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Negative Secular Trends in Medicine: Training Needs More Emphasis on Maturity, Independence, and Self-Reliance

Published:January 09, 2021DOI:https://doi.org/10.1016/j.amjmed.2020.12.013
      In 2016, I had a series of 6 commentaries in this journal on negative secular trends in medicine. These commentaries were on the things I thought made it less likely that the smartest kids in the class, the people we want to be our physicians, would choose a career in medicine.
      • Doroghazi RM
      Negative secular trends in medicine: student debt.
      • Doroghazi RM
      Negative secular trends in medicine: high CEO salaries.
      • Doroghazi RM
      Negative secular trends in medicine: the ABIM maintenance of certification and over-reaching bureaucracy.
      • Doroghazi RM
      Negative secular trends in medicine: prolonged training periods.
      • Doroghazi RM
      Negative secular trends in medicine: summary.
      • Doroghazi RM
      Negative secular trends in medicine: high hospital profits.
      At the top of the list was long training periods. If one goes straight from high school to graduate from college at age 22, graduates from medical school at age 26, and undergoes basic medical training for 3 years, he or she will be 29 years old when it is time to enter the real world. If you start medical school at the average age of 24 to 25, graduate at 28 or 29, add 3 years of internal medicine, then pursue cardiology training and a further subspecialty such as electrophysiology, you could be elected President of the United States before you leave the financial purgatory of training and are eligible to sit for your subspecialty board examinations. All the while your attorney, MBA, and entrepreneur, college contemporaries, have been in the real world for 5 to 10 years, and can hold a responsible, or even prominent, position. A 35-year-old with 3 children, in his last year of fellowship, who notes he is yet to own a home, told me that such a prolonged slog numbs the mind and drains initiative. Some physicians are even considering multiple fellowships. Where will it end? The result of this near-endless training is that we have turned our young physicians into heavily-indebted professional students.
      One direct, practical result of longer training periods is that with more physicians in training, there are fewer procedures to go around. Procedures previously performed by the intern are now performed by the resident, those performed by the resident are now saved for the fellow, and so on. It is perversely self-reinforcing. Longer training = fewer procedures = even more training required.
      We have previously shown that for each year training is shortened equates to the gain of a year of the average physician's salary,
      • Doroghazi RM
      • Alpert JS
      A medical education as an investment: financial food for thought.
      currently $300,000. Shortening the time from high school graduation to the completion of training by 3 years would increase the value of a career in medicine by almost $1,000,000. It will also save the average physician at least $20,000-25,000 by avoiding further compounding of their quarter-million dollars of student loans.
      Why do we keep our young physicians so long in the “minor leagues,” a pejorative, but, unfortunately, accurate description?
      • 1)
        I believe the already long training periods of many subspecialties are being unnecessarily prolonged to create an aura of exclusivity. I also believe that many new subspecialties are being proposed, with their commensurate longer training periods, and expensive board examinations, for the simple reason that someone wants to create a new pond where none existed before so they can become a big fish.
      • 2)
        I have already discussed in detail why I believe the explosion of knowledge argument is specious.
        • Doroghazi RM
        Negative secular trends in medicine: prolonged training periods.
      • 3)
        The notion I wish to dispel now is that these long training periods are required because physicians lack maturity. One of the routine canards against the 6-year combined undergraduate-MD programs is that the graduates of these programs lack maturity, although they do equally as well on standardized exams as the traditional student who attends college and medical school for 8 years.
        • Loftus LS
        • Willoughby TL
        • Connolly A
        Evaluation of student performance in combined baccalaureate-MD degree programs.
        A 25-year-old with a physician-quality intellect lacks maturity? Please. If that is the case, then maybe they should not be in medical school in the first place. You get what you expect.
      Let me provide some example of what you receive when you expect people to be mature.
      • 1)
        During the Barbary Wars, Stephen Decatur led a daring raid to scuttle the captured frigate USS Philadelphia. For this, and other acts of leadership and heroism, Decatur was elevated at age 25 to the rank of captain. He remains the youngest captain in the history of the US Navy.
        • Kilmeade B
        • Yaeger D
        Thomas Jefferson and the Tripoli Pirates.
      • 2)
        During the US Civil War, David “Damn the Torpedoes, Full Speed Ahead” Farragut was the first man in the US Navy raised to the rank of admiral. In the War of 1812, at the age of 12—“12,” that is not a misprint—Farragut was given command of a prize captured by the USS Essex to be sailed back to port.
      • 3)
        Twenty-two-year-old graduates of the US service academies are considered mature enough to lead men and women into battle.
      • 4)
        The Israeli Defense Force is extremely aggressive in the downward delegation of responsibility. Their military pyramid is narrow at the top; there are few colonels and an abundance of lieutenants. The 23-year-old company commanders “are kids…Each of them is in charge of one hundred soldiers and twenty officers and sergeants, three vehicles…that means a hundred and twenty rifles, machine guns, bombs, grenades mines, whatever…Tremendous responsibility.”
        • Senor D
        • Singer S
        Start-Up Nation: The Story of Israel's Economic Miracle.
      I trained in the late 70s and early 80s, and retired at the end of 2005. I do not say this to show how tough us old-timers had it and how easy things are for the youngsters (although I did walk to the hospital barefoot in the snow, 5 miles, and uphill both ways), but rather to point out that I now get in the hospital only occasionally, which allows me to notice trends that one there every day may not appreciate.
      Maturity and decision-making are the same thing. Residents taking calls without in-house faculty back-up are forced to assume more individual responsibility, to sink or swim. In-house faculty can easily result in the residents assuming a more passive approach vs. taking the initiative. It is also my impression that decisiveness is not encouraged; many decisions that I believe could be easily made by the treating physician alone, are now often made “in collaboration” by “the team,” or even a board or panel. To say the current generation of physicians are coddled is both untrue and unfair. However, I feel strongly that physicians should be more challenged.
      It is also my clear impression that being aggressive is actively discouraged by those teaching and supervising the current generation of physicians-in-training. Of course, I do not mean the undesirable aggressiveness of intimidation and bullying, but rather the ability to question authority, think independently, push the boundaries, and move forcefully and expeditiously to achieve the desired goal. Those who want to get ahead and push hard run the risk of being dismissed as “gunners” and might even be ostracized by their associates. Assertiveness can result in a negative evaluation by the ancillary help. Hospital administrators, the employers of an increasing number of physicians, are trained to be aggressive, hard-nosed businessmen and women. In medicine, we are cautioned to never make a guarantee, but I can assure you that hospital chief executive officers prefer not to have to deal with equally aggressive, independent-minded, hard-nosed physicians.
      If you want mature, and ultimately, better physicians, you will get it, and the way to do it is to shorten training periods and encourage self-reliance and independence.

      References

        • Doroghazi RM
        Negative secular trends in medicine: student debt.
        Am J Med. 2016; 129: 8-10
        • Doroghazi RM
        Negative secular trends in medicine: high CEO salaries.
        Am J Med. 2016; 129: e1-e2
        • Doroghazi RM
        Negative secular trends in medicine: the ABIM maintenance of certification and over-reaching bureaucracy.
        Am J Med. 2016; 129: 238-239
        • Doroghazi RM
        Negative secular trends in medicine: prolonged training periods.
        Am J Med. 2016; 129: 352-353
        • Doroghazi RM
        Negative secular trends in medicine: summary.
        Am J Med. 2016; 129: 459-460
        • Doroghazi RM
        Negative secular trends in medicine: high hospital profits.
        Am J Med. 2016; 129: 1141-1142
        • Doroghazi RM
        • Alpert JS
        A medical education as an investment: financial food for thought.
        Am J Med. 2014; 127: 7-11
        • Loftus LS
        • Willoughby TL
        • Connolly A
        Evaluation of student performance in combined baccalaureate-MD degree programs.
        Teach Learn Med. 1997; 9: 248-253
        • Kilmeade B
        • Yaeger D
        Thomas Jefferson and the Tripoli Pirates.
        Sentinel, New York, NY2015
        • Senor D
        • Singer S
        Start-Up Nation: The Story of Israel's Economic Miracle.
        Twelve: Hatchett Book Group, New York, NY2009