- Let Me Heal: The Opportunity to Preserve Excellence in American Medicine by Kenneth M. Ludmerer
A history of medical residency training has been long overdue. Fortunately, Kenneth M. Ludmerer, the author of two earlier books on the history of medical schools, has accepted the challenge. As Ludmerer points out, the latest book is a tougher task. Medical students are basically students pursuing advanced education. [End Page 158] But residents are students, caregivers, and employees, a combination that has engendered challenges and controversies. The story is more complicated.
Let Me Heal includes some isolated mid-nineteenth-century examples of young doctors taking extra training, but the heart of the book begins with descriptions of the first residency program implemented at the Johns Hopkins Hospital in Baltimore in the 1890s. There is perhaps a tendency to romanticize Johns Hopkins, and Ludmerer is a graduate of its medical school, but he makes a strong case that William Osler and his esteemed colleagues, building on their experiences in Europe, shaped the modern American residency program.
The original programs at Hopkins had three phases: internship, assistant residency, and chief residency. As trainees progressed, they assumed more and more clinical responsibility. But Hopkins insisted they always be thought of as students, learning how to become “scientific practitioners.” Osler’s colleague William Welch liked to call the residents “graduate students.” At the Massachusetts General Hospital, they were known as “house pupils.”
Indeed, one of the pleasures of Let Me Heal is the opportunity to learn the historical derivations of terms that educators use all of the time—not only “residents,” but “house officers” and “house physicians.” As would be imagined, these terms connoted the extensive time commitment made by those who resided in the house—that is, the hospital. Call schedules as frequent as every other night ensured that residents could spend large amounts of time both learning clinical medicine and getting to know their patients, demonstrating what Osler called the “quality of thoroughness.”
In a mostly chronological manner, and with his usual meticulous research, Ludmerer takes the readers through the dramatic evolution that occurred in residency training during the twentieth century. Developments reflected not only changes within medicine, such as the introduction of antibiotics and intensive care units, but also those in society. As more women and minorities entered medicine, for example, the “old boys club” that had characterized early residency programs had to evolve. So, too, did the unfortunate tendency that encouraged residents to see poor patients as “teaching material.”
But the biggest revolution in medical training, which began in the 1980s, focused on the issue of working hours. Ably revisiting the Libby Zion case, the Bell Commission Report and changes in American College of Graduate Medical Education regulations, Ludmerer shows how concerns about exhausted house officers—who supposedly caused medical errors—led to an overhaul of the earlier system, in which residents were essentially treated as cheap labor. One of the ironies of the reforms, which limit the time that doctors-in-training can spend in the hospital, is that there are no good data to show that long work hours actually lead to worse patient care. A more significant concern is lack of senior supervision of residents, something that has not as fully been addressed.
Ludmerer rightly spends a substantial amount of time at the end of Let Me Heal discussing the ramifications of this new “shift work” scheduling for medical education. Do today’s house officers, with one eye on their patients and another on their watches, receive as good training as their forefathers? And what about [End Page 159] “throughput,” the push by today’s teaching hospitals to get patients in and out of the hospital as fast as possible? Ludmerer appropriately asks how the all important doctor–patient bond can survive this type of arrangement.
Let Me Heal is not only a history book but a policy book. Chapter 13, “Preserving Excellence in Residency Training and Medical Care,” is full of careful, historically grounded recommendations...