Department of Medicine
Con necting Tec h n olog y, Educ a tion a n d D iscov e r y w i t h H u m a n i s m i n M e d i ci ne
The Patient is the Textbook
history, perform a detailed physical examination, and then synthesize these observations into a differential diagnosis. He required trainees at all levels to teach one another at the bedside, too. After more than a century, many physician educators still believe that learning to confidently manage the seriously ill inpatient is the foundation for providing comprehensive outpatient care. Others note that the opportunity to convert medical knowledge into clinical reasoning is more efficient. Inpatients are sicker. Their needs are more immediate. Students can connect complex disease concepts because outcomes of treatment decisions are answered in real time. Learners may return immediately to the patient to validate their physical findings or review aspects of the history, rather than wait for a follow-up clinic visit. The benefits of inpatient learning do not just apply to medical trainees. Attending physicians often view their rotations with the house staff team as an opportunity to read and review areas of medicine they do not see in their outpatient clinics. Others enjoy the challenge of demonstrating and teaching the critical thinking necessary to unravel complicated clinical problems. “Becoming a physician is like becoming a parent,” says one experienced UTMCK attending. “You can read all the books in the world, even memorize them, but you don’t learn and understand how to do it until you are doing it in all its amazing variety.” In an era where patient scenarios can be simulated in the lab, where the history has become a template of drop-down computer choices and the physical exam is in danger of being replaced by redundant and overlapping imaging procedures, HSM is an anchor to the past, an echo from a simpler time when the patient was the primary text, and some memorable attending taught us how to read.
Over the past quarter century, the management of even the most complex diseases has migrated toward the outpatient setting, yet internal medicine residencies continue to build training programs around a foundation of hospital-based practice. In a survey of internal medicine program directors and internal medicine residents published in the Journal of General Internal Medicine in 2009, more than half of the medical residents wanted more of their training in the hospital. Slightly less than half of the program directors agreed with them. The house staff medicine (HSM) teaching framework traces its genealogy back to Sir William Osler’s organization of the medical service at Johns Hopkins in the 1890s. He established a full-time residency, in which physicians lived a monk-like existence and trained sometimes for seven or eight years. He introduced the core clerkship for medical students, exposing them to intense and real responsibilities of patient care at a time when physicians often left medical school and started practice having never touched a sick person. Osler developed the idea of bedside teaching rounds, where learners of all levels could observe an experienced physician take a
Points of View
Rajiv Dhand, M.D., Chair
In the not so distant past, but certainly until the end of the last century, the “triple threat”--the academic physician who excelled as a clinician, teacher, and researcher-was the envy of physicians all over the world. Young physicians in training aspired to become such individuals, who disproportionately represented the “stars” of academia. Their leadership resonated with physicians and trainees because they represented the best-ofthe-best that medicine had to offer. Surveying the landscape today reveals a shrinking number of physicians
Vol. 3 Issue 3 July 2014
who can rightfully claim to be “triple threats.” Medical research, which transformed modern medicine within the past fifty years, is increasingly becoming the prerogative of large academic health centers and other established research institutions. Financial and sociological factors, among others, contribute to a declining interest in research among trainees in many academic departments. Most medical students have a substantial amount of accumulated debt that can be a significant encumbrance for young physicians. Moreover, clinical, educational, and family demands preclude residents from spending long hours needed for research work. While medical students understandably receive intensive training in clinical medicine, only a few are exposed to the rigors of research. Clinical work comes naturally to physicians, is a priority area, and has a more linear relationship between effort and reward. Research, on the other hand, requires additional training, is cumbersome, tightly regulated, continued on page 3
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