Medical education failures

Here is a story of someone in another state, but it is a story that could have happened in our town.

After having had a persistent cough, a person was experiencing back pain. The person did some online exploring and discovered that such back pain can sometimes be caused by the motions of repeated coughing. Physical therapy was suggested as a possible treatment for the pain. In order for insurance to pay on the physical therapy, the person needed a referral from a primary care physician. Not having an established relationship with a primary care physician, a choice was made, feeling that a single appointment would result in the referral.

At the physician’s office, after waiting beyond the scheduled time for the appointment, the person was taken to an exam room, weighed, had blood pressure, blood oxygen and temperature taken and was asked a battery of screening questions. After another wait, the physician entered and began to question the person about the blood pressure reading, which had been elevated. The person tried to get the doctor to focus on the back pain, but the doctor showed little interest in his symptoms. The doctor suggested prescriptions to medicines for hypertension. The person suggested that given his age and previous history lifestyle modification might be a first response to hypertension rather than medication and reminded the physician once again that he would like a referral to physical therapy for the back pain. The physician quickly wrote a script for physical therapy for “stroke assessment.” The appointment finished, the doctor left the room without repeating the blood pressure measurement and without every looking at or touching the patient's back.

I should add, I suppose, that the person is young, in his 30’s. He has good medical insurance and is able to pay deductibles and other expenses. He is also a trained medical researcher with over a decade serving as a medical librarian and hospital administrator overseeing libraries and research for one of the largest hospital corporations in the nation. And, for the sake of full disclosure, he is my son.

He subsequently bought a blood pressure cuff and the high blood pressure has not been repeated. He also made an appointment for physical therapy. It took a few weeks, but when he finally was assessed by the therapist, who, in spite of being confused by the order to make a stroke assessment, discovered two sprained sections in the patient’s spine and three ribs that were wiggling, but still attached. There was also evidence of a rupture of a costovertebral joint. Physical therapy has begun and full recovery is expected in six to eight weeks.

I wish that the doctor who wouldn’t listen and the delay in treatment were anomalies. They aren’t. I hear stories like the one above all the time. There is the patient who asked for a referral to a gastroenterologist, but could not get one from a primary care physician. The patient lost over 40 pounds and was eventually hospitalized, where he suffered for over a week before a gastroenterologist was summoned and finally made an accurate diagnosis of the condition.

There was the elderly patient who was suffering intense pain as a side effect of a statin medication for high cholesterol whose physical kept dismissing the reports of the pain and refused to change the medication even when the patient asked for it.

We have a system of what we like to call scientific medicine in the United States. Physicians are trained in chemistry and biology and other scientific disciplines, but their education also systematically excludes other sciences that would help provide for better patient care and better patient outcomes.

It is not appropriate to call medical education in the United States scientific. It is based on educational theories that are over a century old. The intentional shortage of physicians created by a system that admits far too students and excludes many capable students makes inaccurate assessments of who should become physicians in the first place. Then the system operates without regard to the conditions in which students learn best. Students are overworked, deprived of sufficient sleep and forced to focus solely on short-term evaluations. Knowledge that is required for tests and in-person evaluations is required for periods of a year or less in most cases and subsequent evaluations of knowledge are rarely made. Therefore the education focuses on short-term memory and has few components which produce good long-term memory results. It isn’t scientific, but it is what the teachers had to endure so it is how things continue. Instructors in medical schools may be good chemists and biologists, but are rarely evaluated for their skills as teachers. Medical school administrators seem to lack knowledge about the scientific evaluation of teachers and teacher performance.

Then, once in practice, physicians seem to ignore social science. They seem to be ignorant of solid scientific research that has already been made. There have been many studies of how to manage a practice and appointments that move patients through clinics without the need for large waiting rooms filled with people. Mayo Clinic in Rochester, Minnesota is a good example of a clinic where appointments occur on time and patients are not kept waiting. It can be done, but very few other medical practices even make an attempt at reducing patient waiting.

There are multiple studies that demonstrate that data obtained from medical tests that are conducted before the physician listens to the patient are of little medical value. A single blood pressure reading is not valid for diagnosis. It takes multiple readings to determine whether or not a medical condition exists. The physical who suggested hypertension medication for a young man based on a single reading that the physician herself did not witness was irresponsible on the verge of malpractice. Hypertension medication has its place, but to order it without solid evidence of a medical condition is irresponsible, especially in a young patient, who will likely outlive the effectiveness of the medicine. Even if hypertension were present, lifestyle modification should have been the first treatment option considered. It is unlikely that the physician was malicious. It is far more likely that the physical is poorly trained and is unaware of the relevant studies.

i could go on an on. There is nothing scientific or even modern about medical pricing and billing systems. Patient care is diminished by the systematic practice of teaching physicians the false belief that they are smarter than (and deserve higher salaries than) the people they treat. There is nothing scientific or even modern about the design of medical buildings which are generally among the most expensive construction in contemporary society. Three-story cathedral entrances and million dollar art collections do not improve patient care. Although the buildings are clearly designed to intimidate, there is no evidence that intimidating patients produces favorable medical outcomes.

Perhaps a starting point would be for medical schools to hire some real teachers who have degrees in education and are up to date with the latest science and state of the art practice to help them redesign their educational programs.

The failure to address these issues will result in a continuing degradation of the quality of medical care in our country. We are already falling behind the world despite paying the highest price. And we are not getting what we are paying for.

Copyright (c) 2018 by Ted E. Huffman. I wrote this. If you would like to share it, please direct your friends to my web site. If you'd like permission to copy, please send me an email. Thanks!