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The Fight for Education

¹ Department of Radiology, Riley Hospital for Children, Indiana University Medical Center, 702 N. Barnhill Dr., Rm. 1053, Indianapolis, IN 46202-5200.

Received May 4, 2000; accepted after revision June 8, 2000.

 
Supported by a General Electric Radiology Research Academic Fellowship from the Association of University Radiologists.

Address correspondence to R. B. Gunderman.

Introduction

Top Introduction Seeds of War The Aggressor: Managed Care The Casualty: Education Victory References

 

Quit yourselves like men, and fight.

I Samuel 4:9

In the professions, great wars are won and lost through evolution, not revolution. Victories are not sealed through the sound and fury of epic battles, but slowly and quietly through the action of insidious and often impersonal forces whose effects are all but invisible by virtue of their slow pace and wide diffusion. Only professionals capable of surveying events from the vantage point of history can sense what is truly happening. Often, the full magnitude of the transformation is apparent only in retrospect, when it is too late to change course.

Such a momentous transformation is taking place in health care today, and it threatens the welfare of the entire medical profession, including that of radiology. Changes in the way health care is organized and financed, intended to constrain rising costs, are quietly eating away at our medical schools and residency programs. Spreading like a stealthy cancer, they are slowly undermining the finest programs of medical education in the world. Although few battles are visible, a war over the future of medicine is being lost, as short-term cost containment supplants long-term quality and value with disastrous educational consequences.

Recognizing the full magnitude of the threat requires the counsel of medical professionals whose perspective encompasses a broader sweep than this year's cuts in the education budget. One such professional is Kenneth M. Ludmerer, professor of medicine and history at Washington University, St. Louis, and author of Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care [1]. The book constitutes both a scholarly examination of major trends in United States medical education during the 20th century, and a critique of the more recent effects of managed care on medical students, residents, practicing physicians, and patients.

In March 2000, the Indiana University Department of Radiology, in conjunction with Alpha Omega Alpha Medical Honor Society, sponsored Ludmerer for a 2-day visiting professorship on the Indianapolis campus. During those 2 days, Ludmerer spoke with a medical student assembly, the medical school's curriculum committee and clerkship directors, educators in the radiology department, and the leadership of the medical school and the hospital corporation. He also delivered the Alpha Omega Alpha induction speech and a campus-wide lecture. During those discussions, it became apparent that Ludmerer's message merits a wider audience. This article shares the crux of his timely argument and the discussions it stimulated.

Seeds of War

Top Introduction Seeds of War The Aggressor: Managed Care The Casualty: Education Victory References

 
The historian's account of past events is vital in helping us define the present and chart our future. If we don't know where we are coming from, it is hard to foresee where we are going. Ludmerer's book [1], from which the historical facts and figures cited here are drawn, reminds us that the circumstances of American medical education were quite different in the mid 19th century. Medical schools were proprietary, operated as for-profit businesses. The course of study consisted of two 14-week series of lectures, the second merely a repeat of the first. The only criterion for admission to medical school was the ability to pay the tuition. A high percentage of graduates were illiterate. Patient contact was not a part of the curriculum, and patients frequently suffered when newly minted physicians went out into the world and literally began to practice medicine for the first time.

Abraham Flexner's influential 1910 report, Medical Education in the United States and Canada [2], helped stimulate radical reform in American medical education. Flexner called for all medical education to be based in universities, which had the resources to teach the scientific foundation of medical practice. However, Flexner was less concerned with the teaching of the basic sciences than with the teaching of clinical care. Many university-based medical schools were doing a good job of teaching the basic sciences; the problem lay in teaching medical students how to care for patients. Flexner argued that the current system, in which students were passive learners merely listening to lectures, was a prescription for educational failure.

Flexner argued that medical students had to be transformed from passive observers to active participants [2]. The only way they could learn how to care for patients was by doing it themselves. For such active participation in patient care to be realized, however, medical students needed access to patients. In other words, medical schools needed teaching hospitals. Flexner cited the model of the young Johns Hopkins University School of Medicine, founded several years after the Johns Hopkins Hospital. It was at Hopkins that such standards of contemporary medical education as medical student clerkships and postgraduate internships and residencies were being developed. Through the establishment of alliances between medical schools and teaching hospitals, Flexner argued, medical students could receive a complete education that would truly prepare them to provide high-quality care for the sick.

American medicine enthusiastically embraced Flexner's advice, and soon the proprietary schools were replaced by 4-year, university-based medical schools whose curricula were evenly divided between basic science and clinical practice. In its heyday, through the end of World War II, education reigned as the acknowledged raison d'être of United States medical schools. Although research and patient care certainly received their due, education was regarded as the medical schools' defining mission. Research institutes and private industry could carry out laboratory investigations, and community hospitals could provide medical care. The only unique product of medical schools was the education of physicians.

After World War II, the focus of United States medical schools shifted to research, with a huge growth in medical school research budgets. Beginning in 1965, however, an even bigger shift took place in American medical education. With the passage of Medicare and Medicaid legislation, medical schools shifted their focus from education and research to patient care, paralleling a massive increase in the size of the United States health care budget. Through the early 1960s, medical schools derived approximately 6% of their income from the private practice of medicine. Most patient care in teaching hospitals was charity care based on a social contract between medical schools and society. This implicit contract stated that society would provide financial support to train the next generation of physicians and, in exchange, teaching hospitals would care for the medically indigent, the "clinical material" on which medical students and residents learned how to practice high-quality medicine.

With Medicare and Medicaid, however, tens of millions of charity patients were converted overnight into paying patients, and the business of health care began to explode. Where the private practice of medicine once represented 6% of medical school income, today it constitutes well over 50%, exceeding education and research combined. The size of medical school faculties skyrocketed, as did their revenues. During the 25 years between 1965 and 1990, the full-time faculty of medical schools increased from 17,000 to 75,000. The typical medical school budget in 1965 was on the order of $20 million. By the 1990s, it had grown to $200 million or more.

This prodigious growth in United States medical schools was driven not by education or research, but by an expansion in clinical care, something very much like the private practice of medicine. Traditionally, the medical school professor cared for patients as an academic endeavor, seeing relatively few patients to permit high-quality teaching. As the medical school and its teaching hospital became increasingly indistinguishable from today's multispecialty group practices, however, the medical school professor began to operate in a more private-practice mode, seeing as many patients as possible to generate revenue. As the professor saw more and more patients, the time available for education diminished. Even the sacred cow of research, long the basis for promotion and tenure at top medical schools, began to suffer. In 1965, approximately 6% of United States health care dollars went into research; today that number is approximately 3%.

As the scholarly faculty underwent this transformation into a clinical faculty, another important change led to the establishment of today's managed care model. Health care payers became increasingly concerned about annual double-digit rises in the cost of health care. Between 1965 and 1995, United States health care costs rose from 3.5% of the gross domestic product (their level throughout most of the century) to more than 14%. As a result, at least 1 of 7 United States dollars is now spent on health care. Alarmed by this trend, health care payers began to search for ways to constrain the rise in costs. Managed care presented itself as a plausible therapy for what ailed the health care system.

The Aggressor: Managed Care

Top Introduction Seeds of War The Aggressor: Managed Care The Casualty: Education Victory References

 
In the fee-for-service system, hospitals and physicians were paid in proportion to what they charged, rendering the marginal revenue of each additional unit of service positive. In other words, the more services they provided, the more money they made. Capitation, in which providers are paid a fixed amount per covered patient, was envisioned as a means of making hospitals and physicians bear some of the costs of providing additional services, thereby rendering the marginal revenue of each additional service negative. For the first time since the advent of Medicare and Medicaid, providers could actually lose money if they ordered an additional test or kept the patient in hospital for an additional day.

In the cost-cutting climate of managed care, payers became less and less willing to pay teaching hospitals a premium for providing care. For decades, the costs of caring for patients in teaching hospitals had hovered approximately 30% higher than the costs for comparable patients in community hospitals. This discrepancy reflected the fact that teaching hospitals provide more charity care and practice medicine less efficiently because education slows the pace of care. Every hour a medical school professor spends teaching medical students and residents is an hour taken away from direct patient care, meaning that a medical school professor who teaches can see fewer patients per day than a colleague in private practice. With managed care, however, health care payers were no longer willing to subsidize that inefficiency, and they progressively reduced the premium they paid teaching hospitals.

Suddenly, teaching hospitals found their principal revenue base in dire jeopardy. To compete effectively for patient care dollars, medical schools quickly discovered that they had to increase the clinical productivity of their faculty. Medical school professors who, by virtue of Medicare and Medicaid had already begun to resemble private practitioners, were subjected to incentive systems that forced them to compete with the most efficient private practitioners around. As Ludmerer [1] points out, even the American Association of Medical Colleges today defines the productivity of medical school faculty according to income generated, which renders the most productive medical school faculty members the ones who generate the most clinical income. As a result, a busy cosmetic surgeon who never publishes a paper or teaches a student is likely to rank well above even the most outstanding academic internist or pediatrician in terms of professional "productivity."

Beginning in the mid 1980s, the focus of patient care in medical schools underwent a profound shift. Whereas patients had once stayed in the hospital for an average of 10 days and on a busy admitting night an internal medicine resident saw three or four patients, the average length of stay was reduced to 3 or 4 days and admitting nights of eight to 10 patients became common. Most patients arrived in the hospital with a diagnosis, and much of the recovery took place after discharge. The hospital was transformed into a procedural assembly line, and the medical student and resident, into admission and discharge machines. An academic medical enterprise whose hallmark had once been careful deliberation and attention to detail—esteemed virtues of the master clinician—was replaced by a commercial ethos characterized by an intense effort to get patients in and out of the hospital as quickly as possible.

The Casualty: Education

Top Introduction Seeds of War The Aggressor: Managed Care The Casualty: Education Victory References

 
For a time, medical schools could cross-subsidize their teaching missions from clinical revenue, using the academic premiums insurers were paying for clinical care to support their educational enterprises. As those premiums evaporated, however, it became increasingly difficult to generate enthusiasm for teaching excellence in the minds of medical school and hospital administrators. Teaching medicine, the medical school's very reason for being, was transformed from a primary mission into an economic liability.

The problem in academic medical centers was especially severe in specialties such as radiology, which had grown accustomed to economic and political prestige in the medical school culture based on its status as an important revenue center. Through much of the 1970s and 1980s, radiologists could ascend faculty promotions and tenure ladders on the basis of relatively modest research productivity and little or no medical student teaching. Despite a record of research and teaching that compared poorly with those of other disciplines, such as internal medicine, radiologists were able to command high salaries because of the high levels of clinical revenue they generated.

With the coming of managed care, however, an incentive system that had once rewarded the performance of diagnostic tests reversed itself, and revenues from diagnostic imaging began to plummet. Departments responded by asking faculty to increase their clinical productivity in an effort to sustain the revenue stream. However, increasing attention to clinical work further eroded already underperforming research and teaching programs. Academic radiologists who once had the opportunity to devote significant time to teaching medical students now found themselves under so much pressure to increase clinical throughput that good teaching became improbable and, in some centers, nearly impossible. In academic medical centers increasingly dominated by fiscal imperatives, what incentives exist for academic radiologists to sustain, let alone augment or develop, educational programs for medical students?

Ludmerer [1] warns that medicine is returning to the proprietary model of medical education that Flexner [2] decried at the beginning of the century. The clinical work of performing imaging examinations, interpreting studies, and consulting with referring physicians has become so fast-paced that medical students and even residents are being increasingly marginalized, relegated to the status of passive observers. The single-minded fixation on clinical productivity has tended to diminish both the frequency and intensity of educational interactions taking place in academic radiology departments. Not only is the radiologist unable to teach as well, but the students aren't able to learn either, as opportunities for hands-on experience are swept aside by the demands of clinical throughput. Improved educational materials, simulation devices, and computer-based instruction are touted as stop-gap measures, but Flexner would undoubtedly remind us that there is no substitute for learning by doing. The practice of medicine, including radiology, simply cannot be learned at a distance, no matter how sophisticated the technology delivering it. Moreover, the opportunity for radiologists to serve as advisors, role models, and mentors is fast disappearing [3].

Managed care, Ludmerer argues, is based on false assumptions about biology and human beings [4]. For one thing, medicine is not merely a science of managing disease; it is also an art of negotiation with uncertainty. For another, it is impossible to take care of patients in the same way that you produce fast food. Good medical care depends on the cultivation of a level of trust between patient and physician that can only be built over time and that time is precisely what is missing from managed care today. If every patient arrived in the physician's office with a precise diagnosis that indicated only one course of therapy, then doubling or even tripling the number of patients the physician must see per hour might pose less of a threat to the quality of medicine. Of course that is not the case. Increases in clinical throughput have been purchased at the price of diminished quality of care, against which both physicians and patients are beginning to rebel.

Finally, the practice of medicine is not a business and should not be operated according to the lowest common denominator of business ethics [5]. For example, it is never acceptable to subject a patient to a test merely because the physician would like to make more money. More important, from the standpoint of managed care, it is never acceptable to withhold from a patient an indicated test merely because the health care payer would like to save money. In each of these respects, the therapy of managed care turns out to be worse than the disease of rising health care costs.

Ludmerer argues that in attempting to change the present, we must first understand the past [1]. Only by comprehending how we got to this point can we avoid the same pit-falls in the future. Second, we must confront the issue of cost containment head-on and never again attempt to make it go away merely by pretending that it does not exist. In the interests of our patients, we cannot simply cede the prerogative on cost control to the proponents of managed care—to do so creates the appearance that the medical professional operates first from self-interest. Instead, cost-effective medicine must be become part of our professional definition of quality care. Third, the profession must be seen to address the issue of access for underserved populations. From the public's point of view, the medical profession is vocal about the effects of managed care on physicians' incomes but relatively mute on the issue of access to care.

Victory

Top Introduction Seeds of War The Aggressor: Managed Care The Casualty: Education Victory References

 
How can the war to save medical education be won? Academic disciplines including radiology must seize the current turmoil in health care as an opportunity to reexamine their core values and determine what they are really all about.

Education Despite Cost Control
Why should academic radiology resist the transformation into a cost-minimizing group practice? If the answer pertains to core academic missions such as education, then radiology departments must be prepared to make sacrifices that will enable them to sustain the pursuit of those core missions. From the standpoint of junior faculty, there is no point in remaining in academic radiology if it requires sustaining the same level of clinical productivity as a private practitioner, especially if academic medicine pays significantly less. On the other hand, if academic radiology departments want to excel at their core mission of training the next generation of physicians and radiologists, they must resign themselves to lower levels of clinical productivity for the sake of quality education.

Educational Outcomes Research
Radiology and other medical disciplines need to take the lead in developing indicators of quality and cost-effectiveness in health care, especially in medical education. Thoughtful observers recognize the harm that managed care is wreaking on medical education, but relatively little systematic study of the phenomenon has taken place. As long as we lack good educational outcome measures, medicine's educational mission remains vulnerable to a cost-cutting mentality that values price above quality. Moreover, radiology needs to play a role in developing clear educational goals that extend beyond the traditional curriculum of pattern recognition and differential diagnoses. The curriculum must be redefined in a way that adds genuine value to medical care, including the development of improved consultation skills, enhanced diagnostic reasoning capabilities, and the ability to define more cost-effective imaging workups. Perhaps allowing physicians to spend time with medical students is cost-effective in ways we don't currently appreciate, but we will find out only by developing solid educational outcomes measures.

Medicine's Philanthropic Mission
Radiology must play its part in helping articulate academic medicine's core missions and the damage being wreaked by managed care on patients and students. Radiology must stand up politically for quality of care, and it must do so not alone, but as part of the entire profession of medicine. As long as medical specialties are seen as embroiled in internecine turf battles, radiology's efforts to establish performance criteria are liable to be regarded with suspicion and even contempt as fundamentally self-interested. Radiology departments and medical schools must again genuinely deserve the respect and public support they once took for granted. To regain the respect and public support, they must reestablish their social contract with society by rededicating themselves to their core academic values.

Aligning Education and Practice
Ultimately, a reorientation of medical education can come about only when the larger health care system reflects the needs of high-quality learning. We can browbeat students about the importance of taking their time and being careful until we are blue in the face, but it will do no good if they see that the reality of medical practice is otherwise. To be sure, medical schools need to instill in students a sense of what excellent medicine is like so they go into practice with an internal compass that orients them toward quality care. However, medical schools cannot unilaterally reform the health care system. The best they can do is seek to regain their status as the conscience of medicine and to reestablish their role as society's health care opinion leaders. If medical schools are to succeed in these monumental undertakings, Ludmerer reminds us, they must enter the fray with an unclouded sense of mission and a clear conscience. Herein lies an opportunity for radiology to assume a leadership role in healthcare and the profession of medicine.

References

Top Introduction Seeds of War The Aggressor: Managed Care The Casualty: Education Victory References

 

1. Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. New York: Oxford University Press, 1999
2. Flexner A. Medical education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching, 1910
3. Fox RC. Time to heal medical education. Acad Med 1999;74:1072 -1075[Medline]
4. Ludmerer KM. Time and medical education. Ann Intern Med 2000;132:25 -28[Abstract/Free Full Text]
5. Gunderman RB. Images of the imager: the essential role of ethics in the future of radiology. Acad Radiol 1999;7:148 -155

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