It just happened. I became a doctor. Not just a data base. An immense data base. But a data base with practical applications. I knew which part to use and when to use it. And I knew when to ignore it. It didn't used to be that way. Far from it. But it took seven long and grueling years to get there. And that is The Art of Medicine. The necessity of the track. It cannot happen in 2 years of post graduate nursing. It cannot happen in 2 years of extender school.
It is a physical impossibility. Reading The Physician Executive got me thinking. I remember years back in my medical school days. Internal medicine was a beast. A field of ALL adult medicine. So many medical problems. So many sick people. It was incredibly overwhelming to me, a third year medical student, often the first experience with real patients.
I had the opportunity to do my medical school internal medicine rotation at a VA in our town. A bunch of old men who never ever took care of themselves. Smokers. Drinkers. Stubborn. Gamblers. Most of them were great to talk to. Fun times for sure. As a medical student at an academic institution, we had teams. Students. Interns. Supervising residents. Attendings. I wrote a note. The intern wrote a note. The supervising resident looked things over. The attending wrote a brief (and sometimes not so brief) note.
My six weeks of internal medicine and I remember thinking to myself. I don't know anything. Two years of intense book work. Year one of medical school was all about how the body works. Anatomy, physiology, biochemistry, pharmacology, genetics, embryology etc. Year two was all about how the body breaks down. Pathology and disease. Year three and here I was. Two years of intense book work and I don't know anything.
I remember very vividly thinking to myself. How am I going to pass my test? This stuff is too darn hard. How am I going to pass my rotation? The third year of medical school was filled with "rotations". Internal medicine, pediatrics, OB, surgery, psychiatry, family practice, to name a few. Every one of these rotations had a test. Your third year was full of clinical work and tests. And all I can remember was how am I going to pass my test. This was too darn hard.
Two years of intense book work and I don't know anything.
I did great in my book work. Studied hard, got good grades. I thought to myself, how hard could this be. The doctor thing. Of course, that thought quickly faded. It was tough. And I had no idea how my supervising resident and my attending felt so confident in themselves.
How do they know so much? Why do they always have an answer for everything. They seemed so incredibly smart. And me so dumb. But I knew I wasn't. How did they make that leap? From a data base of knowledge to the clinical application of that knowledge? I was upset I wasn't there. I needed to be there. I was terrified at not knowing anything, but yet knowing everything. Why could I not practice medicine?
The answer lies in the training of doctors. The act of medical school, residency, fellowship is a very organized tract of education that turns incredibly intelligent thought provoking scientists from data gatherers into data interpreters. It is a long drawn out process. For primary care, 7 years. For many surgical and medical specialists 9-11 years. But regardless of the field, the end result is the same. Turning data gatherers into data interpreters.
It takes that long. Years. Maturing of the doctor in training is step wise. I can tell a note from a 3rd year student from a 4th year student from a first year resident (intern) from a supervising resident from an attending. I can see it in the types of data documented. I can see it in the interpretation of the data. I can see it in the plans on what to do with that data. I can see it in what is important and what isn't.
As a medical student, you thrive to get to that point. The point where you know what to do and what not to do. As an intern in training, you are not there. I'm sure most docs would agree with me. It is not until the back end (maybe the last 15-20%) of your residency where most docs can say "I get it".
"I know what I'm doing" For me, there was not an awakening. There was not any one day that just clicked. It just didn't hit me one day. At the end of the grueling road, I just realized I was a doctor. It really was as simple as that. It is a confidence that comes with intense clinical experience, repetition and constant confirmation or dissension from the other docs all around you who "get it" as well.
In retrospect, I realize that as a third year medical student, I was not expected to get it. Only time would give me my gift of doctoring. It is the gift of education. To know your field with great expertise. To use your knowledge to help others. To lend your expertise to other doctors who themselves have their own level of expertise in their own respective field of practice.
But it never stops. There is no end point. Practicing medicine takes practice. So much of it is filled with grey zones. There is no black and white. We are all different, different diseases, expression of disease, responsiveness to disease. This is the art of practicing medicine.
When do medical students become confident clinical physicians? Today. I carry confidence in every single aspect of my practice. I know what I'm doing. I walk into a patients room and can describe in intricate detail a vast array of pathological process from atrial fibrillation, to pneumonia, to small bowel obstructions, to cellulitis, to depression.
I understand the whole gamut of adult medicine, the one thing that I thought as a third year medical student I would never get. The system of training made me get it. It was essentially fail proof. And I thank my lucky stars that the system of rigid educational objects gave me the confidence I feel today to help others heal themselves.
The length of time it took me to "get it" over 6 years, should be a warning sign to any policy maker or patient who think non physicians have a role in replacing physicians in the Art of Medicine.
Blah, blah, blah. You should read Adam Smith on pin making. Undoubtedly, the mass of information involved in providing healthcare is enormous--but virtually every other endeavor in industrial society is equally as complex--from generating and distributing electricity to making operating systems to administering the tax code.
ReplyDeleteWhat has made industrial processes simple is competition--that has forced producers to break down what they do into "mindless" constituent steps--that individuals with little training (or machines) can do.
Is medine sooo hard that it is immune to such operationalizing--or do physician guild monopolists-like their Hippocratic priest predecessors--have a financial interest in maintaining the mystery and wonder.
the nurse practitioners i see coming out are younger and younger. they typically don't have the body of experience you describe. doesn't matter anyways, i don't see np's pursuing primary care when they can work for surgeons and look at the primary care docs with pity.
ReplyDeleteZA: I guess despite your years of education, you never learned logic. Well, you're not the first doctor so afflicted:
ReplyDeleteFirst you say "Your argument is strong and logically cogent" then you say "a few economic buzzwords and quasi-educated phrases taken out of their original context do not make anyone credible" Uh . . . which is it?
Second, "There were reasons we (physicians) were granted a monopoly and we have, for the most part, fulfilled the objectives."
What objectives and how do you know that you've achieved them? How much of what physicians actually do is evidence based? Not much; it's still mostly voodoo the effectiveness of which is unclear. Remember my friend what the public health people have been telling us for years--once you get beyond sanitation and vacciation, expenditure on health care does very little in increase expected life span (once diet/exercise/ smoking) is factored in.
"The anthropology underlying the priest-like role of healers in any society is certainly not something to be ashamed of given a non-objectivist model of medicine."
What the hell does that mean? You want to be a voodoo priest--oh, maybe you do (see above)
" You have confused the nature of the complex, as opposed to the simply complicated."
Ditto. Yes, medicine is hard, so is producing intercontinental missiles or catalytic converters. Let's see whether the processes that made the rest of our economy great can do so for medicine as well.
ZA: I guess despite your years of education, you never learned logic. Well, you're not the first doctor so afflicted:
ReplyDeleteFirst you say "Your argument is strong and logically cogent" then you say "a few economic buzzwords and quasi-educated phrases taken out of their original context do not make anyone credible" Uh . . . which is it?
Second, "There were reasons we (physicians) were granted a monopoly and we have, for the most part, fulfilled the objectives."
What objectives and how do you know that you've achieved them? How much of what physicians actually do is evidence based? Not much; it's still mostly voodoo the effectiveness of which is unclear. Remember my friend what the public health people have been telling us for years--once you get beyond sanitation and vacciation, expenditure on health care does very little in increase expected life span (once diet/exercise/ smoking) is factored in.
"The anthropology underlying the priest-like role of healers in any society is certainly not something to be ashamed of given a non-objectivist model of medicine."
What the hell does that mean? You want to be a voodoo priest--oh, maybe you do (see above)
" You have confused the nature of the complex, as opposed to the simply complicated."
Ditto. Yes, medicine is hard, so is producing intercontinental missiles or catalytic converters. Let's see whether the processes that made the rest of our economy great can do so for medicine as well.
I agree with the sentiments. I have been blessed to work with some wonderful NPs (granted I was in the Finance Department). However, I spent one year at Pharmacy school, and the NPs really were taught the If x then b logic (which is really good logic for most things). They are really good with horses, but are not trained to see zebras. Sometimes I just rolled my eyes at some of the lunhc time talk (that some NPs are really clueless). I was working in a FP clinic, and really, that work is really really easy. These NPs were not delivering babies.
ReplyDeleteI know that many RNs go straight to NPs. And there is a big difference between LPS, RNs, BSN, NPs.
My thoughts on nurse training is the focus on anatomy as opposed to physiology. That was an analogy, not that nurse don't get the physiology in school.
Experience (and intelligence) is the greatest asset.
The problem with NP and PAs is that they go from school to practice without the long process to "independent" work. I think an 2 yr RN working in an ER is more valuable than an NP in alot of ways. I know in theory that these professions are always under the clinic supervision of the doctor.
I think NPs and PAs are great within there practice.
I dunno just my thoughts....
I am going to school to get my masters in social work. I may get clinical training, but I would never try to pretend I know as much about therapy as a psychologist.
Plus my training is focuses on what things can be changed in the environment that can help the person. I think that is a valuable focus.
One problem to be addressed here is that medical education is so needlessly difficult to obtain. If we started pumping three times as many medical students through the system doctors' hyper-inflated incomes would fall drastically and we wouldn't have to rely on NPs and PAs as we do now. Some say the quality of doctors would decrease. I doubt it. Entry into medical school is mostly based on how good a student one is, but there is little evidence to suggest that a "B" undergrad student will make any less capable a doctor than "A" undergrads.
ReplyDeleteThe medical community argues their education is better, which is undoubtedly true, but then the same medical community tries to deny med ed to as many qualified people as possible in order maintain elite status.
"One very basic thing you lack to understand anon is that WE MADE missiles and catalytic converters. We understand both much better than the human body. . . .You don't understand what you don't understand"
ReplyDeleteYeah, we didn't make electricity or platinum either. In fact, the process of catalysis the platinum initiates everyday in our car is still not really understood. You don't understand what you don't understand, indeed.
"Is medine sooo hard that it is immune to such operationalizing.
Yes."
Dear HH--doctors have been saying that for such a long time to protect their monopoly, it's getting old. No one really believes you.
I believe that the processes surrounding the delivery of care can be operationalized, but an understanding of the content and an understanding of the processes involved in an individual consultation remain a black box. I know I don't fully understand it, The Happy Hospitalist doesn't and most (I would say *all*) physicians do not really understand the
ReplyDeleteMy business and policy exposure has taught me that there is a benefit to be had in thinking about individual health services as commodities because we can start breaking down macroeconomic and social dynamics into smaller units that we can actually understand.
Understanding some of the functions of hepatocytes allows us some understanding, but it is easy to extrapolate (the use of inference) into the delusion that we actually understand every nuance of how the liver works.
Such is OpenTheMedEdGates delusion, using snippets from dead old guys economists who were more renowned for their wit that their academic rigor (i.e. Milton Friedman).
Physicians need to understand as much as possible of these external sources of argument regarding the practice of medicine. They are forcing a square peg into a round hole.
Yep: WOW.
OpenTheMedEdGates: An unrestricted supply of medical students may only be achieved with a potentially limitless supply of medical schools or other appropriate instructional venues. Since medical education is largely financed by Medicare, which will soon be teetering financially, drastic expansion of the number of medical schools seems unlikely.
ReplyDeleteMedical education is otherwise financed by the medical student in the form of loans, with average medical student debt upon graduation well into the six-figure range. If increased government spending is not possible, then any expansion of medical schools would have to be funded by the enrollees -- an unlikely scenario given the need for almost 100% of physicians to finance their education currently.
Adding the idea of reduced salaries to this expanded medical education scenario would limit those persons able to financially survive medical training and practice to those who are already independently wealthy.
I agree that supply and demand have been monkeyed with by the federal government in terms of physician reimbursement and the size of the physician pool. However, if you want supply and demand to rule, it must rule o'er all the land, including the concept of people wanting to go into medicine in the first place.