The Heroic Odyssey of Graduate Medical Education

摘要

It's 1895 and you are a house officer at the storied Johns Hopkins Hospital. You share cramped and dilapidated living quarters with 3 other interns. The food is awful and the paint is peeling. It is your third night on call this week, and you have not left the hospital in nearly a month. You remind yourself that, as rough as these conditions are, you feel blessed by the excellent teaching you are receiving from the staff physicians, and know that your counterparts at the hospital across town have it a lot worse. You grab a short nap after taking your seventh admission of the night on the charity ward, a 38-year-old woman with shortness of breath. Your careful percussion of her chest wall shows enlargement of her heart border, and the auscultative skills you learned from the resident, a year ahead of you in his training, reveals a subtle diastolic murmur. You and your cohort of single, white male interns are looking forward to rounding later this morning with Dr William Osler. Fast forward to 2014. You are well rested after your obligatory 10?hours off, but are worried about your sick 8-year-old, who is home from school today with your spouse. Payments on your student loans, which amount to just shy of $200,000, started 6?months ago. You take sign-out on 24 patients from the night float resident, 10 of whom you will need to discharge later today but none of whom you are familiar with. Your clinical decisions, and the fate of your new patients, rely on the input from countless consultants who are nowhere in sight. Nor are their consult notes, which will not be completed and accessible in the electronic health record until early this afternoon. You have little faith in your attending helping you complete your workload. She is notoriously late to rounds and is usually grumpy about the latest mandate from hospital administration to shorten her patients' lengths of stay in the hospital. The dichotomous picture of resident life described above is a slightly exaggerated version of that portrayed by Kenneth Ludmerer in his latest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. He has masterfully assembled a compendium of personal narratives, reflections, and scholarly works from hundreds of original sources that provide a living history of graduate medical education (GME) over the past 140?years—an odyssey replete with struggle, controversy, and change, both evolutionary and cataclysmic. He offers his keen reflections on the current and future state of GME, with strategies on how to preserve and regain excellence in medical training. At its inception, residency training fulfilled a variety of needs, depending on the hospital and the trainee. It often existed in an apprenticeship model, providing a bridge to clinical practice for individual trainees and a cheap labor force for hospitals. In the late 19th century, Johns Hopkins Hospital, under the influence of Sir William Osler and others, created the modern model of residency with which we are familiar today. Rather than primarily offering supplemental training necessary for the independent practice of medicine, house officers at Johns Hopkins, Peter Bent Brigham Hospital, Massachusetts General Hospital, and other facilities comprised a hand-selected group of the best graduates from an elite group of medical schools. Newly graduated physicians at top schools were often recruited to train at their own affiliated hospitals, as the quality of their medical education was viewed as superior to the education of other candidates from lesser schools. Institutions offered mentorship, guidance, and one-on-one training from nationally recognized experts in modern medicine. The overarching goal was to provide an environment in which residents could engage in scholarship, reflection, and in-depth learning. It was in essence a training camp for future leaders in health care, and not solely for the acquisition of specific skills and knowledge. A true community of healer