Knowing What Good Is

One of the best physicians I ever ran across was a man who went to the American University of the Caribbean.  What made him so good?  He read constantly, kept up with all the news in his specialty, infectious disease, which among all the specialties is constantly changing as infectious organisms become resistant to antibiotics and new antibiotics come on line. But more than that, he never failed to take the time to remove the dressing on the wound, which few of his colleagues ever took time to do because time is money and it's such a chore removing dressings and reapplying dressings. He just had that self discipline. If the test of character is what you do when nobody is watching, he passed that one with flying colors, which few of his Harvard educated colleagues did. He stuck with patients, through the hard times, often at his own inconvenience and pain. 

Having said all that, he is the exception. Can you conclude graduates of the American University of the Caribbean are all like him? Not a chance. There simply are not a lot of doctors like him anywhere.  

Decades ago, I thought I could judge other doctors by looking at their training:  If you went to Harvard Medical School, then did your internship at Mass General or one of the other Harvard training hospitals (The Brigham, the Beth Israel) then you were well trained and smart and likely a top notch doctor.  Ditto for graduates of Hopkins and Columbia and Cornell, and for people who trained a big, busy hospitals like The New York Hospital and Memorial Sloan Kettering. Eventually, my world view broadened as I realized not all the smart people were trained on the East Coast, so people who trained at Baylor in Houston or University of Pittsburgh or University of California, San Francisco or University of Washington, Seattle were admitted to the club.  

It was always true there were foolers: Yale, for all the fame of its undergraduate university and Brown and Dartmouth had medical schools which were simply not of the same caliber. 

But the basic idea was you could tell something about the person from the soil in which he or she was grown. Since every physician had to come up through academic centers, from universities, if you could learn the few dozen academic centers, you could establish a hierarchy of quality in your own mind. 

Then came the advent of corporate medicine. Go looking for a job and you find yourself sitting across the desk from a person who had not gone to medical school, who had no idea about this hierarchy and behind that person was a framed diploma from Northern Essex Community College and that person had no idea about judging doctors by the names of their schools. All that mattered to this person is whether or not the doctor had passed his or her licensing exams and maybe his or her board exams, as if anyone who passes these exams is as smart, well trained and well prepared as any other. 

This is the age of "metrics" in which judgments of quality, which were once the provenance of professors of medicine who did rounds with their trainees daily, who quizzed their trainees and read their notes and listened to their presentations, discussions and analyses of cases, now all that evaluation was reduced to "Did he pass his exam?"  

Today, I looked at the training of a new physician who was hired by the corporation which hired me. He was born in Cambodia, graduated from the Saba Univeristy School of Medicine in Saba, the Dutch Caribbean, did his residency in family practice at the Guther Robert Parker Hospital in Sayre, Pennsylvania and he passed his boards in Family Practice.

Is he as well trained as the man who trained at Columbia Presbyterian hospital in New York City where there is a large volume of patients and a huge variety of diseases both common and exotic?  Is it possible to imagine a physician who trains at a small community hospital and sees only a thousand patients over three years with a hundred diseases is as well trained as a man who trained where he saw ten thousand patients and five hundred diseases from the very common to the very exotic?  They both passed the same board exam. Are they not equivalent? 

When systems are designed by people who know only about the design of systems, but not by people who came up through the trenches can they function as well?  This may apply not just to medicine, where doctors who know medicine are no longer included in the process but have been replaced by young MBA's and managers with degrees in system management. This can be applied to the military or to auto manufacturing, I would think.

I do not have the answers, just the questions.  The first is: Have we built dysfunction and low quality into the system?