Dr. Fred, You Are Not Alone


Few of us have the ability to read every cardiology journal, but I am glad that I usually do not miss an issue of the Texas Heart Institute Journal. Under the leadership of Dr. James T. Willerson, the journal publishes interesting editorials, fine case reports, and vignettes and obituaries that show a dedication to honoring the history of cardiology.

Therefore, it comes as no surprise to me that in a recent issue (June 2012), Dr. Herbert L. Fred published an editorial on the state of medical education. He divides his 62 years of teaching (remarkable!) into three eras: the "Patient-Centered, High-Touch Years (1950-1975)", the "Laboratory-Centered, High-Tech Years (1975-2003)" and the "Doctor-Centered, Limited-Work-Hour Years (2003-present)."


It is of course the last era, in which we now find ourselves, that is of most concern to Dr. Fred, who lambasts limitations on residents’ hours, our deference to technology over history-taking and the physical exam, and a transition to what he elegantly refers to as a system that is "doctor-centered, technology-driven, computer-dependent, algorithm-loving, and Internet-based." He hints at but does not quite say that we have engendered a shift mentality and a rise in consumerism by trainees.

Personally, I feel fortunate because, while I trained in the early to midpoint of the "High-Tech Years," many of my teachers were from the earlier era, and we regularly went to the bedside on rounds and even to the laboratory on each floor. What a difference from today when I regularly find myself in dialogues like these:

PH: Did you hear anything on auscultation of the heart?

Resident: I might have heard a murmur.

PH: What is the coronary anatomy?

Resident: The patient had a CABG.

PH: Is the patient in heart failure?

Resident: I don’t know because the echocardiogram hasn’t been done yet.

Of course, there are exceptions. When a great, dedicated, curious, and intellectually focused trainee comes along, who has an interest in and facility with good history-taking and physical exam skills, it is a real cause for celebration.

Dr. Fred does offer some concrete proposals, though not all are likely to be adopted (such as an overthrow of the Accreditation Council for Graduate Medical Education mandate on work hours). I for one would like to see penalties for frivolous lawsuits, downgrading of hospital administrators, limits on government intrusion, and a modification of the documentation culture we face. These would let us focus quite a bit more on teaching and the nurturing of the next generation of physicians. So, what’s the likelihood of all that happening? About as likely as the Chicago Cubs winning the World Series!

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