Cohen, Jordan J. MD
The images of heart-wrenching horror that flooded our TV sets on September 11 are still fresh in each of our minds, and will no doubt remain there for a very long time. In that incomprehensible tragedy, who were among the first on the scene to help? Firefighters and police, thank God. But so too were doctors, nurses, and all manner of health care professionals.
One example illustrative of the myriad acts of selfless professionalism in evidence that day involved Tom Terndrup, chair of emergency medicine at the University of Alabama at Birmingham. He was in Brooklyn at a scientific meeting when the first plane hit the World Trade Center. Tom, along with the nurses, paramedics, and other doctors in attendance—nearly all of whom were there representing academic medical centers—went immediately to the crisis scene, provided on-site treatment for survivors, assisted with triage, and then spread themselves out to various New York City hospitals to volunteer their services. All without having been asked.
The utterly unconditional response of these non—New Yorkers in the face of human need, as well as the astounding readiness of the health care organizations in New York and Washington, and the intrepid valor of their personnel, came as no surprise to anyone—that's who we are. The resulting heartfelt expressions, on TV and elsewhere, of admiration and awe for the humanitarian outpouring of health care workers resonated with most people's deep-seated image of medicine as a moral enterprise.
In recent years, however, that deep-seated image of medicine, and of the manifest need for humanitarian physicians, has been badly tarnished by the bashing that our profession has taken from much of the media. Stories about doctors' decisions being overruled by managed care bureaucrats, doctors' not having enough time to listen to, or truly care for, their patients, and the high cost of malpractice insurance driving doctors out of business are all too familiar.
DO YOUNG PEOPLE STILL WANT TO BE DOCTORS?
In the face of all these downbeat messages, do young people still want to become doctors? Or put another way, if your children or grandchildren asked you whether they should pursue a career in medicine, what would you say? That question deserves an honest answer. Considering the downward trend in the applicant pool, the answer could well be “No.” For five years in a row now, the numbers have been falling for both men and women as well as for all racial and ethnic groups.
One conventional explanation for this apparent waning interest in medicine is that it reflects nothing more than the mirror image of the business cycle. When opportunities in other sectors of the economy are booming, some college graduates who might have chosen medicine opt for alternatives, many of which, of course, promise much faster tracks to gainful employment.
Another possibility is the apparent loss of the autonomy that doctors used to enjoy. As everyone knows, few doctors in practice are their own bosses any more. If not actual employees of a health care system of some kind, most doctors practice within the confines of contractual obligations that constrain their decision-making freedom significantly.
A third possible source of discouragement for potential applicants concerns money and the dire predictions that physicians' incomes are on the decline. This issue is of particular concern given the huge debt burdens that most medical students are forced to bear. Over 80% of our graduates are indebted, and the average debt load for that group is now just shy of $100,000. We can only speculate about how many outstanding candidates for medicine are being lost to the profession simply because the prospect of incurring such a large debt is too daunting for them and their families to contemplate. This concern is, of course, especially worrisome for youngsters from disadvantaged backgrounds. This complex issue demands our serious attention.
There is a fourth, theoretical, possibility that I think is contributing to the decline in medical school applicants, and that is the perception that doctors no longer command respect—worse yet, that they are being oppressed by, rather than being guardians of, the health care system.
Unfortunately, that viewpoint is championed by not a few practicing physicians who do view themselves as oppressed and who are among the most persuasive of those advising students not to pursue careers in medicine. I have no idea what fraction of practitioners feels this way, but it is clearly large and vocal enough to have contributed to a growing perception that medicine no longer deserves the wholesome reputation that most of us grew up with.
Doctors are not the only individuals voicing concern about the state of American medicine. Rosemary Stevens, the noted sociologist and respected student of American medicine, believes that the overarching societal view of medicine underwent a substantial change over the past few decades. She writes: “No longer seen as working quietly for the public good, the American medical profession took on sinister, even antisocial characteristics in its role in the culture at large. Some influential critics also revised the profession's history from a glorious narrative of success to a more ominous tale of hubris.” How could such a widespread view of contemporary medicine not be influencing many idealistic young people to seek fulfillment in other lines of work?
What is the bottom line concern, and what does it have to do with us in academic medicine? Obviously, if medicine ceases to be attractive to the best, the brightest, and the most idealistic and public-spirited of our young people, we have a lot to worry about. Not just as medical educators, but as future patients.
My concern is not so much about today. We are still getting many fantastic students of the caliber we need. I'm sure we'd all like to get even more, but what if my supposition is correct? What if many prospective applicants are rejecting medicine for reasons we have never seen before—because they perceive future doctors not as enjoying fulfilling careers, but as enduring a lot of adversity? If this is true, we are illadvised in the extreme to remain complacent about our continuing ability to pick and choose among a surfeit of wonderful applicants.
For openers, we need to realize—and we need to broadcast to the world—that the transformations occurring in the practice of medicine are not, by any means, antithetical to idealism, and are certainly not destined to victimize doctors. As the stewards of medicine's future, we must be prominent among those who paint a realistic picture of the fabulous opportunities and gratifications that lie ahead for the next generation of physcians.
But before we address misperceptions about the distant future of medical practice, we must address some current realities within medical education itself—realities that I fear are also dissuading many promising college students from seriously considering careers in medicine. The first is the way we select students for admission to the profession, and the second, and even more important, is the way we acculturate the students we do admit to become professionals when they finish their formal education.
THE ADMISSION PROCESS
My concern about the way we pick students for admission is the imbalance that currently exists in how we convey to applicants the selection criteria we use. I'm referring, of course, to our tendency to underemphasize, because they are harder to measure, the personal characteristics we are seeking in our applicants, and to overemphasize the more easily measured indices of academic achievement.
I know how tough this issue is. Don't misunderstand me; in no way am I suggesting that native intelligence and academic prowess are anything less than essential for success in medical school, or for becoming an effective physician or scientist. What I am suggesting is that our admission processes do not project to prospective applicants the degree to which we value, in addition to grade-point averages (GPAs) and Medical College Admission Test (MCAT) scores, those other essential attributes we prize: altruism, fervor for social justice, leadership, commitment to self-sacrifice, empathy for those in pain.
That many idealistic students do make it through the process, despite the distorted signals we send them about what we are looking for, is no guarantee that sufficient numbers will continue to do so in the future. If more such intelligent and dedicated idealists were to perceive that we would give as much weight to what's in their hearts as to what's in their heads, a career in medicine would no doubt attract them strongly. As it is, I'm persuaded that many don't perceive this balance in our selection criteria, and turn away convinced that medicine is only for grade-grubbing Philistines.
To balance the strong message we send about the importance of grades and test scores with more visible evidence of our co-equal interest in humanistic attributes, let me offer six ideas for you to consider:
1. Use MCAT scores and GPAs only as threshold measures. Rather than giving more weight to higher scores, why doesn't each school decide for itself, from data available from its previous students, what level of GPA and MCAT performance is sufficient for predicting success in clearing the high academic hurdles of medical school—and leave it at that. We would send a powerful signal to those intelligent idealists who are currently eschewing medicine if they knew that, once having met the academic achievement threshold, they would be evaluated solely on the basis of their humanistic qualities, their penchant for serving others, their leadership abilities, and so on.
2. Even more daring, how about beginning the screening with an assessment of personal characteristics and leaving the GPAs and MCAT scores until later? Rather than looking first for reasons to reject an applicant—such as evidence of a lackluster start in college, or a bad semester, or a “C” in an organic chemistry course, or a “7” on an MCAT subtest —why not look first for reasons to accept an applicant? These reasons can include evidence of deep-seated social awareness, of having triumphed over adversity, of personal sacrifice for the benefit of others. With this evidence in mind, we could then consider the statistical predictors of mastering our challenging curriculum. Approaching their task in this way, admission committees might well find many instances in which truly compelling personal characteristics would trump one or two isolated blemishes in individual academic records.
3. Look even more favorably than you do now on the more mature applicants, those who chose some other field at the end of college, but who awakened several years later to medicine as their true calling. Such students often manifest a depth of motivation that not only predicts success as future physicians, but also provides inspiration to their fellow students.
4. Stop using the average MCAT scores and GPAs of our matriculants as if they were valid measures of the relative quality of our schools. Take a look at the devastating critique of the U.S. News & World Report's rankings of the “best” medical schools in October's Academic Medicine1 and see whether you don't agree with what the authors have to say. In accepting without objection the use of such misleading measures as average MCATs and GPAs, let alone in bally-hooing them in our own promotional materials, we reinforce the public perception that they are, indeed, our principal criteria for admission.
5. Use past experience to improve our ability to spot the truly outstanding prospects. As a general rule, it doesn't take long for a consensus to emerge among faculty and staff about who among each entering class of students are destined to be the best, most caring, most compassionate physicians. They are the ones who win the humanism awards, who tutor their classmates, who are elected class representatives, who are the pacesetters for student-initiated community service activities. Why don't we look back at those students' credentials at the time of admission and see whether we can find some common characteristics that might be helpful in sharpening our ability to identify such stars among future applicants? And let's use even more of those star students as recruiters and as full-fledged members of our admission committees.
6. Help to devise better tools for evaluating students' personal characteristics. It's too easy to assume that the socalled soft qualities we're looking for are beyond our ability to assess any more accurately than we do with our present crude measures. I just don't believe that. But we'll never know for sure unless we try. As a beginning, I have directed the AAMC staff to see what we can do to develop better tools, and I urge all of you to give thought to this tough problem. Not only may we actually succeed in improving our selection process—there are surely many more dedicated and intelligent idealists out there who would recognize our efforts to seek better measures of character traits as a strong signal that we want them as colleagues.
THE ACCULTURATION PROCESS
Speaking of colleagues raises the second unique contribution we, as medical educators, can make to enhance the image of medicine for prospective applicants. That is to come to grips with the way we acculturate our students and residents to become our professional colleagues after we admit them. Unless we can convert our learning environments from crucibles of cynicism into cradles of professionalism, no amount of effort in the admission arena is going to suffice.
If we wish to increase the attractiveness of medicine for those intelligent and dedicated idealists, we can't continue to kid ourselves about our tarnished reputation as responsible educators. The fact is, we are viewed in many circles as making frankly dehumanizing demands both on our students and on our residents. Many in the general public are convinced that we purposely haze students and residents as some kind of rite of passage. How, they ask, can medicine be all it's cracked up to be if it allows its own acolytes to be treated harshly in the process of educating them?
However discomforting those perceptions may be, the fact remains that we do appear to systematically replace some of the nascent virtue evident in our matriculants with a lot of cynicism by the time they finish their residencies, cynicism arising both from the way they are treated and from the way their mentors model—or fail to model—the avowed values of the medical profession. We have tended to assume that the good people we admit to medical school will remain good no matter what kind of behavior we visit on them or parade in front of them. All the evidence points the other way.
If we wish to deepen rather than drain that reservoir of nascent virtue, we are going to have to do more to reconcile the values we actually teach our students and residents with the values we profess to teach them—what my old Stony Brook colleagues Coulehan and Williams have called the tacit versus the explicit values of medicine. I urge you all to read their provocative article in last June's Academic Medicine, “Vanquishing Virtue: The Impact of Medical Education.”2 It is but the latest in a long string of passionate pleas for us to address the gap—arguably the growing gap—between what kind of doctors we say we want our students to become and what kind of doctors we actually teach them to be. In our various courses and pronouncements on rounds, for example, we talk about the importance of caring, compassion, empathy, respect, and fidelity, and about what it means to be a good physician—about the need to be trust-worthy, honest, and committed primarily to patients' welfare. That's the visible, explicit curriculum.
In the hidden, implicit curriculum that students actually experience in their day-to-day interactions, they typically encounter different values. Our learning environments tend to revere, in Coulehan's and Williams' words, “objectivity, detachment, wariness, and distrust of emotions.” And because those implicit lessons are endlessly repeated, and are imbedded in actions rather than just in words, they are much more powerful and enduring. The result is that technical skills come to be valued more highly than interactive skills. More important, our idealistic students who hear us say one thing and see us do another are often quick to sour on virtue, many opting instead for cynicism.
No matter how successful we are in attracting idealistic, properly motivated students to medicine now or in the future, we have little hope of delivering the same number of idealistic, properly motivated doctors to society unless we can close the gap between rhetoric and reality.
We all want to find ways, not only to make medical school and residency training more humane, but to ensure that what we value is indeed what our students and residents learn from us. I don't have a magic solution to offer—there is none, of course—but I do have a concrete suggestion that might help move us a little further in the right direction.
AN EXPLICIT STATEMENT OF OUR COMMITMENTS
Why don't we prepare and disseminate an explicit statement of our commitments, something along the lines of a Compact between Teachers and Learners of Medicine? You should know that I'm taking a cue here from an effort of the American Board of Internal Medicine Foundation in which I was privileged to participate. The foundation spearheaded the development of an international “Physician Charter on Professionalism” because it wished to bolster the resolve of individual practitioners to withstand everyday temptations to engage in conduct that falls outside the norms of the profession.3
Our compact would articulate, as a statement from the collective of organized medical educators, some guiding principles and the norms of conduct we expect of individual faculty members, especially in their roles as models of professional mores for students and residents. It also would spell out the norms of conduct we expect of individual students and residents as members of a learning community in the process of becoming professionals.
Our compact could be useful not only for bolstering our resolve to sustain professional norms of conduct, but also for signaling to applicants that we do indeed have values that are consistent with their expectations of us. Indeed, it could form the basis for a visible social contract, one that faculty and students might actually sign during orientation to medical school and that we might prominently display as a continuous reminder of our aspirations. I offer in the Appendix a sample of such a compact that could serve as a point of departure for schools that may wish to take up this suggestion.
There is nothing new about the commitments called for in my draft. They are all reflected one way or another in a wide variety of activities already well rooted or well under way in our community. Consider the myriad curricular reforms undertaken by virtually all schools in the last decade, as summarized in the September 2000 supplement to Academic Medicine4: the LCME standards on maintaining a supportive learning environment and on preventing student abuse; the ACGME's standards upholding residents' well-being; the focus on professionalism embodied in our Medical School Objectives Project; the AAMC's guidelines on appropriate treatment in its policy guidance for GME. And then there's the widespread adoption of the White Coat Ceremony promoted by the Arnold P. Gold Foundation.
My hope is that by adopting, discussing, refining, reviewing, and ultimately fulfilling the commitments called for in some version of a Compact between Teachers and Learners of Medicine, our community, collectively, can exert more self-discipline and, in the process, prepare our students and residents to face the future with confidence that the profession they inherit will be a true calling—not just a beleaguered occupation.
We dare not fail in this task. For the medicine that our students and residents will inherit has never, in the history of mankind, been more flush with promise. Our job is not only to ensure that our graduates are fully prepared to convert that promise into reality. We also must communicate that promising future broadly to the public so that interest in pursuing a career in medicine remains commensurate with the enormous possibilities that lie ahead.
Beginning with the absolutely breathtaking science that will underpin the future practice of medicine, the power that future practitioners will have to treat, to cure, and, most marvelous of all, to prevent disease is awesome. As we in the academy know better than anyone, the real transformation that medicine is undergoing has its origins, not in managed care, but in our very own laboratories. The confluence of advances in molecular biology, in genetics, and now in stem-cell research is propelling us unstoppably toward a future that previous generations couldn't even begin to imagine. Having the honest-to-God tools to make life so much better for so many people gives idealism an action plan it has long dreamt of but has never had.
As if the power of modern medical science weren't enough, the power of new information technologies to transform the practice of medicine is an additional boon to future physicians and patients, one that is certain to expand the scope and effectiveness of medicine in countless beneficial ways. What better way for an idealistic member of the information generation to satisfy his or her yearning to help people than to participate directly in this phenomenal expansion of medicine's capacity to care for those in need?
Finally, let's not forget the most fundamental and most enduring of all of medicine's attractions, the doctor—patient relationship itself. Stripped of all the trappings—both the negative trappings of medicine's headlong lurch into commercialism, and the positive trappings of medicine's increasingly powerful tools to do its job—we are left with the fundamental reason for medicine's existence in the first place: the universal need for help when we're sick or injured. That's what we witnessed so vividly on September 11. And the opportunity to fill that need is what appeals above all else to the young people we are seeking to be our students.
By strengthening our explicit commitment to the ethical underpinnings and moral imperatives of the doctor—patient relationship, and by making that commitment unmistakably visible to applicants, to our students, to the public at large, and to ourselves, we can ensure that the best and brightest continue to clamor for entry into medicine, the most appealing of all possible human endeavors.
1. McGaghie WC, Thompson JA. America's best medical schools: a critique of the U.S. News and World Report rankings. Acad Med. 2001; 76:985–92.
2. Coulehan J, Williams PC. Vanquishing virtue: the impact of medical education. Acad Med. 2001;76:598–605.
3. ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136:243–6
4. Anderson MB (ed). A Snapshot of Medical Students' Education at the Beginning of the 21st Century: Reports from 130 Schools. Acad Med. 2000;75(9 suppl).
APPENDIX Compact between Teachers and Learners of Medicine
Preparation for a career in medicine demands the acquisition of a large fund of knowledge and a host of special skills. It also demands the strengthening of those virtues that undergird the doctor—patient relationship and that sustain the profession of medicine as a moral enterprise. This Compact serves both as a pledge and as a reminder to teachers and learners that their conduct in fulfilling their mutual obligations is the medium through which the profession inculcates its ethical values.
Duty. Medical educators have a duty not only to convey the knowledge and skills required for delivering the profession's contemporary standard of care but also to inculcate the values and attitudes required for preserving the medical profession's social contract across generations.
Integrity. The learning environments conducive to conveying professional values must be suffused with integrity. Students learn enduring lessons of professionalism by observing and emulating role models who epitomize authentic professional values and attitudes.
Respect. Fundamental to the ethic of medicine is respect for every individual. Mutual respect between learners, as novice members of the medical profession, and their teachers, as experienced and esteemed professionals, is essential for nurturing that ethic. Given the inherently hierarchical nature of the teacher—learner relationship, teachers have a special obligation to ensure that students and residents are always treated respectfully.
Commitments of Faculty
▪ We pledge our utmost effort to ensure that all components of the educational program for students and residents are of high quality.
▪ As mentors for our student and resident colleagues, we maintain high professional standards in all of our interactions with patients, colleagues, and staff.
▪ We respect all students and residents as individuals, without regard to gender, race, national origin, religion, or sexual orientation; we will not tolerate anyone who manifests disrespect or who expresses biased attitudes towards any student or resident.
▪ We pledge that students and residents will have sufficient time to fulfill personal and family obligations, to enjoy recreational activities, and to obtain adequate rest; we monitor and, when necessary, reduce the time required to fulfill educational objectives, including time required for “call' on clinical rotations, to ensure students' and residents' well-being.
▪ In nurturing both the intellectual and the personal development of students and residents, we celebrate expressions of professional attitudes and behaviors, as well as achievement of academic excellence.
▪ We do not tolerate any abuse or exploitation of students or residents.
▪ We encourage any student or resident who experiences mistreatment or who witnesses unprofessional behavior to report the facts immediately to appropriate faculty or staff; we treat all such reports as confidential and do not tolerate reprisals or retaliations of any kind.
Commitments of Students and Residents
▪ We pledge our utmost effort to acquire the knowledge, skills, attitudes, and behaviors required to fulfill all educational objectives established by the faculty.
▪ We cherish the professional virtues of honesty, compassion, integrity, fidelity, and dependability.
▪ We pledge to respect all faculty members and all students and residents as individuals, without regard to gender, race, national origin, religion, or sexual orientation.
▪ As physicians in training, we embrace the highest standards of the medical profession and pledge to conduct ourselves accordingly in all of our interactions with patients, colleagues, and staff.
▪ In fulfilling our own obligations as professionals, we pledge to assist our fellow students and residents in meeting their professional obligations, as well.