The Residency and the Hospital: The Consequences of Codependency

摘要

In the final decades of the 19th century, the American general hospital served as a social welfare institution for the poor as often as it served as a medical institution for the sick: It provided food, warmth, and cleanliness to the impoverished, along with splints and dressing changes to the injured.1 To the extent that hospitals did offer medical treatment, they catered to the “worthy poor,” composed of the urban working class, many of them recent immigrants, a group whose illness was attributed to misfortune rather than to immoral behavior.2 Anyone with even modest resources preferred to stay at home for medical care, and the vast majority of them did. After all, most of the available medical treatment could easily be provided at home, assuming the patient had a home, his own bed, enough to eat, and a caregiver. The stethoscope and the thermometer were the only medical instruments in widespread use, and although anesthesia had been introduced in the 1840s, routine surgery would have to await the development of aseptic technique in the 1880s. X-rays did not arrive on the scene until 1896, and only 6 therapeutic agents (such as medications, vaccines, and hormones) were commonly used in 1913, compared with 35 in 1943. Given that the hospital was not the site of most medical care, it was not the most obvious candidate to serve as the home for graduate medical education. Yet it was during this period that the hospital and advanced medical education became intimately and inextricably intertwined, with enduring and portentous implications, as Kenneth Ludmerer describes in his comprehensive and insightful book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. The hospital was not the only available option for graduate medical education at the end of the 19th century. Young physicians, as well as medical students, had long sought clinical experience through apprenticeships to practicing physicians. The hospital dispensary, which would evolve into the outpatient clinic, was another site for educating the graduates of America's medical schools. But it was the hospital that prevailed, in no small measure because of the inspiring example set by Johns Hopkins University in Baltimore, Maryland, as well as by the convenience of a ready supply of cases. The critical step was the adoption by the Johns Hopkins Hospital of the German model of the scientific clinician when it opened its doors in 1899. In Germany, the medical capital of the world, physicians were steeped in both bedside medicine and in biologic science, and they were expected to become clinical investigators, applying one to the other. Pioneers at Hopkins, such as William Osler (in medicine) and William Halsted (in surgery), were enamored of the German system, and chose to build residency programs in its image. Crucial to the choice of the hospital as the primary teaching site was also the large concentration of charity patients, patients felt to be deserving of medical care, provided they submitted to the indignities of serving as teaching material. Just as hospital physicians (the 19th century counterpart of today's attending physicians) saw their role as stewards of the lower classes—and benefited from the opportunity to advance their careers by the experience and connections afforded by a hospital practice—so, too, did the newly defined interns and residents.1 And so began the fateful linkage between the hospital and the residency, marked as Ludmerer delineates so well, by an ongoing tension between the service needs of hospitals and the educational needs of young physicians. The codependence of hospitals and residency programs has had profound consequences for American health care. For example, today, when much of the disease burden is in the form of chronic illness, residency education continues to focus on acute medical problems, largely because moving residency training out of the hospital and into the outpatient setting has proved challenging.