Can I Become A Doctor Online?
The cost of medical care and the cost of education in general is sky rocketing. But it is much worse to be at the nexus of these two endeavors – Medical Education. The current path to becoming a doctor in the US involves four years of university followed by four years of medical school. Each of these years carries an ever-increasing price tag that is upwards of $60,000. At the end of medical school, newly minted doctors continue their training by working in hospitals under the supervision of attending physicians. These internships, residencies and fellowships, which can last between 3 to 10 years, and even more, depending on areas of specialization, are marked by upwards of 80-hour work-weeks and low salaries for physicians who owe hundreds of thousands of dollars in debt. Part of the reason for the flight out of primary care and outpatient medicine has very much to do with this economy. It is not hard to imagine why people who owe so much money (the average medical student graduates with $170K in debt), and have had decades of rigorous training, are running away from fields where they can barely pay their loans off. In other countries, there is a combined 6 year college-medical school program, and the cost of medical school tuition is subsidized by the government. Recently NYU School of Medicine announced their plans to offer a three-year path for medical school, and some six-year combined programs have long been in existence in the US, though typically targeted to specific groups.
Everyone is in agreement that something needs to change. Physicians are busy taking care of patients, or at least filling out forms about patients, and little time and energy is left for teaching medical students, residents and fellows. Little time and energy from both the teachers and the students. It has been proposed that medical education needs to be reformed so that it’s not a time-based apprenticeship. The idea is that rather than graduate because you passed some tests in medical school, rather than graduate simply because you didn’t fail your clinical rotations as a fellow or resident, we should evaluate trainees on outcomes. We should decide what is important for a good doctor to know, and then simply evaluate whether the trainee has achieved these “competencies.”
The concept sounds nice. It’s appealing to think that there’s a solid, scientific way of proving that someone knows enough, is good enough, to be my doctor. But the truth is, we have no “gold standard” for what it takes to become a physician. We take lots of tests, sure, and we have to pass them, but in the current system we are not even allowed to take those tests unless we have completed the requisite clinical training. And for good reason. We didn’t get into college, medical school and residency by not being good test takers. In fact, if all that was required to be a physician was successfully passing a test, well then I don’t doubt that many a bright high-school graduate could spend 2-4 years studying for the test and pass successfully.
You have a fix? We should just have the test include a clinical component? Oh, you mean the one where there’s an actor and we pretend to evaluate the problem at hand? Where we listen to their heart and lungs? We get graded on how well we pretend to be empathetic to the actor who is pretending to be sick? Where instead of thinking what a given actual patient may have, we think about what disease the testing committee is likely to ask an actor to pretend to have? No, I don’t see any problem with certifying people as clinically competent if they pass such an exam. Do you?
The thing is, many of the skills required to be a physician are quite complex. We don’t propose that one could get a college degree by simply taking a test, however high the score. Critical thinking, analysis, putting the pieces of the story together, communicating with doctors, nurses and other healthcare providers, with the patient and the family under difficult circumstances, re-analyzing what you may have missed if things are not as you expect, adjusting plans, thinking through possibilities and probabilities in the context of what the patient is willing or able to do, or what you are able to provide, these are complex skills that are not easy to evaluate or teach.
And for a given physician, these skills may vary based on the particular case at hand. Are you kind to the guy that reminds you of your grandfather and dismissive of the “little old lady” who seems depressed and anxious? Did you learn how to navigate difficult family dynamics to figure out what to do for the woman dying in the ICU? Do you know when to listen and when to interrupt? And can you listen to a story and figure out what is going on and present it in such a way, that in a few sentences, I can get the picture and help you with your question? Did you explain it to your patient who is anxious she may have lung cancer, but actually simply has some scarring from an old infection? Did you develop a rapport that encouraged her to trust you and follow your advice? To stop smoking? To wear her oxygen? To take her medications?
Did you learn that you always have more to learn? That you have to read the literature to find the new treatment that didn’t exist when you were in medical school? Or stop using the one that you were taught but has since been discredited? And that’s the other problem with this approach. Having a test certify that someone is now a physician implies that one is ever done learning. Indeed, even the most experienced physician is always learning more, reading more, listening more. In fact, it is the best physicians that I know who are the best learners.
While many doctors fall short of our ideal of what a doctor should be, we still haven’t figured out a better way to evaluate how good a doctor someone is other than seeing them take care of patients, taking care of their patients and seeing where their thinking got muddled, where their patients were frustrated by lack of information, or where they didn’t know enough to ask the right questions.
Medical school, it seems to me, is like learning a language. We learn the anatomy, the pathophysiology, the terminology and the structured way of communicating. These days we also learn the genetics and molecular biology that underpin most of the medications we will be prescribing for our patients, and the statistics that help us know how to evaluate clinical studies critically and spot bias. But it isn’t until residency and fellowship that we do “literary analysis” in the language of medicine. That is when we truly become doctors to our patients. And I don’t know a better way to do that than actually taking care of patients, seeing how other doctors think through cases, and reading about our patients with the urgency that the answer matters because it will help us figure out what is going on right now for a real person. Perhaps there is a better way, a shorter way, a less expensive way. But in a profession where the relationship between the patient and the doctor is at the heart, I just don’t see how a standardized test in “core competencies” of “empathy” or “critical thinking” would be the solution. We should reform medical education, we should aim to standardize it, shorten it, make it less exorbitant an undertaking, which may well improve the quality of our candidates and their objectives at the end of training. But I still think that clinical work that is supervised and some period of clinical training will remain at the core of how we train and evaluate physicians.