Richard Schwartzstein reflects on the benefits of being able to pull on his broad and comprehensive training in medical school and questions whether the move towards specialist training earlier is a good thing.
The plane in which I’m flying to New Zealand is at 35,000 feet — cruising altitude over the Pacific, three hours out from Los Angeles. The cabin is dark and, other than the dull roar of the engines, all is quiet. Then the announcement that physicians hope not to hear comes over the PA system, “Is there a doctor on the plane?”
I catch the attention of the flight attendant and identify myself as a physician. She tells me that a passenger fell in the back of the plane and hit her head. Could I help?
As I move to the rear of the plane, I see a middle-aged woman sitting on the floor of the galley. Someone else is with her. He introduces himself as a pediatrician and, when I volunteer that I am a lung doctor and a critical care physician, he sighs in relief, says “She’s all yours,” and returns to his seat.
I sit on the floor beside the woman and, as we both bounce with the turbulence, ask her name. “Angela,” she responds (not her real name).
“How are you? What happened?” I ask. She tells me that she got up to go to the bathroom, slipped, and fell, hitting her face and forehead on the counter in the galley. I follow with questions about loss of consciousness and history of seizures and try to gauge her clarity of thought. “What medical problems do you have?” and “What medications are you taking?” She mentions aspirin, which I note as a possible risk for bleeding after an injury.
This scenario, being asked to care for someone who is ill or has been injured on a flight, occurs routinely for doctors. Over the years, I have been asked to assess pregnant women as well as individuals with seizures, acute intoxication, and other maladies that are often outside of my specialty (pulmonology). In these circumstances, I fall back on my early training in medical school — training that was broad and comprehensive, the medical equivalent of a liberal arts education.
Unfortunately, this type of general education is becoming less common in medical schools across the country. Responding to students’ desires to focus only on their career aspirations to become specialists, some schools let students take multiple courses and seek clinical experiences in a particular track or pathway rather than ensure they acquire knowledge and skills in a broad range of areas.
Despite the explosion of medical knowledge in recent decades, many medical educators are questioning whether medical school really needs to be four years long. Why not speed things up, save money, and get into your specialty sooner? Why would one spend time in that fourth year embracing areas of medicine you won’t be needing in your post-graduate training? After all, isn’t the goal of medical school to prepare you for residency training?
This approach, which emphasizes early specialization and views medical school as a hurdle to be cleared in the most efficient way possible, risks transforming medical schools into vocational rather than professional training: “Just learn how to do these skills and take care of this narrowly defined list of problems and you are all set.” Furthermore, people trained in this way may be more likely to make mistakes because of their limited knowledge and experience.
Back to Angela. I perform as much of a physical examination as I can under the circumstances. Using equipment from the plane’s small medical kit, I check her blood pressure and heart rate, her eye movement, and how her pupils respond to light. I also assess her for entrapment of muscles (failure of the eye to move in a particular direction), which could indicate a facial fracture.
“How is she?”
I look up. The captain has come to the rear of the plane from the flight deck. He’s interested in Angela’s condition because he is responsible for the passengers on his plane. He also needs to make a decision: “Do we need to turn the plane around?” he asks me.
I explain what happened and my give him assessment of Angela’s status. Trying to be aware of the possibility that my judgment might be affected by a desire to continue to our destination, I force myself to carefully go through all the possibilities and probabilities of what might have happened and what could happen as a consequence. I think she will be okay, but we will need to watch her for the rest of the flight.
We arrive in Auckland hours later; Angela is fine.
As a physician, faculty member, and educational leader at Beth Israel Deaconess Medical Center and Harvard Medical School, I was recently involved in the development of a new curriculum spanning all four years of medical student education at Harvard. There were hours of discussion with dozens of faculty members over several years about the content and teaching methods we thought were best for laying the foundation for the next generation of doctors.
In these conversations, we often talked about the kind of doctors we hoped would emerge upon graduation from Harvard Medical School. Would they be compassionate with good communication skills? Would they be able to think and reason analytically? Would they be aware of cultural differences in our diverse population and understand the effect of societal factors on health and disease? And would they be knowledgeable about electronic medical records?
There are many things that go into being a great doctor. But I would muse from time to time: “I want them to be able to do more than the flight attendant when called to help a passenger at 35,000 feet.”