Thursday, October 14, 2010

Seven Ways Medical School Education Has Changed in the Last 50 Years

In a perceptive essay in the October issue of Connecticut Medicine commemorating the 200th year of the Yale Medical School, Robert H. Gifford, MD, Emeritus Professor of Medicine and former Deputy Dean of Education at Yale Medical School, describes changes in medical education over the past half century. Doctor Gifford, who has been educating medical students during those years and who even today serves on the admissions committee, describes these changes and observes that many of them have been profound.

One, competition for admission has increased. In 1957, there were 1000 applicants for 80 slots. In 2010, 4000 students applied for 100 slots. IN 1957, most applicants were white men. IN 2010, almost half were women, 15% were minorities, and 30% described themselves as Asian.

Two, Yale now offers a greater variety of support services to make the process of medical school education more pleasant and personal. The school now has deans and directors of admissions, student affairs, student research, minority affairs, women in medicine, and financial aid.

Three, the knowledge base required of students has expanded exponentially. The school has responded with small group seminars, courses in medical ethics, health-care policy, and legal medicine, and has integrated and centralized teaching. Today, PowerPoint slides dominate lectures, students gather material from the Internet, students come to lectures bearing laptops. Hours spent in the dissection room are down, and time spent on computerized manikins and simulated experiments are up.

Four, the patient mix is different. Hospitalized patients are less available for teaching fundamentals. The patients are sicker, more complex, and are rushed in and out of the hospital. To compensate, the school now uses trained “patients,” or actors, known as “standardized patients,” and medical students practice the physical exam on one another.

Five, there is more formal teaching , with lunchtime conferences, attending rounds, more resident staff supervision. At the same time, there is less “scut” work for medical students – blood drawing, lumbar punctures, bladder catheterizations, parancenteses, examinations of blood smears, urine sediments, Gram stains of sputums, less handwritten write-ups for the medical record, less teaching by outside practitioners.

Six, today’s medical students are more interested in preparing for careers in surgical subspecialties, radiology, and dermatology than in family medicine, internal medicine, or pediatrics. The shift has been dramatic. Graduating students at Yale in 2010 had an average debt of $132,000. Students now select specialties with regular hours, benefits, time-off for family, and higher incomes. The most popular specialty choices are emergency medicine, radiology, orthopedics, neurosurgery, ophthalmology, otolaryngology, and dermatology . Qualifying for these specialties has become competitive, and students virtually disappear for two to three months at the end of their second year to prepare for Part I of the U.S. Medical Licensing Exam.

Seven, legislation limiting resident work hours has created problems . Hospitals must hire more residents. Residents now must “hand off” patients to incoming residents to comply with rules limiting hours. Because of increases in patient turnover and sicker patients , this creates a frenzied environment complicated by the resident’s administrative burdens to admit, discharge, arrange for tests, contact consultants, search for results. Residents find themselves spending more time behind a computer rather than at the bedside.


Doctor Gifford sums up medical school changes over the last 50 years as follows.

“In summary, there have been significant educational improvements, particularly during the first two years of medical school. Students today are more accomplished, more diverse, and there is now a focus on the highly relevant basic science of medical practice, including medical ethics and public health. The curriculum has been centralized and coordination between various departments has vastly improved as a result. The number of lectures has been reduced, replaced by more effective small-group, problem-solving seminars. Support services for students has made medical school a much more pleasant experience.

On the other hand, the dramatic shift in the nature of hospitalized patients has adversely affected traditional bedside teaching that was such an important part of medical education in the past. Extensive diagnostic evaluations now take place in an ambulatory setting. Hospitals and medical schools have not yet found a satisfactory way to integrate trainees into these venues.

Finally, there has been a marked decrease in the number of graduates seeking careers in primary care, a phenomenon influenced by huge educational debts, the attraction of being able to master a defined discipline, and the desire to combine medical life with a reasonable life-style.

On balance, although the overall education of our future doctors has definitely been improved in the last fifty years, the erosion of fundamental clinical skills has been a disappointment.”


Kent Knauer said...

When I was trained at U of M in the 70's, tests were done to "test your hypothesis" not to figure out what is wrong with the patient. The cost of testing was also emphasized. There were few radiologic tests available then as well. We had a lab where we actually performed some tests. As more testing became available was it relied upon more, at the expense of being a good diagnostician?

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