Medical educators put their art under scrutiny during Washington meeting MILAN KORCOK
The 75th "diamond jubilee" congress on medical education, sponsored in Washington, DC by the American Medical Association, was billed as an international event - a chance to highlight the global nature of medical teaching and honour some of its historic traditions. But after the opening ceremony there was the reality that - like medicine itself - the process of medical education is being told to account for itself by demanding, often irreverent social forces. It's time for medical schools to confront the issues of high-cost health care and alleged physician oversupply, and the growing conflicts between those who feel medical education has gone too far in stressing technology and those who feel it hasn't gone far enough. As one of 11 medical educators (from nine countries) honoured by the American Medical Association for their "outstanding contributions to the education of physicians... throughout the world," Canada's Dr. John Evans said that for too long, medical schools have stayed too clear of such critical issues. "It is currently fashionable to denigrate the contribution medicine can make to health and to criticize the profession, medical educators and research scientists as islands of self interest." But, said Evans, the founding dean of McMaster University medical school and past president of the University of Toronto, "Such a pessi-
mistic position is neither justified nor constructive." In the W.K. Kellogg Foundation 50th anniversary commemorative lecture, Evans told the conference that medical schools were going to have to get down to the basics of community medicine and tangle with such problems as quality of care, costs and organization of services. And that would call for dramatic changes in the way most schools operate. Evans contends that in these respects medical schools have not pulled their weight. Where were the schools when it came time to evaluate the many new diagnostic and therapeutic procedures that have moved into the mainstream of medicine? Cost-effectiveness questioned He told the clearly receptive group that some of the most common medical treatments in use for some time, such as anticoagulants and estrogens, and many high-powered, intensivecare devices and surgical procedures now considered common, have never really been proved cost effective. "Anticoagulants affect blood coagulation but have no demonstrable effect or outcome in patients with myocardial infarction or strokes; (yet) they have been used to treat these conditions for nearly 20 years at enormous cost and significant risk. "Estrogens, clofibrate and other
drugs lower blood cholesterol but confer no benefit on patients with coronary artery disease. They also have negative side effects. "Blood-sugar-lowering drugs do not improve life expectancy in diabetics and have some serious complications.... "Antacids and anticholinergic drugs affect gastric acidity but have no demonstrable benefit on the natural history of duodenal ulcer." In addition, says Evans, there are the "expensive, intensive-care units, coronary monitoring units and neonatal units." They have become standard elements of hospital services "without determining which patients may benefit from their use." And there is some pretty good indication, says Evans, that their disadvantages outweigh their benefits. The same may be said for coronary bypass surgery, he adds. This technique costs $1 billion a year in the United States yet its morbidity and mortality rates give some cause for concern. It has become widely established without proof of effectiveness, says Evans. "When the hospitals are full and Fort Knox empty, we will probably discover that this technique is of benefit to a small, carefully selected subpopulation of those on whom it is now being done, and that the risk of the procedure is acceptable only in units carrying out major numbers of operations." Evans was also critical of the widespread use of CT scanners, which
CMA JOURNAL/JUNE 23, 1979/VOL. 120 1551
he said "cascade into general use without assessment of their effectiveness. We order groups of tests simultaneously rather than in relation to a logical sequence of decisions in diagnosis." Evans noted one large, randomized, controlled, clinical trial that showed that a battery of multiphasic screening tests done on admission failed to shorten hospital stay or improve clinical diagnosis and in fact was associated with a 25% increase in second opinion consultations, a 78% increase in total tests done and a 5% increase in total hospital costs. This and supporting evidence is convincing argument to end "shotgun diagnosis and multiple choice medicine and. . return to critical judgement in the process of diagnosis." Having expressed the urgency for medical schools to get into this type of evaluation, Evans admitted that most, because of their teaching traditions, just weren't equipped to do the job. Too many had ingrained departmental priorities and hierarchies. One thing they need is to bring in clinical epidemiologists, who can combine extensive knowledge of human biology and the natural history and variations of disease with epidemiologic and statistical skills to allow productive evaluation. Once aboard, clinical epidemiologists should be made an integral part of the crew - "they should not be isolated as a new and separate subspecialty. They should interact with all the clinical programs." In effect, says Evans, medical education should encourage the physician to look beyond individual patients to the health status of a defined population, and this means getting into environmental and occupational hazards, social pathology and lifestyle characteristics. It means identifying what needs
certain groups have, and actually searching out those individuals with preventable conditions and treatable disorders. There is evidence that Evans' expanded view of the role of medical schools has support. In 1974 the Association of American Medical Colleges surveyed 88 deans about what changes they considered would have the most profound effect on their institutions. Their predictions included: * Establishment of a national system of control of specialty distribution of physicians. * Greater public accountability for improved medical centre management. * Much higher priority for continuing medical education. * An assumption by the academic medical centre of responsibility for most graduate medical education. They also foresaw the academic medical centre becoming the hub of tertiary care in a regional network of health services. And, not to be neglected, there was a clear signal from the surveyed deans that they wanted a much tighter link between the medical profession, public health and preventive medicine. Obviously such changes would have impact on the roles and expectations of medical students. And that might necessitate striking a more equitable balance between the science and the art of medicine. Return to classics Dr. Lewis Thomas, president of the Memorial Sloan Kettering Medical Center in New York, told the conference he felt there was a means to restore that balance, a means rooted in some classical approaches to education. Medical schools have erred greatly, said Thomas, in becoming ob-
sessed with science to the exclusion of the humanities. Most students now perceive their future in med icine as depending on their getting straight As and having a superman's grasp of science. They take for granted that they are at war with each other and that any means of achieving the desired grades is justified. This attitude leads to some ugly behaviour, said Thomas. it results in sabotaged experiments of colleagues, textbooks vanishing from the library and pages torn out of selected monographs and journals. Because of this obsession with sciences, some of the best courses in the humanities and foreign languages are dismissed. And there goes the foundation of a good education. But not all of this should be blamed on the students, said Thomas. Despite the rhetoric of deans and schools' representatives, students still have a fair perception of what is expected of them. They know that if they are not in the top 10 of academic achievement, their applications have slight chance of being acted upon. Thomas told the educators that the demise of Greek and Latin from American university life was a great "disaster". Classical Greek, he said, should be restored to the curriculum. There is no better way to test the development of the student's mind and to test his "tenacity', resolve, his capacity to understand the human being and his affection for the human condition." In effect, anyone who could master Homer's language and the torment of his poetry will have passed a "shrewd test" of the qualities of mind and character needed to become a physician. Thomas emphasized this is not to denigrate the role of science in medical learning, but just to even up the equation a bit.
The future of US medicine It has become obvious to American physicians that if they want to look into their own futures, they
should ask a Canadian about his recent past. Dr. L.H. le Riche, registrar of the
1554 CMA JOURNAL/JUNE 23, 1979/VOL. 120
College of Physicians and Surgeons of Alberta, told the medical education congress that the recent past is
The 75th "diamond jubilee" congress on medical education, sponsored in Washington, DC by the American Medical Association, was billed as an international event - a chance to highlight the global nature of medical teaching and honour some of its historic traditions. But after the opening ceremony there was the reality that - like medicine itself - the process of medical education is being told to account for itself by demanding, often irreverent social forces. It's time for medical schools to confront the issues of high-cost health care and alleged physician oversupply, and the growing conflicts between those who feel medical education has gone too far in stressing technology and those who feel it hasn't gone far enough. As one of 11 medical educators (from nine countries) honoured by the American Medical Association for their "outstanding contributions to the education of physicians... throughout the world," Canada's Dr. John Evans said that for too long, medical schools have stayed too clear of such critical issues. "It is currently fashionable to denigrate the contribution medicine can make to health and to criticize the profession, medical educators and research scientists as islands of self interest." But, said Evans, the founding dean of McMaster University medical school and past president of the University of Toronto, "Such a pessi-
mistic position is neither justified nor constructive." In the W.K. Kellogg Foundation 50th anniversary commemorative lecture, Evans told the conference that medical schools were going to have to get down to the basics of community medicine and tangle with such problems as quality of care, costs and organization of services. And that would call for dramatic changes in the way most schools operate. Evans contends that in these respects medical schools have not pulled their weight. Where were the schools when it came time to evaluate the many new diagnostic and therapeutic procedures that have moved into the mainstream of medicine? Cost-effectiveness questioned He told the clearly receptive group that some of the most common medical treatments in use for some time, such as anticoagulants and estrogens, and many high-powered, intensivecare devices and surgical procedures now considered common, have never really been proved cost effective. "Anticoagulants affect blood coagulation but have no demonstrable effect or outcome in patients with myocardial infarction or strokes; (yet) they have been used to treat these conditions for nearly 20 years at enormous cost and significant risk. "Estrogens, clofibrate and other
drugs lower blood cholesterol but confer no benefit on patients with coronary artery disease. They also have negative side effects. "Blood-sugar-lowering drugs do not improve life expectancy in diabetics and have some serious complications.... "Antacids and anticholinergic drugs affect gastric acidity but have no demonstrable benefit on the natural history of duodenal ulcer." In addition, says Evans, there are the "expensive, intensive-care units, coronary monitoring units and neonatal units." They have become standard elements of hospital services "without determining which patients may benefit from their use." And there is some pretty good indication, says Evans, that their disadvantages outweigh their benefits. The same may be said for coronary bypass surgery, he adds. This technique costs $1 billion a year in the United States yet its morbidity and mortality rates give some cause for concern. It has become widely established without proof of effectiveness, says Evans. "When the hospitals are full and Fort Knox empty, we will probably discover that this technique is of benefit to a small, carefully selected subpopulation of those on whom it is now being done, and that the risk of the procedure is acceptable only in units carrying out major numbers of operations." Evans was also critical of the widespread use of CT scanners, which
CMA JOURNAL/JUNE 23, 1979/VOL. 120 1551
he said "cascade into general use without assessment of their effectiveness. We order groups of tests simultaneously rather than in relation to a logical sequence of decisions in diagnosis." Evans noted one large, randomized, controlled, clinical trial that showed that a battery of multiphasic screening tests done on admission failed to shorten hospital stay or improve clinical diagnosis and in fact was associated with a 25% increase in second opinion consultations, a 78% increase in total tests done and a 5% increase in total hospital costs. This and supporting evidence is convincing argument to end "shotgun diagnosis and multiple choice medicine and. . return to critical judgement in the process of diagnosis." Having expressed the urgency for medical schools to get into this type of evaluation, Evans admitted that most, because of their teaching traditions, just weren't equipped to do the job. Too many had ingrained departmental priorities and hierarchies. One thing they need is to bring in clinical epidemiologists, who can combine extensive knowledge of human biology and the natural history and variations of disease with epidemiologic and statistical skills to allow productive evaluation. Once aboard, clinical epidemiologists should be made an integral part of the crew - "they should not be isolated as a new and separate subspecialty. They should interact with all the clinical programs." In effect, says Evans, medical education should encourage the physician to look beyond individual patients to the health status of a defined population, and this means getting into environmental and occupational hazards, social pathology and lifestyle characteristics. It means identifying what needs
certain groups have, and actually searching out those individuals with preventable conditions and treatable disorders. There is evidence that Evans' expanded view of the role of medical schools has support. In 1974 the Association of American Medical Colleges surveyed 88 deans about what changes they considered would have the most profound effect on their institutions. Their predictions included: * Establishment of a national system of control of specialty distribution of physicians. * Greater public accountability for improved medical centre management. * Much higher priority for continuing medical education. * An assumption by the academic medical centre of responsibility for most graduate medical education. They also foresaw the academic medical centre becoming the hub of tertiary care in a regional network of health services. And, not to be neglected, there was a clear signal from the surveyed deans that they wanted a much tighter link between the medical profession, public health and preventive medicine. Obviously such changes would have impact on the roles and expectations of medical students. And that might necessitate striking a more equitable balance between the science and the art of medicine. Return to classics Dr. Lewis Thomas, president of the Memorial Sloan Kettering Medical Center in New York, told the conference he felt there was a means to restore that balance, a means rooted in some classical approaches to education. Medical schools have erred greatly, said Thomas, in becoming ob-
sessed with science to the exclusion of the humanities. Most students now perceive their future in med icine as depending on their getting straight As and having a superman's grasp of science. They take for granted that they are at war with each other and that any means of achieving the desired grades is justified. This attitude leads to some ugly behaviour, said Thomas. it results in sabotaged experiments of colleagues, textbooks vanishing from the library and pages torn out of selected monographs and journals. Because of this obsession with sciences, some of the best courses in the humanities and foreign languages are dismissed. And there goes the foundation of a good education. But not all of this should be blamed on the students, said Thomas. Despite the rhetoric of deans and schools' representatives, students still have a fair perception of what is expected of them. They know that if they are not in the top 10 of academic achievement, their applications have slight chance of being acted upon. Thomas told the educators that the demise of Greek and Latin from American university life was a great "disaster". Classical Greek, he said, should be restored to the curriculum. There is no better way to test the development of the student's mind and to test his "tenacity', resolve, his capacity to understand the human being and his affection for the human condition." In effect, anyone who could master Homer's language and the torment of his poetry will have passed a "shrewd test" of the qualities of mind and character needed to become a physician. Thomas emphasized this is not to denigrate the role of science in medical learning, but just to even up the equation a bit.
The future of US medicine It has become obvious to American physicians that if they want to look into their own futures, they
should ask a Canadian about his recent past. Dr. L.H. le Riche, registrar of the
1554 CMA JOURNAL/JUNE 23, 1979/VOL. 120
College of Physicians and Surgeons of Alberta, told the medical education congress that the recent past is
