I thought I was an oddball in college. I’ve only recently learned that I was avant-garde.
Right before beginning college in 1975, I decided I wanted to be a doctor. Being the first-born son – with decent SATs – of an upwardly mobile Long Island Jewish family, I had relatively little choice in the matter. Notwithstanding this predestiny, I felt confident that medicine was a good fit for my interests and skills.
But on my med school interviews four years later, I stumbled when the time came to answer the ubiquitous, “Why do you want to be a doctor?” question. The correct (but hackneyed) response, of course, is “I like science and I want to help people.” You’ll be comforted to know that I had no problem with the helping people part. It was the science thing that threw me for a loop.
It wasn’t that I didn’t like science, mind you. I found biology interesting, and organic chem was kind of cool, in the same way that Scrabble is. But I barely tolerated Chem 101, and disliked physics.
In contrast, I was gaga over my political science and history courses. Watching the Watergate hearings in high school turned me into a politics junkie, and I found that my real talents were in thinking about systems, history, and how to understand and influence the behavior of people and their institutions. My social science professors were dynamic, the reading was fascinating, and I had a flair for the material.
Yet I remained certain that I wanted to be a doctor.
As a senior in high school, I found a “How to Get Into Medical School” book that simultaneously frightened and reassured me. The frightening part was the admission percentages and the required GPAs. I was a good, but not great, high school student and the numbers were wildly intimidating, particularly since, to me, college was a scary and foreign place. (I was the oldest kid in my family and my parents had completed a total of one semester of college.) However, I was reassured when I read something like, “Medical schools no longer automatically reject non-science majors.” A chart displayed acceptance percentages by major, and I recall that music and English majors were as likely to get in as biochem majors, perhaps slightly more so.
So the day before I left for Penn, I puffed out my chest and told my parents that I was going to be a doctor… and a political science major. And that was that.
I was lucky enough to get into medical school (also at Penn). When I began, my goal was to become a practicing physician, perhaps also a teacher. My interest in politics and policy would remain an avocation, like golf or gardening. But, as so often happens, the Gods of Serendipity thought otherwise. When I was a 3rd year student, I met John Eisenberg, who was then a young professor of medicine at Penn. John was astonishing: movie star-handsome, charming and funny, and scary smart. He was a terrific clinician and teacher. He had an MBA, which was exotic, and his research focused on the healthcare system. It was through meeting John – who would later become the founding director of the Agency for Healthcare Research and Quality (where he was promptly dubbed “John of AHRQ”) but tragically die of a brain tumor at age 55 – that I realized that I could combine my social science interests with a career in medicine. And that’s what I did.
There are several things that bring this to mind right now. I’m writing from Vancouver, the site of the annual ABIM Foundation Summer Forum, which brings together a remarkable number of healthcare’s movers and shakers. This year’s theme is the future of medical education, and much of the discussion has centered on how to build a workforce of physicians (and others) who understand quality, safety, financing, leadership – all topics I began to think about in college. More than one attendee has remarked that – in addition to transforming our medical schools and residencies – we should rethink our medical school prerequisites.
The second item that brings this to mind is the recent publication by three UCSF faculty (David Irby, Molly Cooke, and Bridget O’Brien) of a book entitledEducating Physicians, commissioned by the Carnegie Foundation on the occasion of the 100th anniversary of the Flexner Report. I’ll say more about this powerful document, which addresses how we should be training physicians in 2010, in a subsequent post, but one of its top recommendations is that we rethink pre-medical requirements.
A third reason is last week’s New York Times front page story describing Mt. Sinai’s Humanities and Medicine (HuMed) program, which accepts 35 students every year with liberal arts degrees – students who, unlike me, have not completed standard scientific premed requirements, including taking the MCATs. A recent study in Academic Medicine compared the medical school performance of 85 HuMed graduates with 606 traditional Sinai students, and found that the HuMed students match the traditional pre-meds on virtually every measure (honors grades, research distinction). While there are methodologic caveats, this finding raises real questions about the importance of a scientific background in preparing for medical school.
Finally, last Friday I had a chance to meet with nearly a dozen UCSF medicine residents who are enrolled in our Leadership Pathway. All our residents are now encouraged to select a pathway (which you might think of like a college minor), in areas ranging from global health to clinical/translational research. Leadership pathway residents participate in a core curriculum in leadership, change management, and quality and safety, and complete a mentored project. This year, they analyzed a variety of physician payment strategies and presented their findings to leaders of the Pacific Business Group on Health. Prior groups have analyzed and improved our anticoagulation practices and our methods of communicating with primary care physicians when their patients are hospitalized.
My interest in political science, a chance meeting with John Eisenberg, and a whole lot of happenstance led to my career in policy, quality, and safety. In contrast, for the residents in our Leadership Pathway, interest in quality and systems change is anything but accidental. They are completely intentional in their desire to improve the healthcare system. They are devouring a real curriculum that gives them a skill set that I didn’t pick up until 20 years after graduation. Finally, they have stellar mentors (led by Drs. Arpana Vidyarthi and Read Pierce) who help them on the journey toward productive and satisfying careers.
Here’s my hope and prediction: In the future, all our medical students and residents will be schooled in the core principles of systems improvement and leadership, and many will receive advanced training. Moreover, within 5 years, undergraduate pre-medical science requirements will be relaxed and modified, and new social science requirements will help ensure that students have the foundational knowledge essential to systems change.
Don’t get me wrong – we don’t need all physicians to be poets and pundits, any more than we need them all to be molecular biologists. Medicine needs its world class scientists, and the system must continue to attract such folks to medical school. Nor do I favor eliminating all undergraduate science requirements. I agree with Emanuel (Zeke, not his brother Rahm), who wrote:
Genetics, molecular biology, and biochemistry are much more essential to medicine than organic chemistry and physics…. Rather than debate what to reduce or eliminate, it might be more valuable to focus on what should be required as part of medical education: communication, bioethics, statistics, health care financing, health law, and management sciences.
Somewhere in an American college today is a student who wants to be a doctor but is passionate about policy, or management, or cognitive psychology, or ethics. My hope is that this student is encouraged to blend these interests, and that neither she – nor the members of medical school admissions committees – find anything odd about this combination.
Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.