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To Be Educated or To Be Trained?

      Can anyone doubt that the ship of American medicine is plying turbulent waters that herald the coming storm? Even the most optimistic among us must be preparing more for unrest and challenge than for repose. The problems facing us are many and grave. Foremost among them is the increasing cost of medical care, which threatens the integrity of our health-care system, its availability, and above all its quality. In large part, our scientific, technologic successes have fed this cycle of exponentially expanding costs. We seem incapable of managing what we have created. Society is reacting with political, fiscal, and regulatory constrictions, many of dubious wisdom, that raise concern about further dislocations that could result in the mediocritization of American medicine. For its part, the medical community has reacted with a variety of responses, including prepaid plans that, in the minds of many professionals and laity alike, have neither stemmed costs nor mitigated a decline in the quality of care. Solutions to our multifarious problems will necessarily be found over extended time with irregular and, occasionally, frustratingly incomplete results.
      In my view, a major correction may derive from a reappraisal and redirection of American medical education. In this journal and elsewhere, I have previously expressed some concerns and proposed some solutions to which the reader is referred for more extensive discussion, particularly regarding the pyramidal theory of education.
      • DeRemee RA
      What became of the rotating internship? (editorial).

      DeRemee RA: On excellence and related matters (letter to the editor). Mayo Clin Proc 54:209-210,1979

      DeRemee RA: The great pyramid of medicine: a case for the rotating internship. Bull N Y Acad Med 58:628-635, 1982

      I retract nothing previously stated and reaffirm some basic premises. Currently, a renaissance of liberal education can be found at the undergraduate college level. A return to a broad-based fundamental education in lieu of focused training is being seen once again as the soundest preparation of the mind to meet societal change and to maximize the potential for personal fulfillment. Yet, in American medical education the trend has been in the opposite direction. Led by a flawed appraisal of the role of technology and an overweening fear of expansion of knowledge, medical educators have set a table of Spartan food. Evidences of this unliberal trend abound. Witness, for instance, tracking (or, as I have called it, specialty predeterminism), shortcut teaching of basic science, and elimination of the rotating internship. The trend is also reflected in attitudes that aggrandize the acquisition of expertise in technical procedures to the denigration of broad, cognitive competence. These tendencies are further reinforced by unbalanced fee schedules that favor procedures over purely cognitive services. In short, physicians are being trained, not educated. They are being fed mere facts, not tantalized with questions. The results include some of what we are now seeing, such as the mindless, unbridled application of technology—another computed tomogram before another thought; another blood test, not another reflection. Many highly sophisticated parts are unarticulated and disoriented in the total medical environment. The costs in money and human tribulation are incalculable.
      Some of my solutions follow from the previous discussion. We ought to establish liberal medical education. This proposal means no shortcuts. It means that basic sciences should be taught in their purity, not incidentally applied here and there in the so-called systems approach. The same guideline applies for the teaching of the now almost arcane subject of anatomy. To me it is a mystery how physicians can properly deal with a body about which they have only passing knowledge. There ought to be no tracking. It is intellectually and emotionally unsound to expect one to make informed selections of specialty before broad exposure to the larger field of medicine. At the end of 4 years, all physicians should have similar, broad, liberal educations; then—and this is of equal importance—for 1 year all should be required to take a rotating internship to solidify their education.
      An integral part of instigating and managing any system is its continual monitoring or evaluation. This raises the question of grading, a subject that I have previously addressed.

      DeRemee RA: On excellence and related matters (letter to the editor). Mayo Clin Proc 54:209-210,1979

      In this regard, I will not extend the discussion lest the further attraction of lightning blind the reader's eyes to the previous points.
      I do not naively claim that all problems facing American medicine arise within the profession. Not at all, for there is abundant evidence of the miscreant manipulation by politicians and lay persons of the emotionally charged issue of medical care. I suggest, however, that we of the medical profession have not adequately scrutinized our educational system for its deficiencies. After all, this is where it all begins. Any balanced, long-term, remedial analysis cries out for such a reappraisal. Will we broadly educate or simply train? Will we provide the basics to stimulate creative, intuitively responsive physicians, or simply purvey a litany of insipid algorithms for medical technocrats?


        • DeRemee RA
        What became of the rotating internship? (editorial).
        Mayo Clin Proc. 1981; 56: 396-397
      1. DeRemee RA: On excellence and related matters (letter to the editor). Mayo Clin Proc 54:209-210,1979

      1. DeRemee RA: The great pyramid of medicine: a case for the rotating internship. Bull N Y Acad Med 58:628-635, 1982