Views of Medical Education and Medical Care [Reprint 2014 ed.] 9780674366626, 9780674366619

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Views of Medical Education and Medical Care

Views of Medical Education

and Medical Care Edited by John H. Knowles, M.D. Harvard University Press

Cambridge, Massachusetts

1968

© Copyright 1968 by the President and Fellows of Harvard College All rights reserved Distributed in Great Britain by Oxford University Press, London

Library of Congress Catalog Card Number 68-14262 Printed in the United States of America

To John Ε. Lawrence Trustee of the Massachusetts General Hospital, of the Board of Trustees, 1964-

1947-Chairman

and Francis H. Burr Trustee of the Massachusetts General Hospital,

1962-

Who combine head, heart, hope, and humor

Preface T h e ultimate goal of medical education is to provide for excellence in the continuing and comprehensive care of the sick and to enhance the quality of life by the prevention of disease. Teaching and research are the university's means to these ends of humanitarian service. Medical science and technology are making it increasingly more possible to realize these goals, and the public interest has increased proportionally. In recent decades, the deficiencies of our system of medical education and medical care have become clearer and more comprehensible to an expanding and highly vocal segment of the public. Many educators share the uneasiness and recognize the need for change. Rising expectations have been matched by rising costs resulting in justifiable demands for better organization, distribution, and utilization of health services. Insufficient manpower, usually insufficiently trained and poorly utilized, is recognized as one of the major impediments to the realization of our collective aspirations for high quality medical care for all Americans. T h e

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evaluation and control of quality is in an uncertain state. The arrival of medicare, culminating a thirty-year march to prepaid medical care, and resulting in powerful political and other "third-party" interests in the life of the doctor, has highlighted the social forces with which the physician is ill-prepared to deal. These and many other problems demand a more effective articulation of the work of medicine with the wants and needs of the people. Perhaps the best way of achieving this is through the system that educates the student and trains the doctor. Medical education was examined in a series of lectures sponsored jointly by the Lowell Institute and the Massachusetts General Hospital during the spring of 1966. The essayists whose works are collected here were assembled from a diverse group which had the following common characteristics: dissatisfaction with complacency and the conventional wisdom; a deep and demonstrated interest in medical education; and the intellectual equipment to rationalize and transmit their views. In addition, the fresh view of individuals looking at the subject from pivotal but nonexpert positions was thought desirable. Thus the group consisted of a politician, a professor of physics, and a university president, in addition to a professor of surgery, a professor of pediatrics, the new Dean of the Harvard Medical School, and a hospital director. Each one here describes the elephant as he sees it and thereby brings a fresh view from his particular vantage point and colored by his own experience. When they wrote their essays, Dr. Oliver Cope, Professor of Surgery, and Dr. Jerrold Zacharias, Professor of Physics, had just completed a most significant review of medical education which is referred to in Dr. Cope's essay. President Millis of Western Reserve has recently been Chairman of the

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Citizen's Commission on Graduate Medical Education, charged by the American Medical Association with reviewing the field of graduate, in-hospital medical education. Lieutenant Governor Richardson is a former Assistant Secretary of the Department of Health, Education and Welfare and Trustee of the Massachusetts General Hospital, and is presently responsible for the development and implementation of health and welfare programs in the Commonwealth of Massachusetts. The essays are addressed to all, to expert and nonexpert, profession and public —all of whom will be able to understand them. Knowledge is power. Hopefully, these essays will increase understanding and help to provide the power of reason necessary to change medical education, so that it can better serve the public good. July 1967

John H. Knowles, M.D.

Contents A Physicist Views Medical Education

1

Jerrold R. Zacharias, Professor of Physics, Massachusetts Institute of Technology

Table: Cost of education

11

Concerning the Need for Behavioral and Social Science in Medicine

19

Nathan B. Talbot, M.D., Chief of the Children's Service, Massachusetts General Hospital; Charles Wilder Professor of Pediatrics, Harvard Medical School

The University President's View of Medical Education and Medical Care

51

John S. Millis, President, Western Reserve University

Medical Education and the Rationalization of Health Services

65

John H. Knowles, M.D., General Director and Physician, Massachusetts General Hospital; Lecturer on Medicine, Harvard Medical School

The Politician Views Medical Education in the Social Context of Medicine

99

Hon. Elliot L. Richardson, Lieutenant Governor, Commonwealth of Massachusetts

Medical Education and the University

117

Robert H. Ebert, MD., Dean, Harvard Medical School

The Endicott House Conference on Medical Education

139

Oliver Cope, M.D., Visiting Surgeon, Massachusetts General Hospital; Professor of Surgery, Harvard Medical School

Notes

170

Index

177

List of Illustrations J e r r o l d R. Zacharias: A Physicist Views Medical Education 1. Status of internships and residencies, 1945-1964 2. Graduates of medical schools, 1930-1964 Nathan B. Talbot: Concerning Behavioral and Social Science 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12a. 12b. 13. 14. 15. 16.

9 10

the Need for in Medicine

Dual position of man in nature Factors in disease Human factors in causation of disease Perception of well versus sick role Perception of illness and therapy A community's perception of need for medical attention Social and psychological events surrounding illness The socioeconomic factor as a key determinant The division of the medical curriculum Electrode stimulation of "feeding area" of rat's brain Apparatus to determine ocular orientation—schematic Wandering of eyes without triangle projected Response to triangle on wandering movement of eyes Infants' ability to distinguish faces Physical handicap and order of liking Frames of reference. Gray shades are identical Frame of reference—young or old lady

20 25 27 29 30 32 33 34 36 39 39 40 41 42 44 46 47

Oliver C o p e : T h e Endicott H o u s e C o n f e r e n c e o n Medical Education 1. Evolution of medical education at Harvard Medical School and Massachusetts General Hospital, 1850-1950 2. Curriculums for surgeon, general practitioner, and medical scientist

157 161

Views of Medical Education and Medical Care

A Physicist Views Medical Education Jerrold R. Zacharias

For the past several summers, Dr. Oliver Cope and I have chartered a sailboat for a relaxed week of cruising. Two years ago we invited a psychiatrist, a biochemist, and a lawyer to come along, which made up an interesting crew. Since our psychiatrist was Dr. Douglas Bond, Dean of the Western Reserve Medical School, it was natural that between picking up buoys and drinking martinis we talked about the education of medical students. I was surprised and pleased to see how closely some of the educational procedures at Western Reserve resemble the methods that some of the people working on curriculum reform are finding best suited to teaching young children, and how much both of these resemble what is now being tried in some of our colleges. All these programs are predicated on bits of educational psychology which are, perhaps, obvious to anyone who has had experience working with people. First, students are brighter than you think. They can do more and go further, provided you don't demand that they do the impossible. Secondly, if you want someone to learn how to take

J errold R. Zacharias 2 responsibility, start early letting him have the authority necessary for taking responsibility. Thirdly, if you want a student to learn how to follow his own natural path through a problem or a set of problems, the educational pattern should be geared to what the philosopher David Hawkins calls "living in trees" instead of "threading a predetermined maze." 1 T h a t is, if at every decision point in a maze we indicate the proper turning without giving the consequences of taking other possible paths, we are fostering a very limited kind of learning. Courses, lectures, books, p r o g r a m m e d aids, films almost always provide only a single pathway. Let me give an example of "living in trees" by quoting f r o m the Teacher's Guide for Microgardening,2 a study of the growth of molds devised by Professor William Weston a n d his colleagues and published by the Elementary Science Study of Educational Services Incorporated for use in middle or u p p e r elementary schools. 1 WHAT ARE MOLDS LIKE? (Three activities, about 7 - 1 0 days) With h a n d lenses the children observe mold growing on bread and discuss what they see. T h e class starts a mold garden to determine what things will mold. Challenged to grow mold on a piece of bread and given the f r e e d o m to try whatever they think will work, children immediately become involved with basic questions. As their bread begins to mold, they try to sort out the reasons for this development. If microscopes are available, the students can examine the details of mold structure and make comparisons among different kinds of molds. 2 WHAT INFLUENCES THE GROWTH OF MOLDS? (Four activities, about 4 - 5 weeks) T h e children are encouraged to set u p experiments to

A Physicist Views Medical Education 3 show the factors that influence the growth of molds. At first their experiments may be indeterminate and confusing, but through mistakes and successes they encounter the need to sort out and test variables such as water, light, and temperature, one at a time. The children are given a chance to apply the knowledge thus gained by investigating how to prevent mold from growing on bread. 3 WHERE DO MOLDS COME FROM (Five activities, about 4 - 5 weeks) The children are introduced to a fundamental technique—sterile procedures. The children expose culture dishes of sterile potato agar to the air and discover a flourishing growth of mold a few days later. They then try to grow just one kind of mold by placing spores on sterile potato agar. Further experiments confirm the fact that spores, although invisible, are nearly everywhere, but they are not to be found in healthy living tissues. These experiences help the children to grasp the significance of historic events such as Pasteur's experiments on the presence of spores in the air, and to understand some of the principles of aseptic surgery and the germ theory of disease. 4 WHAT CAN MOLDS DO? (Three activities, about 3 - 4 weeks) The children grow pure cultures of a species of Penicillium which produces penicillin and then seed the cultures with harmless bacteria. The results of this experiment lead to a discussion of antibiotics in general and of Fleming's discovery of penicillin. After observing some seedlings that have begun to mold, the children develop the idea of isolating the mold, growing it, and then inoculating healthy seedlings. Having thus followed the historic steps of establishing that a microorganism such as a mold can be the cause of disease, they discuss the story of Robert Koch, who first worked out this procedure.

Jerrold R. Zacharias 4 Looking further into what molds can do, the children refer again to the mold garden, and discuss the role of molds in breaking down materials. 5 WHAT INFULUENCES THE RATE OF MOLD GROWTH? (Two activities, about 2 - 3 weeks) This area offers an opportunity for experimentation with more precision. Using growth tubes containing sterile potato agar inoculated with pure cultures of molds, the children compare rates of growth of various molds. They also investigate the effect of alternating daylight and darkness on the rate of spore production of certain molds. With the growth tube as a tool, children with special interest and motivation can go on unendingly devising experiments as time and equipment allow. We have found that this little piece of science study is entirely manageable by the students and their teachers. The pupils are learning, not by being told, but by doing. In fact, they learn by making nature work for them. Questions, generalizations, and then, more questions arise naturally. A student can go at his own rate; he can learn from other students; and he can think u p an unlimited number of experiments to try. This subject, microgardening, was not picked at random. It engages the student in the scientific method and focuses on important scientific questions. But what seems to me most important is that, with the help of the teacher, the child can get into his own brier patch and have to. hack his way out. Compare this with what is offered to first-year medical students at Western Reserve. Every freshman is assigned to follow a family and, specifically, the development of a

A Physicist Views Medical Education 5 baby, from before birth until it is several years old. He accompanies the expectant mother to the obstetrician, to the delivery, and finally, to the pediatrician. In handling such complicated, but manageable, situations, and with the help of a physician and other students, the freshman medical student is involved in all sorts of biological and psychological problems. I can well imagine that there are times when a student wishes he knew a little more biochemistry; but when this happens, it is he who becomes aware of the need. ^ We have had many similar project laboratories for the undergraduates at the Massachusetts Institute of Technology. It is always surprising how much sophisticated biology, chemistry, physics, and mathematics a student can handle if he has the authority and the responsibility to handle it. As a result of our sailboat discussions, some of us agreed that we should have an extended conference to consider the preparation of practicing physicians, medical scientists, and medical administrators. Dr. Cope took the initiative in forming a steering committee which selected participants interested in various aspects of medicine and medical education to meet in the summer of 1965 for two weeks at M.I.T.'s Endicott House. A report of the study has been published, 3 and Dr. Cope discusses the conference in detail later on in this collection of essays. I want to discuss some of my own reactions to the Endicott House conference. I entered the medical education study with some ideas already formulated. The undergraduate colleges are receiving better prepared and more interested students than ever before. This is especially true in mathematics and the sciences of physics, chemistry, and biology. There may be no single reason for

J errold R. Zacharias 6 this, but I would like to believe that the improved subject matter available to them in high school is part of the cause. Also, the colleges are now finding a greater disparity among the students, since some of them have attended good secondary schools with good new programs, and others have not. It follows, then, that the college courses were (and in many colleges still are) not suitable for the very well-trained students, in several ways. For some, the courses are not sophisticated enough, for some they are too rigid. A number of the leading colleges are in the process of revising their courses, especially for the early years. I think it is safe to say that the wave of curriculum reform that was generated ten years ago for the high schools is now reaching the colleges, primarily in mathematics and the sciences. This reform is going so well that for a sophisticated student, one who is going to be a professional scientist, technologist (for example, an engineer), or physician, American colleges will within a few years provide superb scientific education. However, there are real problems in other respects. For instance, for the student who does not intend to pursue a scientific career, our teaching of the sciences is not yet adequate. In general, subject matter is offered to a student who is not initially interested in a topic, the material having been watered down from lessons that were arranged for students who were already interested. College faculties still have the job of learning how to engage the attention of the nonscientific student so that he develops the educated citizen's interest in science and mathematics. In addition, those concerned with the social and behavioral sciences, history, and the humanities have not yet made enough progress in curriculum reform. It is a pity that the teaching of human

A Physicist Views Medical

7 psychology in the colleges is not undergoing radical reform. However, important as these subjects are for the prospective medical student, they do not influence the training and education of students in medical school nearly as much as do mathematics and the sciences. Any discussion of education must include the question of numbers. How many students should be going into medical schools now and over the next twenty to thirty years? How can we obtain these numbers? There are now in this country roughly 280,000 physicians. If we take thirty-five years as a reasonable term of service for a physician, then we would need about 8000 new physicians per year. By great good fortune, there are 9000 new medical students entering our schools each year. The numbers produced should balance the need, but it is not so simple. First of all, the medical schools must prepare three types of professional men: the practicing physician, the medical scientist, and the medical administrator. In addition, the medical schools must allow for appreciable attrition. Not all of the selection procedures on the part of both schools and students are perfect. Attrition because of inadequacy, disaffection, disability, service outside the United States, and others must be taken into account. Even if we had a static population, the present 9000 entering medical students would not be enough; but the situation is worse than that. T h e population is growing at roughly 2 per cent a year, so that during the ten years that these new medical students are in training, the needs will have risen by well over 20 per cent. (Remember that one has to use the arithmetic of compound interest, but even with the arithmetic of simple interest, it is bad enough.) The rate of increase is likely to continue in this country. My estimate is that

Education

Jerrold R. Zacharias 8 we should be educating at least 12,000 to 15,000 medical students per year at the present time, and that the rate should be increasing at the rate of increase of the population, namely, about 2 per cent per year. These numbers are necessarily soft. One cannot say how many physicians, medical scientists, and medical administrators we should have. My complaint is that the increase in the number of medically trained people has not been keeping up with the increase in the population for the last twenty years. And worse, there has been no constructive planning. This omission can be laid at the door of any group that could have done the planning. I believe that we should not continue to staff our hospitals with physicians imported from nations less endowed than the United States. We should be an exporter of expertise, not an importer. The Coggeshall report 4 states quite clearly that almost 20 per cent of the interns in American hospitals come from nations that we would ordinarily consider as underdeveloped. I regard this as a national scandal. Two graphs from the Coggeshall report (Figure 1) are instructive. If you combine the numbers of internships and residencies for the year 1963-64, some simple addition shows that of the total of 50,000 places offered, only 28,000 were filled by graduates of American medical schools. A total of 22,000 such positions were either unfilled or filled by foreign graduates. This is another simple and immediate reflection of the factor of two that I have been discussing. Furthermore, you will see by the lines in the graphs that the breach is broadening rather than narrowing. It is easy to see why, if you look at the line for the number of graduates of American medical schools displayed in Figure 2. That number is not increasing

A Physicist Views Medical

Education

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