Duke University School of Medicine - Aesculapian Yearbook (Durham, NC)

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present, which have meaning and special appeal. If one follows the mainstream of life, problems, perplexities, and disappoint- ments can be anticipated as well as success and happiness. Win- ston Churchill provided sound advice when he said, The only guide to a man is his conscience, the only shield to his memory is rectitude and sincerity of his actions. It is very imprudent to walk through life without this shield, because we are so often marked by, a failure of our hopes and upsetting of ouricalcula- tions, but with this shield, however the fates may play, we may always be in the ranks of honor. Another feature deserving specific recognition is the im- portance of flexibility in daily life. This is very aptly expressed in the Socratic statement, A man though wise, should never be ashamed of learning more, and must unbend his mind . . . and so the ship that will not slacken sail, the sheet drawn tight, unyield- ing overturns. She ends the voyage with her keel on top . . . The message of being alert to the need for change, when change is prudent, is indelibly clear. Finally, this writer has never found a statement which cap- tures the prescription for a successful and happy career in medi- cine as well as that of Sir William Osler. When asked by the medical students at Yale for the reasons explaining his own attainments, Osler was very forthright, It seems a bounden duty on such occasions to be honest and frank, so I propose to tell you the secret of life as I have seen the game played, and as I have tried to play it myself. . . This I propose to give you in the hope, yes, in the full assurance that some of you at least will lay hold upon it to your profit. Though a little one, the master-word looms large is meaning: WORK. It is the open sesame to every portal, the great equalizer in the world, the true philosopher's stone, which transmutes all the base metal of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart all things are possible, and without it all study is vanity and vexation. The miracles of life are with it. . . To the youth it brings hope, to the middle-aged confidence, to the aged repose . . . It is directly responsible for all advances in medicine during the past twenty-five centuries. David C. Sabiston 5 .T 3 FD JP E '4 as 3 3 F THE FUTURE OF MEDICAL EDUCATION A View Toward The 21st Century It is tempting to say that I never look back, but it simply is not true. Though it is more fun to think and plan for the future, past history has the sobering impact of attempting to minimize the recycling of previous mistakes made in the United States and abroad. Medical and health science education in the past 200 years provides an objective launching pad from which we may ex- trapolate future changes. Some of the directions we are current- ly following have proven disastrous in other countries. At times, elements of our national leadership appear to be wearing blindersg the day-to-day preoccupation with complex problems in education and health care are not conducive to careful plan- ning for the future. In this column, I shall endeavor to touch only a few of the major issues which loom before us in the next two decades. A more complete rendition would require a monograph. Changes in Admission to Medical School Today, the starting line to gain admission is located where your parents have decided to work and live. You are locked in an environment which can determine whether or not you are in an educational channel that might lead to admission to medical school. The valedictorian of a small rural high school in North Carolina may not gain admission to one of the nation's top fifty colleges that produce the bulk of successful applicants to medic- al school. The new North Carolina Residential High School of Science and Mathematics is an experiment to correct this dispar- ity in opportunity. Lessons to be learned from such a model may be replicated in other states and provide one solution to the problem. At the collegiate level, currently there prevails a unitrack quantitative science rat race to compete for admission to medi- cal school. Only one out of three applicants is successful on the national scene. The remaining two-thirds end up frustrated, angry, and sometimes hostile towards medicine, they may go into careers that surround medicine, but they and their families will never forget the four years of the vicious college race. The Program to Strengthen the Medical Science Education in College, supported by the Commonwealth Fund of New York City at Duke's Trinity College and seven other universities, is one attempt to provide alternative pathways to medicine. It makes available respectable tracks to other careers in health and fields related to medicine. It defuses the quantitative biological science unitrack as an all or none option. Youngsters gain a practical field experience in health care to get a feel for the trenches by Working as volunteers in hospitals and clinics. It provides the opportunity to sample the basic medical sciences while in college. The early provisional acceptance to medical school as sophomores in college gives the student an opportun- ity to select broader non-science courses in the humanities and social sciences. Consideration for future careers in economics, political science and law at the interface with medicine have exposure to what medicine and health care is all about in the process of formal collegiate education. Current medical school admission committees do the best job possible today. They are more discriminating than other profes- sional and graduate programs that tend to formulate criteria that consider grades and aptitude tests exclusively. Interviews and letters of recommendation may be helpful at both ends of the intellectual spectrum, they can weed out the genius who belongs PHILOSOPHERS 25

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DVNPCI 9!q9S 'Cl 'U01 F E J 'G'IN COMMENTS FOR THE AESCULAPIAN MEDICINE: No other profession can boast ofthe same unbroken continuity of methods and ideals. We may in- deed be justly proud of our succession. Schools and sys- tems have flourished and gone, schools which have swayed for generations the thought of our guilds and systems that have died before their foundersg the philosophies of one age have become the absurdities of the next, the foolish- ness of yesterday has become the wisdom of tomorrow, through long ages which were slowly learning what we are hurrying to forget - amid all the changes and chances of twenty-five centuries, the profession has never lacked men who have lived up to these ideals. - Osler Medicine, which has attracted the most scholarly and commit- ted students for hundreds of years, continues to stimulate the aspirations of the finest graduates of our colleges and universi- ties. One cannot avoid being astonished at the variety of career opportunities currently available to all those in this select group. Until relatively recently, most physicians were largely of the same mold, but in the past several decades a number of specific opportunities for in-depth specialization have developed. It is this change, more than any other single factor, which has been responsible for the notable advances which have occurred in medical science during this period. Nevertheless, the student who wishes to pursue a broad approach to medicine and to have the responsibility as well as the gratification of caring for a large number of patients and treating a variety of illnesses may still pursue such a course by choosing the field of family medicine. Thus, the medical student today can specifically select a career designed to provide the opportunity to contribute to progress as well as finding happiness in life. This spectrum has been in the state of continuous change during the past several decades, and today a series of widely ranging opportunities are available including community medicine, group practice, part-time affil- iation with a medical center, or a full-time university academic appointment. Further still, challenging opportunities are avail- able for physicians in research institutes, industry, government, foundations, and civic enterprises. Bearing these features in mind as the background of modern medicine, it is very gratify- ing and a much appreciated experience to be invited by the editors of the AESCULAPIAN to comment on some personal thoughts about a career in medicine. 22 PHILOSOPHERS In reflecting upon my own experience, Alfred Blalock, a much respected mentor, provided the primary stimulus. In his daily teaching and example, it was apparent that he felt there were few satisfactions in life as meaningful as a combination of clinical and investigative medicine. Becoming convinced of the necessity for thorough clinical training and taking the time required to achieve it, it was also equally clear that if one is to undertake meaningful clinical investigation, then carefully disci- plined training in the laboratory is essential. This conviction became stronger as it was recognized that clinical experiences alone were inadequate in providing an appropriate foundation for objectivity in clinical research. For this reason I decided to spend two years in full-time research with Dr. Donald E. Gregg, who had a reputation for being a purist in investigative physiolo- gy as well as a world authority on the coronary circulation. To him much credit is due for teaching me the fundamental princi- ples and the basic concepts of research as well as the objective interpretation of experimental data. It is my own belief that such a laboratory experience must of necessity be full-time, without the press of any concomitant clinical responsibilities. Moreover, a significant and continuous period of time must be spent in order to adequately acquire the necessary experience as an investigator. A combination of these experiences places one in an optimal situation for a later combination of research and excellence in the care of patients. Few challenges are as reward- ing as original investigation, and one has the clear obligation of reporting such observations in the literature. This in itself is a learning experience since the investigator is called upon to state in clear and precise terms both the description and an inter- pretation of the specific research. If one is interested in assimi- lating data in the preparation of a textbook, earlier experiences in experimental and clinical laboratory are very helpful in pre- paring and editing such works. Moreover, the writing of texts provides a relatively easy way to remain abreast of the current literature and ofthe changing concepts in diagnosis and therapy. Teaching is another important challenge, especially since it provides an opportunity to relate closely and benefit others. Few privileges are more meaningful than the training of bright and committed students for careers in medicine. Their achieve- ments bring much more happiness than one's own successes, and there is the added gratification that the students themselves will rapidly experience the stimulation and happiness derived from such contributions. For example during the past decade, thirty-six Chief Residents have completed the training program in General and Cardiothoracic Surgery and thirty of them cur- rently hold appointments in university medical centers and six are in the private practice of surgery. It should be emphasized that in training programs a combination of those who are solely interested in academic work as well as those who are solely interested in clinical practice is very important, since neither alone is nearly as stimulating as the opportunity of working with both groups. There are many features which underscore the productivity of these residents including the fact that last year forty-four publications appeared in the scientific literature which originated from Residents in the Department as the primary authors. The leadership roles which these young men and Women achieve both locally and nationally provide them increasing confidence as well as genuine happiness which is also shared by their families and friends. In being asked to comment specifically on a philosophy of life, it is readily admitted that in the past I have seldom given much time on philosophical thoughts. Rather, it has seemed appropriate to learn as much as possible from respected leaders and to seize upon certain relevant quotations, both past and

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in a laboratory doing research rather than taking care of sick fellow human beings. I have no clear solution to propose and will continue to agonize about this issue. The Medical School Experience Clearly, the elective curriculum instituted in 1966 at Duke has been successful at this institution. It is the way of the future as useful medical information increases exponentially. We rec- ognized in the 1960's that it was no longer possible to expose medical students to all pertinent medical knowledge. The first two years were tailored to acquaint the student with the lan- guage of biomedicine and the process of problem solving. The last two years provided the opportunity to sample specific areas in depth. An additional dimension will have to be added - the changing process of decision-making as well as the changing information base. The evolving physician-computer interface is constantly a changing process. The Myocardial Infarction Re- search Unit CMIRUD instituted at Duke in 1967 is a splendid example of how decisions will be made in the future regarding the care of patients with coronary artery disease. Human mem- ory becomes increasingly fallible. The clinical experience of one physician is an insufficient data base for decision-making. The MIRU model is already being adapted to the field of cancer. In succession, other diseases will be managed with the same pro- cess and will be used by medical students, residents and clini- cans. The data base will be made available to community physi- cians by satellite terminals. Already proven to be cost-effective, the computer-physician process should be supported by third party insurance as a mechanism for a higher quality of care and for cost containment. Having an objective basis to sort out patients with myocardial infarction who can be discharged in 5-7 days instead of 21 days will be increasingly important as the per diem in coronary care units climbs up to 351000 per day in the 1980's. Changes Anticipated in Residency Training Because of the interdependence of clinical services, institu- tions will need to be accredited for graduate medical education. The patient with heart disease coming to a teaching hospital requires a spectrum of bench strength in medicine or pediatrics, radiology, surgery and anesthesiology. Each is an important link and quality cannot be unacceptable in any one. Today, Residen- cy Review Committees and the various specialty board tend to look at individual programs. The patient may be in jeopardy if one residency training program is on confidential probation unbeknownst to the others. Some mechanism such as the Liaison Committee on Graduate Medical Education will need to have muscle at the national level to accredit teaching hospitals aspiring to provide residency training. As a second set of teeth, the Joint Commission on the Accreditation of Hospitals should not accredit hospitals with residency programs that are not certified by the LCGME. Other issues that will evolve in the 1980's will be the problem of accomodating the larger crop of graduating MDs into avail- able Year I Residency Programs. As the LCGME improves quality by accreditation, some residency slots may be discon- tinued. It is possible that we may see a situation comparable to France and Spain where the number of Year I slots are less than the number of graduating MDs. A clear trend is already in view to correct speciality maldistributionf' Recent graduating classes have listed not only their preferred internships for the specialty of choice but for other less sought specialties as well. Finally, we can anticipate changes in the financing of residen- cy training. To date, each specialty board has designed the criteria for accomplishing residency programs. There is no 24 PHILOSOPHERS across the board consideration of whether the trainee is still a dependent highly supervised individual or if, indeed, he or she can be considered to be a relatively independent junior staff person - e.g., the 8th year resident in cardiac surgery. Residents are currently supported by the patient care budgets of teaching hospitals. It makes more sense to support the cur- rent more senior relatively independent residents on the same basis as the faculty, be it fee-for-service or some other basis. Collectively, residents do not have a comfortable national voice. They are being wooed by the AMA as future members thereofg they are sought by the unions as employees of hospi- tals. The medical educational associations need to incorporate the legitimate interests and membership of the 64,532' resi- dents in the teaching hospitals of the United States. Continuing Medical Education This is probably the biggest challenge of them all. Why? The average duration of compartments in the continuum of medical education is as follows: Premed - 4 years, medical school- 4 years, residency - 4 years, continuing education - 55 years. Given the 5-year half-life of useful information in biomedicine and the changing process of learning and practice, continuing medical education is a sleeper. In the 1980's and l990's, there will be a shift in the center of gravity of educational programs in the continuum of medicine, from medical school and residency training to continuing education. Fortunately, by our current tax laws, it is possible to be a self-financing area. How to do it? Unfortunately, at this time we know what works and what doesn't in continuing education at the extremes. We have no objective basis on which to judge the usmorgas- borg of offerings on the international scene. Evening lectures that follow long cocktail hours and massive dinners probably are inconsequential. Spending a month every two years with the house staff as a fellow in a given specialty at an academic medical center to learn new diagnostic and therapeutic skills is probably effective. Evaluating the net impact of a specific type of con- tinuing education program on the patient care of a given practi- tioner is lacking. Humanism in Medicine Of significant concern is the question: Does the increasing science and technology of medicine put it in an adversarial relationship with treating patients and their families as human beings? My answer is a hopeful, resounding no !! lwould not be honest if I did not express my grave concern in this issue. As the complexities of diagnosis and treatment increase exponen- tially, there has been a decrease in the ability of the physician to communicate with the patient and the family. The role models of faculty were never perfect. In the 1940's and 1950's, we still had professors who denied the patient the truth about having cancer, it put the patient and the knowledgable family in a difficult situation. Today, the problem with the clinician is not protecting the truth to avoid shocking the patient, but a lack of awareness of how to communicate effectively with the patient and the family. It behooves faculty members to behave as role models for the medical students and the residents. Furthermore, the subject of communication process should be incorporated in clinical rounds. What to say - how to say it - where to say it! The effectiveness of the physician in communication has a domino impact on other health professionals who have to deal with patients and their families. The poor physician communicator can have a devastating emotional impact on the patient, the family and the other health professionals. A striking example of the latter is the resident who is insecure and anxious about death