Mapping the Terrain of Graduate Medical Education: A Patient's Perspective

摘要

Kenneth Ludmerer's Let Me Heal: The Opportunity to Preserve Excellence in American Medicine is an absorbing book that transports the reader through the evolution of physician education over 2 centuries. The discourse on the topic is much needed. Writing in spare and elegant prose, Ludmerer traces the concept of American graduate medical education from its antecedents in the unpaid apprenticeships of the 18th century to the institutionalized, heavily taxpayer-supported residencies of today. For nonphysicians, the book shines a light on a mysterious world and answers questions many did not even know needed to be asked. Several leitmotifs define Ludmerer's perspective on his topic. Chief among these are the intrinsic contradictions that he identifies as keeping the medical residency in a state of constant tension. One of these is the inherent conflict between medical education and the economic exploitation of residents, a dynamic that Ludmerer calls the “fundamental fault line” of the residency system. A second is the tension between medical education and patient safety, potentially the central issue in the eyes of the public, but one that has been surprisingly muted over the years. These 2 themes are closely related. The recurring debate of recent decades has centered on resident duty hours, with the controversy framed as need for sleep versus the concept of continuity of care and learning. Yet, the primacy of the duty hours issue is in some ways curious. As Ludmerer points out, it has never really been the main concern in terms of patient care. The pivotal Libby Zion case in New York and the ensuing Bell Report that laid the basis for state and, much later, national duty hour restrictions were at least as concerned with the problem of resident supervision as the work hours that made them famous. Patient activists, too, have traditionally focused on resident supervision and the fear of “ghost surgery.” But fatigue has been the issue that resonated with the public, perhaps because it is both easier to understand and fundamentally less alarming. The result has been an emphasis on 1 aspect of the problem that may have worked to the detriment of more comprehensive approaches. Intertwined with this is the conflict between adequate resident supervision and the idea of allowing residents to develop the ability to act autonomously. In the urban charity wards where the modern residency system developed, resident physicians were given almost complete autonomy. As medicine has become more complex and faster paced, the near impossibility of doing this safely has emerged. Yet, the concomitant adjustments are not always being made. At the same time, the concept of supervision as what Ludmerer calls an “underutilized” educational tool—the idea that a learner needs a teacher—has eroded, leading to a confusion of independence with education. Implicit in his analysis is the idea of the corrosive effect of the profit motive on both learning and the concept of professionalism. Ludmerer harkens back to the mid-20th century, when legendary medical educators interacted closely with students and patients; when residents had the time to follow the clinical course of patients throughout a hospital stay; and when academics—and not just medical ones—disdained the idea of money as a yardstick of success. Yet, even in this golden age the ideals did not carry over into resident supervision: Ludmerer quotes Yale Professor Thomas Duffy as reflecting on his residency as “a form of training that plunged young physicians into waters far above their heads.” Ludmerer sees this as exacerbated in recent years by financial motivations that have led to work compression rather than work relief in response to resident duty hour restrictions. This increased workload in an already arduous occupation has far-reaching implications in its effect on both patient care and resident attitudes: reduced compassion, reduced intellectual curiosity, a task-oriented approach to work, lo