Curatives And Correctives "Let Me Heal" weaves lines between service and education, internship and apprenticeship

Let Me Heal: The Opportunity to Preserve Excellence in American Medicine

Kenneth M. Ludmerer (Oxford University Press, 2015) 431 pages, with notes and index

Graduates of medical school receive the M.D. degree and are called “doctor,” but they are not yet ready to take care of their patients. Rather, every newly minted physician continues for a further three-to-nine years of training collectively called graduate medical education (GME), commonly referred to as internship, residency, and fellowship. In these years, they learn how to practice medicine and they specialize, transforming from a medical school graduate into an internist, psychiatrist, gynecologist, surgeon, etc. Let Me Heal traces the emergence and development of American graduate medical education from its origins in the nineteenth century to the challenges it faces in the 21st. Kenneth M. Ludmerer approaches this subject as both a practicing academic physician and a professional historian at Washington University whose two previous books, Learning to Heal: Development of American Medical Education (1986) and Time to Heal:American Medical Education from the Turn of the Century to the Era of Managed Care (1999), detail the creation, reform, and institutionalization of medical schools in the United States. This third book builds on his expertise in medical education to explore the next stage of physicians’ training. Surprisingly, it is the first book-length history of GME, a crucial stage in the development of doctors that, more than medical school, teaches them how to care for the ill.

Organized chronologically, the book begins by examining predecessors to the current residency system, focusing mostly on the quasi-apprenticeships available at some elite east coast teaching hospitals in the 1800s. It then traces the familiar story of how this apprenticeship model blended with the German academic tradition of assistantships to form the uniquely American residency system, first at Johns Hopkins then, through Hopkins’ missionary-like graduates, around the country. Crucially, Ludmerer does not draw a straight line from Hopkins residencies to modern GME, as many other authors have facilely framed. Instead, he demonstrates how these early opportunities differed from current practices. Specifically, he highlights the heavy research focus of the early programs and the effort to create not specialty clinical care providers but clinical investigators who would discover new knowledge and train the next generation of doctors.

Its rarity also distinguished early GME from its modern form. When Johns Hopkins accepted its first resident in the 1880s, medical education in the United States was a for-profit, haphazard affair, as Ludmerer depicted in detail in his previous books. Reform efforts in the late 19th and early 20th centuries, headlined by the Flexner Report, focused on improving medical school; residency remained limited to the elite few practitioners focused on a career in the ivory tower (GME was not required to practice medicine by any state until 1904). By the 1910s, with medical schools rapidly improving, professional organizations like the American Medical Association turned their attention to internship—the first year of supervised hospital practice after medical school. They issued guidelines, constructed lists of approved programs, and tried to formalize the process; it nonetheless remained an ad hoc affair. Only a dozen states required internships to practice in 1925.

When explaining the emergence of the internship, Ludmerer initiates a thread that runs through the remainder of his book: service v. education. To what extent was internship/residency a service to the hospital, providing cheap, highly skilled labor, and to what extent was it a purely educational experience for the residents, like medical school? Ludmerer takes pains to differentiate internships from the apprenticeship experience featured in many 19th century hospitals, identifying the latter as service-oriented. In contrast, internships included didactic lectures, teaching conferences, case reports, reading journals, and close interactions between faculty and interns to foster pedagogy. Academic institutions largely maintained this distinction, but as internships spread to community hospitals, the line between service and education blurred. As physicians working long hours for room and board (and perhaps a pittance of a salary), interns represented a great source of cheap labor, taking care of patients in the hospital while fully trained doctors focused on their profitable office practices. The struggles of the profession to manage this tension recurred throughout the twentieth century and into the present.

Ludmerer does not draw a straight line from Hopkins residencies to modern GME, as many other authors have facilely framed. Instead, he demonstrates how these early opportunities differed from current practices. Specifically, he highlights the heavy research focus of the early programs and the effort to create not specialty clinical care providers but clinical investigators who would discover new knowledge and train the next generation of doctors.

By World War II, almost every medical school graduate completed at least an internship, but residencies – an additional two to four years of training – remained rare; within a decade they too became standard. Whereas internship prepared one for general practice, residency produced specialists. Limited in its early years to a select group of institutions, it focused on “teaching the teachers,” emphasizing research and clinical investigation. Ludmerer explains how the spread and democratization of residency changed its character, too. Expanding after World War II to community hospitals around the country, it became a time to train specialized clinical practitioners rather than academic professors. As with internships, this expansion again challenged the educational character of the experience.

In describing the rise of residencies, Ludmerer exposes some territory future scholars may wish to explore. Ludmerer largely defers to the excellent work of other historians like George Rosen (A History of Public Health, 1958), George Weisz (Divide and Conquer: A Comparative History of Medical Specialization, 2005), and Rosemary Stevens (In Sickness and in Wealth: American Hospitals in the Twentieth Century, 1989) to explain the waning of general practitioners and the rise of specialists. But what was the effect of GME on this shift? To what extent did the push toward specialization drive the spread of residency versus building residencies create a plethora of specialists? Moreover, these years saw the creation of regulatory bodies (Residency Review Committees) that created the standards by which programs had to abide thus, in effect, determining the structure and entrance requirements for each specialty. This process became an enormously complex and vitriolic bureaucratic battle for control over the professions that Ludmerer covers in a brief few sentences. Through these Review Committees, the basic structure of GME that exists today was wrestled in place by the 1950s.

A real strength is Ludmerer’s description of “the life of a resident,” both before and after the Second World War. Drawing on archival records, diaries, published memoirs, and interviews, he portrays what it was like to be a house officer. This bottom-up view provides an invaluable perspective on the development of GME. Illuminating to both laymen with little notion of what encompasses a day-in-the-life of an intern as well as to medical professionals curious how their predecessors were trained, these sections limn the daily challenges and satisfactions of residency. Though bifurcated into pre- and post-war chapters, the content emphasizes the commonality of the experience. He describes rounding on patients, exasperation with bureaucracy, frustrations of encountering incurable diseases, excitement of successful treatment, and the satisfaction of learning. Noting the once-close relationship between faculty and house staff, Ludmerer paints this era in a positive light. Interns and residents worked very hard for long hours but expressed satisfaction with their job and seemed to love what they did. Certainly, it was not perfect. Ludmerer points out how minorities—Jews and blacks—and women faced discrimination in obtaining positions and prejudice once in the system. Separate hospitals for both patients and practitioners ameliorated the situation, but complete integration has eluded the profession to this day.

These chapters again highlight the tension between service and education, which came to a head in the 1970s. Ludmerer does his best work providing the social, cultural and political context of the time and demonstrating its effect on GME for this era. Both medicine and the society in which it was practiced changed dramatically. New technologies like CAT scans, intensive care units, and improved drugs complicated the care of patients, who were often much sicker than before. At the same time, Vietnam War protests, the Civil Rights campaigns, feminism, and other social movements created an antiauthoritarian zeitgeist that pervaded the medical profession as well. Residents, upset with working conditions, formed national unions and even went on strike, shocking and infuriating their elders. Ludmerer notes that the amount of work hardly changed from previous decades. The type of work and, more fundamentally, the attitude toward that work transformed radically. Not only did residents experience an increase in scut work (repetitive tasks with little educational benefit such as drawing blood, or wheeling the patient to the CAT scanner), but they felt less valued as faculty and chairmen decreased direct involvement in education and denied house staff time to learn as pressure to care for more and sicker patients seemed to increase. GME, once passionately regarded as training for a life’s vocation, had become in the eyes of many residents just another job – and one for which they demanded improved conditions. It took several more decades, and the death of a New York socialite, before real change occurred.

Ludmerer spends the final 100 pages – nearly one-third of his book – chronicling the last 30 years. Shortened perspective always complicates contemporary history, but this section holds the greatest interest for most readers and particularly for clinicians. Classifying the 1980s and 1990s as “the era of high throughput,” Ludmerer demonstrates how changes in reimbursement mechanisms led to hospitals treating increasing numbers of patients in order to maintain solvency. Federal caps on the number of residents meant increased work in the same amount of time, again denigrating the educational experience in favor of service. But the severest challenge to GME came from inflexible regulations imposed by a scared but ill-informed society.

In 1984, Libby Zion was admitted to a Manhattan hospital; 24 hours later she was dead. Her father, a well-connected New York lawyer, and the ensuing public reaction blamed sleepless residents for a medication error that might have caused her death. Digging through the details of the case, Ludmerer debunks much of the popularly understood conclusions (including showing how well-rested the residents actually were). However, perceptions trumped truth, and the episode directly led to duty hour limitations in an example of society’s power superseding that of the profession. Residents could only work 80 hours a week in rigidly proscribed shifts and schedules. Resisted by the profession until essentially forced upon them by threats of federal legislation, duty hours have defined residency in the modern era.

These latter chapters shift from objective historical reporting to a more polemical bent as Ludmerer rails against the current system of educating residents. While not arguing for a return to 120 hour weeks of yester-year, Ludmerer exposes the lack of any reputable evidence proving duty-hours have benefitted patient care (and points to some studies that demonstrate the opposite). He deplores not the time limitations per se but their effect on education—how they force internists to go home before completing a patient workup or demand surgeons to leave in the middle of an operation, thus denying them opportunities to learn. Moreover, while hours spent in a hospital might have shrunk forcibly, the number and complexity of patients continued to increase while the ranks of residents remained stable. Thus, the same number of residents performed more work in less time, a formula damning for teaching, learning, and patient care. In the final pages, Ludmerer highlights examples from Harvard and—to bring the story full circle—Johns Hopkins where residents rotate on specific teaching services with fewer patients, senior physicians dedicated to pedagogy, and thus the time to learn how to heal—what residency used to be and to where he thinks it ought to return. Ludmerer recognizes, though, that the applicability of these expensive models to cash-strapped community hospitals preparing the bulk of America’s practitioners is unrealistic.

The slow-paced, education-centric approach highlighted by the Brigham and Hopkins teaching services hearkens back to residencies in the 1950s and 1960s, which Ludmerer nostalgically seems to hold as an ideal, albeit an imperfect one. Yet perhaps the modern era—with lawsuits, sub-sub-specialization of physicians, patient autonomy, increasing participation of physician extenders in providing care, and now the implementation of the Affordable Care Act—demands a more radical rethinking of how best to train doctors. Henry Kissinger remarked that “history teaches by analogy, shedding light on the likely consequences of comparable situations.”[1] The systemic and dramatic changes in how our society practices medicine and receives medical care may have transformed the current situation in health care to such an extent that looking back no longer illuminates the path forward.

Let Me Heal focuses almost exclusively on internal medicine and surgery. These two disciplines comprised the majority of medical school graduates over the last century and certainly provided the models that other fields followed. There nonetheless remains room for future scholars to investigate the development of residencies in other fields—such as psychiatry or pathology—with unique characteristics, histories, and challenges. Comparing other specialties against the standard medical/surgical trajectory Ludmerer establishes could reveal interesting trends and differences while exposing the scaffolding of other specialties.

Ludmerer draws on an impressive array of archival digging at multiple schools to weave together this account. Institutions west of St. Louis are less well represented, but Ludmerer convincingly argues for the similarity of experiences among academic medical centers. More troubling is the over-representation of teaching hospitals like Johns Hopkins and Brigham. Granted, institutions like Hopkins and Harvard set the standard for programs around the country, but by 1955, small community hospitals educated 80 percent of residents. These smaller institutions rarely maintained records or minutes, and practitioners emanating from them infrequently published memoirs or appeared in biographies, challenging any historian trying to research their story. However, community programs educated such a large portion of American doctors and encompassed such a different experience than academia that a fuller portrayal of their participation would have helped complete the story of GME in this country.

Let Me Heal chronicles the history of graduate medical education in the United States, from its origins in 19th century apprenticeships to its birth at Johns Hopkins to its changing character in the late 20th century and the challenges it faces today. It is the definitive account on the topic. This book has obvious appeal for historians of medicine and physicians interested in their past as well as to the lay public curious about the training of their doctors. It also has pressing relevance for policy makers shaping the future of residency. A crucial time that transforms medical school graduates into independent, practicing physicians, effective residencies have tremendous implications on the health of a society. Ludmerer clearly establishes how their history and evolution have shaped their current status. He pleads for a future that restores education as the priority of residency to ensure another generation of competent, confident, and compassionate physicians excited to make new discoveries and heal the sick.

[1] Henry Kissinger, Diplomacy (New York: Simon and Schuster, 1994) 27.

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