The History of the Problem
The American University was a phenocopy of the European University, but the liberal arts college was a unique American contribution, wherein teaching was considered a legitimate academic pursuit. Even the closest analogues in Europe (the colleges of Cambridge and Oxford) are not as purely an educational institution as the American liberal arts college.
The evolution of American medical education (adapted and updated from: Ludmerer KM. Time to Heal, Oxford University Press, Oxford, 1999) may be divided into five eras.
I. The pre-Flexnerian era (1776- 1910) was entirely proprietary in nature. Virtually anyone with the resources could start a medical school. There was no academic affiliations of medical school and no national standards.
II. The inter-war period (1910-1945) was characterized by an uneasy alliance between hospitals and universities. Four major models emerged. In the Johns Hopkins model, led by William Osler, the medical school and the hospital were married and teaching of medicine took place at the bedside. The Harvard model in which the hospitals grew up independently with only a loose alliance with the medical school, represented a hybrid between pre- and post-Flexnerian medical education.
The Massachusetts General Hospital grew from a pre-Flexnerian prototype, while the Brigham was founded in 1913 just after the 1910 Flexner report and more closely approximated the Hopkins model, to a large extent because of Cushing’s experience under the influence of Osler at Hopkins. The State University Model consisted of a group of hospitals (city, county, VA, university) that were allied with a medical school under the leadership of a powerful dean. The Special Interest Medical School model arose when a specific group (African Americans, women, Jews) created their own schools out of the perception and often reality of prejudice.
III. The post-WWII period (1945-1985) was marked by the dramatic rise in the influence of the National Institutes of Health (NIH), which made research profitable, combined with the advent of Medicare (1965), which made clinical work and residency training profitable for academic medical centers. These events had two effects. One was the rise of the “submarine”, meaning the biomedical scientist-physician, who spent greater than 80% of the time engaged in research and then “surfaced” to behave like a doctor, one day a week or one month a year. The second effect was the orphanage of medical student education. This occurred because research was profitable as a result of the growth of the NIH extramural program and clinical work and residency training was profitable because of Medicare. Nothing was earmarked for medical students.
IV. The paradoxical era of cost containment and scientific mania followed (1985-2000). The concept of “translational research” is born. Physicians-scientists proclaimed that the current era was the most unique in the history of humanity and that we are on the threshold of solving the major mysteries of disease. Cancer, heart disease and neurodegeneration are thought to be soluble with the tools of molecular biology. Despite this hubris, society is not convinced that the era of the growth of the NIH has yielded enough “cures” to justify the cost, so the era of cost containment frustrates the physician-scientists who believe that this “false economy” will risk our losing the opportunity to solve the major human diseases, but their protestations smack of self-interest.
V. A replay of the era of proprietary medicine is upon us (2000- ?), almost exactly a century after the Flexner report brought an end to the last such era in 1910.
Business models now dominate the hospitals. Some of these hospital leaders are trained as doctors, but they have been transformed into something very different. Recall the William Cameron Menzes film, Invaders from Mars (a precursor of The Bodysnatchers), where beings from outer space come to earth but have no bodies in which to live, so they kidnap people, and replace their brains with computers that are controlled via a small antenna that one can find by inspecting carefully at the nape of the neck. Gradually, more and more people are turned into these evil automatons. One can never tell whether the person next to you is “one of them” without looking carefully for the telltale electrode in the back of the neck. There are many signs that the “invaders from mars” actually have taken control of organized medicine. The following is a compilation of words I have heard in real hospital meetings over the past few years.
I’m afraid that if we don’t drill down on our brand equity on the front end, we’ll have to model it out on the back end to align our seemless incentives or pad our ask regarding the co-branding deliverables on the horizon. As an FYI, this empowerment is going to require an elbow to elbow champion getting under the covers for a 360 of the eRoom to facilitate a paradigm shift in order to achieve buy-in among the stakeholders if we’re going to tip our toe into that water and get the low hanging fruit before our clients incentivize the burning platform with new metrics. After all, you are the process owner who needs to reach out in the proper bandwidth to push back on the KOL’s or we’ll have to sunset your blue ribbon committee for not trimming the fat on the real-time escalation project. We need to do more due diligence before we hitch our wagon to that indexed outcome measure, and let’s be careful how we message it and roll it out to the core constituency. We can model that projected gap, but we don’t want to get out ahead of our audience before sensitizing them to the moving target. Let’s not drop the meat in the dirt but rather vet a pause point, collapse it up to a high level statement and assess the current state in order to connect the dots to achieve the ideal state and have you weigh in at the portal for service oriented architecture. After all, at the end of the day, we’ll have more skin in the game and be in a better space if you walk the stakeholders though it so that they can leverage their halo to birddog that from 10,000 feet. If you could create a placeholder to move the needle in the continuous quality improvement initiative, some heavy lifting might give us a report card so that there can be the accountability for a decent ROI, unless the co-branding produces a choke point so severe that the balanced score card causes a culture change, one by each. Just between you and I, you need to parking lot that issue, take the deep dive and put the rubber to the road with a degree of commonality that will re-engineer a sea change in our SWOT analysis so that we bake it into the budget of the high level implementation group. We have to move the ball down the field and prevent leakage. Net-net there is value added for a win-win, rather than a zero-sum game. You can manage the matrixed organization on the frontline and in the back office. With central discipline and local control we can achieve savings and margin, while penetrating that segment of the market. A lot of what we have to do to reduce our trend is blocking and tackling in different spaces. Bottom line on top, if I don’t report to myself, we could really take a haircut before we can trim the fat out of the box and shift the culture beyond this pilot demonstration program. That having been said, the PEST analysis shows that if you step up to the plate and evangelize the brand, we can be about the business of creating a placeholder of new buckets with more vertical silos so that we can finally tell whether we are on foot or on horseback. Comparing apples to apples, it is clear that this is not a plug and play culture, so that you’ll have to hold your nose and jump in order to filter the noise and incentivize the process owners in a more granular fashion before it becomes a major mission drag. A bread crumb has been forming so let’s put some stakes in the ground to leverage our insights as enablers of change to circle back on a more granular view, and tee up our clinical levers to mine insights from the benchmarks and beat the waste out of this process. We will cleanse our application platform and get ready for the first wave of ambulatory e-care care go-live across the family and take advantage of the elbow-to-elbow support of the super-users and be back to 100 percent productivity by the second week. Having said that, we traffic-lighted that report so you can optimize the outcome metrics. If we can get the whole group on board in this arena we can try to boil the ocean with a six sigma culture change. We mean to hit this one out of the park and get some substantive returns in the coin of our realm to avoid any mission creep. It’s a non-starter to analyze the dashboard for crosswalking noise, so we need to slice and dice our organic growth, peel the onion and hardwire the initiative with more boots on the ground. If this could be the pause point for a new value initiative, that’s where the metal meets the road. Let’s reach out, using our optimized tool kit to go anything north of zero and put a hard stop on this turn-key operation. If you would like to get some trend lines and traction from this piece, I can ping you a copy of my deck.
If you hear any of these terms come from the mouth of someone who looks like a doctor, carefully check at the nape of the neck for the telltale antenna.
The Institute of Medicine’s 1999 report entitled “To Err is Human” heralded the beginning of this new era, in which we are still ensconced. The report declared that 98,000 Americans die annually from inpatient medical errors and that these errors were the leading cause of death in the US, exceeding motor vehicle accidents, breast cancer and AIDS. The report, meant as a self-critical professional analysis, became public and took on a life of its own, spawning an enormous “movement”, only a few examples of which are the Institute for Healthcare Improvement (IHI), the Leapfrog Group, hospital and doctor “report cards” (Consumer Reports, US News & World Report’s lists, Consumer’s Checkbook, Healthgrades, Inc.). Buying into the self-hatred of the culture of error and blame, creating elaborate guidelines and systems to prevent error, believing it to be the major enemy, only avoids the uncomfortable fact that it is disease that is the enemy against which the forces of medicine should be aligned and that mortality is a fact of the human condition. The death rate remains one per person; unchanged from ancient times. We should, of course, try to prevent error, but we should realize that the patient safety movement is a self-fueling industry, in which the solutions to the patient safety problem are sold by the very people who declared that the problem exists; a classic conflict of interests that undermines the social contract between doctors and society and de-professionalizes medicine; hardly different from the proprietary snake oil salesmen who, almost exactly a century earlier, called themselves doctors in pre-Flexnerian America.
A new era of physician-scientists from the heyday of the NIH era lead the medical school departments by propagating the myth of the triple (quadruple if one includes the capacity to run the business that is now an academic department) threat. This is a cruel hoax, which makes young doctors believe that they are not living up to the monumental accomplishments of their predecessors unless they “do everything well.” If you were a fly on the wall of our promotions and search committees you would be shocked to learn that we are surrounded by veritable Supermen, combining the skills of the great scientist with the brilliance and empathy of the wizened clinician, while running the marathon, raising a family and playing the clarinet.
Clinicians succeed by servicing the rich (witness the birth of concierge practices). The wealthy, but medically unsophisticated, clientele are encouraged to believe that error is avoidable, that their intellectual contributions to the boards of trustees of hospitals are actually substantive, that life can be extended virtually forever and that the cures for major illnesses (cancer, heart disease, neurodegeneration and even ageing itself) are close at hand requiring only more money. The myth of our specialness (“never in the history of humanity has there been a more exciting era of science with its potential to eliminate disease”) is used to cynically harness personal fear of disease and death to extract resources from philanthropists and government, yet there is no reason to believe that this is true. When in history have we not been at the advancing edge of the accumulated knowledge of all that went before us. When Hooke first gazed down his compound microscope, was he not also at the cutting edge? Did he not also believe that the new world that he visualized would hold the solutions to all of medicine? The following quotation has been attributed to William James, the psychologist and philosopher: “There is no doubt that great revolutions of human scientific thought will occur in the next century and in the century after that and in a thousand of centuries afterward; so which of our current pet scientific dogmas will be among the first trashed away by new facts and sudden clarities?
This proclamation about the perceived uniqueness of ourselves and our time is the subject of Princeton philosophy professor Harry G. Frankfurt’s little book entitled “Bullshit.” Its opening words are: “One of the most salient features of our culture is that there is so much bullshit.” Frankfurt argues that it is likely, though not certain, that there is more bullshit today than ever before, if only because there is more communication of all kinds than ever before. Thus, even if the proportion of bullshit is about the same as ever, the total amount is enormously greater. Email is certainly a good example of this phenomenon. “Bullshit is unavoidable,” Frankfurt argues, “whenever circumstances require someone to talk without knowing what he is talking about.” Thus, if one believes that the leaders of academic medicine are actually quadruple threat Supermen, one is constantly putting them into positions wherein they must opine about “matters of which they are to some degree ignorant.” Watching the submarine wax eloquent about a clinically complex patient comes to mind as an example familiar to all of us. Gourmet clinical medicine and teaching are further orphaned and the word education comes to mean re-education (indoctrination).
The Natural History of the Great Physician in the Academy
Academic life is not the smooth trajectory that is appears in retrospect. Joseph Babinski (1857-1932) was denied associate professorship by the Board of Medical Examiners of Paris in 1892 (age 35) by one of his former students, Charles Bouchard, who was president of the board and in competition with Babinski for leadership of the faculty. This made it impossible for Babinski to ever obtain the chair in neurology. He made four unsuccessful attempts to become responsible for a medical department before taking a position at La Pitié, a peripheral hospital that moved next door to the Salpetriere in 1911, where he stayed for his entire career, retiring at age 65 in 1922. His department had no administrative links to the university, so he was limited to rare medical students on electives and a few residents. “The sign” was described in 1896 in a 26 line single authored paper entitled: “About the cutaneous plantar reflex in some organic diseases of the central nervous system.” It is unarguable now that Babinski is the most recognizable name in all of neurology. He was also interested in treatment when everyone else in neurology was obsessed with phenomenology (“diagnose and adiose”). Furthermore, he was actually a nice guy; good to his students and friends, philanthropic, cultured (a serious opera buff), modest, kind, productive, insightful, loyal to his teachers, to Poland, where his father was born, and to France, for which he served twice in the military, including in WWI at the age of 60.
Babinski’s experience highlights one of the major challenges in academic medicine: dealing with assholes. It sometimes appears that narcissistic, mean spirited, self-righteous, overconfident assholes have the right formula for success in the academe. If you believe this is true, you must read a little book entitled The No Asshole Rule written by Stanford Business School professor, Robert I. Sutton, published in 2007 by Warner Business Books. In it Sutton outlines the reasons that management should allow only a few assholes in a business and why behaving like a creep actually does not pay.
The Efforts to Reform the Promotions System in Academic Medicine
The concept of tenure, created to protect academic freedom, has undergone a fundamental change because of its inordinate costs. The fall of tenure is a salient feature of the new academic era. Medical schools’ struggle with their role in the larger university is epitomized by efforts to describe the academic roles of physicians. Harvard Medical School is one such leading institution, whose history reflects the ambivalence that marks the role of the medical faculty in the context of the university. The Harvard promotion tracks resulted in a struggle with the rest of the university. One track was replaced by two (clinician, investigator), which were replaced by four criteria (laboratory investigator, clinical investigator, teacher-clinician, clinician-scholar), which were replaced by two criteria (teacher-clinician, investigator). A caste system of prefixes attempts to maintain the hierarchy of the ancient university order in many universities (e.g. Professor of Clinical Medicine and Clinical Professor of Medicine). At Harvard, then President Bok was only willing to accept Dean Daniel Tosteson’s proposal to have a clinician-scholar track if the prefix “Clinical” was placed in front of the title. Dean Tosteson engineered a compromise whereby that prefix would be removed at the level of full professor but remain in place for the lower levels. The newest iteration is system that requires a major in one of three areas (investigation, teaching and educational leadership, clinical expertise and innovation), with an optional minor in one or both of the others.
The bottom line is the same: At Harvard the titles mean the following;
Instructor: entry level
Assistant Professor: local reputation
Associate Professor: regional reputation
Professor: National & international reputation (international without national does not count)
In the words of Hillel: “All the rest is commentary”
Justice Louis Brandeis defined a learned profession as one with a specialized body of knowledge that it passes on to the next generation, which sets it own standards that it self-regulates and is altruistic (i.e. puts the needs of others over one’s own). In return for maintaining professional values, doctors are afforded a number of tangible benefits including financial reward, societal respect, access to the most sensitive and intimate information and broad freedom to carry out research, even involving other human beings. The Charter on Medical Professionalism, which was published simultaneously in the Annals of Internal Medicine and The Lancet in February, 2002, was developed by a task force of the Medical Professionalism Project, sponsored by the American Board of Internal Medicine Foundation, the American College of Physicians-American Society of Internal Medicine Foundation and the European Federation of Internal Medicine. The three basic principles of professionalism in medicine are: primacy of patient welfare, patient autonomy and social justice, supported by ten professional responsibilities: professional competence, honesty with patients, patient confidentiality, maintenance of appropriate relations with patients, improving quality of care, improving access to care, just distribution of finite resources, scientific knowledge, maintenance of trust by avoiding conflicts of interest, and professional responsibilities.
The transition to becoming a professional is gradual but begins at the start of medical school. Medical students are junior colleagues. Simulations are fine for learning technical skills (e.g. tying knots, learning CPR), but using simulations in place of real patients transmits the idea that the students cannot be trusted with patients. This infantilizes what is really a mature graduate student and deprofessionalizes medicine. Excessive dependency on artificial core competencies and guidelines changes medicine from a professional into a trade.
A Checklist For Surviving Clinical Medicine
Decide who you are and don’t kid yourself
Don’t bluff; the triple (quadruple) threat is an illusion
Know your subject; teaching is not a trick; you must have something real to transmit
Don’t replace substance with gimmicks (e.g. fancy powerpoint)
Simulated patients produce simulated doctors and de-professionalize students
Respect your teachers but don’t believe in the Days of the Giants; they have feet of clay
Don’t become “one of them.”
Develop a reputation beyond the local environment
Train people, but remember that some will not respect you (remember Bouchard)
Stand proudly for clinical excellence
Write briefly, simply and parsimoniously (remember Babinski)
Be a professional
Don’t be an asshole
Martin Samuels is a professor of neurology at Brigham and Women’s Hospital in Boston.