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Sunday, August 15, 2010

Our dysfunctional medical school families

I am an avid reader of my colleague's blog "DB medical rants". I have never met Dr. Centor but I can discern from his blog that we share many of the same sentiments. In late July he wrote a blog entitled "Caring about students- Why is this not the norm?" http://www.medrants.com/archives/5684

I am an academician and have observed this phenomenon for more than 20 years. I never gave this much thought until recently. I was a product of training at a state sponsored medical school and I made only a very financial investment in my own education. I viewed my training as primarily self directed within an environment that gave me appropriate back up and guidance. I learned my craft in a see one, do one, teach one environment.

The world is different now with some changes sorely needed while others best characterized as being providing no or negative enhancements. Initiatives driven by the professional educator class at the LCME have pushed to create learning environments where students are less viewed as sources of cheap labor and increasingly afforded a status consistent with the large sums of money they pay for their education. One would hope that this change would result in better training. I am not so sure this is actually the case. Medical students are not as empowered to assume real responsibilities any more. They are often reduced to the status of what my children used to refer to as "watching guys".

When I was in training most of the training I actually received was from the house staff immediately senior to me. There are now initiatives to change this and increase interactions of medical students with attending physicians. This sounds reasonable given the tuition many schools charge. Shouldn't students have more interactions with the highly paid professors as opposed to the medical equivalents of the post-docs?

My question is who actually best models the behaviors which we want medical students to adopt? In some sense the medical school faculty are like surrogate parents. In the old model, medical students were raised by their older siblings because to a great degree the faculty functioned in absentia. The see one, do one , teach one model had its faults but at least the doctors who we modeled our behavior knew their primary role was the care of patients.

Because of the priorities of universities, medical school faculty who care to advance in the academic hierarchy need to place patient care and teaching related to patient care below other activities. They focus on specialty medicine because it allows them to generate sufficient salary to free up time to do research. This is not easily hidden from their medical student charges. The students are generally frighteningly smart and insightful. They quickly see this and see that there are few ramifications from not placing patients and patient care first. Like the alcoholic parent who tells their children not to drink, or the reckless driver who tells their child to be careful behind the wheel, they may hear us tell them that patients are important but our actions speak much louder than words.  They will not likely follow our advice when we ask them to do as I say, not as I do.

1 comment:

  1. I couldn't agree more. I have even observed (in my own experience as a medical student and as a resident) that students who greatly emphasize patient care and well-being are assumed to be trying to compensate for a lack of fundamental knowledge.

    When I was a medical student, the administration of the medical school spent a fair amount of time (and space in printed and electronic communication) about the need to recognize the importance and expertise of physicians who devoted themselves to teaching. However, while several individual faculty members were indeed known for their outstanding clinical teaching, they were not highly respected within the institution. Sure, there were awards for "excellence in teaching," but the general culture was clinician educator < clinical scientist < physician scientist. It should be no surprise, though, given that medical school "ranking" (which, despite their protestations to the contrary, medical schools are very concerned about) is so dependent on amount of research funding obtained by the institution. Yet another example of assigning value to something simply because it can be quantified while ignoring important but more subjective factors.

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