Dr Martin is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.
There has been a lot of talk about reforming medical education. Reading through the American Medical Association’s “Accelerating Change in Medical Education” proposals to reform both medical school and graduate medical education, “innovation” certainly remains the buzzword of the day.1 Ironically, this seems to reflect more of an old-fashioned “keeping up with the times” mentality, with a general premise of breaking away from perceived dogma. As to specifically what these “times” are that seem to be passing the rest of us by, and what has become problematically dogmatic in training, I admit I have been unable to locate in any of the proposals other than the broader, “timely” rubric of change for change’s sake.
Granted, the “times” have spun violently out of control over the past 20 years: witness the digitization and corporatization of medicine. The training process itself, for physicians, has remained relatively unchanged. And it is almost certainly the growing disconnect between the end of medical school and the start of residency that is driving the movement to reform training now. The old “medical” world is now the “health care” world, with many different hands in the pot. And whereas physician training remains conservatively geared toward creating “good doctors,” administrative training is often diametrically opposed to this.
Proposals for changing physician training, especially as more corporate entities tinker under the health care hood, rather than suggest administrators broaden their own education more humanistically, focus on aligning physician training more with corporate goals. That is, replacing the time-worn critical-dialectical process with the informatic-algorithm. Less art, more “science”; less wisdom, more analytics.
Standardization or chaos?
In these algorithmic times, then, how is it that we can broaden and make medical education more fulfilling? Currently the clinical training—an experiential mix of bedside lecture, bedside quizzing, and bedside suffering—can be demoralizing, dehumanizing, and humiliating. It can also be inspiring and uplifting. It is a training highly dependent on trust and chance, on both teamwork and individual decision-making. “It could always be worse,” is the telling mantra, and mistakes are not tolerated. In other words, clinical training resists what makes the informatic-algorithm work best: standardization.
And this illustrates the critical difference between medical school and post-graduate training. The greater appeal of medical school today, and especially the pre-medical path, is almost certainly that it offers a rigidly disciplined structure against a tide of otherwise increasingly fragmented and unfocused learning options, especially through adolescence and young adulthood. This phase of training does lend itself well to standardization, at a time in training when it is absolutely necessary.
Residency, on the other hand, is all about the art of mastering chaos. Only worse. Doing so while suddenly crushed with soul-numbing debt, while suddenly scaling impossible learning curves and juggling major teaching responsibilities. It is about mastering the pretense of knowing everything while rapidly absorbing new technological and administrative requirements. All the while studying for licensure exams, applying for fellowships, starting families. All the while negotiating the gauntlet of abuse and bullying from seniors, attendings, nurses, administrators, patients, families.
We used to half joke in residency that this generally “miserable way of being” had evolved as a means of helping one learn about suffering through suffering. Many of my previously jovial colleagues, however, soon found themselves subsisting on the increasingly standard pharmacologic stew of stimulants, “benzoes,” and antidepressants. Burnout reaches its nadir in residency.2 Learned helplessness, PTSD, and the victim mentality are ubiquitous, and one may justly wonder whether “education” is even really the right word.
1. American Medical Association. Accelerating Change in Medical Education. https://www.ama-assn.org/education/accelerating-change-medical-education. Accessed January 30, 2019.
2. Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA. 2018;320:1114-1130.
3. The Medical Activist Generation. Medtech Boston. August 13, 2014. https://medtechboston.medstro.com/blog/2014/08/13/the-activist-generation. Accessed January 30, 2019.
4. Palma M. Training for Activism, Action and the Future of Medicine. in-Training. May 26, 2016. http://in-training.org/training-activism-action-future-medicine-11054. Accessed January 30, 2019.
5. Phillips J, Frances A, Cerullo MA, et al. The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis. Philos Ethics Humanit Med. 2012 May 23;7:9.