At Odds: Quantity vs. Quality

Posted on April 27, 2012

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Do we dehumanize our patients? (Image: Hüseyin Tuncer / Scientific American)

As a medical student who just completed this third year of training, I took special interest in Dr. Pauline Chen’s recent article about Harvard Medical School’s “Integrated Clerkship” – a program that eliminates traditional block-style clerkships and asks students to follow a panel of “up to 100 patients” longitudinally over the course of a year in order to emphasize continuity of care and the humanistic aspects of medicine.  Dr. Chen shares a story about one of her classmates who, in her eyes, began to reduce patients from people to diagnoses.

The program has made headlines in recent years, and other U.S. medical schools schools have initiated similar programs.  Many feel it’s a model that should be applied at the national level – the claim being that this style of training will combat the “ethical erosion” that accompanies the latter two years of medical school, while still allowing students to maintain academic performance.

I disagree.

Firstly, there is not an “ethical erosion” but rather a decline in empathy that has been shown in multiple studies of medical students’ attitudes as they approach graduation.  It’s an important distinction to make, since the term “ethical erosion” implies that we are producing physicians who make morally reprehensible decisions in patient care – say, requiring a woman to submit to a transvaginal ultrasound when it’s not medically indicated.  Ethics are, in fact, taught in medical school, and tested on exams – not only do I believe students have a firmer grasp of medical ethics by graduation, but we are expected to uphold them in practice over our personal beliefs.

There’s no doubt, empathy does decline, on average, as a medical student nears graduation.  But is this less a result of the training system and more a result of the mismatch between a student’s ideals and the reality of the healthcare system we’re plunged into?  Coddling students for another year and shielding them from the demands of their inevitable future will not necessarily make better physicians.  In fact, I would argue that such students may be in for a big surprise in their fourth year sub-internships and residencies!

This sort of training begins to appear unrealistic when we consider that we’re training students to work in an environment where doctors now spend more time typing than touching, where error is unacceptable – and lack of knowledge, or applying it inappropriately, is threatened with litigation.  Isn’t that, after all, the reason we spend so much time simulating various situations, doing thousands upon thousands of practice questions, and earning CME credits – so that we never make a mistake?

Besides, I've already learned all I need to know about empathy from this guy.

A medical student who recently completed a longitudinal third year program had this to say:

“Unlike my classmates who did a block rotation in surgery, I did not see 30 [laparoscopic gallbladder removals] during my surgical clerkship; I saw maybe 5. But for each one, I met the patient first in the [sic], took a detailed history, did a physical exam, and developed a differential diagnosis.”

I’m sure I saw well over 30 of these procedures during my surgical clerkship, but also performed well over 5 detailed histories and physical exams, with my residents and attendings expecting a differential and interpretation of labs and imaging that followed.  I’m not tooting my own horn – I’m simply trying to impress upon the reader that it is possible to be thorough while obtaining exposure in a traditional clerkship model.  Sacrificing quantity does not always mean an increase in quality.

I think we would be doing our current and future patients a disservice by decreasing the volume of patients we ask third years clerks to interview and examine.  Further, with the impending physician shortages and expanding patient base, we must ask ourselves if this style of training is practical.  We must either train a higher volume of physicians, or train physicians better able to balance the demands of practice that will arise in their very first year of residency – not some remote future.

An experience comes to mind – there was one instance on my medicine clerkship where my foreign-trained residents suggested a diagnosis of acute mesenteric ischemia in a patient whose presentation, history, and physical exam were inconsistent with the condition.  I spoke up, a discussion followed, and it turned out that neither my intern nor 3rd-year resident had seen a case of acute mesenteric ischemia in person.  Now, I don’t remember the names or favorite colors of the patients I saw and treated, but I sure as hell remember what they looked like, and this guy wasn’t it – the attending agreed.  Perhaps all I did was save the medicine team from an embarrassing surgical consult in this case, but it illustrates my point about how important exposure to a variety of patients can be when it comes to clinical decision making.

The current educational model isn’t perfect, and I’ve had my own criticisms, but I don’t believe a shift to longitudinal experiences will improve medical education in the clinical years – such a model is perhaps better suited for pre-med programs and clinical experiences in the first two years of medical school.  I’d like to hear your thoughts:  physicians, medical students, and patients alike.

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Posted in: Medicine