Less education for tomorrow’s doctors?

If Dr. Ezekiel Emanuel gets his wish, tomorrow’s physicians won’t deserve to be paid as well as physicians today because they won’t be as well trained.

Dr. Emanuel, a brother of Chicago Mayor Rahm Emanuel and a chief apologist for the Affordable Care Act, is the lead author of a startling opinion column in the March 21 Journal of the American Medical Association.  He argues that there is “substantial waste” in the current medical education system, and—in a time when medicine gets more complex every day—advocates cutting the training period for young physicians by no less than 30 percent.

Dr. Emanuel’s plan would reduce both the time spent in medical school and in residency training, which (as every physician knows from experience) is the period of three to seven years that a new graduate physician spends learning to practice a specialty.

Many people don’t realize that residents already receive less training than they used to, because stringent limits have been set on the amount they are permitted to work.  Since the duty hour rules were rewritten in 2003, residents are limited to 80 hours a week in the hospital, which includes overnights on call when they may be asleep (what the rules refer to as “strategic napping”).  First-year residents, or interns, as of 2011 aren’t allowed to work more than 16 hours at a stretch.

Many senior physicians are concerned that today’s residents aren’t seeing enough patients. Evidence suggests that board examination scores are on the decline in fields from neurosurgery to pediatrics, as reported in the Accreditation Council for Graduate Medical Education (ACGME) Bulletin in 2009.  The American Board of Internal Medicine reports that the passing rate for first-time exam takers slipped from 94 percent in 2007 to 87 percent in 2010.  Unfortunately there’s no evidence that residents are using their increased off-duty hours to pursue either knowledge or sleep.  There’s no proof that patient care has improved, or that medical errors are fewer.

Now Dr. Emanuel thinks that even this amount of training is too much.

“For internal medicine, pediatrics, and similar 3-year residencies,” his article claims, “the third year is not essential to ensure competent physicians.”  And in surgery, “subspecialist surgeons could be trained to achieve clinical competence without spending several years performing general surgery”.

What’s the real agenda here?  If you believe that a young surgeon doesn’t need to learn to tie a perfect surgical knot on a simple wound before moving on to brain surgery, then no argument can convince you otherwise.  But what Dr. Emanuel really wants to do is cut down drastically on the amount of money that the federal government spends on Medicare support of teaching hospitals—about $6.4 billion in 2011.  The easiest way to do that is to reduce the length of medical training, whether or not that’s good for physicians and patients.

This threat to professional standards in medicine makes sense, in a perverse way—if we diminish the status of physicians by training them less, then we can justify slashing their payments from Medicare or government-run insurance exchanges.  And that’s exactly what Dr. Emanuel and his co-author would like to do.  In their words, less education would “enable physicians to recognize their limitations as well as their competencies”, and no doubt agree meekly to pay cuts.

If new physicians have less training, Dr. Emanuel argues, they will “become comfortable with group decision making, standardization of practices, task shifting to nonphysician providers”—in other words, they’ll lack confidence in their own judgment.  They’ll lack the scientific background to inform their decisions.  They’ll like the protection of the herd.  The new physicians will be content to practice medicine by cookbook, which is a sure path toward having the federal government write the recipes for everyone’s health care.

The arguments in favor of physician supervision of advanced practice nurses and physician assistants are founded on the fact that physicians undergo far more education and training.  If we allow our educational standards to fall, we will tacitly allow mid-level health care personnel to take over our work.  We will complete the transformation of physicians as a class from professionals to shift workers.

Every physician practices as part of a care team, whether we work in offices, clinics, intensive care units, or operating rooms.  The point is that every team needs leadership.  Excellent physicians help the whole team to excel and take pride in their work. This is the opposite of the Emanuel vision, which is best described as a planned descent into mediocrity.

The Emanuel article proposes further that a college degree shouldn’t be required for entrance to medical school.  Certainly you don’t need classes in English literature to practice medicine.  But it would be a great pity for students not to learn to think critically and write clearly before they begin their medical training.  Consider instead the enlightened view of Shirley Tilghman, the president of Princeton University, who told a class of incoming freshmen that the purpose of their education “is most decidedly not to prepare you for one profession, but for any profession, including ones that have not yet been invented.”

While the process of medical education warrants critical review, the Emanuel prescription for cutting it by 30 percent would be a disaster.   Instead, the prescription for the health of American medicine should be to support medical education at every level, and uphold the practice of medicine so that the brightest young students will always aspire to be physicians.




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