How Will the COVID-19 Pandemic Affect Medical Education?
The delicate balance between core values and financial reality.
Posted Jun 15, 2020
Kenneth Ludmerer has authored three books addressing the history of medical education. He recently published an essay in the journal Academic Medicine reviewing the relevance of his work. This invited commentary was written prior to the COVID-19 pandemic. Ludmerer is a physician, professor of internal medicine at Washington University School of Medicine, and a noted medical historian.
Ludmerer believes that “academic excellence is the core principle, and service the core value, that underlie the U.S. system of medical education.” Academic excellence involves teaching trainees to utilize scientific methods when determining the best way to help patients. It also means “fostering problem-solving skills, the capacity to obtain and critically evaluate new information, the ability to manage uncertainty, and curiosity.” To Ludmerer “service” means “putting the needs of patients and the public first, ahead of self for individual medical educators and physicians, and ahead of financial remuneration for institutions.” In other words, altruism and professionalism are important ingredients in becoming a physician.
Over the last several decades, many hospital systems, including those that are not-for-profit, and medical schools have become big businesses. Insurance companies generously reimburse technically sophisticated procedures more than time spent with patients. Thus, specialists such as pediatricians, family physicians, and psychiatrists are among the lower income-generating physicians because their work, for the most part, is not procedurally-based. Medical centers have become dependent on income generated by physicians who are proficient at highly reimbursed procedures. In addition, financial considerations have increased pressure on physicians to evaluate and treat more patients more quickly in order to generate more income. This has made it increasingly difficult for academic physicians to devote sufficient time to train medical students, residents, and fellows. On the other hand, regulatory agencies have increasingly exerted pressure on medical schools and hospitals to devote more resources to their educational missions, including one-on-one and small group training sessions, and to find a workable balance between the financial bottom line and education. Some medical centers have responded by helping to support a cadre of physicians who specialize in medical education.
Then came COVID-19. Hospitals and medical centers returned to their core values and rapidly implemented systems designed to help large numbers of extremely ill patients, particularly patients from complex high risk groups – the elderly, underserved minorities, and individuals with significant medical comorbidities. Patient care was the primary mission; financial considerations did not drive the response. Health care workers made truly heroic efforts — some sacrificing their lives. There were repeated outpourings of appreciation from the public.
Soon, however, financial realities started to hit. Some hospitals were unable to survive without the income from cancelled procedures. Many larger hospital systems and medical centers started to furlough or lay off staff, including physicians. Downsizing became a necessary reality. Faculty at medical schools, including those on the frontline working with COVID-19 patients, were notified that their salaries would be cut. Medical students demonstrated altruism by helping in myriad ways, but were not permitted to work in inpatient hospital settings for several months thus interrupting their education. So much changed so suddenly, and the impact will have long-term consequences.
These dramatic and tragic events offer an opportunity for doctors, hospitals, and medical centers to re-evaluate the priorities of the medical profession. Many physicians regained an understanding of altruism, felt a sense of purpose, and demonstrated their professionalism. Students witnessed that becoming a physician is a calling and a privilege but one that includes obligation to duty even under highly adverse and risky circumstances.
Perhaps leaders of hospitals and medical schools will now rethink the balance between the “big business” side of medicine and the obligation for professionalism and altruism. Perhaps the various members of the medical-industrial complex will realize the value of preventive approaches and wellness promotion including mental health as well as the importance of supporting physicians spending time with their patients. The solution to these concerns will also require a major reconsideration of how third party payers, including the federal government, reimburse heath care. Health care systems and providers do what they are incented to do. The current crisis has highlighted major problems with the collective health of our communities, particularly those who are underserved and most vulnerable.
Perhaps the COVID-19 pandemic will lead the medical profession and hospital leadership back to core values. Time will tell.
This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.
Ludmerer, K.M. (2020). Reflections on Learning to Heal, Time to Heal, and Let Me Heal. Acad. Med. 95:838–841.