As for postgraduate training, Emanuel and Fuchs attacked the increasingly common requirement that residents and fellows complete laboratory or clinical research projects. They don’t buy the popular ideal that every doctor must be a “physician-scientist.” Referring specifically to surgeons, they wrote, “The most important factor in becoming a competent surgeon is high volume—performing specific procedures many times over. A research year does not add to surgical volume and skills building.”
Shortening the training process would entail costs. Kenneth Ludmerer, a professor of medical history and author of two books on this topic, argues that research isn’t merely about scientific discovery, but learning to approach diagnosis and treatment like a scientist. He points out that even Abraham Flexner, writing more than 100 years ago, noted: “The practicing physician and the ‘theoretical’ scientist are thus engaged in doing the same sort of thing even while one is seeking to correct Mr. Smith’s digestive aberration and the other to localize the cerebral functions of the frog.”
“There is an inevitable tension in medical education between preparation and practice,” Ludmerer says. “It is a perpetual dilemma that has become more severe, because there is now more to know.”
Another solution, perhaps more elegant, is the outcomes movement. American medical schools and residency programs have traditionally relied on the “tea steeping” method: They expose students to information for a prescribed amount of time, and assume they’re ready at the end of it. Years can be added if a student demonstrates gross incompetence in exams, but there’s no opportunity for exceptional students to accelerate the process. Offering that chance makes educators uncomfortable—both because it relies heavily on imperfect examinations and because it partially undermines the traditional process—but it’s time to experiment.
“Experiment” is the key word. The fundamental problem here is that the argument between traditionalists and reformers is essentially theoretical—we are in an evidence vacuum. It’s ironic, because in virtually every other aspect of medicine, tradition and intuition were discarded decades ago. Researchers rigorously test what is the best moment to start someone infected with HIV on antiretrovirals or a patient with high cholesterol on statins. But doctors have very rarely examined their own training. When Emanuel and Fuchs published their proposal two years ago, they could find just a single study comparing the competence of physicians from the traditional four-plus-four medical education system with that of doctors from shortened programs.
There is no reason not to do this important research. More than a dozen medical schools now offer high school graduates the chance to earn a medical degree in six or seven years. Fellowship programs also vary in length. It’s time to compare the medical boards scores, patient mortality rates, and other metrics for doctors with different lengths of training. The studies won’t be easy—students entering shortened programs may be different in a number of ways, for example, biasing the outcome. But assiduous matching of the test and control groups, paired with honest statistical analysis, will partially address that problem.
The rank-and-file physician may herself be an impediment to reform. Every generation of doctors seems to be convinced that the next is inadequately trained, because the younger doctors didn’t live in the hospital or spend enough sleepless nights there. Many warn that shortening premedical education will inevitably produce awkward automatons who can’t relate to patients (as though the current system is flawless in that regard).
In recent years, however, studies have shown that reductions to working hours during residency have harmed neither patients nor doctors-in-training. We need to subject assumptions about duration of training to the most rigorous scientific assessment possible. It’s time for doctors to turn the microscopes on themselves and their own training, and accept that the system that produced them may be imperfect. It’s nothing against you, Doctor, it’s just a scientific inquiry.
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