E. Albert Reece, Dean/Medicine/UMSOM*
With the assistance of Julie Wu**
In December last year, The Chronicle of Higher Education published a commentary written by Richard B. Gunderman, M.D., Ph.D., Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, and Philanthropy at Indiana University, about the shortcomings of current medical education. In his article, Gunderman argues that, due to cost-cutting and a reliance on new technologies to teach students, medical school faculty members have been reduced to “content deliverers,” not teachers or role models, who only focus on the “competency” of students, rather than training excellent future physicians, through a “mass production” of graduates, and not highly-skilled trainees. He cites a recent Annals of Surgery study, which surveyed surgery fellowship program directors who felt that 56% of their fellows could not suture, 21% were unprepared for the operating room, and the majority of fellows could not design or conduct academic research projects. Gunderman points to this study as evidence for an “ailing” medical education system that no longer holds excellence and patient care in the highest of regards. He posits that re-establishing a diverse culture of superior quality in medical education, which holds human relationships at its core, can “cure” the system.
To his credit, Gunderman’s underlying message is one that we at the University of Maryland School of Medicine (UMSOM) can firmly stand behind: health care only advances when those who provide it do so in the relentless pursuit of excellence. Institutions that lose sight of this goal warrant scrutiny. It is true that we have room to improve. The Annals of Surgery article, news stories of medical misconduct, the greater need for super-specialists who can handle the growing intricacies of human disease, and the increasing pressure for everyone to “do more with less,” are critical challenges facing medical education today. Additionally, as biomedical research scientists continue to make great strides in uncovering the genetic and molecular bases for disease, so too must clinical practitioners keep pace with the latest discoveries, thereby providing patients with the most up-to-date—and ever-more personalized—care. Physicians must have a firm grasp on how research is conducted, regardless of whether they step into a laboratory or lead a clinical trial. Gunderman is correct in believing that medical schools that fail to maintain standards will cheat their students from obtaining critical training and experience. However, his sweeping critique of the current medical education system paints a skewed picture of reality.
In the United States, we have a uniform accreditation structure, set forth by the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME). The review that each U.S. medical school program is subjected to is rigorous and objective and receipt of accreditation not guaranteed. Standards are very high for each school, and that expectation of excellence passes from the institutional leaders, to the faculty members, to the students. If it were accurate that over half of young surgeons could not suture or that a quarter of them were unprepared for the operating room after they received their training, then we would see an onslaught of schools losing their accreditation status each year—this is not happening.
Additionally, if it were true that future physicians were being taught in a turnstile fashion, kept out of touch with patients and merely becoming “competent” in health care, as Gunderman contests, then we would not see new innovations from new medical students. Just one look at the list of Forbes’ “30 under 30,” celebrating the top advances of young medical students, fellows, scientists and entrepreneurs in health care under 30 years old, and it is clear that medical schools are not simply churning out “clones” who cannot think critically for themselves. Indeed, the UMSOM’s new Foundations of Research and Critical Thinking course, required for all medical students at UMSOM, will encourage a culture of analytic thinkers with the potential to make great contributions to biomedical research science as well as discovery-based medical care.
The results of the survey published in The Annals of Surgery that Gunderman cites reveal worrying statistics—could it truly be possible that young surgeons cannot perform operations for more than 30 minutes without close supervision (according to the article, this was true for 66% of fellows)? On the surface, the data are alarming, but digging deeper, one realizes that the results reflect the opinions of only a proportion of surgery fellowship directors, and is a measure how prepared these directors believe the new residents are coming into a specialized surgery program. Although the skills that a student obtains during the general surgery fellowship is critical to how quickly a trainee can learn during his or her specialized training, the purpose of specialized education is, at its most basic level, to receive the education needed to become an expert.
Evaluating a trainee’s skills prior to receiving his or her training is somewhat like evaluating how well an athlete will play at the professional level before actually playing at the professional level. Although collegiate sports may give a player some of the necessary skills to be successful, only after he or she competes at the professional level can an accurate assessment be made. By this same token, a surgery fellow who has received five to six years in general surgery training will acquire many of the skills necessary to perform advanced procedures, but the techniques required to successfully complete the type of surgery evaluated in the Annals of Surgery article—advanced laproscopy, bariatic, hepatopancreatobiliar, colorectal, and thoracic surgery—are of a unique nature. Gunderman would have us believe that the majority of surgeons cannot suture, full stop. That a fellow who can suture an incision in the chest may not be able to suture an incision in the pancreas, one of the most complex and delicate organs of the body, at the outset of his or her training, is not surprising. The novice cannot be measured on the scale of the virtuoso. Inevitably, he or she will fall short, and labeling the amateur as inadequate is biased and unfair.
Gunderman’s closing statements speak to a lack of physician-patient interaction. He argues that the use of new technologies, virtual classrooms and simulations in medical education are depriving students of the hands-on experience required to develop a bedside manner. I would contend that American medicine is not devoid of patient contact but is regarded as a world leader in health care because of excellent physician-patient relationships. In some other countries doctors are held in the highest esteem and patients expected to merely accept whatever the physician says. The U.S. system is the opposite. Doctors here are expect to have meaningful conversations with their patients and, in the light of the Affordable Care Act, may be penalized if they fail to provide the best possible care, which includes knowing, seeing, and interacting with patients. It is not enough to read a patient’s chart or review laboratory results to provide a diagnosis. Physicians must communicate with their patients. The Annals of Surgery survey Gunderman uses in his commentary to criticize American medical education also revealed that 79-92% of fellowship directors felt that their incoming trainees demonstrated effective communication skills and were respectful of patients and colleagues. This statistic does not indicate a lack of physician-patient interaction, as Gunderman would have us believe.
The commentary in The Chronicle of Higher Education motivates us to have a conversation about the future of medical education, and its author clearly has an agenda. Gunderman certainly gives us food for thought, and it is important to continually evaluate the quality of our programs to ensure that we truly are training the very best future healthcare professionals. Presenting data can effectively support an argument. However, it is important to keep in mind that data also can be construed in many ways to prove a point. Gunderman selects specific data to prove his point—medical education is failing, whereas I examine all the information and find that, although there is room for improvement, we are not falling down on the job.
*E. Albert Reece, M.D., Ph.D., M.B.A., is Vice President for Medical Affairs at the University of Maryland, the John Z. and Akiko K. Bowers Distinguished Professor, and Dean of the University of Maryland School of Medicine.
**Julie Wu, Ph.D., is the Senior Medical/Science Editor at UMSOM.