Nearly 100 years since American medical education was rocked by an uprising, another revolution is underway which may have equally significant and long-term impact. A century ago, the revolt was mostly about what was being taught to qualify one as a physician, while today’s battle is over how to provide physicians with appropriate education and training. Both conflicts have wide ranging impact on the entire scope of medical practice. Understanding the history surrounding the first revolution and what followed can provide insight into an approach to the current issues.
In 1800s America, an intellectual debate raged between allopathic medicine and homeopathic medicine. The American Medical Association commissioned a report through the Carnegie Endowment for the Advancement of Teaching to evaluate all medical education programs. Abraham Flexnor’s landmark report in 1910 strongly favored the allopathic model and specifically endorsed the John Hopkins model of medical education: formal basic science classroom work followed by an apprenticeship model of clinical education. In the wake of this report, economic advantage was bestowed by the Carnegie Endowment and other foundations on selected medical schools, forcing the majority of medical schools to close their doors. This allowed the AMA to acquire firm control over both medical education and licensure. Strong pharmaceutical support (drug sales depended on the disease model promoted by allopathy) and legislative initiatives ensured that the monopoly flourished.
During the next few decades, the effects of this medical revolution were fully realized. Specialty medicine took root and specialty boards began advanced licensure. The system then seemed to flourish and grow for the next 50 years. However, hidden within this unfettered growth of a monopoly were the seeds of the second revolution.
As the 21st century neared, American medicine and medical education faced a number of daunting challenges. One was the exponential growth of medical science and increasing subspecialization, an occurrence that particularly strained graduate medical education. Rapidly rising healthcare costs were another strain which led politicians and consumers to look more closely at the medical profession. Consumerism and public demands for accountability were on the rise. Organized medicine was slow to respond and, as a result, external solutions were imposed.
The Second Revolution
The current upheaval in American medicine is about how to provide the best medical education and institute a career-long educational process which will limit errors and achieve the best quality of patient care. In an attempt to achieve these goals, a spectrum of mandates was imposed on medicine. The mandates with the greatest impact on graduate medical education are the work hour regulations and the components of the Accreditation Council for Graduate Medical Education core competency project.
Neurosurgery, a specialty of only about 3,200, is particularly vulnerable to these mandates. Our training programs are among the longest and most stressful, and the work hour restrictions are particularly difficult to accommodate in the residency programs. Neurosurgery faculty traditionally has adhered to educating as role models rather than as mentors.
The future of neurosurgery depends on the profession’s ability to successfully train neurosurgical residents after making the necessary adjustments to the constraints of the changed environment. Many in neurosurgery have spent considerable time and effort fighting the changes and trying to win exemptions for our “unique” specialty, with little success to date. A more productive approach might be to accept the changes and find ways to make them benefit our residents, our patients, our faculty, and our specialty.
To accomplish this, neurosurgery as a whole must work to redefine our relationships with each other. Collaborative rather than competitive efforts among training programs can ease the burden of meeting the ACGME core competency project. Without such collaboration, we may be forced to endure less desirable solutions utilized in programs quite different from ours such as internal medicine and psychiatry.
Embracing and instituting a more effective educational program may pay unexpected dividends in job satisfaction, quality of training, and loyalty to the training institution. Cooperative efforts between those in academic and nonacademic practice could help ease the burdens of time restrictions and extending shared endeavors to the wider scope of a neuroscience program would bring even greater strength and flexibility to all neurosurgeons. Engaging the public, patients, and perhaps even government will raise confidence rather than skepticism and help restore to neurosurgery its independence.
American medicine and neurosurgery must survive this second great revolution in medical education. Many lives depend on it. If the rise of the AMA during the 20th century taught us one thing, it should be that there is strength in unity. Working together and looking forward may be the only choice we have.
Deborah L. Benzil, MD, is associate professor in the Department of Neurosurgery at the New York College of Medicine, Valhalla, N.Y.