American Physicians and Multiple Intelligences

"This system results in rigid, time-based, non-learner-centered training...Some analysts have suggested that the average duration of medical training could be reduced by approximately 30%--partly by eliminating 1 year of medical school--without compromising physician's competence or the quality of care provided."
--Steven Abramson, New England Journal of Medicine September 19, 2013.

 One of the many things the Phantom admires about his dog is there is no future or past tense in his mind--he lives entirely, as far as the Phantom can discern, in the present tense.

When the Phantom reads and reacts to Dr. Abramson's article about shortening medical school, he is thrown back 40 years to his own experience in medical school, which can only be described as transformative, and he realizes nothing he has to say will be heard as anything but the plaintive ruminations of a man past his prime, stuck in 20th century thinking,  a use-to-was-er, destined for the trash heap of outdated, obsolete ideas and experience.

In some ways, the suggestion to eliminate the 4th year of medical school arises from the decision, motivated by the prospect of financial advantages for the university medical schools of the mid twentieth century, to no longer require specific clinical rotations for the 4th year--no more second rotation to the medical ward, to the surgical ward, to the obstetrical ward--but students could leave the campus entirely, go off to wander Africa, Europe, Asia, as long as their "program" received the very readily granted permission of some dean.  

Most medical students of his era, when queried about the value of that 4th year will say it was the best time they had since 2nd semester senior year in high school, which is to say, it was full blown fun in the fields of the gods of bacchanalia. Then, they will pause, get a funny look in their eyes and say, "But, you know I learned stuff...stuff I'll never forget, some of it was medicine."

What Dr. Abramson is saying, of course, with the phrase "time-based, non-learner-centered," is that simply requiring a student to spend time, a year, four years, before awarding a degree is unnecessary and backward thinking. If a student can learn enough material to pass his examinations in three years, two years, six months, then that examination is the measure of what it takes to be called, "Doctor." 

Of course, this sort of thinking has wrought huge changes in American medicine. If the exam is the only important thing, then it doesn't matter whether you've trained at Harvard or Columbia, or at The American Medical School of the Caribbean, at Guadalarjah, at the Ohio School of Osteopathy--if you can pass your exam, you are as well trained, knowledgeable and competent as the kid from Harvard.

And, for at least two decades, this sort of democratization of opportunity has been operative in American medicine. Unlike the prestigious, high paying law firms which limit their recruitment to Harvard, Yale and Stanford law schools, beyond a very few American faculties of medicine, the only thing that counts when doctors go looking for a job is whether or not they have the paper they need--have they passed their exams, got their licenses, a pulse, and can they speak enough English to find their way to the cafeteria.
 
Well over 90% of American physicians are not self employed, but are employees, and the corporations and groups hiring them do no "vetting," no evaluation of them personally. If they have the paper, they are hired, on short term (not more than 3 years, often one year) contracts and if they do well enough, in terms of producing dollars for the company, they will be offered a new contract; if not, they are sent packing to another job which will hire them on the same basis.

The problem, of course, is the concept of the "the test."  Is there any test which can be given and graded by machine, i.e., which is not essay but multiple choice, or some version of computer format, which can assess the multiple intelligences a person uses to acquire the ability to diagnose and treat patients?

The Phantom thinks of the time an eighteen year old woman was wheeled down the ward floor, direct admission from the Emergency Room, with her eyes rolled up into her head, as if she were fixed focused on the ceiling, weeping.  The wheeled chair passed a gaggle of medical students and interns at the nurses' station, and one of the interns, an Asberger's/ autistic type intern said "Better get a syringe of Benadryl. That's an occulogyric crisis. Someone probably gave her Compazine."  The Phantom ran off with a syringe of Benadryl, injected the patient and her eyes came down, like magic. The Phantom asked the intern how he knew that and he said, "There isn't much I haven't read about. I know everything in Harrison's [the standard textbook of medicine]."  There was the raw power of knowledge, not time spent, nor charm nor personality. 

But, fact remains, the Phantom had also read about occulogyric crisis occurring in children and adolescents given Compazine, but until he had actually seen his first case, it meant nothing to him and he missed the diagnosis. Once he had seen it, he would never forget it. And likely, that intern, who claimed he knew everything there was to know in medicine because he had read every word of every textbook, would never have known what he was looking at,  had he not spent enough time on the busy wards of The New York Hospital, and seen a wide variety of illnesses, drug reactions, and other clinical events.

As far as the Phantom is concerned, the most valuable stuff he learned as a medical student was not in his room with his books--and he spent plenty of hours there--but on that astonishing field of trauma and trial--the hospital, where 30 years of experience could be compressed into four years of trial by fire. It was time-based, to be sure, and it was not "learner-centered"--it was patient centered--but it was where the learner should have been centered.