Local physician’s new book exposes challenges facing residency training

BY ROBERT A. COHN, Editor-in-Chief Emeritus

Dr. Kenneth M. Ludmerer, the Mabel Dorn Reeder Distinguished Professor of the History of Medicine at the Washington University School of Medicine, has published a new book, “Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.”

“Let Me Heal” has also been described by Abraham Verghese, professor of medicine at Stanford University, as “an eye-opening analysis of residency training and a wonderful exploration of its evolution.”  The book  focuses on the origins and development of graduate education of U.S. medical doctors, and the dangers of decline as the hospital industry becomes more and more commercialized, as well as on what needs to be done to reverse this trend.

Ludmerer lives in Ladue with his wife, Loren, and their daughters Jordan and Lindsey The family belongs to Temple Israel. The Jewish Light caught up with Ludmerer recently to talk about his book and his proposed prescriptions for dealing with the challenges facing medical residency in the United States.

 What prompted you to write and publish your new book? Is American medicine in danger of a decline?

New Mt. Sinai Cemetery advertisement

The idea of writing this book came to me while I served on a committee of the Institute of Medicine that studied the issue of resident work hours. While on the committee, I discovered that the topic of residency training was intellectually rich, politically topical and completely unexplored. I also felt that the recommendations the committee made in its report (published in 2009) were off the mark. Hence, I decided to write this book.

How did the concept of residency develop in the United States? 

The residency system has dual roots, in part in the German university system and in part in the American apprenticeship system. The founding faculty of Johns Hopkins Medical School, all of whom had done postgraduate study in Germany, combined these two elements into the modern residency system, which they introduced when the Johns Hopkins Hospital opened in 1889. The residency programs at Johns Hopkins represented a unique departure in medical education, but after a while it became the universal model – for the United States and abroad.

You indicate that much has changed in American medicine since the residency concept was started in the 19th century. Your book refers to “present-day struggles to cope with new, bureaucratic work-hour regulations” for residents. How have these new regulations adversely affected medical residency or medical practice in general?

Work regulations apply to interns and residents but not to physicians in practice. Hence, their impact is felt only in a “graduate” medical education. Virtually everyone in medical education today is glad to see house officers working fewer hours than in the past. However, the regulations have been imposed in a rigid, inflexible fashion that requires house officers to leave the hospital in the middle of performing an operation or while managing a complex case of diabetic ketoacidosis or talking with a family.

 How do these disruptions affect medical education and patient care?

These disruptions are not good for learning or for providing good medical care. Many of us in medical education believe that regulations should be liberalized to allow house officers to finish their work the day after being on call. We believe that education, medical care and morale would all be improved by doing so. This can easily be accomplished without compromising the important goal of a more humane residency system. My hope is that we will establish more flexibility in work hours in the next few years and that this book will contribute to the process.

You refer to the importance of efforts to preserve excellence in medical training amid a highly commercialized health care system. Are you optimistic that reforms could be put in place to ensure that such excellence is indeed preserved?

Doctors learn their specialty in the real world of patient care. Hence, the fate of medical education ultimately depends on the fate of the health care delivery system. To the degree that doctors-in-training work in a patient-oriented system where individuals are valued as people, the time necessary to provide humane caring and proper attention to detail is present, and excessive testing and treatment is discouraged, medical education will benefit. To the degree that doctors-in-training work in a highly commercialized environment that maximizes financial profitability and the “throughput” of patients, medical education will inevitably suffer.

In the years since you completed your residency, has medicine in general and residency in particular declined or improved?

Since I became a physician, doctors’ ability to manage patients has improved enormously. It is inspiring to consider how much more we can do. This, of course, benefits everyone. But at the same time, the health care delivery system and medical profession has been commercialized and commoditized to a degree none of us at that time could have imagined. Many physicians and health system leaders worry that caring has become a lost art in American medicine.

Residency training today is a much more humane experience for those going through it. The hours of work are more reasonable, and the caring of the faculty for residents’ well-being is much greater. Greater diversity among trainees (more women, Asian-Americans and African-Americans) has been another positive. On the other hand, the commercialization of the environment in which residents learn and the lack of time to care for patients properly have had negative effects on the residency experience. The net effect is that it often resembles vocational training more than professional education today.

Has the pressure of the constant paperwork required in today’s practice of medicine taken the romance out of practicing medicine? Are you seeing more burn-out among younger physicians?

Unnecessary paperwork is a major problem in American medicine today. However, so is the loss of time to communicate with and understand patients, particularly elderly individuals, patients with multiple or unusually complex problems, and individuals with significant psychosocial issues. The heavy debt facing medical graduates today, medical legal concerns  and the loss of autonomy in practice are other large concerns. Studies have shown that burnout is a widespread phenomenon among doctors in America, affecting both younger and older physicians. The incidence of burnout is particularly high in primary-care fields such as general internal medicine, general pediatrics and family practice, where the above problems tend to be the most intense.

Is there a role that patients of overworked physicians can play in reducing the stresses of medical practice?

The opportunity for patients is to participate in the political process concerning the character and direction of our health care system. Many candidates for office and legislative proposals will foster a more humane, caring health care system; others will promote the further commercialization of health care. Ultimately, the public must – and inevitably will –  decide what type of health care system it wants and what values and attributes it would like the health care system to embody.

How well have U.S. medical schools responded to the challenges facing contemporary medical practice?

Medical schools have proved phenomenally adaptable to the environment in which they operate. They have responded well to the incentives of our current system and have learned to maximize their market share, income and financial profitability. In doing so, however, they have not adequately defended the traditional values of medicine, such as thoroughness, caring and placing the interests of patients first. At many schools, the emphasis on making the “clinical enterprise” ever larger and ever more profitable is interfering with their educational and research efforts. Fortunately, we have many highly principled, insightful, dedicated leaders in academic medicine today, and “Let Me Heal” presents many ideas for medical schools that wish to provide genuine leadership in making the system better.