Doctors: Training for Tomorrow’s Needs

The manifesto rang with a tone of bitter disappointment. “We are growing intellectually passive,” it said. “Much of our time is squandered in academic exercises from which we learn little.”

Rigid curriculum, formal teaching methods, an overlong lecture schedule —little about their studies seemed to please the 25 students who presented their complaints to Dr. Robert H. Ebert, dean of Harvard’s prestigious medical school.

The dean was neither annoyed nor surprised. A relative newcomer to the job (TIME, July 9), he was just back from a White House conference where he had, like his students, questioned most of the basic assumptions of U.S. medical education. Dr. Ebert told the future doctors that they were on the right track. He encouraged them to work out their own choice of lab demonstrations and lectures—in effect, to acquire knowledge as they think best.

Learning to Think. All over the U.S., medical education is suffering from growing pains. The U.S. needs to produce 11,000 new doctors a year by 1975* to maintain the present, barely adequate ratio of one practicing physician to every 1,000 people. Existing schools turned out only 7,400 graduates last year; enlargement of classes, and at least two dozen new schools, should reach the desired goal by the late 1970s. But the problem of quality will remain. Rising living standards and a growing sophistication in health matters are creating a clamorous demand for the best .in health care. And it is this demand that confronts medical educators with their greatest challenge.

Man has learned so much about medicine, says U.C.L.A.’s dean of curriculum, Dr. David Solomon, that “the schools now cannot cover more than a small fraction of the total medical information available.” Yet, paradoxically, several leading medical schools have come to the conclusion that the way to meet the problem is not to prolong medical education but to shorten it. Today, for virtually all physicians, education takes a minimum of nine years after high school: four in college, four in medical school, one in an internship. Specialists spend two to seven years more in an ill-paid residency.

One of the first requirements of a renovated curriculum, says Dr. Hans Popper of Manhattan’s burgeoning Mount Sinai Medical School, is to “replace the process of fact cramming with instruction in the principles of thinking. What the medical student needs most is to learn basic principles.” After that, said the A.M.A.’s Council on Medical Education at a Chicago meeting early this month, the young doctor must put his training to practice as soon as possible.

Four into Three. No matter how well taught, medicine remains an inexact science. “You will find it difficult,” University of Rochester Physiologist Dr. William D. Lotspeich tells his students, “to exist in a state of not knowing—but you must get used to it. You will, unhappily, often have to make decisions on the basis of incomplete information.”

To make sure that the young doctor’s necessarily incomplete information is still adequate, several schools have begun to turn their curriculums inside out. Instead of teaching a few subjects intensively in unwieldy, time-consuming blocks (anatomy all through the first year, pathology in the second), Western Reserve University began as long ago as 1952 to slice the four standard years into three functional phases. It also took the revolutionary step of assigning each freshman student to a pregnant patient, to serve as assistant to all the doctors who care for her and her family for the next two years.

Many aspects of Western Reserve’s reforms have since been adopted by other schools, and last month Dean Douglas D. Bond announced that the Cleveland progressivists already consider their system outdated. They want to break down the big blocks of time still further—mix them so that students will learn more bedside medicine in their first year and get more basic science in upper-class years.

The University of Rochester has put in a “general clerkship” in the third year to introduce the student early to the problems of diagnosis and treatment. All through Rochester’s four years, the student has a wide choice of tutors, and substantial blocks of time are set aside for electives in such fields as psychology, sociology, engineering or chemistry.

M.D. or Ph.D.? Even while they break the tradition of block teaching, more schools are finding other ways to help able and hard-working students to get through faster. Each year, Northwestern University accepts 25 to 30 of the nation’s brightest high school graduates and puts them into a grueling six-year program that combines undergraduate science and the humanities with a graduate M.D. course. Boston University has a similar system; Johns Hopkins puts students, after two years of college, into a five-year M.D. course.

Rhode Island’s Brown University, which has no medical school, began a six-year science program in 1963. Though it will not necessarily shorten the time between high school and practice, it provides four years of undergraduate and two of graduate work, capped with a “master of medical science” degree. Brown’s reasoning: many men headed toward a medical-science career need extra time to decide whether to go to the bedside with an M.D. or into the laboratory with a Ph.D. Under the Brown plan they can go either way and finish in two more years.

New G.P.s. None of the innovations are designed to downgrade either the vital scientific aspects of medicine or the profession’s proliferating specialties. But the most progressive of the schools are going out of their way to encourage a new crop of general practitioners.

What the public wants, say the educators, is a more abundant supply of family doctors—”generalists,” as some G.P.s style themselves. And what the public needs, say the educators, are G.P.s with a difference. “The average G.P.,” says Dr. Ward Darley, former dean at the University of Colorado, “is trying to see 50 to 60 patients a day and do surgery as well. That’s no way to practice medicine today.” What Dr. Darley hopes to see is a specialist in family medicine who will drop surgery and concentrate on the general aspects of psychiatry, pediatrics, and internal and preventive medicine. His status, Dr. Darley says, should be as great as the surgeon’s.

Besides holding a high status, he will offer a more highly valued service. For if the better medical schools have their way, their graduates will soon be concentrating as much on preventive medicine as on curing diseases. To the extent that the curriculum changes are successful, the patients of tomorrow will enjoy both better care and better health.

* Meanwhile the U.S. will avert a crisis in doctor supply only by continued foreign aid: 15,500 graduates of foreign schools (mainly in the Philippines, India and Pakistan) have acquired U.S. medical licenses in the last 15 years. Countless U.S. hospitals are utterly dependent on 11,000 interns and residents from foreign schools.