You don’t know what you don’t know.
That’s the fundamental issue with ophthalmology intern Dr. Akhilesh Pathipati’s recent Washington Post op-ed, “Our doctors are too educated.”
Yes, our health care system is broken ― for a lot of reasons. Dr. Pathipati blames our nation’s health care deficiencies on a doctor shortage and advocates that the solution is as simple as shortening medical school curriculums and research requirements.
However, the issue is not a pure question of supply and demand, but of distribution of resources ― to primary care vs. specialties, urban vs. rural areas, and academic vs. “private” practice, for example.
Our medical system currently comprises more than 120 specialties and subspecialties ― specialties like cardiology and pediatrics with subspecialties like advanced heart failure cardiology and pediatric transplant hepatology. As these specialties and subspecialties proliferate into smaller and smaller niches, we are faced with a paucity of doctors able to coordinate care and provide cost-effective preventive action.
After finishing four years of medical school, three years of emergency medicine residency and earning my board certification, I am still humbled every day by the pathology I see while on shift.
On the quest for lifelong learning that we call medicine, there is nothing you learn more than that there is always more to know.
The idea that doctors are too educated is riddled with the naivety of a physician who hasn’t seen enough patients or read enough research, studies or case reports. This is not to question Dr. Pathipati’s credentials, but merely to challenge his perspective.
“And we’d be remiss to assume that specialists need no primary care experience (or that primary care providers need no speciality experience).”
Our ophthalmologists are pressured to see an overwhelming number of diabetics with retinopathy, but wouldn’t it be better if we just managed those patients’ diabetes better in the first place?
Our cardiologists see heart attack patients for invasive, expensive catheterization procedures and artificial cardiac support like LVADs, pacemakers and defibrillators, but what if we’d just controlled the patients’ blood pressure, cholesterol and diet 20 years earlier?
Our pulmonologists place patients on expensive on-patent medications to manage patients’ COPD, but what if that patient had just been counseled off smoking years before?
We need more early intervention and prevention, not more late-stage expensive patches. Smoking cessation counseling isn’t sexy the way humming machines and newly approved biologics are, but it’s effective, inexpensive and what our country really needs. Unfortunately, the way the house of medicine is carved now, it’s not the specialists who are providing it.
The balance between primary care and specialty services is a delicate one, and some would argue that health care is already too specialized ― why does one patient need an entire Rolodex of “-ologists” — a cardiologist, a nephrologist, an endocrinologist, a pulmonologist and a dermatologist?
Patients are not sliced into the “organ systems” we divide specialty lines across. And there is no better example of this than the patients we see in the emergency room, confused by their multiple canisters of co-interacting meds, sent to see us by one of their specialists who, after expensive tests on the organ of expertise, couldn’t figure out what was going on and sent the patient to the ER. Ophthalmologists refer patients to the ER for high blood pressure found in the clinic. Orthopedists send patients to the ER when they find incidental elevated blood sugar prior to an operation.
Yes, some referrals are appropriate, but some are plainly wasteful. The ER, designed to be full of “resuscitation-ists” — providers trained to take care of life-threatening events like heart attacks, strokes and gunshot wounds — has quickly become a catch-all of “available-ists” — providers who happen to be available 24/7/365. In between the heart attacks and car accidents, I also counsel patients on smoking and drug cessation, advise them on the importance of seat belts, teach them to use their glucometers and adjust their daily meds.
Why? Because not only are these patients unable to get in to see all of their specialists in a timely manner, but many don’t even have a primary care doctor.
We can’t force medical students to become primary care physicians, nor should we. But education reform isn’t necessarily going to fix our health care system, either.
“The ER, designed to be full of 'resuscitation-ists' ... has quickly become a catch-all of 'available-ists.'”
The argument that medical education should be shorter is fair to a degree, but we must tread carefully. Basic science curriculums, traditionally two years in duration, are already becoming 18 months or shorter at many institutions. Three-year medical school programs are being actively investigated as a possibility. Students who “know” what specialty they are going into can now take earlier elective clinical rotations, but most students change their specialty choice during their four years of medical school, anyway.
Robbing undecided students, or even students who think they are decided, of the real-life experience of clinical rotation in the name of shortening a medical school curriculum is misguided for a few reasons. Choosing a specialty is one of the biggest decisions a medical student makes, and making an uninformed decision will inevitably only lead to jaded, unhappy physicians, further depriving America’s health care system of the empathy and passion we hope to see in all of our caregivers.
And we’d be remiss to assume that specialists need no primary care experience (or that primary care providers need no specialty experience). The knowledge that comes with the medical school electives Dr. Pathipati advocates cutting is sometimes the only experience a future specialist will have on disease processes out of his or her expertise. This valuable clinical time is also the only chance students have to be exposed to all types of practice and decide their best career fit.
Truncating the medical education and experiences of young physicians isn’t the answer to a complex and broken health care system. Rather, we should train physicians for both breadth and depth, because the health care system needs both. A few months of additional investment in experiences as a medical student is worth it for the future decades of patient care as a physician. When it comes to health care, we have to take the long view.
Dr. Ho is a board-certified attending emergency physician, published writer and national speaker on issues pertaining to health care, with work featured in Forbes, Chicago Tribune, NPR, KevinMD, and TEDx.