As a trainee on the brink of the fellow-to-faculty transition, perhaps I am particularly reflective about the issues raised by Kenneth Ludmerer's newest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. This exhaustive history of graduate medical education inspired me to feel nostalgic—partly for a past I never experienced, but mostly for the transformative 8-year educational period of my own career that is quickly drawing to a close. Reading the book also helped me place my training in perspective. It left me feeling reassured that my experience as a resident and fellow has truly prepared me for my profession, and cautiously optimistic that our ever-changing system of graduate medical education will continue to produce outstanding physicians. From the first chapter Ludmerer articulates themes that echo throughout the history of physicians' education after medical school, and still resonate today. More than a century ago, he teaches us, there was an increasing trend toward physician specialization, due in part to the rapidity of advances in medical science. Although residency training at the time was a privilege rather than a professional requirement, house officers served as both providers of patient care and performers of menial tasks. With each successive decade, patient complexity increased and hospital length of stay grew shorter. Combine these changes with the mounting external requirements for documentation, and residents' workloads became ever more clerical and less clinical. Readers will realize, however, that the conflict between education and service is not a product of the 80-hour workweek; rather, it is inherent in graduate medical education. Similarly, achieving the proper balance of autonomy and supervision, finding time for clinical investigation, and learning to deal with sleep deprivation have always challenged house staff and their mentors. Although conditions and circumstances have changed over time, Ludmerer illustrates that resident education is not different from other aspects of society—history repeats itself. That history contains lessons as well. Meticulously researched, Let Me Heal is sprinkled with anecdotes that serve as fables, each with a moral for today's generation. For example, Ludmerer tells the story of a Johns Hopkins surgical resident who told the revered Dr Halsted that his patient was doing well, when in fact he had not examined him. Actually, the patient was not doing well, and Halsted summarily dismissed the resident “not for failing to visit the patient, but for saying he had.” Other than the fact that it involves Halsted, there is nothing terribly remarkable about that event. Honesty, including admitting one's own mistakes, remains a central tenet of medical training. Through similar tales, Ludmerer uses the founding fathers of graduate medical education (Osler, Cushing, Christian, Stead, Moore) to remind current trainees and their teachers that the fundamental principles endure: call for help, know why you do something, be intellectually curious, know when not to operate. Although the role of the house officer has evolved, the moral groundwork of medicine remains constant. Ludmerer shows us that certain issues and challenges in graduate medical education are not unique to our time, yet he certainly does not claim that the current system is not broken, nor does he advocate that we embrace the status quo. Indeed, even in the sections of Let Me Heal that seem to stagnate in repetitive detail, readers feel the constant undertow of residents' diminishing roles in caring for their patients. With each major shift in the health care system—the elimination of wards, the introduction of Medicare, the societal focus on patient safety, the enforcement of resident duty hours—house officer autonomy has suffered, and the residents' clinical role has diminished. The cumulative effect of these systemic changes has been a gradual erosion of the importance of trainees in
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