While in medical school, students are supposed to know the answers. They spend hours cramming, memorizing arcane language and hard-to-remember numbers so that if the question appears on a test—or worse still, if a resident decides to quiz them during rounds—they can answer it.
“I don’t know, but I know where to look it up,” is not an acceptable response.
“Looking up the answer is considered cheating,” Dr. Denis Cortese, president and CEO of the Mayo Clinic pointed out on the opening day of Mayo’ s National Symposium on Medical and Health Care Education Reform.
Yet, Cortese observed, once the student becomes a doctor, he is supposed to “cheat”—i.e. look things up. He is not supposed to “take a stab” at the right dosage the way he might take a stab at the right answer on an exam. His patient’s well-being depends upon him knowing where and how to look up the information he needs, or whom to consult. A doctor who is reluctant to admit “I don’t know” is a dangerous doctor.
Today, we recognize that medicine is a team sport. No one doctor can know everything that he needs to know, even in his own specialty.
Yet, we continue to train would-be doctors as if they were going to be practicing medicine circa 1950, when “The Doctor” was supposed to have all of the answers.
The Symposium acknowledged that today, we are educating medical students the way we always have—preparing them to work in the old, broken system that we are trying to reform. Just as the system requires change, so does medical education.
For instance, the symposiums’ participants recommended that “Exams should test information use and information gathering rather than memorized knowledge.” Moreover, rather than spending all of their time in classrooms and hospital wards, students should spend more time learning to practice medicine in real-life settings. Voting on the best solutions to improve medical care, the majority of the audience agreed that “to understand patients, students should interface with the patients in their communities, experiencing medical care through their patients’ eyes and experiences.”
Finally, we need to change the way we choose students for admission to medical school. One speaker made a persuasive argument that today, we rely too heavily on grade point averages (GPAs) and medical college admission tests (MCATs). We need to draw medical students from a larger pool.
Talking About Death
While moderating a panel on making medical education more “patient centered,” I suggested that dying patients should share in decisions about end-of-life care. This means that students must learn how to approach a dying patient and see her as a whole person, with fears, hopes and priorities that she needs to express—and that a doctor must respect.
Students training to become doctors and nurses should spend some time studying “palliative care”–the art of caring for patients who may well die. This includes controlling their pain and helping them consider their options. Palliative care specialists know how to talk to dying patients and their families, how to outline the pros and cons of various procedures, and how to help the patient decide whether or not he or she wants to pursue a particular course of treatment. Too often, if a patient doesn’t have a palliative care team, a doctor will simply announce: “This is what we do next. This is the protocol.” The patient is given little choice.
A palliative care team made up of a doctor, nurse and psychologist are not embarrassed by the fact that the patient is dying. They understand that the patient cannot make meaningful choices unless that fact is acknowledged. Students should be assigned to sit in when members of a palliative care team talk to patients and their families (with the permission of patient and family.)
Students need to spend time with a palliative care tem because in many medical schools death is not part of the curriculum. According to the Institute of Medicine, a 1990s study of third-year medical students revealed that 41 percent reported that they had never heard a doctor talking to a dying patient; 35 percent had never discussed care for dying patients with an attending physician, and the great majority had never been present when a surgeon told a family that a patient had died. Almost half of patients could not remember any consideration of death and dying in the curriculum.
In his 2007 book, Last Rites, Steven Kiernan cites more recent studies which reveal that death continues to get short shrift in medical education.
Yet nearly every doctor will, at some point, find himself treating a dying patient. And nurses spend more time with the dying than anyone else in a hospital. It is imperative that they learn how to control pain. Today, too many nurses are wary of giving patients the painkillers they need; some are afraid that a dying patient will become “addicted” to the opiate.
Ultimately, a doctor may well want to call in a palliative care team to make sure that the patient is getting adequate pain relief, and to help the patient consider his options. But first, the doctor who has been caring for the patient needs to acknowledge that the patient is probably dying, make peace with that fact, and communicate with the patient in a way that makes it clear that the doctor does not consider the patient’s death—or the patient himself– a “failure.”
Collaborating, Rather Than Competing
As part of their training, doctors and nurses need to learn how to collaborate with their patient, and they also need to practice collaborating with each other. This means that they must respect each other.
Too often, doctors view nurses as their handmaidens, and surgeons see themselves as “the stars,” (which means, as I noted in an earlier post, that they view other doctors as “the chorus girls.” ) Even among surgeons, there is a pecking order. Orthopods, for example, often become the butt of jokes: “an orthopedic surgeon is someone who is strong as an ox and twice as smart.”
Participants at the conference agreed: students must learn that making derogatory remarks about other specialties “just isn’t professional,” no matter how witty the wisecrack may seem to the person making the remark.
Finally, conference participants recommended that “medical and nursing schools should introduce team-based standards early in the training program that reflect all health team members contributing at their highest level of training.” In other words, students should be assessed, not just as individuals, but as members of a cooperative group.
Teachers Must Emphasize that Medicine Is Always Changing
Too often, Nursing students, medical students and residents who dare to ask questions are told: “this is the way we do it.” Such a dogmatic response suggests that medical knowledge is carved in stone, i.e. “we have discovered the ultimate treatment.”
Dr. Jack Wennberg, the father of what is now known as “the Dartmouth Research” refers to such certainty as the “Doctrine of Manifest Efficacy”: this is what we do therefore, it must be right.” (Wennberg notes that when his children were growing up, a similar argument was made to justify subjecting millions of children to unnecessary tonsillectomies. Some of those children died.)
How do we help students understand the ambiguities and uncertainties of medicine? One nurse at the symposium made an excellent suggestion: “When showing a student a procedure, we might say, “This is the way we used to do it—but we realized that led to too many errors. So now, we do it this way.” And a thoughtful mentor might add: “at some point in the future, we’ll probably find an even better way.”
Learning How to Acknowledge Mistakes
Students who learn that the art of medicine is all about “continuous improvement” also must learn how to tell a patient –or a patient’s family–that they have made a mistake.
We know that openness and honesty reduces malpractice suits. As I explained in an earlier post on malpractice a number of prominent academic medical centers, including Johns Hopkins and Stanford, are experimenting with candor. By “promptly disclosing medical errors and offering earnest apologies and fair compensation, they hope to restore integrity to dealings with patients, make it easier to learn from mistakes and dilute the anger that often fuels lawsuits.”
It is not surprising that patients want to sue when they feel that someone is looking them straight in the eye—and lying. Often, an open admission of what went wrong combined with a sincere apology and a fair offer of compensation will defuse the situation.
Otherwise, victims often feel a responsibility to make sure that what happened to them won’t happen to others. When doctors admit errors, hospitals are in a much better position to analyze their systems, and devise ways to guard against similar mistakes. Telling the patient what they are planning to do will temper the desire to sue.
Changing the Way Medical Schools Assess Applicants
When student compete for places in medical school, interviewers should emphasize that today, healthcare is a team sport. This could lead to asking applicants what experience they have working with a group—as part of an athletic team, as part of an orchestra, working in a political campaign, or in some other collaborative endeavor.
After the student has described his or her experiences, the interviewer might add: “And do you usually find yourself the team leader?”
“Yes” is probably the wrong answer. Today, medicine needs more professionals who value the experience of working with a group. Students who are too quick to expound on why they are natural born leaders may have difficulty recognizing others as their peers—especially when a nurse speaks up to point out that a doctor is making a mistake.
In one panel discussion, Dr. John Stobo, senior vice-president for health and health services at the University of California, went a step further, suggesting that we might want to put less emphasis on grades and Medical College Admission Tests (MCat) scores. Relatively small differences in GPAs (say the difference between a 3.4 and a 3.9 on a four-point scale) don’t necessarily measure intelligence.
But those differences do tell us which students are most competitive—and, as noted, they many not be the best team players. A student who must place first is more likely to let his ego get in the way when it comes to asking an experienced nurse for advice, or admitting that he made a mistake.
Undergraduates who are obsessed with their GPA also are less likely to take a humanities course that piques their curiosity; more often, they’ll stick to courses where they know they can excel. But we need doctors who are curious—open, and eager to consider new possibilities.
As for MCATs, Stobo pointed out that we know that they discriminate against low-income students. Yet, he noted, today more than ever, “we need to pick our medical students from a larger pool,” that does a better job of reflecting the diversity of the patient population.
Reliance on MCAT scores when considering students for admission also undermines the goal of recruiting primary care doctors, and doctors willing to work in underserved rural areas, observes Dr. Robert C. Bowman, director of Director of Rural Health Education and Research at the University of Nebraska. In a paper titled “Comparing Physician Distribution and the MCAT,” Bowman writes: “Basically everything that would help distribute physicians [more broadly, in specialties and geographic areas where they are needed] is defeated by reliance on the highest MCAT scores.” Students with higher MCAT scores are more likely to have grown up in a city, are younger, and come from families with higher incomes. “Less urban origins, age, and lower income levels correlate with lower MCAT scores and better distribution. Schools with the highest scores distribute almost nothing,” Bowman notes, “ et receive the most NIH and GME dollars.” Meanwhile, “Students with the highest MCAT do not choose family practice or rural practice.”
“MCAT is no different than the SAT and ACT regarding income, ethnicity, and urban bias.” Bowman continues, “and the cumulative impact of ACT/SAT and MCAT is likely. The problem is not standardized testing, but over-reliance on standardized testing. The standardized tests are also the least valid on the students most likely to distribute well. Studies on those choosing primary care note a clear discrimination bias in the MCAT, likely a result of income differences.
“No physician would use any medical test with the specificity and sensitivity of the MCAT,” he adds. “Multi-school studies note that MCAT subscores of 8, a total of 25, and a GPA of 3.0 give maximal opportunity for diversity without increasing academic failure to a great degree.
“There is also even more to be concerned about. The increase of the MCAT of 1 point in bioscience alone in the past decade may indicate that students and colleges are gaming the system and teaching to the test, without increasing academic preparation. These games may be the exclusive venue of those of higher income or schools with more higher income students who have already been scoring higher. This, coupled with the rapid increases in admissions of those of higher income (see yearly data past decades from AAMC), also indicates that medical students are increasingly unlikely to choose family medicine, rural practice, and service to the underserved. The MCAT use may also be responsible for declines in the probability of rural born students being admitted, as well as lower numbers and ratios of rural, older, and low income students over time. The declines in some minorities choosing family medicine also suggests that higher income minorities such as urbanized Native Americans are gaining access to medical school while lower income minorities are not.”
Finally,“Bowman points out that “Students with privileged origins and every parent advantage are likely to have done all that they can before medical school. Students of more humble origins have greater potential for improvement if given better opportunity. Older students in particular seem to be able to take advantage of the opportunities in medical school and choose careers involving direct patient care in much greater percentages. The changes seen with age also tell us what we must do to improve all US physicians. We must require those who are academically prepared to be maturationally prepared. We need to raise the bar in people skills as high as we have in academic skills and not cave in and admit physicians who cannot meet the tests in both categories.”
With that goal in mind, Dr. Stobo made this recommendation so the Mayo conference: students applying to medical school should go through twelve “mini-interviews” designed to assess the student’s ability to work well with others, to communicate with patients, and other “people skills” that a compassionate doctor needs if he is going to practice “patient centered, collaborative” medicine.
Nice post, Maggie. I spent 4 years on a medical school admissions committee and, I have to say, it was a depressing experience. I grew so tired of arguing for more students from liberal arts backgrounds. As such an applicant myself, way back in 1973, I realized I would never have been admitted by the same committee. This was ironic, because it was, in fact, the medical school I graduated from.
Excellent! There is a brand new US medical school opening its doors in Scranton, Pa. this very August.See http://www.thecommonwealthmedical.com.I sent the leaders this piece since I am on the volunteer faculty.
Most of the old entrenched US Med Cchools are too stodgy,ankylosed,and hopelessly bureaucratic to change. So they will die over time.
Dr. Rick Lippin
Southampton,Pa
Thanks Maggie. You have hit on many of the key problems in medical education. Just keep in the mind that any proposed pedagological solutions will only be as effective as the health care system in which physicians work. Changing medical school admissions and teaching paradigms will have little to no impact on physician practice behavior unless the system in which they work also changes to support patient-centered, fully informed, cost-aware medical care.
Good Stuff Maggie! Doesn’t This looks like an awesome place to begin your academic program! The True Blue Campus at St. Georges University.
http://www.sgu.edu/som/campus-facilities.html
David, Chris & Dr. Rick–
Thanks for your comments.
David,–
I agree, our healthcare system–not to mention its mentors and teachers– will have to change as well.
This will not happen quickly. But I am very hopeful that over the next 10 to 15 years, we’ll see a radical change in the system.
Chris–
I sympathize. For two years, I was on Yale’s admissions committe for undergraduates, one of seven people who voted “yes,” “no” or “maybe.”
I won’t tell tales out of school here, but it was depressing to see very talented students turned down because they were too creative, too outspoken (in their essyas) and just didn’t fit the “mold.”
Dr. Rick–
Thanks, and good luck with the new school.
12 “mini” interviews wont give you any more information than the current 2-3 interview system. MD-PHD programs use 8-12 interviews and there’s no evidence that they are any better able to sort out “good folks” from jerks any moreso than regular MD programs.
The academic medical faculty would balk at such a proposal, because it means you take time away from research or clinical work to do non reimbursable administrative stuff. I guess you could account for that by charging more in tuition or by increasing application fees (which are already around $200 for each school) but taht would only encourage less of the “lower socioeconomic groups” to apply.
Its time to admit that no matter how many little 30 min interviews you do, you cant see into the heart of a person. People are too good at faking it for such a brief period of time. Its time to admit that at best you could only discover huge glaring personality disorders, you’re not going to be able to “screen out” the “uncompassionate” or “non-wholistic” folks. Its a pipedream.
In terms of palliative care, the best way to do it is resident training, not at the med student level. Residents are almost always involved in “end of life” issues because they are usually obligated to ask about “code status” at admission and do a lot of the legwork when a patient codes or dies in the ICU setting. Attendings generally arent around for that. You could argue that residents need more formal training in “end of life” issues and thats fine, I think you should focus efforts on that instead of at the med student level.
From personal experience, patients balk at having med students involved in end of life care, UNLESS the med student has been a consistent focus in the patient’s care. However, to “institutionalize” a formal palliative care training program, you are going to have to drop med students in on patients who are dying who they dont know very well, and thats going to cause discomfort on the part of patients and families.
Most of the physicians posting on this forum are hypocrites when it comes to palliative care issues. If you ask them whether med students need training on the issue, they will say yes. But when its THEIR family member who is dying, they all balk at the idea of a med student who is at hte forefront of the palliative care discussion. Hell most of them wont even let RESIDENTS be the spearhead, they only want to deal with the attendings.
Now lets talk about “humanities” in medical training. 2-3 decades ago, medical schools got enamored with the idea of encouraging “humanities/liberal arts” majors from college to go to med school, because they would be “well rounded” and supposedly better able to deal with patients on a personal level compared to science geeks who did research in a lab for 4 years.
Well there’s no evidence to suggest that anything has changed in the 30 years since that unofficial policy was adopted. Many people would argue that its tremendously inefficient to force people to get an undergraduate degree in humanities and draw up 100k in debt just for the privilege of going another 100k in debt for med school and being pushed away to the high paying specialties in order to recoup that cost.
The UK does not have any preference for a “humanities based” undergraduate degree, they go straight to med school from high school, and there’s no evidence to suggest that they are any less “compassionate” or possessing fewer “people skills” than a person trained in 4 years of liberal arts/humanities.
The demands on medical education seem to be quite HIGH relative to other professional fields. I dont see this level of handwringing for teacher education, or lawyer education. It seems we want doctors to be all things to all people–excellent scientists, excellent clinical care providers, as well as possessing excellent “people skills.” What institutionalized educational pathway is under so much pressure to have that trifecta?
“Most of the physicians posting on this forum are hypocrites when it comes to palliative care issues.”
Joe, exactly how is it that you know this?
Higher MCAT scores predict better performance in medical school. Specialists come from the top of the medical class. That is the likely explanation for primary care doctors having lower MCAT scores.
Not many people from the top of the class choose primary care, because, as you have noted, it is not a great job. That is the real problem.
I just wanted to make 2 points:
1)A dozen interviews are probably impractical for more than just faculty reasons. Organized programs for those interested in medical school to volunteer in a medical setting, and be assesed over a period of weeks/months by physicians and other professionals in that setting, might be an alternative to identify those that work well in a team.
2)While far from perfect, Osteopathic Medicine has a long history of taking an older, more diverse student base and turning out a greater proportion of primary care physicians.
Christopher George, Joe Blow, Kitt–
Chritopher George–
Student with higher MCAT scores may well get better grades in med school.
But we don’t have evidence that higher MCAT scores equals better doctors. (It is of course, hard to define “better doctors” beause so many skills ae required to be a very good doctor).
We do know that students with lower MCAT scores are more likely to be from lower income families (both white and minorities) and more likely to be from rural areas.
We also know that a signifcant percentage of people who grow up in rural areas, or in inner cities are willing to go back to work in those areas–to help their neighbors and people that they identify with.
They understand the problems of poverty, how aribitray it is that some people are born into poverty and others are not. They are comfortable with patients who are much like the people they grew up with.
Students coming from affluent urban environments are less likely to be comfortable with poorer patietns and, it seems, less likely to have the commitment to serving an underserved community.
No matter how good their grades in med school, if they don’t know how to talk to their patients, and don’t have a real commitment to service, they will not be good doctors.
This is why we want to put less emphasis on grades and MCATS –to broaden the pool to include those who are more likely to want to become family practioners,
pedicatricians, etc.
Finally, you seem to suggest that studets with high grades who become specialists are smarter than those who become primary care docs.
I would suggest that being an excellent family practioner is much more difficult than being an excellent cosmetic dermatologist (one dcotor I know summed up the science of dermatology this way: “if its wet, keep it dry; if it’s dry,keep it wet) or
radiologist.
Certainly a radiologist needs excellent judgement and eyes, but to some degree he is doing the same thing, over and over again, all day.
It’s a vey important and demanding job, but I would argue no more demanding that being a
family practitioner who is diagnosing and treating a very wide range of diseases, and counseling patients on a wide range of issues.
OF course some FPs just refer patients to specialists. But the best do far more than that.
Joe Blow–
I would echo Chris’ question.
On the value of having of having a good education in the humanities– if you had it, you would know. If you didn’t, it’s hard to explain.
All I can say is that courses in literature, history and philosphy teach studenst to analyze,
to ask questions, to begin to understand human behavior, and to be open to new ideas.
As for mini-interviews– how do you know they wouldn’t yield more information? Everything would depend on how they were designed.
As for whether they are practical–they are being used at some schools.
Kitt-
What you say about osteopathic medicine is interseting and makes sense. (Over the years, my husband has gone to some osteopaths who he liked very much.)
I also agree that organized programs where students volunteer in a medical setting could yield letters of recommendation that would tell who was good at working in a team.
But the undergraduates involved would need to be smart and very mature, or they would be in the way.
Twelve 15-minute interviews that were well-desigined, perhaps using videos (an 8 mintue video of a patient, and then the student asked to talk for 5 minutes about what he would say to that patient); a two person interview where two applicants were given a task an asked to work together, etc. could be revealing.
This technique of using 6-12 “multiple mini-interviews” (MMIs) is being tried at some medical schools where students are asked to address an ethical problem, or some other topic.
Once again, I didn’t make myself clear. Currently, (almost)anyone who can get out of primary care, does. That means the people with high MCAT scores, who for what ever reason, tend to do well in medical school go into specialties.
If your low MCAT students, who interview convincingly, do well in medical school, they too will go into specialty practice.
But no matter; unless you make being a doctor in primary care more attractive ( a lot more attractive, and not just money ) , you can interview all you want, and those who can will go into specialty practice.
That isn’t going to happen.
This is not an admissions interviewing problem. (As an aside, You must know different radiologists than I do. )
I will give you my prediction: no one really wants to make the PCP’s life better. Reformers are not pro-primary care doctors, they are just more anti-specialistdoctors than they are anti- primary care doctor.
In the new world, primary care will be done in the future by physician extenders.
Christopher George–
I’m afriad I wasn’t clear.
Many med students from low-income backgrounds PREFER to go into primary care in parts of the coutnry where they are needed (rural, inner cities.
This is probably because their desire to beocme a doctor stems from reocgnizing a need in thier communities . . .
As the article suggested, these (seomtimes older) students coming from non-affluent backgrounds make greater progress in med school and residency than younger students coming fom more affluent backgrounds.
Those make the greatest progress could become specialists, but many still choose family practice.
Why are we trying to instill humanity in medical students before sending them through 3-10 years of dehumanizing residency?
Eric-
Residency is definitely part of the “medical education” that needs to be reformed with more
collaboration, more emphasis on the patient as a whole person (rather than as a liver, a heart, etc.), and much less “hazing.”
Those making admission decisions are most comfortable with “more of the same”, dooming chances of changing who gets into medical school.
I started my career as an orderly (nurse’s aide) straight out of high school and learned a lot about taking care of patients. I also learned very early that nurses could make a doctor’s life easy or a living hell.
I think the first person to see prospective medical students should be the administrative secretary who can easily assess how the candidate treats subordinates. You’d weed out a lot of potential Dr. Shortfuses very quickly.
David Rivera, MD
Lombard, IL
I wholeheartedly disagree with each and every one of your points.
The majority of the problems in medicine are due to two main issues:
1). Loss of doctor autonomy, respect.
Nurses, PA’s, and NP’s have successfully butt into medicine and demanded all the respect with none of the sacrifice, hard work, education, or threat of liability.
Medicine is worse off because the doctor is no longer the top dog in the house. Doctors are expected to get along and put up with pretenders, lazy bossy wannabes, and undereducated buffoons.
2). Doctors pay. At one time, as recently as the 1980’s, doctors may have been ADEQUATELY PAID. Back then, fees were paid either by insurers or medicare on a scale set by physician’s “usual and customary” fees. Hence, a strenuous, challenging, risky, but life-saving procedure like Coronary artery bypass was paid over $7000.
Now? Doctors are MOST DEFINITELY UNDERPAID.
Grossly underpaid. Criminally underpaid. While everyone and their mailman made off like railroad barons from 1995-2008, doctors/surgeons salaries are either frozen or precipitously dropping. Meanwhile, the hideous malpractice insurance premiums are rising to unimaginable levels.
That fee for coronary artery bypass in 2009? It is $1500. So trying to pay all your bills, all your secretaries, your office rent, your malpractice, etc., based on fees that are $1500 today compared to $7000 in 1987.
Medicine is doomed. Nothing happens without the expert care of your highly trained, highly motivated doctor or surgeon. He/she needs more autonomy, more power, more free rein to care for their patients, and frankly, be justly and richly rewarded for their uncomparable hard work and immeasurable sacrifice of their minds, their bodies, and their families.
If you want the zombie staring, poorly educated, “diversity trained”, MCAT hating, group think, nurse/adminstrator loving new age physician, have at it.
Just realize that this species won’t make a dime over $70,000, won’t come in at 2am, come in before 9am, will leave promptly at 5pm, and not be available on weekends. He/she will get a small pittance bonus to deny care to you and your family, and won’t care as you get placed 6 feet under.
Enjoy America. Enjoy it very much
2).
Most physicians start out idealistically because they truly love medicine as well as treating and helping people. Those interested in amassing a fortune go into business nowadays.
Removing the debt that future physicians will be buried under allows them to concentrate on medicine.
You want them to go into low income areas? You want them to be a certain specialty?
Reward them and it will happen.
For a pledge of your desired goal, allow them to go through medical school with a stipend and no bills. Carry this forward to the residency and set them up in practice with a decent salary and the malpractice paid for.
With less financial demands placed on your “new” physician, he or she will be able to focus on what is important-treating the patient- not the ICD9 sheets.
I found it really informative and more important thing is it provide the guidlines so the guidline make it different from the other blogs. let me intorduce a site that is more relavent to the medical studies so the function of the site is provide the help of the medical students to get the more information and the have the oppertunity to get the maximum experience…
I have been surfing the internet for doctor in education and have come past your blog and I can say that what you have posted is relevant in today’s medical field. Too many times medical personnel do not collaborate with one another making the relay of information slow. I also have not seen any doctors present during the dying hours of a patient and I think that basing the admission on the entrance exam is unfair as there are more doctor-to-be who are not intelligent or textbook based but are very good with practical applications. I think that a review on how students are to be accepted in medical school should be done.