LOOKING UPON THE WATER

Sojourns Along the Costa da Morte When properly administered, vacations do not diminish productivity: for every week you're away and get nothing done, there's another week when your boss is away and you get twice as much done. Daniel Luten, quoted by Paul Dickson

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HIS PAST SPRING our family went to Spain. Rather, two of us went. A third member met us there. We drove from Madrid through Salamanca, around the northern border of Portugal and into Galiza (known as Galicia to much of the world outside). We went to Santiago de Compostela and stayed 3 days. It was not enough! Santiago (that's St. James in Spanish) is near the end of the Camino de Santiago and has been the goal of religious pilgrims for a thousand years. They came at first by foot from Europe, Iberia, and the Mediterranean. They come now by ship, air, and train from all over the world. As they enter the cathedral they touch a pillar. Their fingers have worn deep depressions in this marble column. They must have numbered millions! We went to Santiago as vacationers, not pilgrims. We came home as pilgrims. Santiago de Compostela, in the upper left corner of Spain, in what the guidebooks describe as the most impoverished province in the country, is a wonderful, inspiring city. It converted us. On this one particular day, we drove west from Santiago to the coast. Now, one might expect that the northwestern coast of the Iberian Peninsula would be a lonely, barren place indeed. I did. After all, one stretch of the shoreline is known as the Costa da Morte (Coast of Death). And one of its capes is Cabo de Finisterre (Land's End). As its name implies, Finisterre was the edge of the known world until the 15th Century. Such names to me are foreboding; they imply gloom, hostility, and desolation. But let me tell you, Citizens, Galiza does not seem impoverished and its coastline is not gloomy, hostile, nor desolate! Galiza is a warm and friendly place. The beaches are plentiful, white, and sandy. The seafood is delicate, the wines are light, the people are cordial. Sure, it may drizzle once in a while, but the Costa da Morte it is not! 394

Such were my thoughts as I basked in the shine of a Spanish sun on the white sands of a deserted beach north of Cambados and in sight of Finisterre. The flesh of crab and shrimp reposed in some distant folds of my gastric mucosa. Remnants of a local white wine coursed through my veins. These orts brought to my disposition the benevolent feelings that are the due of aUrinarian vacationing in a foreign land. There was a calmness within me. . . a calmness that, little did I know, would disappear when I came home, stood on another Finisterre, and peered off another Costa da Morte into seas that rage, this time around graduate medical education in this, the fair land that we call home. The site of my recent agony was Santa Fe, New Mexico, where at the end of May, the American Association of Medical Colleges sponsored the first gathering of their Section on Resident Education. Some 175 persons attended. Not all were physicians nor medical educators. Some were representatives of the Gummit. Some were from industry. Some were from think tanks east and west. All were addressing the circumstances that call for change in medical residency and fellowship training programs. You need to be conversant of the issues. They promise to affect all physicians, academicians, and practitioners alike. They challenge nephrology because they will lessen the training funds and manpower that are now available to our specialty. The issues that surround graduate medical education and that were discussed in Santa Fe encompass money, location, curriculum, and student body. It seems, in the minds of some. . . The Minds of Some! Another of those great, nebulous external forces that control our lives. Bow, Citizens, as do I, in the presence of the Minds of Some! It seems, in the Minds of Some, that you and I have failed in our task of training doctors for

American Journal of Kidney Diseases, Vol XX. No 4 (October). 1992: pp 394-395

LOOKING UPON THE WATER

the practice of general medicine. Instead, we have succeeded too well in training specialists. Specialists are not needed. They are too numerous. They go out into the world of the sick and ailing and do too little for too many while expecting too much. What is needed, opine the Minds of Some, are more generalists. Generalists keep people well and happy. Generalists always can refer when necessary to specialists, who surely will be waiting for their calls. To get more generalists, think the M's ofS's, one must discourage specialty training (cut training funds) and encourage the training and practice of general medicine (increase stipends in general medicine, pediatrics, and family practice and supplement fee payments for practicing generalists). It seems clear in the M's of S's that generalists cannot be taught appropriately in the great teaching (make that tertiary care, Citizens) hospitals of our country. They must be taught in clinics and offices. Preferably, most of these would be physically distant from tempting technologies of the intensive care units, dialysis units, cath and 'scopic labs, and imaging centers of our country's major medical centers. If the system were to change now, the impact would not be felt at the practice end of the pipeline for 5 to 7 years. Too long a time! To get started sooner, inducements will be offered to those already in training and practice. Pressures will mount for students, housestaff, and even young physicians to take advantage of opportunities to meet the medical needs of our land. . . and the needs of their pocketbooks, already emptied of change by high tuition costs and low houseofficer salaries. At this moment, new graduates and specialty jumpers can receive $125,000 per annum to practice general medicine on the West Coast! "Ah, but . . . " you inquire, "who would want to go through life being called a generalist?" No one? That can be fixed! We've solved it before. We'd train 'em for the work but call them something else. How about training 'em in Neonatal Gerontology? We'd call 'em Neonatal Gerontologists and raise their fees. They'd give health care from the cradle to the grave! But I digress. . . The Association of Professors of Medicine proposes that 50% of medical residents' training take place in the out-patient setting. That's 6

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months each year, 18 months in 3 years. What does that mean? It means that residents will not be on the wards nor in the units and labs. They will be gone, away from the influences you, the nephrologists, might bring to bear on their career choices. Away from the places where you ply the nephrology trade. . . and where you depend on their availability and help in the care of your sickest patients. Thus emerges the issue of who will take the place of residents on the floors of teaching hospitals. Well, more physicians for one. But they are expensive, more costly than residents. How about physician extenders? Not too bad an idea, but it is not likely that many of them will be recruited into nephrology fellowships. How about more residents? There are plenty out there especially if international medical graduates are included, but in the M's of S's, we will serve US graduates first. In the M's ofO's (Minds of Others. Pay attention! Think!) we should not discriminate based on country of training. Then, there is a question of where the money might come from to pay for these extra bodies, whomever they might be. Up go the costs of health care! Know, Citizens, that it is the 85,000 residents now in training in our teaching hospitals who provide most of the medical care that is given to the 37 million Americans without health insurance. Know further, as we have discussed on these pages, that most of the funding for residents comes from the Federal Gummit and amounts to about $5 or $6 billion per year-a bargain when one considers that 240 million Americans spend $600 billion on health care. Know that in the money and the costs, in my judgement, lies salvation if there is salvation to be had. The void that will be created by relocation of resident training from hospitals to clinics may just be so vast and so difficult to fill that residents will not be taken in substantial numbers from the hospitals where we ply our trade. You may, as you stand with me on these shores and gaze with me into the turbulent waters along this Costa da Morte-the death of residency training as we have known it-wish to consider your position on the matter.

Kenneth D. Gardner, Jr, MD University of New Mexico School of Medicine Albuquerque, New Mexico

Looking upon the water. Sojourns along the Costa da Morte.

LOOKING UPON THE WATER Sojourns Along the Costa da Morte When properly administered, vacations do not diminish productivity: for every week you're aw...
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