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A Struggle For The Soul Of Medicine

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  • 1. PHOTO: SHUTTERSTOCK/ZSOLT NYULASZI November 5, 2007 America Vol. 197 No. 14, Whole No. 4792 Can physicians be trained to care? A Struggle for the Soul of Medicine – BY MYLES N. SHEEHAN – A T MOST MEDICAL SCHOOLS in the United States, students are given a white coat during a ceremony in the first weeks after matriculation, and they are told about the role they will play and their obligation to serve others. These days medical training, both at the undergraduate and post- graduate (residency training) levels, is explicitly linked to attaining spe- cific competencies. The decision to require demonstration of competencies reflects a perception that American doctors might be well trained in science and technology but lack some other crucial skills one would want from a doctor. It is an effort to remedy the worst deficiencies. The Accreditation Council for Graduate Medical Education, the governing organi- zation for postgraduate physician training, requires the mastery of six particular com- MYLES N. SHEEHAN, S.J., M.D. , is senior associate dean and the Ralph P. Leischner Professor of Medical Education at Loyola University Stritch School of Medicine in Chicago, Ill. This article is based on a lecture presented at Trinity College Medical School, Dublin, Ireland, in May 2007. November 5, 2007 America 9
  • 2. petencies before one can be recognized as a specialist in a particular discipline. These are medical knowledge, com- munication skills, practice-based learning, patient care, pro- fessionalism and systems of health care. That last term refers to the ability of a physician in training to understand the differing environments in which patients are cared for, to work with the health care system to ensure continuity of care and to cooperate with efforts that ensure patient safety and standards of quality and proficiency. Increasingly, medical education combines knowledge of basic science and skills in caring for patients with explicit curricula in communication, simulation and team training. It also develops in practitioners a habit of reflection that leads them to review individual cases and make comparisons with the evidence in the literature and in conformity with national standards. The problem is that this broader curriculum is being developed at a time when faculty members of medical schools already feel pressed by productivity demands that limit the time clinicians can spend with students and that force researchers to juggle classroom teaching and writing applications for the grants necessary for ongoing funding. What lies beneath the current discussion about profes- sionalism in medicine is that, despite increasing technical and scientific opportunities, the purpose of medical educa- tion is still to train physicians who understand the values they profess, the meaning of what they do and the impor- tance of their relationships with patients, other caregivers and society at large. The struggle for medicine’s soul is being waged on the field of medical education. Training in Virtue Medicine is a humane discipline that combines art and sci- ence, but it depends above all on practitioners who are pas- sionate about caring for patients. To use terminology from scholastic philosophy, medical education is training in virtue, with virtue understood as a human potential brought to action by education, training, reflection, consideration of role models and experience. Medical education requires growth in both intellectual and moral virtues. The intellec- tual virtues of art and prudence aim at finding the reality of the clinical encounter. The moral virtues of temperance, fortitude and justice aim at right action in the best interests of one’s patient. The struggle about how best to form physicians is not new, but a variety of new challenges makes it especially pressing. The possibilities in medicine—of treating individ- uals, of providing a variety of technological solutions for a particular problem (including the promise of molecular genetics)—are dazzling. Yet physicians also struggle with how to live well as persons, how to care for the poor and how to befriend those who seek their assistance. These days 10 America November 5, 2007
  • 3. there is more to distract us, like worries about how to main- tain a reasonable income, meet productivity demands and deal with regulatory and bureaucratic requirements. Education that ensures respect for patients while not dimin- ishing the humanity of those in training remains a daunting challenge. Focusing on the Physician in Training When developing a curriculum, my aim is to train students who are ready for the demands of patient-centered medicine. Such students can deliver personalized care while using knowledge and skills that are highly technical. They can understand how a person’s individual genetic makeup will allow appropriate therapeutic choices, tailor treatment for cancer and other illnesses, and make prudent decisions about ways to limit risk. But personalized care and patient- centered medicine also mean retaining and deepening an older tradition: the ability to communicate with those in our care and to work with them in making decisions about their health care that serve their best interests. It is hard to see how students can grow in their ability to provide patient-centered care if medical educators do not grow in student-centered education. Behind this assertion are some simple considerations. Medical school curricula are too often dominated by a feudal mind-set; individual departments hold sway over students as they move from dis- cipline to discipline. Increasingly, however (accelerated in the United States by accreditation and regulatory require- ments calling for demonstrated proficiency in core compe- tencies), a curriculum is being developed that looks at the objectives necessary to prepare those ready for the next stage of training. Individual disciplines are crucial but in an instrumental manner; each works to provide training that imparts the necessary knowledge, skills and attitudes to developing the ideal graduate. My own training has given me a high level of knowledge in biochemistry, physiology, anatomy, microbiology and pathology, plus a more practical set of skills and knowledge in the clinical disciplines. But it did not prepare me well to take care of people with a cold or individuals facing a life- limiting illness, or to talk to a person who has just received a bad diagnosis or to work in the best way with nurses and social workers. With a bit of exaggeration, I suggest that my medical school and residency training emphasized personal mastery, but did not address well how to deal with change or conflicting evidence or how to work as a team member or to act like a human being with patients. I could detail bio- chemical pathways about carbohydrate metabolism (and am still fairly good at that), but I had much difficulty telling a poor obese patient what to do with diet, exercise and medi- cation in the face of Type II diabetes mellitus. At Loyola University we emphasize an education com- November 5, 2007 America 11
  • 4. mitted to ethics and service and to a translational knowledge find an answer, rather than passively receive it. of basic science as well as to the development of robust clin- It is difficult for some medical school faculty people to ical skills. We seek to provide very strong student services recognize that the old methods of learning are not effective (part of the Jesuit educational tradition of cura personalis) for this generation, which was brought up on computers, while delivering a value-laden education that gives students accustomed to streaming video and hooked up to an iPod. extensive exposure to care of the poor, international service Given the glut of information, teachers must acknowledge trips and rigorous basic science training. In addition, our that some of what they cherish in a particular discipline may clinical rotations are very demanding, with many overnights not be very relevant in contemporary practice. As a new “on call” and an expectation that the student will become graduate in 1981, I could have told you much about the life increasingly independent in responsibility, while under cycle of the pinworm, but I look back on that now with appropriate supervision. some horror, recalling that more than 20 hours in my cur- If the medium is the message, far too much of medical riculum were devoted to lectures on parasites, but only an education is passive in format: lengthy lectures impart much hour or two on end-of-life topics. As a geriatric specialist information but can leave a learner bewildered about what today, I realize I was not well prepared. Pinworm rarely is essential. Focusing on objectives helps, but it is not afflicts my centenarians. My students and I can search the enough. For a format that relies too much on lectures not Web to learn about parasites when we need to. The faculty only ignores the needs of active learning but also fails to rec- does have essentials to impart, but students and faculty alike ognize the experience students bring to their education. must still learn much more once the core topics are mas- Small-group learning focused on cases or problems may tered. improve on this, but it is no panacea. For this to succeed, faculty members must be willing to facilitate, not control, Focusing on the Patient learning. Most threatening in my experience were the times Although not every physician will work directly with I had to admit I was not sure of an answer when the students patients, the goal of medical education is to provide the best moved a discussion beyond my intellectual safety zone. care possible. Part of the rationale behind competency- Modeling how to address such questions helps students get based objectives and standards for training is to move used to the need to work together and figure out how to beyond knowledge-based examinations. That emphasis may November 5, 2007 America 13
  • 5. Itprovide patient-centered carecanmedical educators do to is hard to see how students if grow in their ability not grow in student-centered education. be new, but medicine has always recognized the exemplary who are both skilled and caring. Second, put the best and performance of physicians who care for patients with a deep brightest physicians who care about students and physicians wealth of basic and clinical knowledge. Such physicians are in training into positions of authority and leadership. Third, also attuned to each patient’s individual characteristics and recognize the importance of role models and ensure that the specific needs as human beings. They show a willingness to doctors who represent the ideals of what a doctor can be try to heal a patient even when a cure or technological rem- provide most of the clinical teaching. edy is not always possible. Developing patient-centered care Formation in technical knowledge, practical knowledge requires practitioners who are ready to grow as humans and and wisdom does not mean training nice people who are as clinicians during their training and afterward. It also ignorant but pleasant; rather it aims toward growth in demands that they become increasingly sophisticated in virtue, which is hard work and inevitably entails some fail- mobilizing the resources of a particular health care system. ure and frustration. This model is not typical. In the United A physician must use the talents and skills of other health States, assigning responsibility for running a training pro- care professionals in a collaborative manner, while attend- gram has often been a way of providing a salary to some ing to best practices, prevention, quality and safety. bright young academic physician while he or she develops a How does one promote an education by which students research agenda and searches for outside funding. The and novice physicians can grow in technical skills, practical training program provided relatively cheap labor (the physi- knowledge and some degree of wisdom? Let me suggest cians in training), with minimal supervision. Much learning three steps. First, take medical education seriously as a for- still took place, but what counted was that the young physi- mation process whose goal is to develop men and women cians got the work done, did not complain and passed their 14 America November 5, 2007
  • 6. specialty exams. A student could be thoroughly objection- able in matters great and small but still advance. Training doctors in person-centered care works only if the educators doing the formation understand the process of giving such care and also care deeply about the doctors they are training. Such learner-centered education requires individual assessment, assistance in areas where growth is required and encouragement of students’ questions. It takes discipline to ensure that the education is properly bal- anced: ongoing learning in science, attention to skill train- ing, team development and personal growth. It takes edu- cators willing to work with trainees who may be very bright but manifest little interest in developing communication skills, behaving professionally or learning other behaviors that may once have been considered pleasant but merely optional. Ultimately, the future of medical education depends on medical school faculty and administrators who care about education and patient care. In a very complex environment, that means devoting time and resources to students and physicians in training. It also requires selecting, paying and promoting faculty members who excel in both their partic- ular discipline and devotion to their students. A From America's archives: Myles N. Sheehan, S.J., M.D., on “Dying Well” (7/29/00), at www.americamagazine.org November 5, 2007 America 17

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