A Plea for Medical Education Reform

On the day before writing this, I attended a seminar on medical professionalism.  The room was filled with physicians at all stages of our careers.  I enjoy opportunities to think about aspects of my profession that are beyond the digestive organs that I dally with daily.   At the seminar, a video clip was shown from the 1991 movie The Doctor.  The scene depicted an attending physician berating an intern in the presence of the medical team after he casually referred to the next patient to be seen as being ‘terminal’ without identifying him by name.  If fact, it became clear that the young doctor did not even know the patient’s name.  While the attending physician was correct to recognize that patients are living breathing human beings, not diseases or hospital room numbers, it was a breach of professionalism to humiliate an intern in public.

After a few comments were offered by seminar attendees chastising the senior physician’s cruel approach to an intern, I raised my hand.  I shared that his behavior was very typical of my medical school experience in NYC decades ago.  On a regular basis, I and other students were humiliated.  It seemed that abusive behavior and publicly exposing the ignorance of team members who are lower on the medical hierarchy was an actual pedagogic technique.  I asked at the seminar  if others in the room had  similar experiences and nearly every hand was raised. Indeed, very recently I spoke with a 3^rd year medical student who is attending a different medical school in NYC, and the vignettes she shared were very reminiscent of my student days.

Here’s a typical medical hierarchy schema:

Attending Physician

Chief Resident

3^rd Year Resident

2^nd Year Resident

Intern

Medical Student

Medical Student’s Pets

Pet's Chew Toys

To paraphrase a common aphorism, the excrement flows downhill.

The hapless intern gets blamed for everything and is eligible for direct criticism from any of the layers above..   If the intern is up all night and performs a hundred tasks admirably, but has not yet had time to check on a lab result, guess what feedback he or she is likely to hear when the team assembles in the morning?   To those who are outside of the medical profession, imagine that you are an intern.  You are given tremendous responsibility, often without adequate supervision, with a very limited medical knowledge base while suffering from chronic sleep deprivation.   I’ll let readers ponder if adding public humiliation to the intern’s job description is likely to enhance job performance and professionalism.   (I’ll give you a hint.  It doesn’t.)  It is more likely to create jaded interns who will later assume an abusive posture as they ascend the medical hierarchy. 

A somnambulating intern cares for complex patients.

The intern has but one avenue of relief.  While he or she is low on the ladder, luckily the medical students hang on the lowest rung below.   So, if the intern feels a need to unload, guess who the target will be?

Of course, there were and are physician role models very different from those I have described above.  But, the darker culture I have presented still exists.   If you were designing a medical training system to cultivate and model humanity, empathy and compassion, would it resemble the one I described?