From the day I got back my first college biology exam and realized I just might be able to be a medical doctor some day, I have had to think about that imperfect, dysfunctional, ridiculous, arduous and discouraging process called medical education, as it exists in this United States of America.
It's a story of sheer stupidity, cupidity, commercialism in the worse sense, but it has produced some pretty good doctors along the way.
Recently, some New York medical schools and hospitals have expressed misgivings about foreign medical school graduates as they insinuate themselves into training programs at various city hospitals. This provoked a number of letters to the New York Times, mostly from paid spokesmen for various interest groups, but one from an American physician who had moved to Canada and found his American medical training was judged inadequate by the Canadians. He concluded for all our bragging, the American system of medical education was inferior to the Canadian system.
He may have had his own axe to grind, but I am prepared to believe we may not have the best system of medical education in the world.
We likely have among the most exclusive and competitive medical schools, by which I mean we make it difficult for applicants to gain acceptance, but it remains an open question whether we are excluding the right applicants and admitting the "best" ones.
And that just speaks to the process of undergraduate premedical education, by which we cull the applicants. What happens when students actually become medical students is another matter.
Beyond medical school, there is the real show, internship and residency, what is called "Post graduate training" by which newly minted MD's are turned into real, useful doctors.
The problems with this phase of training have been widely presented, discussed and dissected, mostly by people who do not know what they are talking about, or by people who've been through it and want to tell you how tough it was and how it was the only way to forge physicians and surgeons of sufficient toughness, steel tempered by the hot flames of intensive training.
From the perspective of years and watching all the changes in the system, I'm more humble than I was when I was freshly minted.
For one thing, the landscape into which all these new doctors are dumped has changed.
When I entered private, solo practice years ago, most of the doctors who had trained me and most of the doctors I saw around me were self employed. Now fewer than 12% are. Eighty-eight percent of practicing physicians, I am told, are using W-2 forms, not 1099's. How many of these are actually self employed, but employed by a small doctors' group of 10 or less calling themselves a "practice," is unclear.
But now there are all sorts of "practitioners" out there. In a highly competitive market like Washington, DC, New York, Philadelphia, Boston, most of the doctors are MD's but beyond these concentrations of doctor rich cities, there are significant percentages of "DO's," doctorsof osteopathy, who deliver a lot of medical care in smaller cities and towns.
Beyond the DO's are nurse practitioners who practice in offices without doctors, doing many of the things only doctors were allowed to do in the past--writing prescriptions, ordering expensive tests like MRI's, nuclear medicine studies, CAT scans. And there are Advanced Practice Nurse Practioners, Physicians assistants, Nurse practictioners, specialized nurse practictioners in dermatology, urology, as well as general practioners nurse practictioners in family practice and internal medicine.
There are podiatrists doing complicated reconstructions of feet in the operating rooms.
And in smaller towns you have homeopaths, chiropractors, optometrists, naturopaths, writing presciptions, advising patients.
There are any number of certified practitioners, all the way from certified nurse midwives (who have two to four years of college, two years of nursing school and two years of nurse midwifery training) to certified diabetes educators (who may be nurses or dietitians) and pharmacists, pharmacy techs,
There are nurse anesthetists, putting patients to sleep in the operating rooms. There are surgical physicians assistants doing procedures we used to sweat bullets over when I was an intern trying to learn these things--thoracentesis, subclavian sticks, cut downs on peripheral veins, harvesting veins for bypass grafting
Just about any procedure you can name has been "Certified" with some sort of exam and somebody who may have graduated high school can be trained to do it.
Of course, this does not apply to colonoscopy or any procedure which is still a cash cow for some group of doctors--there the MD's only are allowed to do a procedure which takes six months to a year to master.
And the MD's have changed. There are now as many or more women medical doctors emerging from medical schools as males, and these women are not at all reluctatn to say their children come first, before the needs of their patients.
There are women doctors who have changed the whole dynamic the whole psychology of medical practice. One "Laser dermatologist" told me she did not want to cut out a pigmented lesion she noticed on a patient because if it came back as a melanoma, she'd feel uncomfortable having to give the patient the bad news. She wanted to do only cosmetic dermatology in her beautiful office, which she had spent six figures on creating with the help of architects and interior decorators, and where she sold her own line of dermatologic lotions and make up. She took month long vacations in Europe because she had a European boyfriend. She could do this because she made more than $400,000 a year doing laser dermatology.
And she saw nothing about this to apologize about.
She was trained at Duke and Harvard. She was the best of the best, as far as she was and she practiced in a glamor city among the rich and famous.
In the same city, I knew a man who graduated from the American Medical School of the Caribbean and he trained at a non university hospital for his residency before gaining his fellowship at Georgetown. He has worked his way up, in status terms from a "fourth rate" medical school to a "third rate" residency to a university fellowship.
And I never have had the privilege of practicing with a better physician in thirty years. He was up to date in the medical literature, an astute clinician, a wonderful observer, but mostly he always put the needs of his patients first, no matter how late it made him, how much it cost him personally or financially, and he never failed to take the time to remove the dressing to look at the wound, while all the graduates of the first tier medical schools and programs raced past their patients.
Now, basing broad conclusions on exceptional cases, is an invitation to bad policy, I know, but it's tough to know how to do the best job when you can see the exceptional cases out shining the Ivy Leaguers.
If I were the benign dictator of medical education, I could (as could many of my friends) do a much better job than is currently done.
But we do not have a benign dictator.
We've got what the union army had during the civil war, a lot of generals with political connections, who fell along a spectrum of being simply inadquate to being truly disasterous.
But we're only talking about medical training medical care here.
It's not like having the wrong people at the head of General Motors and Chrysler. If you have the wrong people in those positions those industries crumble from pressure from foreign competitiors.
With medicine in this country, you can keep telling everyone they've got the best system money can by and nobody will ever know the difference.
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