From Medskool

During the first two years of medical school, students intensively study the sciences that form the basis of medical practice. These courses have traditionally been taught through lectures and laboratories and tested by rote recall of literally thousands of pieces of information. This model hearkens back to a previous era when physicians were expected to master all the scientific knowledge that then existed as the foundation of medicine. The explosion of biomedical science over the last several decades has rendered this once challenging task now frankly impossible.

THINK, AS AN EXAMPLE, of our knowledge of infectious diseases over the last 50 years. In 1944 bacteria and viruses had been discovered, but little was known about how they caused disease. The entire antibiotic armamentarium consisted of sulfa and penicillin. Medicine had nothing else to offer for a multitude of fatal infections. Today, we know about many thousands of disease-causing organisms and scientists regularly discover new ones. The hospital where I work routinely stocks 47 antibacterial agents, not counting antiviral and antifungal medications that are in their infancy and just beginning to proliferate. The latest edition of a major pediatric infectious disease textbook runs two volumes and 2,395 pages (and it just covers pediatric diseases). A lifetime of study could easily be spent on this one important but relatively small part of medicine. Yet medical students, with a crash course over a handful ‘of weeks, are presented with a vast portion of the current knowledge. Having had no clinical experience themselves (clinical rotations do not normally begin until the third year of medical school), students cannot separate out of the sea of information what is most critical for them to know. So they try to learn it all. Anywhere from two to four other courses are going on at the same time. Students often feel abject at their inability to master all the material, and these very motivated, intelligent young people flounder at their impossible yet seemingly expected task. It is an understatement to say that student morale is often devastated.

IN ADDITION to the sheer weight of modem medical knowledge, the advent of the molecular age of biomedical science adds further educational challenges. A generation ago, the basic science curriculum of medical school focused on subjects like gross anatomy, physiology and pathology, each of which had a palpable and obvious connection to real patients. The birth of molecular biology has forced these traditional disciplines into smaller segments of the curriculum, while much more abstract studies like cell biology, biochemistry and immunology make up an ever-increasing part of the course load. These newer subjects are indispensable to the modern practice of medicine and no doctor would be considered adequately trained without them, but they bring to medical education a level of abstraction and remoteness from living, breathing, whole patients unprecedented in medical history. Simply put, it was much easier to dissect a diseased lung and imagine, even empathize with, the person to whom it once belonged than it is to study the unseeable molecular mechanisms of lung tissue and feel the same connection.

In no way do I propose that medical students not learn the molecular science that has revolutionized medicine. However, our system of medical education has made no allowances for the new challenge that molecular medicine presents to students. Most who choose medicine as a career do so with the intention of one day caring for sick people, but the heavy emphasis on molecular science from the very outset of medical school without any humanizing patient-care experiences to balance it begins to drive a wedge between the physician-to-be and his or her future patients. The impersonal, sterile, unsatisfying doctor-patient relationship that many of us have experienced has its earliest roots here.

Underlying the first two influences I have discussed–the explosion of medical knowledge and the molecularization of medical science–is a philosophy of scientific materialism that dominates medical school education during the early formative years. The intense study of disease almost exclusively from a molecular, cellular and organ perspective without consideration of the intact patient reduces illness to the level of specific defects. The human being becomes nothing more than a conglomerate of molecular pathways and cellular mechanisms. In principle the whole of the human condition is supposed to be knowable in this way. Illnesses once mysterious and even spiritual, stillbirth or depression for example, are at last giving up their secrets to new technologies and modes of investigation. Why then should not all of human experience–an artist’s genius, a child’s love for her mother, the self-sacrifice of a saint-be a function of programmed molecular processes and no more?

This philosophy of scientific materialism is reinforced by the fact that almost all the first-year courses in medical school are taught by Ph.D. scientists, not physicians. Their perspective differs dramatically from that of practicing doctors and their influence, along with the seeming remoteness of the subject matter from clinical medicine, redefines the self-understanding and goals of many students. Having come to medical school to learn to care for sick people, they begin to see themselves as scientists first and caregivers second, if at all.

The only concession that most medical schools make to the humanistic aspects of the profession is a course in medical ethics taught over a few weeks sometime in the first or second year. A few schools have recently introduced more extensive courses roughly centering on the theme “The Physician and Society,” yet these offerings at most represent isolated and abstract attempts to introduce humanism into the students’ vision, coming as they do buried amid the hard science courses that dominate the students’ time.

PERHAPS EVEN MORE fundamentally, students are subtly but strongly taught in the early years of medical school that the career to which they aspire is foremost about science and only secondarily about people. They lose the sense that while science may be the indispensable foundation of modem medicine, the fundamental goals of science and those of medicine differ. Nowhere in medical school is it stated or even implied that science is about determinism–how process A inevitably leads to result B–while medicine is about freedom–striving to help individuals be as healthy as possible to live out their lives in their essential human freedom.

Much of the depersonalizing approach to patients found in medicine today stems from this early dominance of scientific materialism in medical school. Here are sown the roots of dismissing a man with excruciating pain as “the kidney stone in Room 10″ or seeing a dying woman only as a particularly interesting case of breast cancer. Popular medical dramas always portray interactions with demanding or unsavory patients as the root of doctors’ dissatisfaction with patient care, but nothing could be further from the truth. The clinical encounter between doctor and patient remains the ultimate humanizing and empathizing moment in medicine. Unfortunately, doctors routinely reduce patients to their diagnoses and dismiss their humanity because they have been taught from the most formative beginnings of their medical education to think in strictly scientific and not humanistic terms.

The last sweeping change in American medical education came in the mid-19th century, when Dr. William Osler first brought medical students out of the laboratory and lecture hall to the patient’s bedside. Until then, there had been no hands-on clinical training in American medical schools, and caring for sick patients was learned as an apprentice after medical school had ended. Osler’s revolution in teaching formed the basis for the two-year pre-clinical and two-year clinical curriculum that makes up medical school today. As I have indicated, however, this model has become sorely outdated. A new revolution in medical education is needed that would bring the student to the patient’s bedside from the first moment of medical school to allow the humanizing effect of the clinical encounter to flourish. Immersion in the care of real patients from the outset is the only way to counterbalance the influence of the scientific materialism that now predominates. Students will also much more easily gain a sense of what is clinically relevant in the basic science curriculum and can thus direct their own learning more efficiently to deal with the overwhelming quantity of modem medical knowledge.

Some medical schools, most notably Harvard’s, have begun to move generally in this direction. Harvard’s “New Pathway” program introduces medical students to the clinics and hospitals early in their training, but as yet only in small increments. Other schools have followed suit and some may still introduce more radical changes along the same lines. These moves are encouraging and demonstrate that some influential medical educators have recognized the problem. Yet the steps so far have been modest and change slow, as change in medical education is wont to be.

In the end, though, such fundamental change must come. The vast transformation in medical knowledge since Osler’s day is too overwhelming to be taught by the same system without the inevitability of doctors drifting further and further away from their patients. Early immersion in the clinical setting–interviewing and examining patients, observing and assisting physicians, becoming involved in the lives of real patients–is the only answer to the great challenges of medical education today. Otherwise, the exploding quantity of knowledge, the further molecularization of science and the pull of scientific materialism will only more profoundly alienate doctors-to-be from the very people who seek their help.

Voco, vocare, vocatus–the Latin root of the word “vocation” means to summon, to call, to name, to call upon, to invite, to challenge. The American Heritage Dictionary of the English Language defines the word thus: 1) a regular occupation, especially one for which a person is particularly suited or qualified; 2) an inclination, as if in response to summons, to undertake a certain kind of work, especially a religious career. The phrase, “as if in response to a summons,” introduces a mystical quality. If the word “profession” is brought into the discussion, there is a degree of religious-secular conceptual crossover. One definition of that word, from the same dictionary, is: an occupation requiring considerable training and specialized study. In most religious orders and congregations the taking of final vows is referred to as “making one’s profession.” Profession is a part of vocation, but vocation suggests a higher calling, something requiring time, training and commitment, with an ineffable quality that goes beyond a job.

Vocation in Depth.

Religious have explored and developed the concept of vocation in depth and detail. Consider Your Call, a book by Dom Daniel Rees and a group of English Benedictines that examines the vocation to Benedictine monastic life, supplied much food for thought. Three passages from this book apply also to medical training:

* Vocation also means a call to service of other people at some stage in the unfolding of God’s covenant.

* A human person says yes to God in a matter that seems to affect only himself, but the repercussions of his choices are felt far. beyond his own life. He serves the economy of salvation precisely by being or doing what God is asking him to be or do and on his obedience may hinge the destinies of many in ways entirely unknown to him.

* The greatest of all Old Testament vocations is that of Abram. “Go from your country and kindred and your father’s house and to the land I will show you. These three statements suggest service, influence or role model and faith in God’s presence.

Service is a mandate and the easiest topic to discuss. In the Letter of James we read: “You have faith, and I have works. Is that it? Show me your faith without works, and I will show you the faith that underlies my works.” Service need not be as heroic or exotic as that of Dr. Albert Schweitzer or Dr. Tom Dooley. The potential for service in medicine is enormous: waiving fees, working in an inner-city clinic after hours, short-term work in foreign missions, consulting in an AIDS hospice. Only a little imagination is needed. One of the changes in medical education over the past two decades is an emphasis on community service by medical students. This can range from tutoring reading to work with the homeless or medically indigent.

Gratitude.

The impact of the exercise of one’s vocation on the destinies of others is more mysterious. Rarely are we aware of our effect on others’ lives or how others influence our lives. Two personal examples can illustrate this.

My twin brother and I attended a small public high school. Regina Robaczewski, the librarian, was determined that students should become self-sufficient in a library of any kind. About 17 years after finishing high school, while planning the guest list for a party to celebrate his master’s degree, Jim was adamant that Miss Robaczewski, who had been in retirement for over a decade, be invited. He responded to a quizzical look saying, “The only thing I learned in high school was how to use the library, which is how I got through this degree. If it weren’t for her, this party wouldn’t be happening.” The surprise on my face reflected that I had felt something similar years earlier upon first walking into Penn State’s sprawling Pattee Library as a freshman. “Big … but I can handle it.” During the party we were able to thank her for the influence she had on our education. She glowed.

The second passage returns to medicine. After practicing geriatric internal medicine for 10 years, I returned to residency training in psychiatry. In the interim between closing my practice and beginning residency I was able to spend three months working at St. Joseph’s Mercy Hospital in Georgetown, Guyana. Mary Liguori Cantilin, R.S.M., M.D., was one of two surgeons at the 100-plus bed hospital. She made rounds seven days a week and was on duty for stretches of up to two months. Even when she was not officially on duty, she was available to advise me on problems unique to that unfamiliar tropical setting.

Except to attend Mass, Sister Ligouri rarely left the hospital complex in which the convent was located. In her late 60′s, her stamina after two and a half decades as a missionary surgeon in India, Guam and Guyana was incredible, as was her obvious joy in what she did both as a nun and as a surgeon. One evening, a little less than a year later, I received a phone call that she had died suddenly earlier in the day. Looking out over the lights of center-city Philadelphia, where we had hoped to meet during her upcoming from leave, I realized she had, by her dedication and joy in what she did, reminded me of something I was starting to forget: It is a privilege to be a physician.

The lives of both these women, one whose vocation was to teach and the other whose religious and medical vocations were inextricably joined, have had an impact that is probably well beyond anything they could have imagined or realized.

The third text, which promises God’s presence when facing the unknown, is particularly relevant to the physician in training. Abram was asked to leave all that was familiar and trust in God. The limits of his world and existence were to be expanded. Like Abram, the physician is called to go to the limits of his or her world and existence–in this case, the limits of knowledge, ability and physical stamina–and expand them. Becoming and being a physician are not easy. Too little sleep and relaxation, coupled with too much stress and too many deaths, characterize the training of most physicians and the practice of many. Graduation from medical school marks the beginning of more severe challenges and training that continue for three or six or more years. Giving of oneself daily can siphon everything before replenishment is possible. There may be no one to comfort the comforter or heal the healer. Remembering God’s promise to Abram to show the way can take one through some very difficult moments.

Hippocrates Censored.

A tradition older than Christianity outlined the vocation of medicine in the oath attributed to Hippocrates. The oath set out the relationship between physician and student and proscribed giving deadly medicine to anyone if asked, giving a pessary to produce abortion and seducing patients. Two versions of the oath lie before me as I write. The traditional text, from which this synopsis was made, is in a frame that was propped up, along with a crucifix, inside the lid of my father’s coffin in 1974. He was a 1931 medical graduate whose life and vocation influenced many. The version of the oath administered at my graduation from the same medical school 44 years later deleted references to abortion, ignored the mandate to teach and glossed over administering deadly medicine by suggesting only that criminal considerations should stay the physician’s hand. Many schools have revised the oath and others have ceased administering it, thereby changing the ritual of profession.

Over the past few years much has been written describing changes in the business of medicine. They are too numerous to detail here. Capitated care, in which the cost of lab tests, specialty consultation or imaging studies is essentially deducted from the ordering physician’s salary, is one example. The potential for financial interests taking precedence over patient needs is obvious.

A commitment to residency training and teaching, to passing down the tradition and learning, is being questioned as something that is costly to the physicians who do the teaching. The amount of time spent teaching students and residents at the bedside has diminished over the past two decades. This is tragic. The best way, perhaps the only way, to learn medicine is at the bedside or in the clinic, watching seasoned physicians, not slightly more advanced trainees, interact with patients and having one’s own work as a trainee observed and evaluated by those same experienced practitioners.

Continuing Medical Education, or CME, remains a big advantage for the US health system.

But like nearly every other aspect of medicine, CME has undergone radical change in recent years, and there will be more dramatic changes likely to be just ahead. Sure, Dr. Brown still attends an occasional out-of-town conference, but at the core of the CME effort in the new millennium lies the concept of a multimedia CME training location – a comprehensive, local information clearinghouse using the latest technology to aid the physician in the difficult new world of medicine while providing an exciting new opportunity for marketing.

Wide-ranging materials are available on most medical subjects, to provide the information physicians need to best serve their patients, and to advance their specialty training and education. Programs can be custom-tailored for each doctor, following an initial assessment that pinpoints his or her strengths and weaknesses. The staff (or someone on-line) then designs an individual study program with precisely the materials needed to improve practice skills. Materials come in whatever format is best suited for a particular physician, taking full advantage of such new technologies as teleconferencing, electronic consulting, direct television, multimedia programs for personal computers via the Internet, or CD-ROM, video, and audiotapes. The resources of the center are always state-of-the-art.

Industry support underpins much of the activity through innovative sponsorship platforms. Some healthcare companies support the center itself; others underwrite the preparation and distribution of learning materials, sometimes on a cooperative basis.

A revolution underway

But that will be then, and this is now. The CME revolution is already underway and the opportunities for industry participation are wide open. Let us describe a current example that foreshadows the shape of things to come – taking into account that multimedia training locations are not yet up and running.

One pharmaceutical company was looking for an innovative way to introduce a new anti-androgen product for use in the treatment of prostate cancer. Specifically, they wanted to use an educational tool to attract physicians’ attention. The purpose was not to tie the educational material directly to the product, but rather to create awareness among specialty physicians that this company was going to be a major player in this field.

Together, we came up with the idea of sending videotapes that would prepare doctors for urology board examinations. We decided not to send them directly to physicians and residents – that would have been too expensive and represented considerable waste circulation – but to all 126 resident directors of urology at the nation’s medical schools.

The tapes were broken down into three primary parts: comprehensive medical content, questions and answers, and board exam simulation exercises.

In addition, new time-saving technology allowed users to pinpoint exactly the segments of the tapes they wanted to view. Within weeks, some two dozen letters from directors were received, thanking the company for making these materials available at no charge. In fact, the company was so pleased with the results that it plans to continue its educational efforts in other specialty areas, such as oncology.

Does such non-promotional education translate into sales? Not easy to say. Name recognition and goodwill are intangibles. But working in a field where companies compete fiercely to be recognized as leaders by their target audiences, a company that initiates creative programs will likely be remembered … and rewarded.

The concept of multimedia training is at least on the radar screen of the most innovative players, although no one yet knows what to call it, much less what final form it will take. It may be completely “virtual” and accessed from the physician’s home or office; it may include specified carrels in medical libraries or hospitals around the country; or it may involve freestanding multimedia centers in major population centers. Physicians may pay-per-view for satellite-borne applications, or pay “admission” or user fees in a library; or be given complimentary “memberships” by healthcare companies.

Whatever the ultimate configuration, we believe that the concept of multimedia training locations is the emerging new model for CME. Industry will discover dynamic new opportunities to reach audiences in the form of sponsorship and other forms of support through arrangements that satisfy their own marketing objectives as well as Food and Drug Administration (FDA) requirements.

The forces of change

There are many forces fueling the rapid evolution of this concept. Physicians have an expressed need to more efficiently design and manage their continuing education. The relentless squeeze on healthcare costs make the old ways of disseminating CME too expensive and time consuming. There is a glaring need for new channels of communication among industry, CME providers, physicians, and medical schools following the dramatic shift towards managed care. Changes in FDA and American Medical Association (AMA) guidelines during the first half of the 1990s have reduced industry involvement in CME. And, finally, the advance of new information technologies, which have the potential to slash CME costs overnight and to make delivery systems more efficient, have made the concept of a centralized, interactive multimedia center not only practical, but inevitable.

The most obvious manifestation of the cost-reduction pressures in healthcare, of course, is the enormous shift from private practice care to managed care organizations (MCOs) which has deprived many physicians of their autonomy in deciding how much time and money to spend on attending far-flung CME conferences.

The other key change of recent years was the publication of revised FDA (draft) and AMA guidelines. Under the new rules, industry must clearly separate its educational and promotional messages. In some cases, this has drastically limited industry participation in sponsorship programs. Finding new ways to reach its target markets has proved difficult and, often, companies simply opted to withdraw the financial support they had routinely given CME providers such as medical schools and community hospitals. Funds formerly devoted to CME were shifted to other areas of marketing and promotion, weakening the once-strong link between industry and information providers.

Despite these changes, industry’s need to reach these important audiences, coupled with doctors’ need for continuing education still remain, and so does the providers’ need for financial support. And while the role of MCO doctors in choosing specific drug brands may have diminished, their opinions still have substantial influence on therapeutic decisions. The MCOs, meanwhile, have a strong stake in keeping their doctors updated and board-certified, if only for competitive reasons.

The combination of these factors still gives industry a strong incentive to underwrite CME offerings and to use traditional CME providers as a link to physicians. Only if accredited providers sponsor CME courses and materials will doctors be able to earn CME credit, and accreditation remains a driving factor in determining which courses they will sign up for. Ultimately, the prestige of the provider will also greatly influence whether they accept the information as credible.

Finally, the FDA has suggested strongly in its draft policy on pharmaceutical-supported education that partnering with CME providers helps the company to make sure that it meets FDA criteria for objectivity, balance, independence, and scientific rigor. That means industry will usually have to partner with medical schools, accredited communication companies, hospitals, and professional associations. Only if planning and editorial control rests with these third-party sponsors can pharmaceutical companies be sure that they will be able to get word out on their products through educational media without falling afoul of the FDA.

Mutual cooperation needed

The new information technologies, meanwhile, have gone largely unexploited by traditional CME providers, mainly because they have been unable to finance these advances without industry’s support. That’s why the rationale for mutual cooperation is, if anything, stronger than ever.

The bottom line is that physicians are starting to turn away from traditional delivery systems, putting pressure on innovators to blaze new trails. Most industry players, however, are having a difficult time keeping abreast of the new opportunities, much less in deciphering where the future lies.

This is hardly surprising given the enormous amount of change that has taken place over a so short a period. Yet if our prediction is correct – that the future of CME will be focused on centralized, information-centered CME media centers, there will be a resurgence in industry-funded CME in the years immediately ahead. Those unprepared will break down on the shoulders of the information highway while more visionary players surge ahead.