I
9
EDUCATING THE PROFESSION FOR HIGH-QUALITY CARE* HENRY ARANOW, JR., M.D. Attending Physician Presbyterian Hospital Professor of Clinical Medicine Columbia University College of Physicians and Surgeons New York, N.Y.
THE primary objective of those who have struggled over the years with the design and implementation of medical curricula has been to produce physicians who would render high quality care. As the physical, biological, and behavioral sciences have broadened and extended their scope, there has been a continuous revision of the definition of high quality care. It is certain that for a number of illnesses the criteria for such care will be significantly different a decade hence from what they are today. The geometrically expanding data bases of the so-called "hard" sciences related to medicine-anatomy, biochemistry, physiology, biophysics, microbiology, and genetics, to name but a few-provide more and more observations relevant to medical practice. The somewhat slower increase in the body of knowledge in the behavioral sciences also offers the physician increasing opportunity to improve his management of the patient's illness as distinct from the patient's disease. A disease is an abstraction as well as a classification of phenomena related to disordered structure and function which are grouped together for a variety of medical reasons. Illness is the total of the physical, emotional, economic, and social alterations produced in an individual patient by his disease. Identical Colles fractures-a common type of wrist fracture -will produce a very different illness in a violinist than in a radio announcer. There is no reason to believe that there will be a significant diminution in the rate at which new knowledge is acquired or in the *Presented in a panel, Educating the Health Professions for High Quality Care, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health Care, held April 24 and 25, 1975.
Vol. 52, No. 1, January 1976
I 2 0
H.
120H.
ARANOAV, JR. ARANOW,
need to discard or modify old concepts shown to be erroneous or incomplete. It is currently fashionable to emphasize the knowledge explosion and the overwhelming number of facts relevant to medicine. Study of the medical curricula of more than a century ago shows that the students of those days had an equally large number of facts to master. What has changed is our concept of the relevance and validity of the facts whose mastery was required of the early i9th century medical student. It is inevitable that the 2 ISt century will regard many of today's facts in a similar light. One of our goals, therefore, must be to produce a method which will enable the individual physician to evaluate new observations for both their validity and their influence on current theory and practice. It is the method of science that has made science such a worldmodifying force, much more than the mere accumulation and classification of an enormous number of facts. If the physician uses the scientific method he is prepared to appraise new observations. If he realizes that the delivery of high quality health care demands a lifetime of study he will be aware of those new observations and concepts which have relevance to his practice. The acquisition of the scientific method and of the habit of continuing study are, then, two of the primary objectives of medical education, which are requisite for the long-term delivery of high quality care. These qualities are not different from those required of a competent scientist in any discipline. The activity which distinguishes the physician from other scientists is the application of his knowledge to disease at it occurs in individual patients. The delivery of high quality care involves an understanding of the illness which the disease produces in a particular patient as well as of the phenomena common to the disease in many patients. It is important that the physician be aware of those factors in the physican-patient relation which made medicine an honored and useful profession long before its acquisition of a scientific base. L. J. Henderson, the distinguished biochemist, is credited with the statement that it was not until a decade into the 2oth century that the average patient with an average disease encountering an average physician stood better than a 50/50 chance of profiting from the encounter. It is clear that Professor Henderson's statement referred to the patient's disease rather than to his illness. Schrodinger, the great physicist, once defined science as looking at nature in the Greek way. Many societies, including some Bull. N. Y. Acad. Med.
EDUCATING THE PROFESSION2
I 2 I
contemporary ones, regard nature in a different and less objective way. Practitioners of the healing arts in such societies often enjoy esteem and rewards comparatively as great or even greater than those accorded to modern physicians. The person who is ill brings to his relation with a practitioner of the healing arts a number of fears, hopes, and expectations which often play a major role in his illness. In some illnesses they may completely overshadow any objectively measurable deviations from normal. Although in many illnesses, for example acute bacterial infections, these aspects are pushed into the background during the acute phase of the disease, they are rarely absent; they may modify compliance with a prescribed regimen, the duration of convalescence, and the return to premorbid levels of function. Understanding, tact, and empathy may enable the physician to speed the patient's recovery by intelligent use of the factors in the doctor-patient relation. In some instances these spell the difference between acceptance and rejection of a therapeutic intervention which may be life-saving. The concern for people and the desire to help them which lead many people into the medical profession are often accompanied by these qualities, but in varying degrees. The behavioral sciences are furnishing us with insights into many aspects of the doctor-patient interaction which should enable physicians to use them with greater understanding to provide greater benefit to their patients. They should also make it possible for physicians less endowed with empathy and related qualities to derive therapeutic gains from the relation. The clinical education of the physician, starting in medical school and continuing through internship and residency, should inculcate these principles through both example and precept. In his first contacts with patients throughout his training period the physician-in-training should learn that the illness of an individual patient is unique, although the pathological alterations produced in that patient by disease may be indistinguishable from those in a multitude of other patients. His teachers should not only help him to dissect and analyze such aspects of disease as are signaled by changes in electrolytes, blood counts, or other measurable parameters; they should also teach him to get to know the individual in whom these changes are occurring-to find out about the patient's background, education, job, family, environment, Vol. 52, No. 1, January 1976
I 2122
H..AANW ARANOW,
JR. R
and relation to all of these factors as well as the patient's response to previous illnesses. The teaching environment should be structured in such a way that the young physician learns which aspect of the patient's illness should be dealt with at each of the several stages of its management. He will see that in the management of major trauma or hemorrhage all efforts initially must be directed toward control and correction of the evident physical disturbances. He will appreciate, too, that when symptoms and disability outlast evident organic disturbances their cause is as likely to be the impact of the patient's illness on his personal life, hopes, and fears as it is in some minor structural or biochemical deviation from accepted norms. These principles can be best inculcated in the physician-in-training by exposing him to teachers who exemplify them. The increasing subdividing of medical knowledge and its spectacular advances have made it inevitable that some physicians must concentrate on the elucidation of the mechanisms of disease while others devote themselves primarily to caring for the sick. A better balanced physician will result from a clinical faculty which includes some teachers who are devoted primarily to each of these activities, giving the trainee ample contact with both types of teachers. Let us now turn to assessments of quality and their relevance to the educational process. In the broadest sense, every presentation of a clinical problem by a junior to someone who is his senior either in knowledge or experience is an assessment of the quality of the work that has been presented. This is true whether it be an initial presentation of a history and physical examination by a clinical clerk, a presentation of a new case by an intern to his resident, or a review of the diagnosis and management of a complicated problem in a subspecialty presented by a senior fellow to his division chief. In each case the standards of the reviewer will be modified by the presenting situation, the stage of training of the presenter, and the reviewer's personal priorities. In reviewing the problem of a digestive disturbance, one reviewer may find the stresses in the patient's interpersonal relations more relevant than the lactose tolerance test requested by another. To make these assessments didactically valuable to the trainee, each reviewer must be able to explain clearly what relevance and importance his criteria have to the problem presented by this individual patient. Bull. N. Y. Acad. Med.
EDUCATI'.\'G THE PROFESSION
EDUCATING
I23
123
The sum of a series of such assessments performed as the trainee assumes increasing responsibility for the management of the illnesses of patients is, in my opinion, the core of clinical education. The assessments are made more vibrant by their direct relevance to the patients under the trainee's continuing observation, and they are particularized to individual patients. The trainee then is helped to make generalizations from his own personal experiences, supplemented by those cited to him by his teachers and colleagues, and those described in the literature. Such assessments of quality are different in kind from those made on the basis of retrospective review, usually by persons unacquainted with the specific case. Assessments of quality based on studies of outcomes have much to teach us. Large research efforts to determine outcome criteria which can be applied to a wide range of diseases are justified. From them we may hope to learn which features of our therapeutic regimens have positive value, which do not influence outcome and, importantly, which have negative effects. Because of their statistical nature, however, it probably will not be possible to evaluate the reviewed procedures in a way which will determine their appropriateness to the idiosyncratic illnesses of individual patients. I have great misgivings about the more easily implemented process review. Such reviews are unlikely to reveal the appropriateness of a particular diagnostic or therapeutic program for the particular illness of an individual patient. More importantly, they are likely to define a number of procedures whose value has not been established. One can imagine a primitive tribe in which it is the established practice of medical men to bow three times before the village idol before repeating the traditional incantations; practitioners bowing twice or four times could be cited after process review as deviating from accepted practice. It is my hope that the advocates of outcome review will receive a sympathetic hearing from the legislators before the hydraheaded Professional Standards Review Organizations process review spawns a long-lived bureaucracy which will certainly increase medical costs.
When Dr. Charles A. Ragan requested me to give this presentation in his stead, I asked him what he had planned to say. He replied, "A major objective is to make compulsive neurotics out of all physiciantrainees." By this I think he meant that each physician should not only Vol. 52, No. 1, January 1976
I 2
4
124
H. ARANONN', JR.
H.
ARANOW,
be taught to apply all of his skills to the problems presented by each patient, but that the physician's superego should be so hypertrophied that it would not be possible for him to do less than his best in the presenting situation. With his usual perspicacity, Dr. Ragan indicated the keystone of the arch between physician and patient. Education should enable the physician to discern the optimal course permitted by the circumstances, but his character-moulded, we hope, by education-should compel him to follow it and to avoid shortcuts which might save time or effort for the physician but would not be in the best interests of the patient. Finally, it would be inappropriate to close a discussion of high quality care without mention of the caring function of the physician as distinguished from his curing function. Francis Peabody's aphorism, "The secret of the care of the patient is in caring for the patient," epitomizes this. Abundant evidence indicates not only that this caring function is highly regarded and widely sought, but that in some instances it is essential for cure. Modern medical education in general has underemphasized this important aspect of the physician's role. It cannot be taught by precept alone. Wise and humane teachers can help to inculcate it by example and by analyzing its great value as they do so. This role of the practitioner of the healing arts dates from prehistoric times, and constituted the medical profession's major contribution to the patient until relatively recently. Today it continues to be an indispensable feature of medical therapy.
Bull. N. Y. Acad. Med.
9
EDUCATING THE PROFESSION FOR HIGH-QUALITY CARE* HENRY ARANOW, JR., M.D. Attending Physician Presbyterian Hospital Professor of Clinical Medicine Columbia University College of Physicians and Surgeons New York, N.Y.
THE primary objective of those who have struggled over the years with the design and implementation of medical curricula has been to produce physicians who would render high quality care. As the physical, biological, and behavioral sciences have broadened and extended their scope, there has been a continuous revision of the definition of high quality care. It is certain that for a number of illnesses the criteria for such care will be significantly different a decade hence from what they are today. The geometrically expanding data bases of the so-called "hard" sciences related to medicine-anatomy, biochemistry, physiology, biophysics, microbiology, and genetics, to name but a few-provide more and more observations relevant to medical practice. The somewhat slower increase in the body of knowledge in the behavioral sciences also offers the physician increasing opportunity to improve his management of the patient's illness as distinct from the patient's disease. A disease is an abstraction as well as a classification of phenomena related to disordered structure and function which are grouped together for a variety of medical reasons. Illness is the total of the physical, emotional, economic, and social alterations produced in an individual patient by his disease. Identical Colles fractures-a common type of wrist fracture -will produce a very different illness in a violinist than in a radio announcer. There is no reason to believe that there will be a significant diminution in the rate at which new knowledge is acquired or in the *Presented in a panel, Educating the Health Professions for High Quality Care, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health Care, held April 24 and 25, 1975.
Vol. 52, No. 1, January 1976
I 2 0
H.
120H.
ARANOAV, JR. ARANOW,
need to discard or modify old concepts shown to be erroneous or incomplete. It is currently fashionable to emphasize the knowledge explosion and the overwhelming number of facts relevant to medicine. Study of the medical curricula of more than a century ago shows that the students of those days had an equally large number of facts to master. What has changed is our concept of the relevance and validity of the facts whose mastery was required of the early i9th century medical student. It is inevitable that the 2 ISt century will regard many of today's facts in a similar light. One of our goals, therefore, must be to produce a method which will enable the individual physician to evaluate new observations for both their validity and their influence on current theory and practice. It is the method of science that has made science such a worldmodifying force, much more than the mere accumulation and classification of an enormous number of facts. If the physician uses the scientific method he is prepared to appraise new observations. If he realizes that the delivery of high quality health care demands a lifetime of study he will be aware of those new observations and concepts which have relevance to his practice. The acquisition of the scientific method and of the habit of continuing study are, then, two of the primary objectives of medical education, which are requisite for the long-term delivery of high quality care. These qualities are not different from those required of a competent scientist in any discipline. The activity which distinguishes the physician from other scientists is the application of his knowledge to disease at it occurs in individual patients. The delivery of high quality care involves an understanding of the illness which the disease produces in a particular patient as well as of the phenomena common to the disease in many patients. It is important that the physician be aware of those factors in the physican-patient relation which made medicine an honored and useful profession long before its acquisition of a scientific base. L. J. Henderson, the distinguished biochemist, is credited with the statement that it was not until a decade into the 2oth century that the average patient with an average disease encountering an average physician stood better than a 50/50 chance of profiting from the encounter. It is clear that Professor Henderson's statement referred to the patient's disease rather than to his illness. Schrodinger, the great physicist, once defined science as looking at nature in the Greek way. Many societies, including some Bull. N. Y. Acad. Med.
EDUCATING THE PROFESSION2
I 2 I
contemporary ones, regard nature in a different and less objective way. Practitioners of the healing arts in such societies often enjoy esteem and rewards comparatively as great or even greater than those accorded to modern physicians. The person who is ill brings to his relation with a practitioner of the healing arts a number of fears, hopes, and expectations which often play a major role in his illness. In some illnesses they may completely overshadow any objectively measurable deviations from normal. Although in many illnesses, for example acute bacterial infections, these aspects are pushed into the background during the acute phase of the disease, they are rarely absent; they may modify compliance with a prescribed regimen, the duration of convalescence, and the return to premorbid levels of function. Understanding, tact, and empathy may enable the physician to speed the patient's recovery by intelligent use of the factors in the doctor-patient relation. In some instances these spell the difference between acceptance and rejection of a therapeutic intervention which may be life-saving. The concern for people and the desire to help them which lead many people into the medical profession are often accompanied by these qualities, but in varying degrees. The behavioral sciences are furnishing us with insights into many aspects of the doctor-patient interaction which should enable physicians to use them with greater understanding to provide greater benefit to their patients. They should also make it possible for physicians less endowed with empathy and related qualities to derive therapeutic gains from the relation. The clinical education of the physician, starting in medical school and continuing through internship and residency, should inculcate these principles through both example and precept. In his first contacts with patients throughout his training period the physician-in-training should learn that the illness of an individual patient is unique, although the pathological alterations produced in that patient by disease may be indistinguishable from those in a multitude of other patients. His teachers should not only help him to dissect and analyze such aspects of disease as are signaled by changes in electrolytes, blood counts, or other measurable parameters; they should also teach him to get to know the individual in whom these changes are occurring-to find out about the patient's background, education, job, family, environment, Vol. 52, No. 1, January 1976
I 2122
H..AANW ARANOW,
JR. R
and relation to all of these factors as well as the patient's response to previous illnesses. The teaching environment should be structured in such a way that the young physician learns which aspect of the patient's illness should be dealt with at each of the several stages of its management. He will see that in the management of major trauma or hemorrhage all efforts initially must be directed toward control and correction of the evident physical disturbances. He will appreciate, too, that when symptoms and disability outlast evident organic disturbances their cause is as likely to be the impact of the patient's illness on his personal life, hopes, and fears as it is in some minor structural or biochemical deviation from accepted norms. These principles can be best inculcated in the physician-in-training by exposing him to teachers who exemplify them. The increasing subdividing of medical knowledge and its spectacular advances have made it inevitable that some physicians must concentrate on the elucidation of the mechanisms of disease while others devote themselves primarily to caring for the sick. A better balanced physician will result from a clinical faculty which includes some teachers who are devoted primarily to each of these activities, giving the trainee ample contact with both types of teachers. Let us now turn to assessments of quality and their relevance to the educational process. In the broadest sense, every presentation of a clinical problem by a junior to someone who is his senior either in knowledge or experience is an assessment of the quality of the work that has been presented. This is true whether it be an initial presentation of a history and physical examination by a clinical clerk, a presentation of a new case by an intern to his resident, or a review of the diagnosis and management of a complicated problem in a subspecialty presented by a senior fellow to his division chief. In each case the standards of the reviewer will be modified by the presenting situation, the stage of training of the presenter, and the reviewer's personal priorities. In reviewing the problem of a digestive disturbance, one reviewer may find the stresses in the patient's interpersonal relations more relevant than the lactose tolerance test requested by another. To make these assessments didactically valuable to the trainee, each reviewer must be able to explain clearly what relevance and importance his criteria have to the problem presented by this individual patient. Bull. N. Y. Acad. Med.
EDUCATI'.\'G THE PROFESSION
EDUCATING
I23
123
The sum of a series of such assessments performed as the trainee assumes increasing responsibility for the management of the illnesses of patients is, in my opinion, the core of clinical education. The assessments are made more vibrant by their direct relevance to the patients under the trainee's continuing observation, and they are particularized to individual patients. The trainee then is helped to make generalizations from his own personal experiences, supplemented by those cited to him by his teachers and colleagues, and those described in the literature. Such assessments of quality are different in kind from those made on the basis of retrospective review, usually by persons unacquainted with the specific case. Assessments of quality based on studies of outcomes have much to teach us. Large research efforts to determine outcome criteria which can be applied to a wide range of diseases are justified. From them we may hope to learn which features of our therapeutic regimens have positive value, which do not influence outcome and, importantly, which have negative effects. Because of their statistical nature, however, it probably will not be possible to evaluate the reviewed procedures in a way which will determine their appropriateness to the idiosyncratic illnesses of individual patients. I have great misgivings about the more easily implemented process review. Such reviews are unlikely to reveal the appropriateness of a particular diagnostic or therapeutic program for the particular illness of an individual patient. More importantly, they are likely to define a number of procedures whose value has not been established. One can imagine a primitive tribe in which it is the established practice of medical men to bow three times before the village idol before repeating the traditional incantations; practitioners bowing twice or four times could be cited after process review as deviating from accepted practice. It is my hope that the advocates of outcome review will receive a sympathetic hearing from the legislators before the hydraheaded Professional Standards Review Organizations process review spawns a long-lived bureaucracy which will certainly increase medical costs.
When Dr. Charles A. Ragan requested me to give this presentation in his stead, I asked him what he had planned to say. He replied, "A major objective is to make compulsive neurotics out of all physiciantrainees." By this I think he meant that each physician should not only Vol. 52, No. 1, January 1976
I 2
4
124
H. ARANONN', JR.
H.
ARANOW,
be taught to apply all of his skills to the problems presented by each patient, but that the physician's superego should be so hypertrophied that it would not be possible for him to do less than his best in the presenting situation. With his usual perspicacity, Dr. Ragan indicated the keystone of the arch between physician and patient. Education should enable the physician to discern the optimal course permitted by the circumstances, but his character-moulded, we hope, by education-should compel him to follow it and to avoid shortcuts which might save time or effort for the physician but would not be in the best interests of the patient. Finally, it would be inappropriate to close a discussion of high quality care without mention of the caring function of the physician as distinguished from his curing function. Francis Peabody's aphorism, "The secret of the care of the patient is in caring for the patient," epitomizes this. Abundant evidence indicates not only that this caring function is highly regarded and widely sought, but that in some instances it is essential for cure. Modern medical education in general has underemphasized this important aspect of the physician's role. It cannot be taught by precept alone. Wise and humane teachers can help to inculcate it by example and by analyzing its great value as they do so. This role of the practitioner of the healing arts dates from prehistoric times, and constituted the medical profession's major contribution to the patient until relatively recently. Today it continues to be an indispensable feature of medical therapy.
Bull. N. Y. Acad. Med.
