Decoding Health Care
Part 26: Medical Education Part Two
When you graduate from medical school you are not equipped to independently take care of patients (no matter how many facts you have memorized). You learn how to take care of patients during your internship and residency. There is a reason you cannot get a medical license without completing some post graduate training.
I did my internship at Barnes Hospital, Washington University School of Medicine in St. Louis (the same place I went to medical school). At the time, it was considered one of the most rigorous training programs in the country (along with Johns Hopkins, Duke, and University of Chicago among others). The toughest rotation was the three weeks spent in the Cardiac Intensive Care Unit (CICU). Washington University was a recognized leader in cardiology, and the CICU was insanely busy. Interns were on call every other night and literally ran from one emergency to another; sleep was unheard of. The interns shared a joke about the rotation:
Q: What is wrong with being on call every other night in the CICU?
A: You miss half the cases.
I learned a tremendous amount on that rotation (among other things that I did not want to be a cardiologist). In fact, I learned a tremendous amount during my entire internship year. The learning curve was very steep. I learned the importance of teamwork. I learned the importance of hard work and commitment. I learned how to talk to patients and their families. I learned how to recognize a sick patient. But it wasn’t really fun.
There is little doubt that post graduate education is a critical component of physician training. But the process has rightfully come under scrutiny. Like everything else in health care, we can probably do better.
Nobody much cared about the training of interns and residents until the Libby Zion case. Libby Zion was an 18 yo college student admitted to New York Hospital in October, 1984. She had a history of depression (for which she had been prescribed Nardil, a monoamine oxidase inhibitor) and a history of cocaine use (which she did not tell her care team about). Ms. Zion had fever and confusion/agitation and was felt likely to have an occult infection. To treat the rigors and agitation she received Demerol and Haldol. Over the next several hours, her temperature spiked to 108 degrees and she had a cardiac arrest from which she could not be resuscitated. Initially her cause of death was felt to be pneumonitis, but ultimately her death was attributed to serotonin syndrome, a fatal drug interaction between her antidepressant and the Demerol.
Libby’s father was Sidney Zion, a prominent lawyer and journalist (who wrote for the NY Times among others). He was a man of influence and means. And he was outraged by his daughter’s death. He felt her death was due to the horrible working conditions of medical residents (particularly long hours resulting in sleep deprivation that impacted medical decision making) as well as inadequate supervision of medical residents by the attending physicians. Over the next several years, this terrible tragedy due to medical error was litigated repeatedly in NY courts.
The legal odyssey followed two major paths (The Lasting Legacy of a Case that was “Lost” – Penn State Law Review). The first was pursuit of a criminal charge. Sidney Zion considered his daughter’s death a murder. At least in part due to Mr. Zion’s urging, the NYC district attorney convened a grand jury to consider criminal charges. Although the grand jury chose not to indict for murder, they did suggest that the resident physicians should be charged with gross negligence. This charge was then considered by the State Board of Professional Medical Conduct which did not feel that the intern and resident were guilty of negligence; however, in an unprecedented move, the Board of Regents overruled them and sanctioned the physicians (which ultimately was overturned by the NY state appeals court).
At the same time, Sidney Zion pursued relief in civil court. He filed a malpractice suit against the physicians involved in his daughter’s care, as well as the hospital. This trial was a circus. It was covered on Court TV, as well as breathlessly by the NY Times. Ultimately the physicians were found guilty of deviating from the medical standard of care. The award was $1 for damages and $750,000 for pain and suffering. This was reduced by 50% because Libby did not tell the physicians of her cocaine use. Sidney Zion was incensed and appealed the verdict. Ultimately, the verdict stood by mutual consent without the cocaine allegations, mostly because both sides were exhausted. It had taken ten years to try the case. It was finally over.
But the wild tidal swings and drama of the case were small compared to the impact on medical education. The trials aired a lot of dirty laundry and called attention to the insane hours residents were working and the relative lack of supervision of house staff. In 1989 the state of New York instituted limits on the number of hours resident were allowed to work (80 hrs per week). In addition, the requirement for attending physician supervision increased substantially. And it wasn’t just New York. Many states followed suit. In 2003 these changes were instituted nationally based on the recommendations of the American Council on Graduate Medical Education.
It is hard to argue that the “old way” of training medical residents was justifiable. Resident mental health and well being is vital. Interns and residents were subjected to terrible conditions in the name of medical education. But there are several other problems with post graduate training that require consideration.
Whether these working conditions resulted in increased medical errors is not so clear (Residents' Duty Hours — Toward an Empirical Narrative | New England Journal of Medicine). In fact, several studies done since the changes were instituted don’t really show much of an impact. That doesn’t mean the changes were unnecessary; quite the contrary. But by empirically defining the time limits on work hours, the consequences with respect to how well interns and residents are trained remains unclear. In fact, many “old timers” have bemoaned how these changes have short changed trainees and turned medicine into a 9-to-5 job.
Hospitals that participate in post graduate medical education have come to view residents as cheap labor. Resident training is underwritten largely by Medicare. From its inception, Medicare has funded the salaries of resident physicians based on the number of Medicare patients seen at that hospital. The second largest funder is Medicaid. Although those hospitals argue that those payments don’t completely cover the educational expenses, all the labor provided by the residents is essentially free. Hospitals like to have medical residents. In fact there are more positions than US medical graduates; about 25% of resident positions are filled by foreign medical graduates.
Medical residencies have historically been focused on care of inpatients. But if you are a practicing physician (with the exception of surgeons and hospital based specialists) those are not the patients you take care of on a daily basis. Increasingly over the last 20 years medical care is outpatient and NOT hospital based. One could argue that the skills learned in managing inpatients is almost totally irrelevant to the practice of medicine. Although some residency programs have attempted to rectify this with outpatient rotations this has been inadequate. That’s because the hospitals need the residents to care for those inpatients.
A substantial (and increasing) number of medical graduates don’t wind up practicing medicine. Although how many choose alternatives to conventional medical practice is not known, it is estimated that at least 10% choose something else. Some of these young physicians pursue careers in basic science research. Others choose work in the pharmaceutical industry or the private business sector. 1% of students graduate with an MD-MBA, and over 60% of medical schools offer a joint degree. 3% of students graduate with and MD-MPH. The truth is that when you graduate medical school you usually aren’t prepared to make an informed decision on what your future career is going to be. And there is no standard, formalized training in medical school for these alternate paths should you be interested in them
And that is the tip of the iceberg. In 1952, the National Residency matching program (NRMP) was established. The NRMP was designed to fairly “match” graduating medical students with residency programs. Prior to the match it was literally a free for all. The NRMP brought order to the chaos, but it isn’t perfect and it certainly isn’t transparent. During the matching process, each program makes a ranked list and each graduate makes a ranked list and the computer optimizes the outcome. But a lot of deals are made outside this process, with a number of “handshake agreements”.
The match process is most problematic for the most highly desirable programs, both within a specialty (ie Harvard is always very competitive) but also across specialties. In fact for a number of years, the most desirable specialties have been either “lifestyle” specialties like dermatology or radiology, or “sexy” specialties like cardiothoracic surgery, orthopedics, plastic surgery and neurosurgery. What do all these have in common? They are all extremely well compensated. Why does this matter?
To start with, there aren’t enough American medical school graduates to fill the “unsexy” specialties like pediatrics and internal medicine. In order to meet manpower needs, training programs that aren’t the top ones will often accept a large number of foreign medical graduates. This isn’t necessarily a bad thing; in fact we need those foreign medical graduates to be trained because we need them to practice in the US when they are done since we don’t train enough doctors. But we can certainly concede that off-shore medical schools aren’t of the same caliber as their American counterparts.
But let’s be honest. How can you possibly know you want to be a heart surgeon when you are a fourth year medical student? Maybe one of your parents was a heart surgeon, or maybe you knew a heart surgeon at some point in your 25 years on earth. But you had minimal exposure during medical school. We are asking a lot of medical students when we ask them to commit. I decided on internal medicine because I hated surgery, ob-gyn, psych, and neurology. But I didn’t decide to be an oncologist until the third year of my residency.
Many have theorized that finances improperly influence student selection of residency training. A lot of medical students have a ton of debt by the time they become residents so they naturally select well paying specialties. This results in a shortage in less well-compensated fields like primary care (more on this in a later post). I am not sure debt is the major reason students reject primary care but we will have a natural experiment ongoing that will help answer this. NYU was the first tuition free medical school, offering tuition waivers in 2018. Since then a number of other schools have gone tuition free. Many others are tuition free on a needs basis. These schools are able to go tuition free because of very large philanthropic gifts. Preliminary data from NYU suggest the number of students who chose primary care in 2024 was the same as the number in 2017 (https://www.statnews.com/2024/04/22/free-medical-school-tuition-primary-care-doctor-shortage/). Disappointing.
Reducing the financial burden of getting a medical education is a benefit in and of itself. The cost inflation we have seen with medical school tuition is beyond belief. My tuition when I started medical school was about $5000/year; at my alma mater, it is now close to $70,000! And lest you think the school has been forced to increase tuition because they are just hanging on, I invite you to visit any medical school campus and make note of the amount of construction and expansion. This is big business. And this is even before we discuss the endowment of top institutions, many of whom could make tuition free across the board without denting their endowments.
Just like medical school, post graduate training needs an overhaul. The hospital focus is all wrong. Training needs to be more comprehensive and more representative of what being a doctor really looks like. And if we can address some of the shortcomings in medical school the quality of post graduate education should improve as well. Irrespective of why medical students make the residency choices they do, it is pretty clear that making that decision when they do (as fourth year medical students) may not be the best thing. This may be a contributing factor to the high physician burn-out rates we are seeing in the medical profession.
Change will be hard to accomplish. Hospitals have a lot of power. The people in charge of post graduate education aren’t the most innovative. It took the tragedy of Libby Zion and a decade to make the work-load humane.
When you finish residency, you really do know how to take care of patients (in general). You can manage asthma, hypertension, and diabetes. But you don’t know how to take care of patients with really complicated problems. For example, you aren’t ready to administer chemotherapy to cancer patients or to do a cardiac catheterization on your patients with ischemic heart disease. In the third part of this post we will discuss the next step in medical education.