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THE FRENCH REVOLUTION AND THE DILEMMA OF MEDICAL TRAINING ALAN B. ASTROW* If we can't agree about how to change our method of choosing and training doctors, we can at least agree that something isn't right. The house staff are working too hard (or not enough). The students are learning too much science (or too little). The premedicai curriculum is too narrow (or too long). The attendings are never around (but when they are, don't know what to teach). Too much time is spent in the hospital (but we need more house staff to cover the work load). Computers , rap sessions, shorter hours, more ancillary help, ancient Greek— all have been suggested as solutions for one or more problems in medical education [1-7]. Whatever the prescription for change, though, the underlying concern is shared: Medicine has lost its soul, and medical training is part of the problem. "Something has gone wrong in the practice of medicine and we all know it," the chief of medicine at New York's Mount Sinai Hospital has put it [8]. The system is out of control, vast, impersonal, legalistic, bureaucratic. Patients no longer trust their doctors, doctors don't or can't speak clearly with them. Young doctors are cold, callous, technocratic. They are "insensitive, have poor patient rapport, are deficient in general medical knowledge and examination skills, and have little concern for medicine's impact upon society," a leading surgeon has complained [9]. By now, the call to "humanize" medical practice and medical education has been voiced so frequently that it is nearly a cliché. What is missing from much of the discussion is an understanding of how and This essay received honorable mention in the 1988 Dwight J. Ingle Memorial Writers Award competition for young authors. The author dedicates it to the memory of his father, Martin Astrow. ""Department of Medicine, Section of Oncology, St. Vincent's Hospital and Medical Center of New York, 36 Seventh Avenue, Suite 511, New York, New York 10011.© 1990 by The University of Chicago. All rights reserved. 003 1-5982/90/3303-0679$0 1 .00 444 I Alan B. Astrow · Dilemma ofMedical Training why we've arrived at where we are today, so that the agenda for change seldom cuts deep. In fact, sensitive physicians have voiced concern for the fate of medicine as a human art ever since medical training moved from the home and office into the hospital in this country around the turn of the century. One hundred years ago, the hospital still played only a marginal role in educating most physicians. "Occasionally we were taken into the wards of the Philadelphia General Hospital or the University Hospital," one physician reminisced, "but I cannot recall that I examined more than two or three cases in the entire course" [10]. By 1930, though, the primacy ofthe hospital, particularly the high-tech university hospital as the centerpiece for medical instruction, had been firmly established , and the intensive hospital-based clinical clerkship, internship, and residency formed the core of the training experience for most doctors . Harvard's revered Francis Peabody, one of the first great academic physicians of the post-Flexner era, noted even then the distance between doctor and patient that the new system was creating. The primary difficulty is that the instruction has to be carried out largely in the wards and dispensaries of hospitals rather than the patient's home and the physician's office. . . . Hospitals—like other institutions founded with the highest human ideals—are apt to deteriorate into dehumanized machines. . . . Moreover , the circumstances under which the physician sees the patient are not wholly favorable to the establishment of the intimate personal relationship that exists in private practice, for one of the outstanding features of hospitalization is that it completely removes the patient from his accustomed environment. [11] Concern for the humaneness of medical training, then, is not particularly new. Neither, though, is it uniquely American. Similar tensions had arisen over a century earlier, in Europe, when hospitals there began to function as centers for medical teaching. In England, for instance, when medical instruction shifted to hospitals in the early nineteenth century, one historian notes that "patients...


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