| Features | Spring 2008 |
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Small Craft Advisory Nine years ago the television program Nightline spent a week at Harvard Medical School filming our approach to patient care. The reporter took ample time with our students and faculty, and the program developed a wonderful picture of our high standards of care and our emphasis on the doctor–patient relationship. At the end of that week, the reporter and I were walking together when he suddenly asked, “What happens if you train your students the way you’ve shown me and they then enter a world that won’t let them practice as they were taught?” Without a moment’s hesitation, I answered, “Then they ought to change the world.” A medical student’s life should be intellectually dazzling, emotionally rewarding, and morally transcendent. It should be intellectually dazzling because the progress in biomedical science—from genomics to imaging to molecular diagnosis to therapy—gives the process of becoming a doctor incandescence. It should be emotionally gratifying because the opportunities for helping individual patients and populations of patients achieve better lives have never more closely aligned with entering students’ aspirations. And it should be morally transcendent because from the first day of medical school one should feel enlisted in the never-ending challenge of achieving better health for all. Yet several imbalances persist in medical education today, while our health care system as a whole is sailing off course. Among these educational imbalances is the one between inspiration and science. At first glance this notion may seem both philistine and counterintuitive. I don’t mean medical schools have too much science; their faculty members in basic science represent a major fraction of the country’s biomedical scientists. These teachers delight in sharing their research passions with medical students. And since the introduction of evidence-based thinking in clinical departments, that domain of medical education has become rich in science. My point, rather, is that medical education offers too little inspiration. Medical students don’t spend enough time with the senior faculty who are eager to nurture their talents. They don’t witness the continuity of patient care that is the essence of internal medicine. They don’t see surgical patients before the patients are draped—that magical moment in which one human gives another human permission to cut into his body. And they spend too much time with junior faculty and with residents who are often too tired, irritable, and troubled to inspire young people. Even Keel It’s a long way from the bench to the examining table. Most of the scientists in our basic science departments hold doctorates but have no training and often little interest in medicine. And in recent years, faculty members have been rewarded for basic science research through appointments, promotions, honors, and opportunities for supplemental income. Important advances in basic science are now crying out for clinical investigation and translational research, and we’re desperately short of people entering those disciplines. We must rebalance the value structure of our schools to invite bright young students into translational research. In addition, we need teacher–clinicians who remain close to the emerging science of their areas—even though they are not doing the research—and can convey the meaning of this progress to medical students and patients alike. These individuals are critical members of medical school faculties and should be developed and rewarded as such. Outstanding examples of the role of teacher–clinician have been grossly underrepresented in the past, and that balance should be restored. A close corollary of this imbalance is an inadequate respect for clinical excellence. Most medical students will practice medicine, and their learning environment and experience should include a veneration of outstanding doctoring with all it entails. There is no such thing as too much attention to the individual when one is caring for the sick. All one’s intellect and empathy must conjoin in the service of diagnosis, management, and care. But in the overall distribution of a medical student’s time, we pay too much attention to what is immediately wrong and give too little thought to preventive measures addressing what is likely wrong or what is going to be. The closer you hover to death, the better a fourth-year medical student or intern can serve you. Yet most people are not at any given time fatally ill, and the almost onanistic absorption with the clinicopathological conference, our most revered teaching function, should be replaced with a broader interest in likelihoods, prevention, and amelioration. This emphasis should be enriched with insights from social science, including a focus on the patient’s family and the public as a whole. By a wide margin, though, the most serious imbalance in the education of our students is the faculty’s focus on the intense care of the sick while the setting in which that care occurs—the U.S. health care system—is in serious disarray and getting worse. As many as 50 million are uninsured, half that number again are underinsured, and many members of the middle class are just a serious illness away from bankruptcy. In addition, gross disparities of care and health indices persist along racial, ethnic, and socioeconomic lines. We fail to apply the power of preventive measures well enough to make a difference, and our health outcomes are barely competitive with those in developing countries. Where is the disquiet that African American newborns have more than twice the mortality of whites? Where is the outrage that more than half our citizens cannot access or afford routine primary care? Where is the shame that among 19 industrialized nations we are ranked dead last in health care measures? Where is the horror these findings should evoke? And where is the agreement, or at least the debate, that health care is a fundamental right, one no more alienable than those protected in the U.S. Constitution? Sailing Close to the Wind To help answer such questions, perhaps we should start by analyzing the clinical exam. Imagine for a moment watching a doctor–patient encounter as though you were utterly naive of it. First, two strangers meet in a closed room, unobserved. One is fully dressed, the other at least partially undressed. Within a minute or two—especially these days—one of them starts asking questions not only about medical symptoms, but also about intensely private matters, such as sexual preference, the number of sexual partners, and the consumption of any illicit drugs. And the other person answers if not with aplomb then certainly with the view that the questions—which would have absolutely no standing in any other setting—are appropriate in that room. Next, the questioner moves on to a physical examination that combines intrusiveness and physical access completely without parallel in social interaction. Without consent, the process of the physical examination would indeed fit an expanded definition of rape. Third, the person in the flimsy hospital gown agrees to take medications the fully dressed individual suggests—up to and including general anesthesia. In other words, there is a total submission, admittedly with informed consent, to an undoing of consciousness and self. And finally, the questioner receives permission to operate on the other person—to remove an organ, to perform a transplant, to alter the body in any way he or she deems fit. This final act, which takes place every day in our operating rooms, would be a felony in any other setting. What justifies this extraordinary transaction? A simple utterance, “Good morning! I’m Dr. Jones.” And with those words comes the unspoken but unqualified promise that the person has the knowledge, skills, and—most important—the commitment to use them ethically on the other’s behalf. Clear Sailing Such imbalances bring me to a metaphor from the world of sailing. There are three principal points of sail. When the wind is at your back, the boat is flat and progress is real but almost imperceptible. There’s no tipping so there’s no problem with balance. When there’s a following sea, however, you can feel a little sick to your stomach. When you’re sailing on a reach, or perpendicular to the wind, the boat is still almost flat and your lunch can remain stable. The sandwiches won’t slide, the wine won’t slosh. Again, balance is no problem. But sailing across the wind will not get you to a challenging target. When you want to go exactly where the wind is coming from, you can’t. You have to slant slightly off the direct course, which is called beating, or sailing to windward. Now the boat is heeling, and maintaining balance can be difficult. But when things go exactly right—the sails are trimmed perfectly, the crew’s weight is distributed correctly, and the sheets are as tight as possible—the thrill is incomparable and you can let out a scream. It’s not truly human; it’s not even primate. But it’s close to a primal scream, and it signals that the boat is sailing as well as it can against the wind, and progress toward the goal is predictable. I stated earlier that the worst imbalance in current medical education is the failure of our medical schools to trumpet the defects of the U.S. health care system and to commit to correcting them. Our health care system has terrible shortcomings. I believe we should enlist medical students as agents of change, committed to designing a system of care that is equitable, cost-effective, prevention oriented, and universal—and thus moral. The students should have coursework, summer experiences, projects, an activist focus, and consistent mentoring on this subject. I envision a program similar to an MD/PhD or other joint-degree design. I picture a cadre of dedicated and innovative faculty who would bring to the program insight from diverse areas of medicine and from the social sciences. Following this rich activist experience should be additional medical training that prepares these students for leadership. I don’t know what the specific recommendations would be. (Peter Medawar, the British immunology Nobelist, said, “Never ask me about the future of research. If I knew what it was, I’d be doing it now.”) But I’m not troubled that we’ll be starting with amateurs. Noah’s ark was built by amateurs; professionals built the Titanic. Similarly, I’m not concerned that we’ll be starting with so few people arrayed against the titans of health care. As Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.” If we can convince medical students and faculty to apply the standards of medical education to the problems of health care; if they search for solutions that are intellectually dazzling, emotionally gratifying, and morally transcendent; if they join with students and faculties from related disciplines in public health, social science, and economics; and if they recognize that a broad systems approach is needed, then we’ll see roaring progress to windward. There’s a big wind out there opposing change. It is generated by a hugely successful commercial and for-profit world entrenched against the radical revision of health care that I believe we need. But when our new craft is sailing just right—when the helm, the sails, the sheets, the keel, and the crew are all in balance—and we start to make our ineluctable course to windward, through the noise we’ll hear that deep, throaty, primal scream, and we’ll know we’re on the way to better health and health care for all Americans. Daniel D. Federman ’53, the Carl W. Walter Distinguished Professor of Medicine at Harvard Medical School, has served as a mentor to generations of HMS students. This article was adapted from a tribute Federman gave to Jordan Cohen ’60, president emeritus of the Association of American Medical Colleges. Photo: Bill Truslow/stone/getty images |
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