sexta-feira, 27 de dezembro de 2013
Michael Morgenstern for The Chronicle
You are about to go under the knife. Perhaps you are having a routine gallbladder removal, or maybe it is a more complex surgical procedure, like the removal of a tumor. As the anesthesiologist moves the gas mask toward your face, you glance at the surgeon and wonder: How well prepared is the person wielding the scalpel? Can I be confident that this young surgeon, whose hands will cradle my life, really knows what she is doing?
Sadly, there is increasing evidence that the answer may be no. A survey of surgical-fellowship directors, the results of which were published in the September 2013 issue of Annals of Surgery, disclosed many serious doubts. Fifty-six percent of respondents say their new fellows—licensed physicians who have completed four years of medical school and five years of residency—cannot suture, 38 percent say they lack a sense of patient ownership, and 66 percent say their new fellows cannot operate for more than 30 minutes without supervision.
It would be comforting to suppose that these problems are confined to surgical education. Yet in fact they are merely symptomatic of more widespread, even endemic flaws in our current medical-education system. To fix these problems and ensure good medical care for our children and grandchildren, we need to peer beyond superficial symptoms and probe the depths of the underlying disorder. Only once we have the full diagnosis in hand can we prescribe the requisite therapy.
One flaw in contemporary medical education is the growing tendency to treat learners as though they were a hazardous material from which patients require protection. Many medical students gain remarkably little practical, hands-on experience in caring for patients—the very thing that future physicians need most. Even the very brightest and most talented and enthusiastic people cannot get better at something they never do.
Yet we must avoid supposing that the primary disorder of medical education is merely technical and not ethical. What medical education most lacks today is not funding, technology, or methodological sophistication. What medical education most lacks today is heart. When we educate future physicians, we are not just cramming brains full of facts or embedding new skills in motor memory. We are shaping human character, and the shaping of character takes place best when human beings have opportunities to interact meaningfully with one another.
Yet most American medical schools are busily reducing the number of student-teacher contact hours. A sea change is under way toward independent learning. Lecture hours are being reduced, students are attending a shrinking percentage of classes, and face-to-face interaction is being replaced by electronic learning techniques. The members of the medical-school faculty, once the very model physicians whom students and residents sought to become, are now being relegated to the role of "content deliverers." Such approaches may permit students to recall what was said but inevitably dull their perception of the curiosity and passion behind it.
Another important factor has been the shift toward competency-based education. At first glance, this seems just the right thing—learners will be taught and then assessed not only on what they know, but mostly on what they can do. Yet at its core, competency-based education means setting the same bar for every learner and doing so at the same relatively low level. Once the educational focus is on competency, the attainment of excellence moves to the back burner. Furthermore, by expecting every student and resident to focus on the same competencies, we tend to overlook each learner's distinctive interests, aptitudes, and experiences, which often end up suffering from inattention.
Medical education increasingly resembles a form of mass production, in which homogenization is the order of the day. The more each student looks like every other, we suppose, the higher the quality of medical education. But in the real world of medical practice, education, and research, the key to genuine excellence is less conformity than diversity, improvisation, and innovation. The very best physicians are not clones. Far from it, each really good physician has a distinctive style.
How have flawed educational approaches become so prevalent? One factor is cost cutting. Despite the fact that medical education has never been more expensive, medical schools and residency programs are trying to do more with less. Another factor is the desire of some leaders to make a distinctive mark, which generally means replacing the old with the new. When revolution becomes imperative, tried-and-true methods like the lecture and apprenticeship inevitably fall into disrepute.
How can we cure what ails medical education? For one thing, we need to re-establish excellence as its true goal. Second, we need to recognize that excellence means encouraging diversity among both learners and educators. Third, we need to reaffirm that the pursuit of excellence is hard work, requiring truly intense dedication over a long period of time. Finally, we need to restore to the core of medical education a focus on human relationships.
From the very first days of medical school, learners should spend substantial portions of time in the company of faculty members and patients. They should see how their teachers interact with patients, practice interacting with patients under supervision, and eventually begin caring for patients on their own, with faculty members as backup. The purpose is not just to log hours or fill out forms, but also to uncover what makes caring for patients truly challenging and inspiring. In most cases, only a good educator can really make this happen.
In the words of one of my students, "It is amazing the lengths to which faculty members are not only willing but eager to go when a medical student expresses interest in learning." The real driver of medical education should not be a minimum score on an exam or a long checklist of procedures and experiences. Those are all just means, not ends. The real driver of medical education should be the shared curiosity and the commitment of learners and educators to the welfare of patients.
Sir William Osler, a Canadian but perhaps the most admired physician in U.S. history, knew this well. He once said that when medical education is done right, the learner "begins with the patient, continues with the patient, and ends with the patient." Everything else, including the whole medical school, he said, is but a means to that end. In order to secure great medical care in the future, we need to promote great medical education today, and this requires that we renew our focus on building meaningful relationships between three essential people: the learner, the educator, and the patient.