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Less research training in medical school? That's actually good

The dean of Temple's medical school, Arthur Feldman, tried to advance an agenda of academic empire building by bemoaning the fact that medical students today receive less research training than in the past.

In Sunday's Health section of the Inquirer, reporter Ilene Raymond Rush interviewed the dean of Temple's medical school, Arthur Feldman. The dean tried to advance an agenda of academic empire building by bemoaning the fact that medical students today receive less research training than in the past. It requires that sort of exceptionally self-serving, academic nonsense to induce one of the exceedingly rare cases where this writer can quote William F. Buckley favorably. The late conservative publicist once said he'd rather be governed by the first 1,000 people in the Boston telephone directory instead of the Harvard faculty. Although Buckley's sentiment may be appropriate for any number of issues, its implicit derision of academic self-righteousness seems particularly apt here.

Feldman acknowledges that the relatively poor access to health care in this country has produced pressure on medical schools to train more practitioners, which in his opinion has started to create a two-tiered system of physician training. Graduates from one segment of medical schools, he fears, will receive abundant biomedical research training while the heavy emphasis on treating patients will stint the research background of those from a second tier.

So why is that a problem? Feldman claims that research training is important if physicians are to understand the torrent of new medical literature that constantly appears and base their treatments on it.

That's pure academic hokum. Few practicing physicians, now or in the past, possess the skills and background to evaluate cutting edge research in the arcane disciplines that set the standards of care in medicine's diverse fields. Fewer still are willing or able to devote the time and effort required to wade through the copious literature that can arrive daily at a physician's inbox.

That situation has always been true in medicine, as well as most other disciplines in a society with an advanced division of labor. The medical profession has been able to satisfactorily handle the matter because in each of the many esoteric treatment issues and sub-issues, a relatively small group of researchers and "thought leaders" evaluate new claims and pass down their assessments to everyday practitioners. The recommendations go from the university medical centers to the appropriate specialty societies and from there, through a "diffusion of innovation" chain, to local thought leaders in the various specialties. Neighborhood physicians get the word by speaking directly with the local savants at their hospitals, over the phone and by other means.

Every first-year marketer and sales rep at every pharmaceutical company is aware of this influence chain, starting with the KOLs -- key opinion leaders -- at the top, whom they pay to favor their particular brand. But it is a laughable deception to think that some boilerplate research training taken during "undergraduate medicine" (which is how physicians refer to medical school) or during residency would enable an everyday Joe or Jane physician to do a better job at selecting treatments in this market of paid-off experts. The only beneficiaries from a heavier emphasis on research would be the medical school instructors such as Feldman who would feather their own nests, even while producing graduates less inclined to provide frontline treatment.

Feldman then bloviates about physicians needing research training to decide about whether to order leading-edge procedures such as genomic testing for patients. Here he runs counter to what is even now emerging as the astute view within the ponderous halls of academe.

Atul Gawande, a health policy researcher, a surgeon at Women's and Brigham Hospital in Boston and a Harvard professor, spoke at the Harvard commencement a few years ago and urged the medical graduates there to embrace a new conception of their professional identity. Rather than conducting themselves in American medicine's traditional fashion as "cowboys," Gawande encouraged physicians in the making to think of themselves as members of a "racing pit crew."

Contrary to Feldman's view of the physician as the rugged, John Wayne individualist, left to his own research training in Monument Valley to decide about ordering genomic testing, Gawande sees physicians as vastly more cost-effective if they act as members of a coordinated team of health professionals, in much the same manner as mechanics in a racing car pit crew.

In this health care pit crew, each step is coordinated with those of other team members, everyone plays an assigned role, and all are guided by analytic data from information systems.  Traditionalists such as Feldman likely deride such an approach as "cookbook medicine," but advanced, progressive thinkers such as Gawande who are not defending guild territory see such "optimal treatment algorithms" as the only way to improve health outcomes while controlling outrageous costs.

In other words, physicians will be able to decide about ordering genomic testing for a particular patient on the basis of formal treatment guidelines deemed by evidence as appropriate for each patient. The physician's time receiving research training would have been better spent in other ways, such as learning to better communicate with her patients.

Looking at the matter historically, one can even make the case that this research orientation of academic medicine is what created the costly professional services and the two-tiered access to care that Feldman claims to disdain.

Medicine in the U.S. during the early twentieth century was imbued with a localized, craft orientation that was devoid of the elite trappings Feldman claims not to like.  The 155 medical schools in this country (14 in the city of Chicago alone) in 1900 represented a considerably higher per capita number than today and most medical education took place outside the universities.  In that year, the only requirement to enter Harvard's medical school was the ability to read and write.

There were two results of that situation.  The first was that the median income of physicians was not much higher than that of the country as a whole.  Second, the abundance of storefront medical schools meant that the quality of medical education varied enormously from place to place.

The early elements of organized medicine, principally the American Medical Association, responded to this situation by obtaining a grant from the Carnegie Foundation to commission a report by a German immigrant named Abraham Flexner.

The highly influential Flexner Report, issued in 1910, made recommendations to reduce the number of medical schools from 155 to 31, increase the requirements for entering medical school, train physicians according to university standards of scientific research, and strengthen state control over medical licensing.

By drastically shrinking the potential labor pool allowed to practice medicine and requiring more of a research approach from students in training, the occupation rose from middling income and prestige at the start of the 20th century, to the top of America's professional pyramid. In other words, physicians enriched themselves and reduced the American public's access to care by doing exactly what Dean Feldman now recommends 100 years later.

As Princeton sociologist Paul Starr showed in his study, The Social Transformation of American Medicine, by emphasizing research within university settings, organized medicine helped raise the income of physicians and created a monolithic industry that now consumes almost 20% of America's GDP.  To support this retinue of self-regarding medical researchers and other, profit-seeking predators, the U.S. pays two to three times per capita more for health care than any other advanced country.  In return for this research focus among physicians, U.S. health care ranks below that of 36 other nations (World Health Organization, 2000) and last among 14 advanced countries (Commonwealth Fund 2011).

More research emphasis? Good for Dean Feldman, but not so much for the rest of us.

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