Time Has Come Today
The New Physician
Physician–leaders identify humanism, diversity and activism as themes that have emerged during medical
education’s past 50 years. But what does the future hold?
“My most shocking experience in medical school involved dealing with death. It began with my first patient who died. I was at the foot of her bed when she passed away. She had an extraordinarily happy look on her face. This was a very important moment for me—almost a transcendental experience.
“Two weeks later, another one of my patients died. Someone told me, ‘Mr. So-and-so just died—let’s go look at the boxcarring effect of the retinal veins.’ I literally ran down the stairs into this cubicle where this guy in his late 40s had just died, and I held back his eyelid and looked into his retina. I don’t recall seeing the boxcarring, but I recall thinking ‘What the hell am I doing?’ Here was a tragic situation—the patient was the head of the fire station and everyone knew him—and I was looking for boxcarring.”
—DR. ROGER BULGER
A KINDER, GENTLER PHYSICIAN
Although it could be an excerpt from the life of a medical student today, Dr. Roger Bulger’s experience occurred in the late 1950s. Throughout his training, Bulger—now president of the Washington, D.C.–based Association of Academic Health Centers—found himself having to continually readjust the balance between respect for patients and what he needed to learn as a student.
Today, medical education is still often criticized for training the humanism out of students. The grind and demands of medical school may eat away at one’s spirit, idealism and capacity for kindness. Additionally, a lack of curricular time for developing students’ humanistic qualities may contribute to their decline.
Mounting evidence indicates that medical schools are addressing these issues. However, the accounts of many former medical students (in other words, today’s physicians) suggest that educators have been slow to recognize the dehumanizing effects of medical training. When Dr. Barbara Ross-Lee, dean of the Ohio University College of Osteopathic Medicine, attended medical school in the early 1970s, she underestimated the challenges, both academic and emotional. “There were challenges to integrity, judgment, maturity, social perceptions and everything that makes up a part of your character,” she recalls. What she doesn’t remember is her school identifying these issues.
As dean, Ross-Lee hopes to move students away from persevering to actually enjoying the educational process and retaining and advancing their humanistic qualities. “Whether or not they get an A or B in biochemistry does not affect the type of physician they become,” she says. “The real issues are whether or not they have the personality and character necessary to be a good physician.” Ross-Lee believes that small-group interactions, self-directed learning and a lessening of the competitiveness of the admissions process will all contribute to training competent, humanistic physicians.
For Dr. Deborah Danoff, assistant vice president of the Division of Medical Education at the Association of American Medical Colleges (AAMC), the sheer volume of work and the intensity of medical school in the early 1970s were overwhelming. “Deciding on a balance between what I needed to do to be a doctor and to be a good person was an issue,” she says. Still, a certain transformation must happen during medical school that Danoff compares to the time between a baby’s birth and when it first speaks. “You go from an unformed person to someone who is capable of medicine,” she says. This should ideally be a positive conversion, not a rite of passage.
To their credit, schools today do have less lecture time, more elective time and varied teaching strategies compared to the medical schools of the 1950s. Allowing students to maintain lives outside of school contributes to training well-rounded, humanistic physicians.
In addition to minimizing the burden of medical school, educators can design courses to provide insight and training in the humanistic side of medicine. Even 50 years ago, however, the fast pace of scientific discoveries dictated the content of medical education. Bulger remembers being told on his first day of medical school, “The wonderful thing about medical school is that science progresses so fast that half of what we teach you will be disproved within three years of your graduation—the problem is that we don’t know which half!” The pressure to keep students up-to-date with current science and technology has increased exponentially since the 1950s. Often, little time, money or energy is left for developing the humanistic aspect of the curriculum.
How has medical education evolved in the last 50 years toward consciously training humanism into physicians? Dr. Jo Ivey Boufford, dean of the Robert Wagner Graduate School of Public Service, harbors doubts about students’ ability to sustain their idealism and basic humanity in the onslaught of science and medicine that schools deem necessary. “Students believe they have to unlearn the things that their grandmothers taught them in order to become a doctor,” she concludes.
Boufford thinks that today’s educators are at least struggling with the right issues—such as doctor–patient relationships and teaching outside the hospital. “These issues, however, were around in the 1970s,” Boufford notes. But they have “remained… demonstrations or models [that have not been] mainstreamed or sustained.”
What are the major stumbling blocks to improvements? According to Boufford, “People think American medical education is the best in the world, and they’re hesitant to change.”
However, some physicians think that medical educators are recognizing the trauma associated with medical school and are working to help students balance their educational commitment and their larger responsibility to themselves and their communities. The AAMC’s Medical School Objectives Project, for example, details how to train altruistic, knowledgeable, skillful and dutiful physicians. Among other topics, this project promotes the doctor–patient relationship, end-of-life care, spirituality and communication skills. Questions remain, however, over the exact competencies that make for humanistic physicians. Additionally, can these qualities be learned? Should they be admissions requirements? How can they be measured? Each answer results in many new inquiries.
“Every day I was in medical school, I knew I was black and female because people let me know. People thought they were helping, but there were lowered expectations for women and minorities. When I was on a clerkship, I finally was able to pass a urinary catheter in a male. They had avoided giving me this task for a while because I was the only female. My supervising physician praised me to high heaven when he found out that I had done it. In reality, almost anyone could accomplish this task—other students did it on a daily basis. I learned to set my own standards because I couldn’t trust the external environment to give me honest clues about how I was doing.”
—DR. BARBARA ROSS-LEE
TWO STEPS FORWARD, THREE STEPS BACK
Issues of equality in medical education for women and minority students are not new. When Dr. Walter Shervington, president of the National Medical Association (NMA), entered the University of Maryland in 1959, the medical school had just graduated its first African American. There were only one or two African-American students in each class, and the hospital wards were segregated. Shervington recalls that his father—only the second African American to serve on the faculty at Johns Hopkins University—wasn’t allowed to admit his own patients for 25 years.
It wasn’t until 1969 that the American Medical Association (AMA) even began requiring medical schools to report minority data. At the time, African-American students comprised 1.5 percent of all medical students, excluding the traditionally black medical schools, Meharry Medical College and Howard University. An article that same year in the New England Journal of Medicine stated that the door to medical education for minorities “is carefully labeled ‘Disadvantaged Students,’ but it is open.”
Women in medicine have faced similar discrimination. Boufford remembers the first day of medical school when her class of 250 students was greeted with, “Gentlemen, welcome to the University of Michigan.” Since she was one of 25 women in the class, Boufford found the introduction inappropriate. “It wasn’t nasty,” she adds. “There was just no consideration.”
Certainly, in the last 50 years, medical student bodies have included more women. Today, some schools are composed of more than 50 percent women. However, women still hold far fewer faculty and administrative positions than men do. Women are more likely than men to report that the careers they were encouraged to pursue were affected by their gender. While recognizing the need for continued improvements, Boufford feels that schools have taken positive steps toward gender equality. “Some students today find some of the sagas from the 1970s pretty bazaar,” she says, referring to the welcome address given at her medical school.
Minority students haven’t fared as well as women in the last 50 years. Currently, underrepresented minorities make up about 9 percent of U.S. medical students. However, about 20 percent of the general population are underrepresented minorities, and a disproportionate number of minority populations are medically underserved. By the year 2020, one-third of the U.S. population will be underrepresented minorities. Minority students still believe that they must be twice as competent to be treated equally. And many minorities and women continue to report a lack of mentors as a barrier to professional development.
The diversity issue can be broken down into a discussion of numbers and a look at programs in the curriculum that address diversity. As an African American who grew up during segregation, Shervington says that medical education has come a great distance in minority education. However, he expresses concern over recent anti-affirmative action laws and practices. “Affirmative action has to do with trying to give a step-up for people who haven’t had opportunities for more than 200 years,” he explains. “It is an attempt to enrich our system by having everyone participate in it.”
Since medical schools actually choose future physicians, Ross-Lee feels strongly that the schools need to take a stand on diversity. “Medical schools have to take leadership from an ethical, moral and practice perspective,” she says. “Affirmative action is a process to reach an outcome. Nobody is looking at the outcome, they’re just objecting to the process.”
Ross-Lee maintains that women and minorities are crucial for successful medical schools because the subtleties of diversity cannot be taught in the classroom. Without diverse student bodies, all students suffer from a lack of exposure to diversity, and many populations are likely to remain medically underserved.
Shervington says that diversity issues must be addressed by society as a whole. Recent collaborations among the NMA, AMA, AAMC and student organizations are encouraging, but changing societal attitudes is more difficult. “Society at large doesn’t care,” Shervington says. “How does one change the attitude of society at large?”
Numbers, although easy to measure, will not guarantee the acceptance of diversity. “Issues for students of color are still pretty profound, including a lack of focus on the richness of their own culture and the lack of faculty of color,” Boufford says. “I’m afraid that numbers aren’t going to force change. People are going to have to make an effort to believe that these students have a lot to offer, and they’re not just students who need remediation.”
Achieving 50 percent women and 15 percent to 20 percent underrepresented minorities in medical school student bodies and faculty is only half of the battle. In order to create a medical education system where everyone feels comfortable sharing their own cultures and beliefs, some educators and students believe that diversity should extend beyond gender and race to include sexual orientation, physical ability, age, socioeconomic status and geographic environment.
Although admissions practices and curricula have improved the diversity of medical schools in the last 50 years, Ross-Lee feels “it’s better than it was, but it’s still not acceptable.” Curricular efforts are still largely elective, token, unevaluated and unintegrated. The numbers of underrepresented minorities have reached a plateau at best and are slipping at worst. And still many more questions remain unanswered.
“I went to a small, Quaker, liberal arts college with lots of interactions. Students were expected to be self-motivated, and students and faculty questioned each other. At medical school, I was told to sit down, shut up, don’t ask questions and regurgitate what I was told. At the end of the first semester, I expected to give feedback to teachers because that’s what I had done in college. I circulated an evaluation form among my classmates. This was perceived as a radical act. It was suggested that this was not the way we do things.”
—DR. ROBERT GRAHAM
STAND AND DELIVER
Dr. Robert Graham, executive vice president of the American Academy of Family Physicians, remembers medical school in the mid-1960s as “rigid, boring and anti-intellectual.” However, he also recollects vividly being part of a generation of student activists. About his experience with circulating an evaluation form, Graham says, “This was both a start for me to try to change medical education, and it was also the beginning of students at my school becoming activists. This was starting all over the country.”
Dr. Fitzhugh Mullan, retired assistant U.S. surgeon general and currently a clinical professor of Pediatrics and Public Health at George Washington University, also became an activist in the mid-’60s while attending medical school. “The summer after my first year, I went to Mississippi as a medical civil rights worker. Seeing poverty, American racism, people who really did not have doctors and how positively they responded to someone who was interested in them and their medical care really made me want to be a doctor.”
Mullan says that schools today vary in how well they foster activism among their students. “Doctors and medical educators are not sociologists or saints. The frontiers of science receive much more attention than the frontiers of justice and equity,” he says.
Why should medical students and physicians be concerned with activism? Mullan maintains that their specialized education gives them a gift that should be shared with everyone. “They are the healers for the population as a whole,” he says. “There is some responsibility for them to develop skills to work with the entire population. The gap between the haves and the have-nots is probably larger than it has ever been.”
Participation in the National Health Service Corps (NHSC) is one way that Mullan lived his responsibility to the population as a whole. From direct participation and later directing the NHSC, Mullan concludes that joining the Corps is a way for physicians to put their shoulder to the wheel for a while.
Activism comes in many forms. Today’s medical students can get involved in shaping their school’s curricula for the future. Dr. Elizabeth Morrison, Director of Maternity Care Education at the University of California–Irvine, thinks that students can affect curricular change. At the local level, students can join student organizations such as the American Medical Student Association and curriculum committees at their schools. At the national level, students can become active in organizations such as the National Board of Medical Examiners. “Student representation is so important,” she explains. Committee members “don’t know what it is like to be a medical student the way current students do.” Morrison admits that students are not consulted as much as they should be, but maintains that students have the potential to make huge differences.
Ross-Lee also says that students are an underutilized resource in medical education reform. “Students don’t always appreciate this role, but their evaluations of the education process are important,” she states. Emphasizing again the need for students to enjoy medical school more, she adds, “We will be able to achieve true collaboration once students themselves start to look at the information as something they want.” These physicians recognize that medical student activism tends to wax and wane, but only students can ensure that there is more, not less, activism.
Changing medical education has been compared to relocating a cemetery. One person who actually accomplished the former feat was Abraham Flexner. Flexner was a layperson with a background in education who studied medical education around the turn of the last century, when it was desperately in need of reform and structure. Major changes initiated by the Medical Education in the United States and Canada, or the Flexner Report, in 1910 included: a four-year curriculum, two years of laboratory science, two years of clinical teaching in hospital and clinic settings, university affiliation, and the adoption of math and science entrance requirements. These changes are almost universally still in place today.
Interestingly, however, the Flexner Report also recommended the following: the integration of basic sciences and clinical training throughout the four years; the encouragement of active learning; the limited use of lectures and learning by memorization; learning by problem solving and critical thinking; and emphasizing that learning for physicians is a life-long endeavor.
When today’s physician–leaders are asked to list crucial turning points in medical education in the last 50 years, the Flexner Report is on several lists. “If I were Flexner and in favor of my model, I would be impressed with its durability,” Mullan says. “Today’s curriculum would not be totally unfamiliar to Flexner.”
Dr. Douglas Wood, president of the American Association of Colleges of Osteopathic Medicine, says, “I don’t think that medical education has changed substantively since the Flexner Report. The first three years have been modified, but we have seen very little change in the clinical years.” Why? Wood cites inertia as the culprit. “We’re doing OK,” he remarks. “We produce prestigious graduates, faculty are strained, even students sometimes object to change—they don’t like to be guinea pigs. There’s not a great reason to change.”
Wood identifies curriculum committees as having the potential to influence medical education, but not as they are currently comprised. “Individuals come with their own interests,” he says, referring to representatives from various departments who traditionally sit on curriculum committees. “Committees need to be made up of people who come because they are the best medical educators in the school and know something about medical education. Their mission should be to put student learning at the forefront.”
While Boufford sees incredible changes in the content of medical education, she does not think the process of medical education has changed much in the last 50 years either. “Changes are not mainstreamed,” Boufford says. “The issue of supporting teaching faculty and the role of faculty as teachers remains a problem for medical schools. Research used to be the priority. Now it’s clinical practice and research. The teacher is the odd person out.”
Likewise, Graham thinks that medical education did not reach its potential in the last 50 years. “There have been curricular chiropractic experiences,” he says. “But we’re just moving the pieces around.” Like Wood, he sees medical education as “comfortable” right now. “If you walk through an academic health science center, people are employed, faculty salaries are not decreasing, medical schools are not closing,” Graham adds. “There is no crisis yet.” Changes must come from the outside, according to Graham, and a drop in the application rate to medical schools may someday cause the crisis necessary to initiate this change.
The Next 50 Years -- What does the future hold for medical education? According to Dr. Jordan Cohen, president of the AAMC, “We need to move more toward establishing learning objectives, performance-based evaluations, and teaching and evaluating professional development.”
Boufford predicts an increased focus on aging, chronic diseases, mental health, cultural competency, communication skills and the doctor–patient relationship. Danoff realizes, “Health-care delivery is changing so fast that medical education will have to follow.” Among the issues she sees in the future are population health, medical technology, dealing with the uninsured, interdisciplinary team-based education, and the engagement of students in the political process to ensure that the environment exists for the healthiest nation possible.
Graham sees the Internet in the future of medical education. “Electronic information will be totally different from texts,” he predicts. “When this information is right, it will be of more value to students than the rigid text and will give students more information about patients who aren’t sick enough to be in the hospital.” Wood also anticipates an increase in technology used for instruction, including interactive computer-assisted teaching and virtual reality. “Particularly in surgery, virtual reality makes sense,” he explains. “You are literally allowed to practice and make mistakes.”
Bulger thinks that someday, medical students may be able to take their first two years of basic sciences via distance learning classes on the Internet, then transfer to a non-virtual medical school for the second two years. This format could increase access to medical school by controlling costs.
What do humanism, diversity, activism, Flexner and the physician–leaders’ predictions for the future of medical education all have in common? They all represent a combination of strengths and weaknesses in the current system of medical education. Medical educators, students and the public need to appreciate aspects of the status quo but must never tire of seizing opportunities to initiate improvements. As one who exemplifies that very strategy, Bulger concludes positively, “After 50 years of thinking about medical education, I wouldn’t change professions. If I were 25 years old today, I would be more interested than ever in entering the health professions.”
Nancy Hood is a former regional trustee of the American Medical Student Association.