April 21, 2011
By Nivedita Ghosh, MD
When I began medical school years ago—attending lectures on anatomy in cavernous auditoriums, dissecting a human body, and memorizing what the extensor pollicis brevis did—I had a hard time making the connection between what I was studying and what I would need to become a doctor. Hell-bent on not flunking out, I put my faith in the established curriculum and dutifully attended all the lectures and labs. But I still frequently thought to myself, “I don’t get it. How will this help me take care of patients?”
Fortunately for my sanity, I soon learned I was not alone. Like most medical students, I began picking and choosing which sessions were worth my time. The clash between establishment and sensibility continued well into my residency training, in which I constantly asked myself how spending two thirds of my time managing inpatients was going to help me become a primary care doctor. By this time, however, I had a better understanding that the rules governing my training were created out of an outdated programmatic or political necessity and were maintained out of tradition.
If rules are created out of necessity, then one can hardly make a better argument for rethinking the guidelines for training today’s medical students and residents. This is particularly important in the realm of ambulatory and primary care. Few areas in medicine are evolving as rapidly and receiving as much publicity as the transformation of primary care, and we have to ask ourselves if the old training rules make sense in this new environment. I believe the answer is a resounding “No,” and once again, I am not alone in my belief.
Recently, I had the great fortune of attending a summit on “Medical Education in the Patient Centered Medical Home,” attended by physicians and non-physicians from multiple disciplines nationwide. The sentiment at the summit was strong and unified: the current system of training does not prepare physicians to practice in the present, let alone the future. Our training models are antiquated. We must more closely align training with the reality of practice, which is increasingly collaborative, team-based, interdisciplinary, evidence-based, technologically advanced, and patient-centered. Exposing students and residents to only one model of care in which the doctor does everything is more likely to overwhelm them than to attract them into primary care, or even to an ambulatory-based sub-specialty practice. For those who still choose primary care, exposure to only that model of care will leave trainees ill-equipped to take full advantage of medical teams and coordinated care efforts.
We are getting better at practicing primary care but we are not allowing our trainees to see this. We must systematically and consistently expose our students and residents to these improvements if we hope to keep them in the field.
This responsibility falls squarely on the shoulders of medical schools and residency programs. This means less time dedicated to memorizing the function of the extensor pollicis brevis (to extend and abduct the thumb) and more time understanding how the inflammation of its tendon (causing deQuervian’s tenosynovitis) prevents a day-care worker from working (she can’t lift children without pain) and the attendant effects on her life.
Primary care has always been a rich and rewarding field. It is now more multi-dimensional than ever with a strong need for practitioners of diverse backgrounds, skills, and interests. If we cannot help trainees see primary care in all its myriad dimensions, we have little hope of keeping them in primary care practice and harnessing their myriad talents to provide ever-improving care.
Nivedita Ghosh is a primary care internist and educator at Brigham and Women’s Hospital and Harvard Medical School in Boston. She serves as the Education Adviser to Primary Care Progress.