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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Natalie Newman MD

Dr. Natalie Newman is a residency-trained, board-certified emergency physician who has been practicing for over 20 years. She graduated from California State University in Sacramento, California with a degree in Biological Sciences. She then attended medical school at Case Western Reserve University in Cleveland, Ohio on an Army scholarship. As a graduating senior, Dr. Newman was presented with the Marjorie M. and Henry F. Saunders award for her compassionate care of patients within the family structure. After her graduation, she was accepted into the Emergency Medicine Residency at North Shore University Hospital in Manhasset, New York. Upon her graduation, Dr. Newman entered active duty service with the U.S. Army. Her first assignment was at Womack Army Medical Center in Fort Bragg, North Carolina. During her stint in the Army, Dr. Newman was deployed to Bosnia-Herzegovina(formerly Yugoslavia) where she was Chief of the Emergency Department at Eagle Base in Tuzla, Bosnia. She had the honor of serving under the command of Colonel Rhonda Cornum(now a retired brigadier general), a urologist, pilot and former prisoner-of-war during the Persian Gulf War. While in Bosnia, and as the only American female physician in the Balkans at that time, Dr. Newman was assigned as the official physician for Queen Noor of Jordan during a humanitarian visit to a local hospital in Bosnia. After her return home to the U.S., she was promoted to Major and completed the rest of her Army service at Fort Bragg. Dr. Newman subsequently returned to her home state of California. She has worked in rural facilities, community hospitals and trauma centers. She has also served as a ship physician for a major cruise line and also provided physician services at the Coachella/Stagecoach Festival in Indio, California for three years. Dr. Newman participates in public speaking engagements discussing the value of education, of which she is passionate. She continues to practice clinically as a traveling physician.

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7 Responses

  1. Fred Powell says:

    Bravo to you, Dr Newman, for bringing attention to this matter. Unacceptable

  2. bethKCZ says:

    I think you’ve hit upon a bigger problem than residency and non-physicians teaching medicine to students/interns/resident doctors. That is general anti-intellectualism.

    In the area of medicine, we are in a day and age where anyone can claim to be an “alternative medicine” practitioner and give out medical advice or recommend treatments. We are in a day and age when someone can be watching a TV sitcom, and see an ad that turns a brooding elderly person on a rainy day to someone playing in the yard with children in full sunlight, and “Ask your doctor about (drug X).” Then, in fast speech, listing off a page of side effects, with no clue as to what Drug X is supposed to treat. And, people go to doctors demanding a prescription for drug X, and if the first 5 doctors they go to refuse, saying that the person has no indications for the conditions which drug X treats, keep going until they find someone who will. Then, they come back and ask for the side effects to be treated.

    I have a scientific and mathematical set of training, and worked in research in a completely different field, but the same thing happens. “Oh, I saw something on Oprah last week, so I know all about X.” or “My high school student child learned about that in school, and says (something different).” It completely downplays the years of education, books and articles I’ve read or reviewed on the subject. Book-learning is being put into the dust-bin, and everybody complains that things don’t work as they should. They just defund education at all levels, and let the chips fall where they may.

  3. Gary Pearce MD says:

    Natalie- you have been in the ER over 20 years. So I am sure you have seen the growing corporatization of medicine. The states determine which paraprofessional is legally allowed to perform which service (and lobby dollars have induced more inclusive Scope of Practice laws every year- I am an ophthalmologist and everywhere the optometrists want surgical privileges- so they get their medical knowledge from a weekend course likely sponsored by a laser manufacturer and then think they can laser everyone who walks in the door. If your intraocular pressure measures “A”, wouldn’t you want me to pull out my laser and painlessly lower that pressure by 2 mm and make you that much less susceptible to getting glaucoma). They cannot make that much money draining styes so that should not be competitive. I will gratefully share ER call with them, as I have already seen them remove that brown “corneal foreign body” that just happens to be iris protruding from a perforated cornea.
    So the bean counters just want RVU’s or CPT codes generated and they don’t care by whom. You can have an ER with 1 MD and 10 mid-levels. Guess what, a CPT is just a CPT and the value of it in revenue has nothing to do with who generated it. BUT THE HOSPITAL CAN CUT COSTS BY USING MID-LEVELS!
    I love it (sarcasm) when I ask a patient with real medical problems who their PCP is and they say “Mary” at Dr Smith’s office.
    Hey I was lucky enough to find out that here in Florida only real doctors can do medical marijuana certifications……..of course it is likely only a matter of time before those independent NP get up enough lobbying money to change that law!

  4. Rick says:

    The businessmen running medicine don’t give a damn about details.
    They just want to get living organisms out into the mainstream so they can start billing. Kinda like slip and fall lawyers just out of law school.
    Great piece, Natalie.

  5. Steve O' says:

    BTW OGOD read flexner. It criticized book learning over clinical experience. We’ve come full circle.
    It has independent chapters promoting racism AND sexism in medicine. This guy was a little off the trail.

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    • Natalie Newman, MD says:

      I’m completely aware of the downfalls of the Flexner Report and the flaws of the racist and misogynistic Abraham Flexner; however, there is good that arose out of that evil. One, it led to the standardization of medical education today and is the reason North America has some of the best physicians in the world. The Hopkins Model of our education is still followed today, so he did something right. Didactics is incorporated into our med school education and continues through residency, so despite what he felt about “book learning”, it is valued. Two, despite his despicable views on race and negative eugenics, the closure of sub-standard medical schools elevated medical education overall. The downside is that five out of the seven Black med schools that existed also closed down, leaving only Meharry Medical College and Howard University Medical School. His perception of why Black med schools should exist was racist and no doubt played a part in decreasing the number of Black schools thus Black physicians–a deficit that remains today.

      With all of his faults, Abraham Flexner was by all accounts an excellent and exceptional educator and he standardized medical education, a change that was sorely needed. My commentary criticizes a system that is hellbent on undoing that standard in the interest of money and politics. It incenses me that there are physicians who are willingly complicit in the ruination of our discipline.

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