The Murder of Medical Expertise

What is happening to academic medicine? Why are physicians relinquishing our discipline into nothingness? Nearly a year ago, I wrote a blog about the value of medical education and its progress from the pre-Flexner period. (https://authenticmedicine.com/2019/11/an-education-about-medical-education/). Because of education matters.

When exactly did it become the norm for medical students/residents to present cases to non-physician practitioners(NPPs)? To be advised on their knowledge base by people who have limited to no medical education and in the case of nurse practitioners(NPs), may have just completed an online program as a NP/DNP one month before? Who decided that this was appropriate and acceptable? What kind of gutless, weak program director or chairperson would permit residents to be taught medicine by people not formally trained in it? Are there no attendings and senior residents willing to teach anymore? To be the guides and mentors who will pass the torch to those future docs who come after? To set the example of leadership? Do they not recognize that a similar type of slovenly education occurred 100+ years ago and IT DIDN’T WORK? Patients suffered; therefore, the quality of care being provided had to be improved; hence, the Flexner Report. And we have maintained those standards..until corporatized medicine took hold and physicians caved. It now seems we are headed backwards. The same attendings who whine about residents not knowing how to do procedures or lacking fundamental medical knowledge force them to stand aside while their procedures are handed over to NPPs and their education minimized. Their devaluation magnified by the sheer dismissiveness of the act. And for the record, I am not speaking of NPPs and RNs who CONTRIBUTE positively to the education of medical students, interns and residents. Every single physician practicing today was influenced by other health care professionals during their journey to physicianhood. Anyone who says they were not is lying. But our education was never turned over to non-physician practitioner “attendings” who then became responsible for training us to become physicians. Without anyone reviewing their credentials, knowing anything about their actual education and most importantly, without their possessing an adequate formal medical education. It’s absurd. But that is exactly what is happening. Why? For metrics? Because it’s easy to use students and residents as indentured servants who can then be utilized to “move the meat” whilst their education is compromised?

The least these programs could do is inform the potential interns and/or medical students up front, in their interviews, that they will have rotations in which the students/trainees will not be taught by physicians. Then allow them to make a choice whether or not they want to attend that medical school or place that hospital on the match list. To lie by omission is despicable. These trainees are paying for a medical education and receiving less than what they were promised. The good old bait and switch. And if they complain, they risk getting kicked out by a non-supportive program that will then get its jollies ruining the potential doctor’s future because the medical student/resident had the audacity to demand their money’s worth of education. How is it that physicians who endorse this nonsense are placed into academic leadership positions? And why would physicians do this to budding physicians?

God forbid the resident expect to be called “Doctor”. I was informed by a trainee who was told by his/her program director that he/she’s insistence on using the title “Doctor” was not a pressing matter. Simply because an NPP on one of the resident’s rotations believed it to be arrogant and hierarchical. Apparently residents daring to use the title doctor is an affront to some NPPs, despite the fact that they are, in fact, doctors and working in a hospital/clinic setting. To accommodate the disgruntled, some now have badges with only their first names and “Resident”. What the program director and other “leaders” fail to acknowledge is that many residents are the first in their family to achieve this level of educational success. America’s past in regard to those who were allowed access to medical education has not always been honorable. Times have changed, but memories are long. Many of us have parents who simply did not have the opportunities we do; however, they set the stage so that we could be better…do better. And when we arrive, a so-called “leader” in medicine arbitrarily decides that residents are not deserving of what they have worked so hard to attain or the title that accompanies it. Instead, the “leader” rips it away in the interest of politics and unfounded resentment by others. It’s disgraceful. No one should have to apologize or feel ashamed for their accomplishments. No one. 

I am extremely fortunate to have attended a program that prioritized my education, understanding that medicine should be physician-led and not a free-for-all. Team cohesiveness was expected and encouraged. My program director, chair and attendings ensured that I had the best training possible so that I would be the best physician I could be. Being adequate was not sufficient, I had to excel. Because every patient’s life depended on my expertise. They were committed to my education and training. My ultimate performance in practice was and is a reflection of their efforts. I wanted them to be proud, not embarrassed or ashamed that they invested their time in me. I had to make the return count; I believe I have fulfilled my obligation honorably.

Currently, medical expertise seems to be a joke; something to be demeaned, disrespected and cast aside–apparently no longer the territory of physicians but anyone who arbitrarily decides to declare himself or herself to be medical experts. Residents are made to understand that they are insignificant and hierarchy is not a thing anymore. Stay silent and be part of the crowd that pretends to be a team but ostracizes the physician. It’s enough to make me sick to my stomach. How dare an esteemed academic institution take the money and run from their responsibilities? How dare they dismiss medical students, interns and residents so callously and then hold the proverbial gun to their head to prevent them from expressing their discontent? Well, these students and trainees contact me(with evidence) and they are rightfully upset–I am speaking on their behalf. I think that it is reprehensible that they feel more comfortable approaching me than they do their own program directors. And it is very telling.

If I could make a list of these programs without risking liability to myself, I would. What I can do is tell my mentees which programs to avoid. By no means do I believe the majority of academic institutions engage in this behavior, quite the opposite. However, even one is unacceptable, in my opinion. Physicians are leaders, but future physicians are now being taught to be followers. By physicians who perceive themselves as leaders. It’s tragic. Cohesive, collaborative teams with physician leaders have existed for decades and worked marvelously. Yet, the myth that collaboration cannot exist with physician leadership is pervasive and has led to this changing of the guard. Formation of medical teams with no identifiable leader, although physicians are the experts in and the only ones possessing a license to practice medicine. They are not permitted to lead effectively because others are offended and insecure. Hierarchy is now a four-letter word. Simple “collaboration” is what is now recommended, which is ineffective for anyone to make a final decision and disposition on a patient or own the ultimate responsibility for management. Imagine that everyone is looking to each other for someone to decide what’s next. Ridiculous. Paraphrased from a colleague, “When the s**t hits the fan, no one will be looking at the team. They will be looking at me.”

The murder of medical expertise and leadership. Everyone participating in it should be arrested.

****THIS COMMENTARY ONLY APPLIES TO THOSE IN ACADEMIC CENTERS FOR WHOM THE SHOE FITS.****

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