American Doctors and Their Education

GUEST: Robert J. Alpern, M.D.
VTR: 11/07/05

I’m Richard Heffner, your host on The Open Mind. And someone recently pointed out to me that I must have a “thing” about doctors and their practices … for so many of my guests over the past near-fifty years have been MDs, ranging from Simon Dack, then the President of the American College of Cardiology in 1967, to Jonas Salk and Robert Michels and Howard Rusk and Kathy Foley and Lewis Thomas and Benjamin Spock and, most recently, Howard Varmus, head of Sloan Kettering Memorial Cancer Center.

Since the series began, in fact, The Open Mind has done 167 different programs on medicine and medical-related subjects … which perhaps just goes to prove that all along I’ve wanted to be a doctor.

Indeed, how best to educate our doctors – how to create the highest possible level of medical education in our country – has been a prime question at this table all these years.

And today I want to put that question quite directly to my guest, Dr. Robert J. Alpern, a distinguished physician widely known for his work on the kidney, who is now Dean of Yale University’s acclaimed medical school.

Dean Alpern has said that American medical education is the best system in the world, yet imperfect. And I would ask him to develop that point. How is it imperfect?

ALPERN: The main problem with medical education today is that there is so much information to share with the students. And the question is how do you do that in the allotted time … turn them from … who are students … students who are committed, who are brilliant but have to absorb all of this information and yet still remain compassionate and passionate for patient care.

So the … let me start by talking about it’s structured and then I’ll talk to you … move into how it’s imperfect.

So students come to us with a basic knowledge of science. And usually with some experience with health care. Frequently on a volunteer basis. In the first year we review the basic science of how the body works. And then in the second year of medical school we move into the mechanisms of disease.

And those areas do quite well, with the exception that there’s just so much new information that you can’t get all of the information into the two years of medical school and we’re continuously having to judge what information is more important than other information. Every year there’s exciting new findings we want to add to the curriculum and we must remove things from the curriculum as we add them.

Where the real problem comes up is in the third and fourth years of medical school. And that’s where we really begin one-on-one teaching at the bedside. And that’s where the students learn to translate all of the facts that they learned in the first two years into becoming a physician.

The paradigm for teaching that was perfect 30 years ago when patients would come into the hospital and stay there for weeks. So a typical patient would come in with abdominal pain. And would get admitted, the doctor would admit them to the hospital and you would, in the hospital, order ten different tests … maybe do some diagnostic procedures and then make the diagnosis. Then you would institute the treatment. And then the patient would stay in the hospital for six or seven days while you would see if the treatment worked and only when you were very confident that the treatment was working would you send the patient home.

HEFFNER: And all that time, I presume, medical students in their third and fourth years had been having their “go” at the patient.

ALPERN: Exactly. And they got to see the natural history of the work-up of the patient from the beginnings of … from the chief complaint to the diagnosis to the treatment to the results of the treatment.

Now, as you know, this is no longer feasible. So what happens is … you go to see your doctor with abdominal pain. The doctor does all the tests in his office. Makes the diagnosis. If there is a need for a diagnostic procedure, the patient would come into the hospital for one day, have the diagnostic procedure and leave.

And then, if there’s a need … if it’s a treatment that specifically has to be done in the hospital, the patient would be admitted for the treatment, probably leave within a day or two; we would find out five days later, ten days later if the treatment worked.

So now the student sees patients come in and go out. And come in and go out. And doesn’t really experience the whole work up. So the in-patient setting, the hospital setting is no longer the ideal place that it was to teach someone how to be a doctor. And it becomes more important to move patients to the out-patient setting. To move … I’m sorry … students to the out-patient setting.

And the problem there … and, and there you can see the continuity where the patient comes into the doctor’s office and the diagnostic workup is planned and everything is instituted and the patient keeps coming back.

There’s a couple of problems with that. Number one, the student might be there for one visit of the patient but might not be there when the patient comes back.

Secondly, in the out-patient setting, the, the doctors are frequently … have a whole waiting room waiting to see them. So it’s not like in a hospital where everyone is sitting in their bed, you know, has no where to go, waiting for the doctor to come. The doctor might be seeing three or four patients an hour and teaching takes time. And so the doctor is forced to teach the student and while they’re doing that, that slows them down and then patients start waiting, unless the doctor has the foresight to schedule less patients. And then the issue is, can the doctor support his office financially while he’s doing that.

HEFFNER: It’s not just foresight.

ALPERN: (Laughter)

HEFFNER: It is economics.

ALPERN: That’s right. And the payors do not pay you any more money as a physician to compensate you for the inefficiencies of teaching.

HEFFNER: Those are incredible problems because they’re built in to what modern medicine is like. But suppose we take those first two years and the question of information.

ALPERN: Right.

HEFFNER: How do you, how do you plan to approach that problem?

ALPERN: So, the … there is not an easy solution to it. And the … once again going back 30 years ago (laughter) when medicine was simpler, you had a chance to really teach all, everything that a student needed to know, or at least it seemed that way at that time, to the student. Maybe not to the faculty.

Now as you know, the amount of new information that explodes onto the scene fills the newspapers, all the news programs and … so, it’s really important that we are teaching the new modern science to the students in modern medicine.

HEFFNER: Does that mean you extend the first two years to three years? Or four years?

ALPERN: Well, we can’t do that.

HEFFNER: Why?

ALPERN: Because there’s already a belief that medical education is too long. So, so right now what happens is in the United States a student goes to college for four years. And then goes to medical school for four years. And then has to do an internship, a residency and frequently a fellowship, which could last from three to nine years.

And …so the problem is it’s, it’s already too … by the time the student is able to become a practicing physician it’s already fairly late in his life, or her life. And so the profession becomes less attractive and there’s some question of the value.

You know, you want as many years of practice as you can for each physician that you train. So, as a matter of fact, most of the discussions at national meetings are what can we do to shorten medical education.

And usually when I’ve been on various educational committees what happens is we start off by saying “Medical education needs to be shortened.” And then we have these discussions about all the material we need to teach. And then it ends up that if we followed our recommendations, medical education would only get longer.

And then we agree that it should just stay the same length. But I don’t think anybody would, would feel that it should get longer.
HEFFNER: Then what is the productive direction to take?

ALPERN: So, I think we rely on the faculty. And we now have curriculum committees that have to make value judgments as to what students should and shouldn’t learn.

One of the big things that emphasized now in medical school, that wasn’t so much emphasized in the past, is to teach students to be continuous learners. That the fact of the matter is that whatever we teach them, even in four years, no matter how much we teach them, everything will be different ten years after they graduate.

And so what we try to do now is really focus not so much on bringing the information forward although we need to do that. But to teach them to teach themselves. To teach them to explore, to read journals, to be critical thinkers. To be able to read the New England Journal of Medicine, read an article and decide whether they should alter their practice based on what they have read or not.

HEFFNER: Does computerization figure into this at all?

ALPERN: I’m sure it will at some point.

HEFFNER: To make accessible some of the information for which we don’t have time in the first two years. Can that be made up for in some way?

ALPERN: Oh, during those two years. We do use computers a lot. I don’t know that it makes it … the teaching more efficient time wise. It, it makes it better, but I’m not sure that it’s actually gotten to the point where it allows us to teach more in less time.

HEFFNER: What does that mean for someone like myself who is simply a layman who has the need for good, basic and then very profound medical care. What do I do? Do I say, “Oh, my god, I wish Mack Lipkin my internist from years ago were back, because he knew whatever the was to know?” What is the direction the patient takes, knowing what you’ve just explained.

ALPERN: So, I think the patient should feel very good. The doctors that we’re training now are learning more medicine than your doctor did 20 years ago because there is so much more information to learn.

Now some of things those doctors learned are not being taught, because we’re determining that they’re not as important as the newer information.

HEFFNER: You know, Dean, the, the comparative “as important” … is what bothers me.

ALPERN: (Laughter)

HEFFNER: In this discussion. But that’s, that’s beside the point. So you’ve identified one very important problem. But what about after those first two years of information accumulation. How do you deal with the problem you’ve described as patients not being available for that old time practice.

ALPERN: So, what we’re doing now is that we are shifting education to the outpatient setting. And one of the problems in the past was that there was too much teaching in the in-patient setting. And even though it was a good teaching setting …

HEFFNER: Why “too much”?

ALPERN: Well, because …

HEFFNER: Or how “too much”?

ALPERN: … there wasn’t enough in the out-patient setting, is perhaps a better way to state that. So, in the past students spent all of their time in the third and fourth years inside the hospital. And then they would do their internship and residency, most of it in a hospital. And then if they went into practice they would find out that 80% of their practice was in their office. And they had no training for that.

So, we have become much more aware of that weakness and have naturally shifted more education to the outpatient setting. Just so that they, they do learn what outpatient medicine is. And that’s true in medical school, and as a resident.

But, in addition now what we’re finding is that we need to shift it to the outpatient setting, not just to teach them how to practice medicine as an outpatient, but also because that’s where all the patient care is occurring.

So, if, if you’re doing a surgery rotation, it’s probably okay as an in-patient. But if you’re learning internal medicine, you need to spend a lot of your internal medicine training in an out-patient office.

HEFFNER: Do you, at Yale, approach the problems you’ve outlined differently than other medical schools do?

ALPERN: So, in this case I would say medical schools vary in how aggressively they’re taking this on. But they’re all identifying the same problem. So, medical schools with the resources that they have are all trying to shift more and more teaching to the outpatient setting.

But the key thing is how much access you have to outpatient offices and to physicians that have the time to be good teachers.

And versus how many students do you have. So, at Yale one of the things we’re very fortunate to have is that we have kept our class size very small. So we have only 100 students per year. There are some medical schools that are over 200 students per year. And by having only 100 students per year we’re … we have been able to do a lot of small group teaching. And we are able to identify very good out-patient experiences for all of our students.

HEFFNER: How does that impact upon the availability of doctors in terms of numbers of doctors being educated year after year.

ALPERN: Our small class size?

HEFFNER: Yeah.

ALPERN: Yes. So, so this is an issue that is, is arising as a new issue. The estimates of the workforce in medicine and how large the workforce that we’re training is compared to the needs has … is not would I would call a science … and so …

HEFFNER: Explain yourself.

ALPERN: So, in other words, there has not been agreement. For many years many different groups have said that we were facing a physician shortage …

HEFFNER: MmmHmm.

ALPERN: … in this country. Many other groups, and frequently those in power have said there’s no evidence to support your contention.

HEFFNER: And where does the Dean of Yale Medical School fit into those contentions?

ALPERN: I was, I was one of those groups as a leader in nephrology who felt that we were facing a tremendous shortage of nephrologists. And argued as such. And in those days our arguments were not accepted.

Now apparently there has been an epiphany among the leaders throughout many areas of medicine. And there is now complete agreement among all parties that the medical profession is facing a severe physician shortage by 2020 and beyond.

HEFFNER: Well, then I have to put the question to you. Don’t we need at Yale 300 students rather than 100 instead of 200?

ALPERN: So … the, the answer is we need to train more students in the United States. The question is how do you do that? And, and what’s the best way to do that? Do you need more medical schools? Do you need larger medical schools? Medical education is very expensive. And we have estimated … our tuition is about $30,000 to $34,000, somewhere around there. And we estimate that that covers about 50% of the cost of educating a medical student.

HEFFNER: Where does the other 50% come from?

ALPERN: It comes from people who generate their income from clinical practice or research grants; working extra hours to teach for free. It comes from … some from endowment. Some from philanthropy … people who just give us gifts to help with our educational programs.

HEFFNER: What would you, yourself, advocate as … not the solution, I know that. But a step toward resolving the question of an adequate number of trained physicians?

ALPERN: The ideal solution is more medical schools rather than making them larger. But the cost of that is huge. And right now it’s very difficult to start new medical schools. In private … to start up a new private medical school would be near impossible. The costs involved would be too large.

But a number of states are starting up new medical schools. A number of states are expanding their medical schools and infusing State dollars to do that.

And, you know, I think that will partially address the issue. The other issue is whether the paradigm by which we deliver health care is the right paradigm. Should, should other people be doing what physicians are doing now?

Personally I think the best paradigm is to still have physicians doing what they’re doing, but if we don’t have enough doctors, I think then we will, at some point, have to look at whether nurse-practitioners or physician-assistants or others should be trained to do things that doctors … that you don’t need an M.D. degree to do.

HEFFNER: To what extent is that happening now with other personnel, other medically trained, but not necessarily in medical school … persons … nurse-practitioners.

ALPERN: Right.

HEFFNER: To what extent is that happening now that we have expanded the base of those who provide health to the needy …

ALPERN: Sure.

HEFFNER: … medically speaking.

ALPERN: So that …that’s happening a lot.

HEFFNER: It is?

ALPERN: Yes. So, so we’re already facing shortages. The issue has been, everyone has known that there are certain locations in the country that have been short physicians … rural areas in the United States. And … in then … there’s other areas that were viewed as having a glut of physicians. So in those areas in which physicians have been short, more and more doctors in practice may have chosen to add nurse-practitioners to their practice to help out.

A good example, for instance is anesthesiologists. There are not enough anesthesiologists to support all of the operating rooms in many … in probably most hospitals. So what hospitals are doing now is they hire nurse-anesthetists who are supervised by anesthesiologists. The anesthesiologists being M.D.s. And what you see is, is that then one anesthesiologist can cover many more operating rooms with the nurse-anesthetist taking care of more routine patients. And it’s allowed us to spread out the medical workforce. So, so that’s a good example.

HEFFNER: Compare us to other countries. Are they facing the same problems?

ALPERN: Yes. So, so we’re in the best situation of most countries.

HEFFNER: Why is that? Or how is that, again?

ALPERN: Well, because we train a lot of physicians and the other thing that we do which is a topic in and of itself is because we have a health care system that pays physicians relatively well compared to the rest of the world. Many, in many countries their physicians move to the United States to practice.

So it’s not uncommon for physicians trained in India, Pakistan, in the Middle East to get their medical education there and then come to the United States to do a residency and then practice … in the United States.

HEFFNER: How far behind are we in terms of this shortage?

ALPERN: I, I can’t give you a number, but what I can tell you is that the … if you look at just what we trained in medical school, we don’t even fill all the residency slots. So, so then, all these other doctors come from other medical schools around the world to fill the residency slots, and then the doctors coming out of the residencies …

HEFFNER: Go home?

ALPERN: No, they … most of them stay here. And, and even then we’re projecting shortages. So now, what I’d say is that there are certain disciplines that we’re short of in physicians. But I think, the projection is that it’s going to get worse in part because the population’s going to continue to grow. But also because the population is aging. As we’re keeping people alive longer and longer, they need more and more medical assistance as they age. And so, so …

HEFFNER: I know that very well.

ALPERN: (Laughter) Yeah. So, the … that’s why if you look at the number of doctors that will be needed per patient it’s going to be much larger. So, so … there are certain regions of the country in which there’s a shortage of doctors. There’s also specialties. And in general it’s hard to make rules, but if you look at specialties and if you look at the … income and the quality of life, you can predict where your shortages will be. So, so there are some physicians who will choose low income jobs or who will choose specialties where they’re up all night and working weekends. There … that’s true.

But in general the average will go towards higher reimbursement; relaxing weekends, sleeping at night …

HEFFNER: I thought doctors weren’t supposed to do those things.

ALPERN: (Laugher) I think, you know, there is … the, the medical … people are changing and the … I don’t know how … I think it has its good and its bad. So I’d say doctors are becoming better parents … (laughter).

HEFFNER: I got the idea. Dean Alpern I appreciate so much your coming to The Open Mind today and discussing this obviously open and very pressing question. Thank you.

And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.