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Requests for reprints should be addressed to Benjamin R. Doolittle, MD, MDiv, Associate Professor, Internal Medicine & Pediatrics, Yale University School of Medicine, PO Box 8030, New Haven, CT 06520-8086.
Department of Internal Medicine, Yale University School of Medicine, New Haven, ConnDepartment of Pediatrics, Yale University School of Medicine, New Haven, Conn
Who is the physician of the future? Our present model of the physician-scientist, developed in 19th century Germany, no longer fits the needs of our patients. The physician did not always look this way, with our white lab coats and stethoscope draped over our shoulders. Consider the lessons of history. In 2nd-century Alexandria, Galen codified the cause of disease as an imbalance of 4 humors—black bile, yellow bile, phlegm, and blood—and set the standard for medical diagnosis for the next 1300 years (Figure).
Unknown, Alchemic approach to four humors in relation to the four elements and zodiacal signs. Book illustration in “Quinta Essentia” by Leonhart Thurneisser zum Thurn (gen. Leonhard Thurneysser). 1574. Available at: https://www.arsgravis.com/UserFiles/image/Andrigino_NOU/androgino7.jpg. Accessed November 23, 2020.
The cult of Asclepius was also influential in this era. After consultation with a priest, patients were admitted to an overnight session in the temple. In the morning, patients consulted again with the priest to interpret any dreams experienced during the night.
Grand hospitals such as the Salpêtrière for women, the Enfants-Trouvés, and the Hotel Dieu housed thousands of patients in long, open wards organized by symptom. Patients with dyspnea were in one ward, those with dropsy in another. The patient's history was deemed unreliable. Therefore, the physicians employed their considerable physical exam skills—observation, percussion, and palpation—with a special emphasis on diagnosis and prognosis. In 1816, Rene Laënnec designed the stethoscope, a product of this new era of examination.
What is happening? How long does the patient have to live? A Parisian physician observed and prognosticated, but offered little in the way of therapeutics.
In the 19th century, the model changed again. Medicine moved from the Parisian wards into the laboratories of Berlin and Vienna.
The modern version of the physician-as-scientist emerged. The body could be better understood through its chemical reactions and microscopic invasions. In 1828, Friedrick Wohler discovered that the process to make urea from inorganic compounds. He wrote to his friend Berzelius, “I must tell you that I can make urea without the use of kidneys, either man or dog.”
Robert Koch, the most famous physician from this era, defined the method to isolate and identify microbial agents that caused horrendous human disease, such as anthrax, tuberculosis, and cholera, to name a few.
The microscope emerged as the most emblematic tool from this era. To be a physician meant to be a physician-scientist.
In the early 20th century, the physician-scientist model became the archetype for medical training. In 1910, the Carnegie Foundation tasked Abraham Flexner with evaluating the quality of American medical schools.
The stakes were high. Those schools deemed unfit would be pressured to close. Those who fit the model, the pinnacle of which was Johns Hopkins, would receive further funding. Schools were required to have access both to patients and laboratories. Flexner recommended 2 years of basic sciences to provide a foundation of pathophysiology, microbiology, and biochemistry followed by 2 years of clinical training. This curriculum has only recently begun to change after nearly 100 years. The Flexner report lifted the practice of medicine from that of a trade to a respected profession.
At the time, this was a paradigm shift. Previously, treatment was informed by tradition and experience rather than the rigors of controlled experiments.
After more than a century, is the physician-scientist model still the standard? Humanity has reaped the benefits of the physician-as-scientist approach to medical education. Life-threatening diseases that the 18th century physician could only observe are now treated routinely. Yet we live in a different age. How is memorizing the Krebs cycle important for septic shock? How is staining a slide important for treating a patient with tuberculosis? Clearly, a certain amount of science is important for medical training, but do we inflict fact overload upon our medical students at the expense of clinical-based training? Is the model proposed by Flexner in 1910 still the model that we need today?
In 2009, the Accreditation Council for Graduate Medical Education (ACGME) proposed 6 core competencies: fund of knowledge, patient care, practice-based learning and improvement, system-based practice, interpersonal and communication skills, and professionalism.
The physician-as-scientist model glances upon only a few of those 6 competencies (perhaps fund of knowledge and patient care) but barely addresses the others. All medical knowledge has a half-life. We no longer prescribe arsenic for syphilis or milkweed for pleurisy; but we do need physicians with a curiosity and discipline to continue their learning. We need innovators.
In 2017, the ACGME formed a task force to explore the changing landscape of medical education. As the Sponsoring Institution 2025 (SI2025), members conducted more than 1000 interviews with stakeholders nationwide, “To develop a future vision for ACGME-accredited institutional sponsors of residency and fellowship programs.” They described three major forces that are shaping the medical profession: rapid democratization, increased commoditization, and advancing corporatization. Medical information is becoming increasingly available to all (democratization). As such, the delivery of medical care becomes indistinguishable from other offerings, with the only difference being price (commoditization). We see this in routine health care offerings in big-box stores and bundled payments for surgical services. To manage all this, health care delivery has evolved into increasingly integrated, complex systems, such as regional hospital systems (corporatization).
Responding to these forces, the SI2025 task force proposed that the physician of the future has the following attributes:Healers who are able to make effective use of technology… to enhance their healing relationship with patients;Servant-leaders who collaborate with others and prioritize the needs of others in decision-makingAdvocates who promote patient-centered care… and address social-determinants of health . . .Team members who work and communicate with health care professionals toward effective coordination of patient care
We are entering a new age of medicine. To be a physician has become increasingly complex. How can we be technically competent, with a current fund of knowledge, caring for our individual patients, with an eye toward panel management and quality? Will this lead toward further specialization? Will we have diagnosticians, proceduralists, coordinators, and other specialized technicians? Some have argued that this has already begun to happen.
As we pass from the Age of Science, through the Age of Technology, what comes next? I believe we are entering the Age of Synthesis, as attributed to the 18th century German Idealist philosopher by Georg Wilhelm Friedrich Hegel. For this school of thought, synthesis was the step to reconcile 2 contradictory propositions, thesis and antithesis.
Medicine is fraught with reconciling disparate, often contradictory, pieces of data. The physician of tomorrow will need to synthesize complex information, coordinate complicated care, and adapt to an ever-changing technology. The physician will need to lead. This will be true of the cardiac surgeon who replaces heart valves, the geriatrician who conducts an end-of-life conversation with a family, and the primary care physician who navigates complicated drug-drug interactions. As we contemplate being a physician in this new age, are we called upon to be philosophers again?
References
Unknown, Alchemic approach to four humors in relation to the four elements and zodiacal signs. Book illustration in “Quinta Essentia” by Leonhart Thurneisser zum Thurn (gen. Leonhard Thurneysser). 1574. Available at: https://www.arsgravis.com/UserFiles/image/Andrigino_NOU/androgino7.jpg. Accessed November 23, 2020.
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