Nurses and doctors in the trenches

I had to drop everything else I was doing and study both of these fine books. I'd actually bought Dr. McCarthy's book first and was eagerly delving into it (after finishing Bob Watcher's excellent new book release "The Digital Doctor" -- scroll down), when "The Nurses" hit my radar. I downloaded it and read it from cover to cover before returning to "The Real Doctor" (which I'd initially cited in my April 16th post).

Both books are utterly compelling.

Stay tuned. This is gonna be a long one. There will be much triangulation with other books on the clinicians' POV (BTW, we'll be focused on the acute care settings).

For now, my elevator speech:

Their hard-won, sophisticated, indispensable clinical skills aside, nurses and physicians are just people like the rest of us, people more or less beset by all of the frailties, foibles, insecurities, and neuroses that typically dog us all across the breadth of our lives. The fractious, high-stakes, irreducibly high cognitive burden organizational environments within which they must function are neither of their design nor under their control, and can (and unhappily do) exacerbate interpersonal difficulties that are counterproductive to optimal patient care. I call the syndrome "psychosocial toxicity," and have blogged about it at some length in prior posts.

It's hardly confined to healthcare, to be sure, but organizational cultural dysfunction in healthcare is ultimately a patient safety issue. To the extent that we continue to view clinical co-workers through "transactional/instrumental," "superior/subordinate" lenses, our improvement efforts will be significantly hampered.

Thinking about nursing school or med school? Read both of these books ASAP. Thinking about healthcare QI, healthcare policy more broadly? Read both of these books ASAP. Thinking that you may become an acute care patient? Read both of these books ASAP.

I read everything I can relating to clinical pedagogy and process imperatives in order to better inform my views on digital health IT (the nominal topic that started this blog nearly five years ago) and healthcare process improvement. apropos, as I asserted last June:

In the face of a dysfunctional healthcare work culture, the best talent will take their skills elsewhere at the first opportunity. A psychosocially healthy workplace, then, is a significant profitability and sustainability differentiator.

A lot to think about today. Beyond citing illustrative excerpts from these books, we'll have to be going back "Down in the Weeds'," and thinking more about "The Art of Medicine." And, ruminating a bit more on the clinical process implications of Marx's "Just Culture."

THE NURSES

This book follows the lives of four nurses as they deal with their tumultuous jobs and their complicated lives. Additionally, topical chapters are interspliced throughout that deal with organizational and policy issues. A nice touch, that.

PROLOGUE

Four hospitals stand within a fifty-mile radius of a major American city. On the surface, they are as different from one another as fairy-tale sisters. Pines Memorial Hospital is a pleasant-looking cream-colored building with a sixteen-story tower and broad, welcoming windows overlooking a quiet tree-lined suburban avenue. After decades of independence , the neighborhood’s favorite hospital was bought out by Westnorth, a large healthcare corporation, which is slowly diluting the local flavor. With 190 beds, Pines Memorial serves a highly educated, wealthy population with a large percentage of academics, retirees, and nursing home residents. Because it is close to a major highway, Pines’ emergency room, which has approximately 60,000 visits per year, often treats victims of major-impact car accidents. Nurses joke that the hospital should be called Highway Memorial, because the risks of the highway are far more relevant to the medical staff than the quiet red pine forests outside of town.

Several miles away, South General Hospital occupies a mostly gray edifice curved away from the road, as if to shield its inhabitants from the gang violence that occurs frequently nearby. The Level-1 trauma center— designated as such because it has the resources to treat every stage of injury, from prevention through rehabilitation— has 300 beds to serve one of the most indigent areas outside the city. South General’s ER sees 95,000 ER patients annually. The reputation of “The South ” is like that of the proverbial kid from the wrong side of the tracks, hoping to keep up with her peers, but unable to overcome the disadvantages of living on the poverty-stricken south side of town.

Forty-five minutes west, in a peaceful corner of the city, Academy Hospital, proud and prestigious, inhabits several white-pillared, brick structures that wind around courtyards and patios, reflecting the storied architecture of its surrounding university campus. With approximately 425 beds, Academy treats a ritzy demographic of young and middle-aged residents in the nearby million-dollar homes and the students at the elite university. The Academy ER treats fewer than 45,000 patients per year, partly because it simply does not have the building space to expand its emergency department walls.

And Citycenter Medical, a longtime teaching hospital, is split between two dusty beige high-rises, perhaps representative of its dual personalities: a stalwart institution with top-notch doctors and an ER so poorly managed it is considered dangerous by many of its own staff. A 390-bed Level-1 trauma center, Citycenter has an emergency department that is crumbling beneath the weight of the 85,000 annual patients it does not have enough nursing staff to treat properly. While Pines Memorial treats more blunt force, multisystem traumas because of the car accidents, Citycenter’s traumas are typically isolated injuries, such as gunshot wounds. Easily reached by public transportation and in the heart of a densely populated city, Citycenter is a destination of choice for homeless people, drug-seeking addicts, and the uninsured.

In each of these disparate institutions, pale blue curtains shroud pods of frightened people. In each, seasoned healers perform routine procedures and medical feats behind bleached sterile walls. And in each, tracking invisible undercurrents through hallway mazes, nurses connect doctors to patients, carrying out copious orders in synchronized steps, entwining themselves intimately in convalescents’ lives.

Robbins, Alexandra (2015-04-14). The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. Workman Publishing Company. Kindle Edition, location 32.

Nursing is among the most important professions in the world.

In no other profession do people float ably among specialties, helping to ease babies into being, escorting men and women gently into death, and heroically resurrecting patients in between. There are few other careers in which people are so devoted to a noble purpose that they work twelve, fourteen, sixteen straight hours without eating, sleeping, or taking breaks and often without commensurate pay simply because they believe in the importance of their job. They are frequently the first responders on the front lines of malady and contagion, risking their own health to improve someone else’s. Nursing is more than a career; it is a calling. Nurses are remarkable. Yet contemporary literature largely neglects them...

To examine what it is like to be a member of this secret club, I interviewed hundreds of nurses in the United States and several other countries. Essays based on their perspectives of the behind-the-scenes realities of nursing support stories that follow a year in the life of four ER nurses in an unnamed region of this country. Most of the people and hospitals in this book have pseudonyms and/ or identifying details changed or omitted to protect their privacy. Some chronologies have been shifted. 

The nurses I chose as main characters illustrate a variety of triumphs and struggles common in the profession. Confident, funny, and charmingly bossy, Molly is well loved by both patients and staff. When Pines Memorial’s anti-nurse policy changes lead her to quit her job, she signs with an agency instead. Molly has given herself one year to find a hospital that treats nurses and patients well enough that she would want to join its staff. At the same time, she begins fertility treatments that place her on the other side of the curtain. 

Lara, an able, trustworthy, committed ER nurse at South General, continues to battle the temptations of prescription drugs that are preposterously easy to steal, and doesn’t know that the coming year will bring major events that could trigger her downfall. Juliette, an ER nurse at Pines, is a hard worker who doesn’t hesitate to advocate loudly for her patients even when it is not in her own best interest to do so. Her blunt outspokenness does not endear her to many of her colleagues. Subsequently, she feels unwelcome in a workplace where patients’ lives depend on collegiality and communication among staff. And at Citycenter Hospital, Sam is a new nurse, young and awkward, whose introversion can come across as unprofessional. Sam is discouraged by her doctors’ and administrators’ overall lack of respect for nurses, but she has to overcome other hurdles, including rumors about her promiscuity. [ibid, pp. 23-25]

 On healthcare's all-too-prevalent "bully culture"

Doctor Versus Nurse

Molly’s experiences with egotistical doctors are not atypical. In fact, they barely scratch the surface of an even more disturbing trend, a doctor-bully epidemic that one doctor described as lurking in the “shadowy, dark corners of our profession.”

In news reports and hospital break rooms, stories abound of doctors berating nurses, hurling profanities, or even physically threatening them: shoving matches in the operating room; a surgeon pushing a nurse so hard mid-operation that he left a bloody handprint on her scrubs; physicians throwing stethoscopes, scissors, pens, or surgical instruments. Physical abuse by physicians is on the rise. In Maryland, a surgeon yelled at a male nurse, “Are you stupid or something?” and threw a bloody surgical sponge at him from across the room. A Texas doctor heaved a metal clipboard at an advanced-practice nurse and told her he was going to strangle her. A surgeon threw a scalpel at a Virginia nurse, who said, “He was angry because I didn’t have a rare piece of equipment he needed, so he endangered me and several others by throwing a tantrum.” North Carolina nurses referred to one doctor as “He-Who-Must-Not-Be-Named,” because he got into a fistfight with another doctor and physically assaulted a nurse.

Most nurses have been victims of or have witnessed doctor bullying. The Institute for Safe Medication Practices (ISMP), a nationally respected nonprofit watchdog organization, has reported rampant bullying in healthcare, including verbal abuse, threatening body language, condescension, and, though less common, physical abuse. A 2013 ISMP survey on workplace intimidation found that in the preceding year, 87 percent of nurses encountered physicians/ prescribers who had a “reluctance or refusal to answer your questions, or return calls,” 74 percent experienced physicians’ “condescending or demeaning comments or insults,” and one in four nurses had objects thrown at them by doctors. Physicians shamed, humiliated , or spread malicious rumors about 42 percent of the surveyed nurses. As a New York critical care nurse said, “Every single nurse I know has been verbally berated by a doctor. Every single one.”

This is a global problem. Significant numbers of nurses in Australia, South Africa, Hong Kong, Canada, and many more countries are bullied by doctors, according to surveys. In 2010, a nurse in India committed suicide reportedly because administrators would not address her complaints about a doctor who was sexually harassing her. A nurse’s association president said, “This case has not been taken seriously because the victim is a nurse.” In South Korea, a 2013 survey found that more than half of nurses were sexually harassed; the majority of the assailants were doctors. Doctor bullying has many serious ramifications. A 2013 study found that the more that nurses experience it, the more likely they are to report poor working environments and to quit their workplace and/ or the nursing profession. This is not the first study to find a link between doctors’ intimidation and poor nurse satisfaction, yet researchers repeatedly have found that most nurses don’t speak out against the behavior.

Why is hospital bullying veiled in organizational silence? Nurses are afraid to report doctors because they believe administrators will prioritize and refuse to penalize physicians who generate revenue or garner media accolades. They worry they might lose their own jobs in retaliation, and they fear the stigma of being perceived by colleagues as a whistle-blower. [ibid, pp. 50-52]

Nurse on Nurse

Nurse-to-nurse bullying has been called “a silent epidemic,” “professional terrorism,” “insidious cannibalism,” and “the dirty little secret of nursing.” And it is crucial that the public learns about it— and hospitals eradicate it— because it affects patient care.

Workplace bullying can happen in any profession. It may come as more of a surprise from nurses, who are expected to be nurturing, empathetic, and caring. But the numbers are staggering. In the United States, a Journal of Nursing Management study found that 75 percent of nurses had been verbally abused by another nurse. It is so pervasive that even the American Nurses Association observed, in literature for its members, “Most of us could probably recount at least one story in which we as nurses encountered or witnessed workplace bullying.”

Nurse bullying is a significant problem in many corners of the world, in countries as diverse as England, Japan, Portugal, Finland, Australia, New Zealand, Ireland, Taiwan, Poland, Canada, and, a country with particularly high rates, Turkey. Worldwide, experts have estimated that one in three nurses quits her job because of it, and that bullying— not wages —is the major cause of a global critical nursing shortage. “We are not ‘angels in white,’” a Japanese nurse told me.

One of the most sobering statistics comes from Boston Medical Center’s director of nursing education and research, Martha Griffin, who found that nurse bullying is responsible for 60 percent of new nurses leaving their first jobs within six months and 20 percent leaving the profession entirely within three years. “It is destroying new nurses,” a Kansas nursing instructor told me. “I have five students who graduated less than a year ago who quit the nursing profession because of this behavior. It makes me very sad.”

It is tempting to attribute nurses’ hostility to their high-stakes work environment. But studies show that more nurses experience bullying from peers than do doctors or other healthcare staff. And nurses are verbally abused more frequently by each other than by patients, patients’ families, and physicians.

As distressing as it is for a nurse to be bullied by a physician, disruptive-behavior expert Alan Rosenstein reported that nurses are more upset by nurse-on-nurse “backbiting and unnecessary scrutiny.” As one nurse wrote him, “I expect that behavior from the surgeons, not the nurses, because I rely on them as my peers.”

In 1986, nursing professor Judith Meissner coined the phrase “nurses eat their young” as a call to action for nurses to stop ripping apart inexperienced coworkers. Nearly thirty years later, the practice festers, and while younger nurses may more often be targeted, no nurse is immune. As a Washington State Post-Anesthesia Care Unit nurse said, “There is a culture of treating other nurses like dirt.” The mystery is why this behavior continues. [ibid, pp. 129-130]

Again, none of this organizational psychosocial toxicity is unique to healthcare. But, the potential adverse stakes for patients are orders of magnitude higher than they are for customers of WalMart.
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THE REAL DOCTOR

We start with Matt McCarthy's painfully candid recounting of his initiation into his first year internship:

Seeing a new patient wheeled into the cardiac care unit, I leapt up from my seat.

“Easy,” said the physician next to me. He placed a hand on my shoulder and guided me back into my chair like a trainer gentling an unsteady colt. “Give the nurses a few minutes to do their thing.” He spoke softly and bore a surprising resemblance to a Charles in Charge–era Scott Baio, all black hair and good-natured smiles. His nose was perhaps slightly too small for his face, in contrast to mine, of which the reverse was true. “The nurses are going to do a lot more for him tonight than you and I are.”

I nodded and eased back into my seat. “Okay,” I said to Baio as I straightened my scrub top. I was anxious. I was excited. I’d just chugged a large iced coffee and could hardly sit still.

After my surgery experience with Axel and McCabe, I had moved on to Harvard’s rotations in neurology, psychiatry, radiology, internal medicine, pediatrics, and finally, obstetrics, where a young Jamaican woman let me deliver her child on my first day. She insisted on giving birth on her hands and knees , her back arched like that of a cat as the baby slowly emerged. An amused midwife later said that I had looked like a nervous quarterback, receiving a snap in slow motion.

As medical school graduation approached, choosing a specialty had proved to be difficult. Ultimately I had settled on internal medicine because it was the broadest field, the one that might allow me to feel like a jack-of-all-trades. But tonight was my debut in the big show, a thirty-hour shift taking care of critically ill patients and responding effectively to anyone who might roll through the door.

“We’ve got a few minutes,” Baio continued, “and I know this is your first night in the hospital. So let’s go over a few things.”

“Great!” I replied. Our orientation leaders, a peppy group of second-and third-year residents, had instructed us to exude a demented degree of enthusiasm at all times, which wasn’t difficult now that my blood was more caffeine than hemoglobin.

“Just relax,” he said, “and take a look around.”

Together we scanned the fluorescent room, an enclosed space the size of a tennis court containing critically ill patients and upwardly mobile Filipino nurses bustling between them. The perimeter, painted a regrettable shade of yellow, housed the patients in glass cubicles, while the center, where we were sitting, was mission control, filled with chairs, tables, and computers.

“It’s just you and me tonight,” Baio said, whipping his stethoscope back and forth around his neck. “And eighteen of the sickest patients in the hospital.”

Every night an intern and a second-year resident presided over the CCU. Tonight was our turn, as it would be every fourth night for the next month. All of the patients in the unit were on ventilators except one, a large Hispanic man who was riding a stationary bicycle and watching Judge Judy in his room. “These patients are receiving some of the most complex and sophisticated therapies in the world.” Baio reached for an antebellum bagel that was sitting on a platter nearby. “Patients get referred to the cardiac care unit when hope is lost or after something devastating happens. Balloon pumps, ventricular assist devices, transplanted hearts, you name it.”

Until a few days ago, I had never set foot in a cardiac care unit. Nothing about the setup looked terribly familiar. I continued to study the room, trying to decode the symphony of incessant beeps and alarms and wondering what each of them meant. It felt like I was sitting in the middle of a giant equation with infinite variables.

“These patients should all be dead,” Baio went on. “Almost every one of them is kept alive by an artificial method. And every day they’re going to try to die on us. But we’re going to keep them alive.” He paused for effect. “And that’s fucking cool.”

It was fucking cool . Back before my stint in the minors, I had studied molecular biophysics and briefly flirted with the idea of going to graduate school in that subject, using my degree to solve the structure of molecules that were too small to be seen under a microscope. But the field lost me when a professor, a young crystallographer , introduced the importance of imaginary numbers in biophysics. Try as I might , I just couldn’t wrap my head around that quixotic concept. I wanted to translate science into something more concrete, more tactile, to seek a profession where I could touch and see and feel . So I changed course and pursued medicine. And thus far, it had seemed like a wise decision. Nothing about this moment with Baio seemed imaginary. Quite the contrary, it felt excessively real.

Baio wiped off the bagel crumbs on his scrubs and leaned in close to me, bringing scores of punctate pores on his nose into focus. “We have to work as a team. Everything is teamwork. So I need to know what you’re able to do. The more you can do, the more time I have to think about the patients. So rather than listing the shit you can’t do, tell me what you can do.”

My mind went blank. Or more accurately, I searched it and found it was blank. “Well…” I glanced at the sedated patient before us. He was on a ventilator and had a half dozen tubes in his neck, arms, and groin, almost all of which pulsed with medications I’d never heard of. As a medical student, I had been exposed to all sorts of patients. But all of those encounters had involved walking, talking, reasonably well-functioning individuals. Lying there, inert and blanched of all color, the patient before me seemed well beyond the reach of my limited powers. If he needed his appendix out or his face stitched together, I was his man. But intensive cardiac care? The learning curve in medicine was so unforgivably steep. What could I possibly do to assist him?

Finally Baio broke the silence. “All right,” he said, “I’ll start. Can you draw blood?”

“No.”

“Can you put in an IV?”

“No.”

“Can you put in a nasogastric tube?”

“I can try.”

“Ha. That’s a no.

Ever done a paracentesis?”

“I’d love to learn.”

He smiled. “Did you actually go to medical school?”

Even I had to wonder. If Baio had been asking me to recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show. But I hadn’t learned much of the practical business of keeping people alive, skills like drawing blood or putting in a urinary catheter. Harvard hadn’t prioritized them. In fact I had been allowed to skip the CCU month of my med school training at Mass General so I could learn tropical medicine in Indonesia. Who had talked me into that?

“I graduated from Harvard earlier this month.”

“Oh, I know you went to Haaahvaahd,” Baio said with exaggerated fake reverence.

“But do you know how to order medications?”

A bright spot.

“Some!” I practically beamed.

“Do you know how to write a note?”

“Yes.”

The moment I said it I realized just how paltry a contribution it would seem to him. Baio must have seen my face drop.

“That will actually be a big help ,” he said. “Examine every patient and write a note on them for the chart. That will save me time. You need to be concise yet precise.”

McCarthy, Matt (2015-04-07). The Real Doctor Will See You Shortly: A Physician's First Year (pp. 14-17). Crown/Archetype. Kindle Edition.

As his internship concludes,

I had spent the final weeks of intern year dissecting my initial struggles and had come to the conclusion that early on, I simply hadn’t had the capacity to fully immerse myself in my patients’ realities. I was so busy trying to master the medicine— to listen for a murmur or a wheeze rather than a note of despair— that I’d missed out on crucial opportunities to intervene in my patients’ lives.

In my primary care clinic, I spent much of the year trying to ensure that my patients had all of the right medications— at times in excess of twenty different pills— and neglected to ask if this was ever too much. I failed to notice the wrinkled brow or the look of distress as I handed someone two dozen prescriptions to fill. But as the year wore on, I developed the ability to think outside the diagnosis, beyond the science of medicine to the art of medicine. I discovered that there is so much more to being a doctor than ordering tests and dispensing medications. And there is no way to teach that. It simply takes time and repetition. [ibid, pg 313]

You will find yourself at times wincing at his (admirable) candor, including significant rookie dx mistakes, and his recounting of the harrowing time he accidentally stuck himself with a needle after doing a blood draw from an HIV patient, a mishap that caused him protracted subsequent stress (he was eventually declared negative after a lengthy regimen of multiple anti-HIV drugs).

On the issue of medical training and pedagogy:

As I was skipping up to the second-floor cafeteria, my thoughts turned elsewhere, to a conversation I’d had with Petrak a few days earlier about the storm that was building in higher education. Powerful educators were now claiming that medical school could plausibly be reduced from four years to three. In broad strokes, the argument was that so much of medicine was learned on the job and that medical school debt was driving many of the top minds into other fields. It was a highly contentious topic, and I had mixed emotions about it. 

I learned very little physiology or pharmacology from Jim O’Connell, but the life lessons I absorbed from him would stick with me the rest of my career. How does one objectively measure the value of something like that? Would I have had time to wander the streets of Boston with Jim if medical school had been crammed into three years instead of four? [ibid, pp. 307-308]

This book provided a powerful tour of the frantic life of a medical intern. Yeah, the OJT was pretty unrelentingly intense in this narrative.

So, what of it? Is the medical training paradigm optimal? The intense med school years of reductive western sciences? Followed by the repeated 30-hour hospital shifts, the carnivorous trial-by-fire, suffer-no-fools-gladly See-One, Do-One, Teach-One methodology? The hard-won inner circle medical priesthood Semper Fi?
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BACK DOWN IN THE WEEDS'

Overview 
Essential to health care reform are two elements: standards of care for managing clinical information (analogous to accounting standards for managing financial information), and electronic tools designed to implement those standards. Both elements are external to the physician’s mind. Although in large part already developed, these elements are virtually absent from health care. Without these elements, the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health information technology from realizing its enormous potential, and deprives health care reform of an essential foundation. In contrast, standards and tools designed to integrate detailed patient data with comprehensive medical knowledge make it possible to define the data and knowledge taken into account for decision making. Similarly, standards for organizing patient data over time in medical records make it possible to trace connections among the data collected, the patient’s problems, the practitioner’s assessments, the actions taken, the patient’s progress, the patient’s behaviors and ultimate outcomes.

Two basic standards of care, and corresponding tools, bring order and transparency to medical decision making:

• First, from the outset of care, relevant patient data must be chosen, and its implications determined, based on the best available medical knowledge, independent of the limited personal knowledge of the practitioners involved. Patient data must be systematically linked to medical knowledge in a combinatorial manner, before the exercise of clinical judgment, using information tools to elicit all possibilities relevant to the problem situation, while defining and documenting the information taken into account. Practitioners’ clinical judgments may add to, but must not subtract from, high standards of accuracy, completeness and objectivity for that information.
• Second, in complex cases, particularly in cases of chronic disease, the organization of data in medical records must be optimized for managing multiple problems over time. This means that each medical record must begin with a complete list of carefully defined patient problems, and that other clinical information in the record must be linked to the problem or problems to which it relates. Without that structure for the medical record, decisions are made out of context, follow-up and coordination of care are haphazard, and records are not usable for rigorous clinical research.

With these two basic standards of care, and the information tools needed to implement them, practitioners and patients can manage the flood of detailed information required for sound decision making over time. With this detailed information, made usable for research in structured electronic medical records, medical care can become increasingly refined and individualized. In contrast, so-called “evidence-based medicine” is derived from large population studies that fail to account for the medical uniqueness of each patient.

Enforcing the necessary standards and tools depends on changing medicine’s culture of professional autonomy for highly educated physicians. Indeed, the concept of a physician as we know it is not viable. All practitioners must submit to meticulous definition and control of their inputs to care (a principle recognized by the patient safety movement). The primary barrier to this cultural change is graduate medical education and credentialing. These social institutions (1) fail to define, disseminate and enforce high standards of quality for provider inputs to care, (2) inhibit effective design and use of information technology to manage clinical information, and (3) suppress competition among providers who might otherwise exploit information technology to generate remarkable advances in patient care and medical knowledge.

Lawrence Weed, MD and Lincoln Weed, JD, Medicine in Denial, pp. x-xi.

VIII.

Medical Education and Credentialing as Barriers to Progress
A. Extending the health care reform agenda to medical education and credentialing
1. A century of stagnation

Productive use of advanced medical knowledge requires an integrated system of care with a rational division of labor in which all participants see clearly how their roles contribute to solving medical problems. All participants should be able to avail themselves of knowledge that individually they do not possess, practitioners should not be permitted to perform at a level beyond their demonstrated competence, and no group of practitioners should be able to pursue its own interests to the detriment of the larger system of care.   Progress towards a rational division of labor within an external network of knowledge tools is largely absent. Isolated advances are not evolving and coalescing into an integrated system of care. We all are trapped in a non-system, where an elite class of practitioners is permitted to rely on limited personal knowledge and intellect. Graduate medical education and credentialing protect this physician elite from competition that could otherwise reshape medical practice. The health care system has thus been remarkably slow to adapt to the new environment created by modern information technologies. And that environment is still developing. Our culture is still working out the right division of labor between human cognition and external information tools. The subculture of education, however, lags far behind the domains of science and commerce in that development... [ibid,  pg 195]

2. The medical school experience 
According to the Institute of Medicine, “many believe that, in general, the current curriculum is overcrowded and relies too much on memorizing facts” and that “the fundamental approach to clinical education has not changed since 1910.” Even though the issue is largely absent from the health care reform agenda, many involved in medical education recognize that this stagnation is unacceptable... [ibid, pg 197]
 
A basic assumption of medical education is that the necessary synthesis will somehow spontaneously occur with talented minds. But this synthesis by no means may be assumed. Synthesis depends on the mind’s limited capacity to match vast knowledge with detailed data. Moreover, teaching medical knowledge in isolation from patient care is intellectually harmful. Applying the rough generalizations of medical knowledge to the uniqueness of individual patients, and experiencing the imperfect fit between the two, is essential to medical education. This reflects a broader point made by John Dewey:  “The most direct blow at the traditional separation of doing and knowing and at the traditional prestige of purely “intellectual” studies, however, has been given by the progress of experimental science. If this progress has demonstrated anything, it is that there is no such thing as genuine knowledge and fruitful understanding except as the offspring of doing.”
 
In this regard, the first two years of medical school resemble the sterile university education that Francis Bacon condemned 400 years ago. The behavior expected of medical students is like the behavior of university students in the late 16th century. They accepted the facts and premises stated by the authority figures who taught them. The approach was not empirical. Logic and formal disputation within this universe of facts and premises prevailed. Ancient authorities were not questioned. Aristotle’s authority at Oxford was so great that students were fined five shillings for every point of divergence from his doctrines. [ibid, pg 201]
 
… health care settings are among the most hierarchical in American society. In these settings, students, residents, nurses, pharmacists, and other health care workers are often intimidated by physicians and reluctant to question decisions or offer alternative views. These are the frameworks in which student values, attitudes and behaviors are shaped. The science content-packed curriculum reinforces these frameworks by its emphasis on the acquired knowledge and primacy of the individual physician and his/her judgment. [ibid, pg 202, citing Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Report of the Lucian Leape Institute Roundtable on Reforming Medical Education]

A major task undertaken during medical training is learning to manage the uncertainty associated with medicine and medical education. For instance, medical students learn the disadvantages of “doubting too much” and displaying these doubts to peers, superiors, and patients. Instead, they often develop a misleading sense of certitude or come to don a “cloak of competence” to help them manage the impressions of others and, ultimately, the image they have of themselves. Confidence and belief in what one is doing is a central component of the “clinical mentality” as Friedson describes it. Doubts about the ambiguities of “unusual” cases, even when acknowledged by the practitioner, are often “silenced” or otherwise not shared with the patient. [ibid, pg 202, citing Katz J.  The silent world of doctor and patient]

Medical students emerge from this process with insufficient sensitivity to patient uniqueness and the fallibility of medical knowledge.Medical education must be reformed to produce practitioners who are resistant to the generalizations and misconceptions of their teachers, who are equipped with scientific habits of rigor and independent inquiry. For this to happen, the only workable mode of education is careful engagement of students in patient care itself. Students must use knowledge rather than learn it in the abstract. They must rely on information tools to access all relevant knowledge rather than erudition to access limited personal knowledge. If the worlds of action and knowledge do not connect easily and securely in this way, then good students become cynical and distrustful rather than fully engaged.

The premises of medical education, the legal authority it confers to act upon unaided judgment, and the financial and social rewards for doing so, tend to reinforce basic traits of human nature—faith in one’s own cognitions and insensitivity to one’s own ignorance—traits that undermine scientific rigor in medical practice. Francis Bacon long ago observed the tension between science and the mind’s normal mode of operation: “The human understanding, when any proposition has been once laid down, . . . forces everything else to add fresh support and confirmation . . . rather than sacrifice the authority of its first conclusions.” Although medical school faculties, students and practitioners try to overcome this basic human trait, their attempts inevitably fall short of what properly designed software tools and medical records can achieve. With the rigorous combinatorial analysis that those devices facilitate in a disciplined environment, the realities of individual patients continually generate rapid, organized, cumulative feedback on the hypotheses of practitioners and the generalizations of medical knowledge. Such feedback represents a superior medical education for all practitioners. “By contrast, our present educational premises and overuse of statistical thinking tend to confirm and buttress past notions, right or wrong. Above all they stifle progress toward expecting and dealing honestly with the ultimate uniqueness of each patient.”

3.  Changing medical education from a knowledge-based to a skills-based approach
At a time when medical knowledge far exceeds the capacity of the human mind to learn it, when knowledge is more accessible than ever before, when medical knowledge can be coupled with patient data using external tools, it no longer makes sense to conceive medical education in terms of learning knowledge. Nor does it make sense to license practitioners based on their undergoing didactic education and passing board examinations on the limited knowledge they temporarily learn. Both students and practitioners need to access and apply knowledge, not learn it. What needs to be learned is a core of behavior, not a core of knowledge. The required behaviors are defined by the system’s standards of care. In general terms, the required behaviors have four dimensions:  thoroughness (does the practitioner consistently perform all required tasks); reliability (does the practitioner perform each task with the required level of skill); analytic sense (can the practitioner provide a rational basis for each action taken); and efficiency (does the practitioner complete required tasks with sufficient speed). [ibid, pg 203-204]

Medical training thus immerses new physicians in environments of undefined, uncontrolled inputs. This form of training perpetuates a “system that predictably produces the current annual epidemic of medical injuries.”

The ordeal endured by new physicians culminates in board certification exams—a reversion to the didactic model of education. With its premise that the human mind can be relied upon to learn and apply medical knowledge, with its acceptance of board certification as the gold standard of credentialing, the didactic model of education embodies medicine’s culture of denial.

The opportunity to overcome the failings of knowledge-based education and credentialing is greater now than it has ever been. Information technology can now radically reduce the burden on practitioners of learning medical knowledge. Simulation technologies now permit students to develop some manual skills to a relatively high level before applying their skills to real patients. Teamwork simulation techniques are now known to improve performance of teams in complex, high-stress situations. Indeed, health care lags behind other sectors (for example, the military, the nuclear power industry, commercial aviation and aerospace) in using simulation to teach individual skills and improve team performance.
 
A skills-based approach to education and credentialing has enormous potential to reduce the time and expense of becoming qualified to deliver care. [ibid, pg 208]

Little accountability exists for poor performance of medical procedures. Creating accountability requires changing the hierarchy of practitioners. Medicine tolerates defective behaviors and the defective services those behaviors produce at the top of the hierarchy. Dr. Peter Pronovost has confronted this reality in his famous studies of a routine hospital procedure—central line insertions. The procedure risks fatal infection of the bloodstream every time it is performed. “This infection is common, costly, and is associated with the death of 31,000 patients annually in the United States, yet it can be accurately measured and largely prevented [with] a checklist of prevention practices, strict measurement of infection rates, and tools to improve culture and team work among physicians, nurses, and administrators,” Dr. Pronovost writes. As part of his studies, Dr. Pronovost asked nurses in participating hospitals, “‘if a new nurse in your hospital saw a senior physician placing a catheter but not complying with the checklist, would the nurse speak up and would the physician comply?’“ Here is what he found:

The answer is almost always, ‘there is no way the nurse would speak up.’  Doubly disturbing, physicians and nurses uniformly agree patients should receive the checklist items. What other industry would accept a routine safety violation that is associated with the deaths of tens of thousands of patients and not be held accountable? The US health care culture still does not support the questioning of physician behavior.

Dr. Pronovost goes on describe the chasm that still exists between the culture of medical practice and the culture of science:

… many physicians have not accepted that fallibilities are part of the human condition. Thus, when a nurse questions them, it causes embarrassment or shame. Clinicians are sometimes arrogant, believing they have all the answers, dismissing team input, responding aggressively when questioned. … autonomy becomes arrogance when actions are mindless and not mindful, when something is done simply because a physician demands it, when a clinician does not learn from mistakes, and when experimentation occurs without a clear rationale or testable hypothesis. Too often autonomy is mindless and driven by arrogance [ibid, pg 216-217]

The medical academic pedagogy and OJT residency training policy discussion is way above my pay grade. I simply present Messrs Weeds' take for your convenience. Their book remains one of my all-time favorites. I would wholeheartedly commend all three of the foregoing books to anyone involved in or considering a career in health care.
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UPDATE

"Remember back when we actually had to know stuff?"

apropos of medical education?

From The Neurologica Blog

The Google University Effect
Published by Steven Novella under Skepticism

I remain endlessly fascinated with the incredible social experiment we have all been living through over the last decade (and I can say, if you are reading this, you are part of the experiment). The internet and social media have changed the way we access information and communicate. The traditional top-down systems of information and opinion dispersion are eroding, being replaced by a largely bottom-up free-for-all.

I think we’re still figuring out all the consequences of these changes, both intended and unintended. One effect that has been casually observed is that many people believe they have expertise they do not have because they have been able to do “research” online. The democratization of information has led to a false sense of democratization of expertise.

While free access to information is great, there is no systematic way in which the public is taught how to use this information to maximal benefit, and avoid the most common pitfalls. Schools are generally behind the curve in terms of teaching students how to manage their online information access. Most adults were done with their formal education before the wave of social media.

The result is the “Jenny McCarthy Effect.” She is a celebrity who feels that she can substitute her own non-expert opinion for the strong consensus of expert opinion on the safety and effectiveness of vaccines because she “did her own research.” She is an obvious example of how searching for information online can give someone a false confidence in an unscientific opinion, illustrating the fact that relying on “Google University” can be extremely misleading. There are some specific pitfalls at work here...

See also

Lessons from Dunning-Kruger
Published by Steven Novella under Logic/Philosophy, Skepticism

In 1999 psychologist David Dunning and his graduate student Justin Kruger published a paper in which they describe what has come to be known (appropriately) as the Dunning-Kruger effect.  In a recent article discussing his now famous paper, Dunning summarizes the effect as:

“…incompetent people do not recognize—scratch that, cannot recognize—just how incompetent they are,”

He further explains:

“What’s curious is that, in many cases, incompetence does not leave people disoriented, perplexed, or cautious. Instead, the incompetent are often blessed with an inappropriate confidence, buoyed by something that feels to them like knowledge.”...

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"Studying a subject alone by searching online can be a crank factory – giving factual knowledge without really engaging with the ideas. Then the echo chamber effect can give the illusion of engaging, but only with a biased community rather than the broader community. The result are people who falsely believe they have sufficient knowledge in areas they do not truly understand. The Dunning Kruger effect kicks in as well, and they likely do not appreciate the gulf between their Google University understanding of a topic and the depth of understanding of true experts...

The internet may be creating an army of overconfident pseudoexperts."

I am reminded of Nicholas Carr's book "The Glass Cage," which I cited last October (scroll down).

UPDATE:

Props to NPR:

Would Doctors Be Better If They Didn't Have To Memorize?

Poor old Dr. Krebs. His painstaking Nobel-winning work on cellular metabolism, called the Krebs cycle, has made him the symbol for what's ailing medical education.

"Why do I need to know this stuff?" medical students ask me.

"How many times have you used the Krebs Cycle lately?" senior doctors jokingly reminisce.

For decades, first-year medical students have had to cram the details of the Krebs cycle into their heads. Now the biomedical model of educating doctors, based largely on a century-old document called The Flexner Report, is coming under fire.

From one end, our long-standing medical education model is attacked as out of tune with the information age. By some estimates, our entire body of medical knowledge doubles every three or four years.

Critics say med students can't possibly master so much information, which quickly becomes outdated anyway. Instead, the new theory goes, students should be taught and evaluated on their ability to find, assess and synthesize knowledge. And they should be educated in teams to help prepare them for what goes on in the real world.

From another angle, critics of the Flexner model correctly point out that Flexner himself, an educational theorist with no medical training, was silent on issues such as poverty, housing, nutrition and other factors that we now call the social determinants of health...

Interesting article. Interesting comments at the bottom, too.
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CODA

Columbia and the Problem of Dr. Oz
BY MICHAEL SPECTER

Mehmet Oz, the heart surgeon whose syndicated television program, “The Dr. Oz Show,” is seen each day by millions of devoted viewers, is arguably the most influential physician in America. For those who have spent time with him, or who watch the show, his popularity isn’t hard to understand: Oz is an eloquent, compassionate, and telegenic representative of a profession whose members often lack those attributes.

Oz also has political skills—you don’t earn the nickname “America’s doctor” without them—as he will undoubtedly demonstrate on his show Thursday afternoon, when he addresses a harsh letter seeking his dismissal from his post as vice-chairman of the department of surgery at Columbia University’s College of Physicians and Surgeons. Last week, a group of ten prominent physicians wrote to the school’s Dean of the Faculties of Health Sciences and Medicine, saying that Oz “has repeatedly shown disdain for science and for evidence-based medicine.” The letter went on to say that by touting unproven remedies for serious ailments, he had “misled and endangered” the public.

Those assertions are frequently confirmed in Oz’s television appearances. Last December, the BMJ (formerly the British Medical Journal) published a study demonstrating that half of Oz’s recommendations either lacked scientific support or were completely contradicted by publicly available data. When Missouri Senator Claire McCaskill, during a Senate hearing on weight-loss pills, asked him about these issues, Oz responded by saying, “I recognize that oftentimes they don’t have the scientific muster to present as fact.” But he continues to act as if he doesn’t care...

Many people argue that Oz should be treated more like a Kardashian than like a cardiothoracic surgeon. After all, he’s a television star and his conduct is, unfortunately, common. There have always been hucksters selling false hope to desperate people. It’s an American tradition. But Oz is different precisely because he is so smart, well trained, and influential...

Need I comment?

But, wait! There's more!

Dr. Oz and the Pathology of 'Open-Mindedness'
In the pursuit of scientific discovery, where is the line between alternative therapies and "quackademic" medicine?

The Dr. Oz Show provides critics with ample material: séances, energy healing, miracle diet products. Once a media darling, Oz has been subjected to a steady stream of public humiliations, from his shaming in front of a Senate subcommittee to an April 15 letter that a group of doctors wrote to Columbia University, urging his dismissal from the faculty, accusing him of promoting “quack treatments and cures in the interest of personal financial gain”—to which Dr. Oz responded with an ad hominem attack on the letter-writers and a defense of free speech. But despite numerous subsequent think pieces about the man behind the curtain, a crucial question stands out: Why call for Dr. Oz’s dismissal, when many medical schools and hospitals endorse the most outlandish of his claims?...

And now, bit of humor from The New Yorker:

Dr. Me
BY PATRICIA MARX

Am I sitting down? I have some bad news to break to me. A lot of doctors would have texted, but I wanted to tell me this in person. This case wasn’t easy to diagnose, even for someone like me, who graduated from med school (WebMD Online University, ’11). But first I’m going to have to ask me some questions. Do I take any medications—other than Splenda, of course? Has anything changed since I saw me during my last visit, this morning? On a scale of one to ten—ten being chapped lips—how much does it hurt when I push here? Three and a third? I see. The medical community is divided on this, but the latest studies posted on WikiSicky.org and AlternativeToAlternativeMedicine.net indicate that I could be suffering from circuitous spleen, an allergy to elevator air, or feline tonsillitis. Or it could be a problem with my pushing finger. I’m afraid it could also be a gateway ailment to ______ ...

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AFTERTHOUGHT QUESTION

[A]s the year wore on, I developed the ability to think outside the diagnosis, beyond the science of medicine to the art of medicine.
- Matt McCarthy, op cit, pg 313

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More to come...