Time and Medical Education

The Length of Study

Medical education has always encountered a dilemma: the proper length of time for medical study. To protect society, medical educators have been obligated to ensure that physicians be properly grounded in theory and technique. However, because it is impossible for an individual to learn all of medicine, even with a lifetime of study, at some point formal education must end and physicians must enter practice.

Through the 1870s, medical education in the United States was surprisingly short: Two 16-week terms of lectures, the second term repeating the content of the first, were the norm. As medical knowledge grew exponentially, the length of time required for medical study began to increase. Sixteen-week terms became 9-month sessions, 2-year courses evolved into 3-year curricula, which then became 4-year curricula. By the early 1900s, the basic structure of current undergraduate medical education—2 years of basic science instruction followed by 2 years of clinical clerkships—was in place (1).

By World War I, it was apparent that even 4 years of medical school was insufficient for the preparation of a physician. Medical knowledge, techniques, and practice were growing and changing too rapidly. Accordingly, the internship, a 1-year period of hospital education following receipt of the MD degree, became standard for all physicians, including most who were entering general practice. In addition, further training became necessary for those who wished to enter specialty practice or pursue an academic career. For these purposes, the residency, a several-year hospital experience following internship, became the customary vehicle. After World War II, as specialty careers eclipsed general practice in popularity, the residency became standard for virtually all physicians, and many physicians embarked on 2- or 3-year fellowships after the completion of a residency to acquire training in a subspecialty. Thus, by the 1960s, physicians were typically engaging in 3 to 7 or more years of preparation after graduation from medical school—a pattern that has persisted through the present (2).

From the 1960s forward, the size of the formal educational “box” has remained unchanged, despite the continued exponential growth of medical knowledge, a series of reports decrying the crowding of the undergraduate curriculum (3), and the well-known rigors of graduate medical education. There have been occasional attempts to lengthen the period of training still further. For instance, in 1959 Stanford Medical School increased its undergraduate curriculum to 5 years. However, such efforts have not become widespread, and there appears to be little chance of any major increase in the length of training in the foreseeable future.

What allowed the existing duration of formal medical training to work was the change in medical education a century ago from a substantive to a procedural emphasis. In the proprietary era, medical education emphasized the inculcation of facts through rote memorization. In the latter part of the 19th century, the objective of medical education became producing problem-solvers and critical thinkers. Through laboratory work in scientific subjects and hospital work with real responsibility for patient care during the clinical years, it was anticipated that learners would develop the power of critical reasoning, the capacity to generalize, and the ability to find out and evaluate information for themselves. Of course, there remained a huge amount of factual information that physicians needed to know, and the tension between the procedural and substantive approaches in medical education never abated. Nevertheless, with the new emphasis on reasoning skills, it mattered far less if a physician had not encountered every clinical situation during his or her formal education. A properly trained physician, who had become skilled in problem solving and dealing with clinical unknowns, was well-equipped to handle the innumerable uncertainties of day-to-day practice (1).

The history of U.S. medical education has been one of striving to achieve, but not realizing, the educational ideal of teaching reasoning skills. Each generation of medical educators has reaffirmed its commitment to this principle while acknowledging the failure to accomplish the objective fully. Nevertheless, patients and the public have been generally well-served. The outstanding reputation of U.S. medical practice in the 20th century owes much to a system of medical education that has produced physicians who not only know facts and understand theory but also can solve problems and deal with clinical uncertainty.

Time To Teach

A distinctive characteristic of the proprietary school was its faculty-centered environment. A course of instruction based almost wholly on didactic lectures may not have been conducive to good learning, but it did represent efficient use of the faculty's time. When faculty were not lecturing, they were seeing private patients. Indeed, the typical medical professor of that period derived the preponderance of his income from professional fees collected as a medical or surgical consultant.

A central tenet of the revolution in U.S. medical education was that faculty should be genuine university professors—that is, the bulk of their work should be in teaching and research. To accomplish this, reformers held that faculty should be retained on one or another version of the “full-time” system so they would be freed from having to practice medicine to generate their salaries. No one argued this more passionately than Abraham Flexner, the noted educational reformer. In 1930 he wrote, “If the scientific budget of a clinical department is once dependent upon the earnings of the clinical staff, that staff will in all probability have to earn the requisite amount—by doing what it is interested in, if it can, by doing other things, should that become necessary” (4).

As a consequence, learners became the central focus of the faculty's attention in the new system of medical education implemented in the early 20th century. Laboratory instruction, clinical clerkships, seminars, small group conferences, individual tutorials, and personalized instruction became the hallmark of medical education in the United States. Such an environment was expensive to provide, but it did allow faculty to concentrate at last on the needs of learners. For instance, at the University of Michigan before World War II, the average faculty member devoted about 60% of his time to teaching or the preparation for teaching (5). At schools that were less research-intensive, an even greater percentage of the faculty's time went into teaching.

From the beginning of the modern era, faculty had important activities besides teaching to pursue—most notably, research. During the first half of the 20th century, and much more dramatically after the establishment of the National Institutes of Health in the late 1940s, research gradually supplanted teaching as the main faculty activity at many medical schools. Nevertheless, good teaching was still widely found, partly because there were more faculty, particularly in the clinical departments, to share the duties. This resulted from the fact that clinical faculty were under relatively little economic pressure to see patients. If they chose to spend time with students or house officers, they could freely do so.

One extraordinary aspect of medical education during the managed care era has been the increasing diversion of faculty time into private practice. Faced with lower reimbursement rates from third-party payers, many schools have begun placing pressure on their full-time clinical instructors to see more patients. Schools have begun to measure the “clinical productivity” of their faculty (defined as the amount of clinical income a faculty member generates) and implement new pay scales that create financial incentives for seeing more patients (6). Like faculty at proprietary schools a century earlier, clinical faculty are now finding their incomes increasingly dependent on private practice.

The expansion of faculty practice has been helpful for the finances of medical schools. However, the consequences for teaching have been decidedly unfavorable. At medical schools across the country, clinical faculty have been forced to spend more and more time in medical practice and correspondingly less in teaching and research. Educational activities have simply not been encouraged by the new rules of faculty practice that penalize any loss of “clinical productivity.” “We don't see how we can be educators and at the same time earn our own salaries [from patient care],” observed a pediatrics professor (7).

During most of the 20th century, medical teaching and research thrived in the United States because medical schools could provide a haven for some of the best and brightest physicians to devote themselves to education and research, free from the burden of having to earn their salary from private practice. In recent years this haven has been disappearing. The educational consequences of this shift have not been the subject of formal outcome studies. However, it is difficult to imagine how the diversion of the faculty's time and attention away from teaching can benefit the education of students and house officers.

Time To Learn

Although good teaching is essential to good medical education, the ultimate responsibility for learning has always rested with the student. This is because all medical learning is ultimately self-learning. Teachers can guide and inspire, but there is no substitute for the learner's initiative. Flexner once wrote, “Though medicine can be learned, it cannot be taught” (8). The high quality of U.S. medical education throughout the 20th century has depended above all on its success at attracting motivated, qualified students and providing them unfettered opportunities to learn (2).

The rich learning environment available at academic medical centers consisted of many elements, such as good laboratories and libraries, an ample and diverse supply of patients, and stimulating teachers and colleagues. Most important was the fact that clinical learning was conducted in settings where students and house officers had sufficient time with patients so that patients could be studied and understood. The 3-week average hospitalization during World War I years, the 2-week admission of 1950, the 11- or 12-day stay of 1980, and even the 7- or 8-day hospitalization of 1990 provided learners ample exposure to the natural history of disease as well as the opportunity to develop problem-solving skills and to pursue questions in depth.

Since the mid-1980s, however, the primary mandate in patient care has increasingly become the rapid “throughput” of patients, as physicians and hospitals have responded to lower prices from third-party payers by increasing the rate and volume of patients seen. Academic medical centers have not been immune from these trends. By the late 1990s, the average length of stay at some institutions had fallen to 4 days or less.

Although increasing the “throughput” of patients seems to have helped the financial balance sheets of academic medical centers, this practice has had an erosive effect on the learning environment of teaching hospital wards. It has become much harder for learners to acquire problem-solving skills when patients are admitted with their diagnoses known and treatment plans already determined. Surgical residents, meeting patients who are under the drapes of the operating table, can still learn how to remove a gall bladder, but their opportunity to develop the clinical experience and judgmental capacity to decide who might actually need the procedure is severely compromised. In addition, as the “throughput” of patients increased, so did the work of interns and residents, who were now admitting many more patients. This increased work load often came in the face of a decrease in the number of nurses and other support personnel as low reimbursement rates from managed care organizations forced many hospitals to reduce staffing dramatically.

The emphasis of the current health care environment on “throughput” has also made it difficult for schools to improve the quality of ambulatory care rotations. There have been many attempts in the 1990s to introduce education to outpatient settings without slowing down the flow of patients; however, there have been relatively few efforts to reduce the number of ambulatory patients seen in teaching settings so that students and house officers might have a better educational experience. Some schools have even prohibited students and residents from working in faculty ambulatory facilities altogether because educational inefficiencies rendered the practices noncompetitive with private practice (9). In addition, the hurried environment carried negative implications for the all-important latent learning of the “hidden curriculum.” Habits of thoroughness, attentiveness to detail, questioning, listening, thinking, and caring were difficult to instill when both patient care and teaching were conducted in an 8- to 10-minute office visit. Few learners were likely to conclude that these sacrosanct qualities were important when they failed to observe them in their teachers and role models.

Given the dearth of good quantitative measures of educational outcomes, it is impossible to know at present how the loss of time in patient care has been affecting students and house officers. However, preliminary reports (10-14) have suggested that the effect has not been positive, and students and house officers themselves have complained that the loss of time with patients has been deleterious to their education (15). Equally unknown, but also a matter of concern, is how commercialization of the academic medical center has influenced students' attitudes and behavior. As one medical educator wrote, “I think the student who learns medicine in an environment where the bottom line is a cash flow will become a different kind of a person than someone educated in an atmosphere where, whether we do it or not, we at least hold out that the bottom line is the satisfaction of the patient's needs” (16).

The irony of the recent transformation of the health care delivery system is that the uses of time that are good for medical schools and faculties are not necessarily good for medical education. Schools feel they can remain financially strong and continue to pay their faculty high salaries if the professors spend more time in patient care and less in teaching and research. Similarly, medical schools and teaching hospitals feel they can do well financially if patients are admitted and discharged quickly, but learners can no longer profit from contact with them. For the first time in over a century, medical education has veered away from a tight focus on the needs of learners; it is difficult to imagine how this can be good for the education of our country's future physicians.

Conclusion

This essay has indicated some of the ways that time is essential to the process of medical education. Time is necessary for teachers to teach, for learners to learn, and for the educational process to be long enough for major educational objectives to be met. Throughout the 20th century, much of the strength of U.S. medical education has been derived from the provision of sufficient time in these three contexts. However, as the new millennium approaches, time is disappearing from the process of teaching and learning medicine, with disturbing implications for the quality of education.

Throughout the history of U.S. medicine, the quality of education has depended heavily on the amount of financial support educators could muster to nourish the educational enterprise. In this context it is hardly a surprise that the hostile economic environment of recent years has not been good for medical education. What is often overlooked, however, is the centrality of time to a proper educational environment. This is a lesson that medical educators would do well to remember in their future efforts to preserve the financial strength of academic health centers. Funds for state-of-the-art libraries or physical facilities will not be put to maximal use if faculty have too little time to teach and students to learn. Medical leaders must work as hard to defend the availability of sufficient time as they do the more visible aspects of the learning environment.