Book Review

Time to Heal: American medical education from the turn of the century to the era of managed care

N Engl J Med 1999; 341:1939-1940December 16, 1999

Article

Time to Heal: American medical education from the turn of the century to the era of managed care
By Kenneth M. Ludmerer. 514 pp. New York, Oxford University Press, 1999. $29.95. ISBN: 0-19-511837-5

Each year, thousands of bright, energetic, highly motivated students are admitted to medical school. I have often pondered how much formal teaching such bright students really need to become excellent doctors. How much does the curriculum matter? How critical is the environment? I asked myself these questions again after reading the last several chapters of Ludmerer's book. They deal with the profound influences of our current system of health care delivery on medical faculty and on the teaching and learning environment of our major medical institutions. Ludmerer skillfully describes how we got into our current educational turmoil. His account cries out for us to think deeply and thoughtfully about how to educate our students and house officers in the future.

In my opinion, Ludmerer, an internist and medical historian in St. Louis, has written the classic work on medical education in the 20th century. Rather than describing the myriad educational programs or techniques set up by individual schools or training programs, he has placed medical students, residents, their teachers, and their institutions in the context of an evolving system of medical practice, medical research, and governmental involvement. From this perspective, he explains how the environment influences students. He explores their mentors and role models: are they caring, do they respect and listen to patients, do they pay attention to details? He expresses concern about the influence on students of the new terms introduced by the conversion of medical care into a marketplace commodity: market share, “throughput,” and population health.

Ludmerer escapes the common trap of historians in which they bracket eras by using dates. Instead, he defines his own periods: an initial period in which the public developed trust in medicine, a middle period of stunning expansion in research and training, and a later period of the erosion of professional values and a deterioration in the environment of medical education. For each of these periods he explores a number of questions: What did the medical care delivery system look like? How was the cost of patient care funded? What were the contributions of federal and state governments to the cost of education? What were the prevailing concepts about the needs of the marketplace for physicians? How did the status of academic medical centers influence teaching programs? How did research support, especially from the National Institutes of Health, influence medical education?

Ludmerer adeptly describes the ways in which money has influenced medical education for more than a century and points to certain benchmarks, including the proprietary medical schools introduced near the turn of the century, the post-Flexner period of minimal educational funding, the growth in the numbers of faculty members and trainees that resulted from the expansion of the National Institutes of Health, the priming effect of Medicare on income from faculty members' practice, and managed care's assault on the time and income of faculty members. Throughout modern history, it is apparent that cash, not educators, has had the dominant effect on the amount and even the kind of medical teaching.

In my judgment, this book is mandatory reading for anyone even peripherally involved in medical education, and it will be the basis for all planning for medical education in the next century. It is critical to reflect now on the direction of medical education, not because the famous ball will descend in Times Square to mark the beginning of a new century, but because of the serious threats to medical education as detailed by Ludmerer.

At no other time in the past 100 years has medical education faced more serious problems. Given the sharp cutbacks in funding for academic medical centers, the new demands on clinical faculty members to bring in more dollars from practice (and thus the reduced time for teaching), the shortened hospital stays of patients, and the biased representation of very sick patients in hospital beds, it is not surprising that many students are now found lacking in the fundamental clinical skills of history taking and physical examination. Moreover, students who begin medical school as idealists become cynical as they witness house officers who treat patients indifferently and physicians and professional organizations that cut the corners of professionalism by adopting a permissive approach toward financial conflicts of interest, product endorsements, and collective bargaining. At the same time, impending technical revolutions, such as the decoding of the human genome and changes in the way we obtain and use information, will have major effects on how we teach, what we teach, and how our students will learn. We ignore these events at our peril.

Those of us involved in teaching and training must immediately begin to envision the future and plan for it. We have not done so very well in the past. We failed to foresee that the focus of care would switch from acute to chronic disease, that preventive medicine would become important, that the system of care was inadequate for the entire population, or that the cost of care would reach a squealing point.

We have a lot of questions to ask. We could start where I did: How much formal teaching do superb students really need to become excellent doctors? How much does the curriculum matter? How critical is the environment? How can we teach better outside the hospital? How can we provide students adequate access to teaching materials? Before we begin to address these questions, however, we need to ask much more about the future of medicine. What will doctors be doing 5, 10, or 15 years from now? Will they face the same kind of clinical issues that they do now? Will they be prepared for the clinical consequences of research in genomics? How will the changing ethnic distribution of the population influence where and how they practice? Will globalization of the economy affect medical practice? What models of care delivery are likely to emerge? What will medical records look like, and where will they be kept? Will the current specialties still be relevant? What kinds of stress will influence physicians' dedication first and foremost to their patients? Will computers finally become sufficiently “intelligent” to give good medical advice? Will doctors get information largely as they do now, or will they receive it on line when they actually need it? Will cost have the same critical role in patient care as it does now?

Planning must continue at the highest level of organizations that contribute to educating students, house officers, and physicians in practice. In the past, such planning was usually done in isolation, with little sharing of resources, as a result of professional competition. Can the information revolution change this approach? Does every educational institution need to develop its own curricular materials? How important will books be? What about paper journals? How promising are new educational concepts such as distance learning and virtual reality — are they worth pursuing, or are they only the newest buzzwords? What about our current love affair with problem-based learning? Is it effective? Is it cost effective? Is it better than traditional methods? Should we give up trying to do real research on medical education until we know more about the ways in which people think and learn?

I have fallen into a common mode — namely, to ask a lot of questions but to provide few answers. I offer no apologies for doing so. The questions often force us to think deeply about issues that are critical to the ways in which we plan for the future. In response to changes in the environment in the past, educators have often made changes in the curriculum and found that these changes energized students and teachers alike for a decade. This approach will no longer work, because changes in the nature and cost of our delivery system and the impending genetic and information revolution are simply too profound to permit that kind of leisurely approach.

Read Ludmerer's book. It contributes the foundation and inspiration for us to meet the challenges of the coming era.

Jerome P. Kassirer, M.D.
Weston, MA 02493