undesirables who have uninteresting illnesses rather than "real" diseases, do not get better, and waste their valuable time on unsolvable psychosocial problems. They call patients abusive names, regard them as adversaries, and strip them of their human qualities. They consider the patient's reactions and emotions unimportant compared to the biomedical aspects of the case.

In the Progressive era that Ludmerer describes, when infectious diseases were prevalent, a narrow biomedical focus was perhaps justified because scientific medicine might well offer cure or prevention. But by the late 1970s, when Mizrahi conducted her study, the pattern of illness had changed. Not acute infections, but chronic illnesses and psychological and social problems sent most patients to hospitals.

Mizrahi argues that interns and residents are socialized by their peers. Attending physicians on the faculty, while nominally responsible for patient care, are more interested in research than in caring for patients. While they concentrate on their narrowly specialized research careers, their clinical skills grow rusty. As a result, faculty do not interfere with the housestaff's management of patients and do not try to change their attitudes. the Progressive reformers' breadth of vision has been lost; there is no supervision, much less leadership.

Ironically, the ideology of scientific research, which strengthened medical education in the Progressive era, leads today's faculty researchers and house officers to neglect patients. Specialization, so valuable to scientific research, has fragmented patient care. To paraphrase Ludmerer, while doctors in Mizrahi's hospital learn the scientific aspects of clinical medicine, they are not "learning to heal."

Doctors may feel that Mizrahi has overstated a well-recognized problem. After all, physicians have decried for years the inhumanity of calling patients "crocks" or "gomers," and the barbaric attitudes she describes may not occur in all residency programs. There is also reason to believe that the ethical and humanistic aspects of medicine are commanding more attention; the American Board of Internal Medicine, for example, requires more teaching on these topics for certification. Specialties like geriatrics and general internal medicine, which incorporate the psychosocial aspects of illness, have grown. And cutbacks in funding have undermined faith in scientific research.

But recent developments may reinforce the inhumane attitudes toward patients that Mizrahi deplores. Prospective payment, for example, leads to pressures for shorter hospital stays, and cutbacks in Medicaid have hurt the poor. Furthermore, as recent educational reformers have stressed, the continued rapid growth of biomedical knowledge, tests, and treatments makes it increasingly difficult for students and residents to master the technical aspects of medicine and biology, let alone to appreciate the limitations of scientific medicine or to develop the attitudes and skills needed for therapeutic relationships with patients.

An Agenda for Change

Ludmerer's historical study and Mizrahi's sociological one challenge the reader to suggest a new agenda for reform of medical education. First, new institution have to be developed. Perhaps medical schools should establish close affiliations with nursing homes and home health agencies in order to teach about long-term, chronic illness in a humane and comprehensive way. The site of medical education may need to shift from acute care hospitals to outpatient clinics and extended care services.

Second, new roles and careers need to be institutionalized, with secure positions on medical school faculties for clinician-teachers as well as for biomedical researchers. Third, new conceptual paradigms are needed to guide reforms. Assimilating the growing body of medical knowledge seems even more difficult today than it did in the 1870s. But yesterday's solutions no longer seem attractive. Indeed, the growth of scientific research has become part of the problem.

To correct excessive specialization and narrow the widening gap between biomedical research and clinical practice, medical schools need to establish a new balance between the scientific and humanistic aspects of medicine. But there is no widely accepted new ideology to guide educational reform in the 1980s. Decision analysis, clinical epidemiology, computer retrieval of information, and artificial intelligence have not yet proved their value in helping the practitioner master the growing mountain of biomedical knowledge. Similarly, there are no convincing paradigms for teaching the human aspects of medicine or for integrating them with biotechnology. For example, although many medical schools expose students to videotapes about doctor-patient interactions, there is no educational philosophy to justify its use or convincing evidence of its effectiveness.

Fourth, new sources of funding may be required to implement educational reforms. Already, pharmaceutical corporations are sponsoring university biomedical research and for-profit chains are investing in teaching hospitals and nursing homes. Perhaps insurance companies and companies that pay health insurance premiums for their employees can also be convinced to support reforms in medical education.

Ludmerer suggests that strong and visionary leaders can catalyze dramatic historical changes. Mizrahi implies that medical school faculty abdicated clinical leadership in the late 1970s. Today, as in the Progressive era, farsighted, courageous, and energetic medical leaders are needed if medical education is to surmount its challenges.

Terry Mizrahi. New Brunswick, NJ: Rutgers University Press, 1986. 230 pp. $27.00.
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Author:Lo, Bernard
Publication:The Hastings Center Report
Article Type:Book Review
Date:Feb 1, 1988
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