Should doctors specialize earlier in their education?

Great Debates
21

Aye there’s the rub.

It is precisely for that decision process that we generalists need to know so much about so many different areas. Recognizing when something needs a specialist, and which sort of specialist is a very tricky bit to accomplish. Training care providers less to make those assessments is not a wise approach. And that sort of pattern recognition (mismatch recognition more than anything else) is what “expert systems” and lower level providers do least well.

Guidelines and algorithms can only get you so far.

22

QFT

I supervise and work with mid-level practitioners (physician assistants and Nurse Practitioners) daily, and a mid-level who ‘knows what they don’t know’ is worth their weight in gold.

But the best ones tend to be ‘less productive’ in terms of volume of patients seen, and this brings on wrath from the bean counters, who look at the bottom line. And the most ‘efficient’ ones who can handle high volume (and are hence beloved by the bean counters) seem to be the ones who are less likely to pick up anomalies.

23

Exactly, DSeid. I can’t agree with you more. That’s why I said ‘ten years’. It’s a serious, deep problem.

But I don’t think it’s an insurmountable one. I think the medical profession is on the edge of a sea change again. It’s had a few, starting with barber-surgeons and learned doctors going through germ theory, surgery that could actually help people, transplants and mechanical assist, designer drugs, and the recent computer aided surgery and diagnostics.

Edit: Qadgop: Again, exactly. The problem is that we need GPs… and GPs really need to know what they don’t know. But we don’t have GPs, so what if we devolve responsibilities for pallative care onto a mid-level practitioner? I know it’s not a pretty thought, but I’m thinking it might be a necessary one. And yes, this brings back the old sci-fi concept of ‘doc in a box’. (What was that story about the ‘magic’ doctor’s bag?) But I don’t see a different way out of the oncoming crisis.

24

Frankly, it could start earlier. But it takes a certain amount of maturity and real-world experience to be able to intelligently choose medicine as a career, recognizing the difficulties and rewards such a choice brings. Anecdotally, I’ve seen younger students in the 'accelerated programs" bail out of med school at a higher rate than the older ones, who sometimes brought with them to med school a perhaps more realistic perspective on what they can and can’t handle.

Personally, I got my MD at age 25, which is rather younger than average, but not greatly so. It was quite the challenge at that age, and while I was not the most mature individual when I was 25, it still tested me severely.

25

Thanks for the discussion all. The majority opinion seems to be that we cannot significantly reduce the required length of education without sacrificing care, though we could tweak it at the edges.

I guess my follow-up question is this: even if a reduction of education will marginally reduce the quality care, is it possible that the trade-off in terms of affordability of care and increase in preventative and primary care would mean there is net benefit to the overall health care system?

Let me offer a concrete example. Suppose we allow RNs to perform regular check-ups of individuals with no known medical conditions (I think these are called wellness checks or something). I assume the RN is bound to miss some things a doctor would find. But if it means a net increase in the people getting wellness checks, mightn’t that be better for the overall community? People could still pay for doctors check-ups if they could afford them, it’s just that people without health insurance or who want a lower copay (or whatever) could also get them.

(Of course, given the ignorance I’ve already displayed, I wouldn’t be surprised to learn that we already allow this. If so, modify my question to include RNs doing some other routine medical task that is not currently allowed.)

26

Well to some very significant degree it does happen now. As QtM points out mid-level providers are often utilized, both as part of practices with doctors (seeing what are supposed to be straight forward standard rooms on up to some states allowing stand alone nurse midwifery), functioning fully competitively with medical GPs, or in the retail clinics (e.g. CVS’s Minute Clinic). I imagine that some have found them to be cost effective.

27

(I agree with DSeid and Quadgop, but that part is already finished discussing).

You can vastly change the system of training doctors by adopting a different approach similar to the European one. (Disclaimer: I watch Grey’s anatomy and House, and all I understand about the US system of educating doctors is that it’s vastly different, seems to be rather complex and not the best system possible. I’m not a doctor here, either, so I don’t know the details of all European methods.)
First step: instead of expensive medical schools, make universities state-sponsored so students don’t go into horrendous debt.
Second: Personally I would combine the practical aspect of seeing things, diagnosing things and doing practical stuff like inserting needles into dummies *, very early into the theoretical part, instead of the seperation of first filling the students’ brains to the brim with facts and then letting them loose on patients as interns without practical experience on dummies first. (If that is incorrect, I apologize - this is from watching Grey’s Anatomy and Scrubs, where I’m appalled at what the new interns are allowed to do.)

  • Yes, I know, that’s usually done by Nurses in the hospital. It’s an example for the hand-on stuff that requires feeling and experience and shouldn’t be done on patients fresh in the practical year.

I would also, as many experts are demanding now, add an extra course about proper bedside manner, which many doctors never seem to learn, when all the concentration is on the hard facts.

I would also abolish those 24hr shifts during the practical year, because that’s only asking for mistakes. Countless studies have been done on how badly judgment goes down with long work hours and lack of sleep, and how concentration is reduced, but doctors ignore this advice.

And the other step necessary is a reform of the healthcare billing/ reimbursement system, where a doctor isn’t punished with less pay if he spends more time with a patient, which is the sign of a good and thorough doctor.

As for letting less trained people do regular check-ups, I wouldn’t think that a good idea. The very purpose of check-ups is to catch deviances from the norm early before the grow into big problems, which means you need a lot of experience and a lot of theoretical background to know what to look for and what a small early problem would look like.

So a nurse can draw your blood and send it to the lab, but the doctor should listen to your chest while breathing and look at the ECG and so on.

28

I did not know the answer to this but wikipedia can be my friend.

There are a variety of models out there with some skipping undergraduate entirely. Japan is a six year program out of High School. In China it is a five year Bachelor degree. France is six years after High School with a large number being filtered out along the way. Germany is a six year program out of High School too.

29

Well, to be exact, it’s advanced High School called Gymnasium, which prepares pupils explicitly for university. And the last two years of Gymnasium are called Kollegstufe, because they are modelled on the College system: four semesters instead of two years, points instead of normal grades, Leistungskurse = major courses and minor courses, and the pupil deciding what courses he wants to take himself. (I’ve also heard from several sources, but don’t know if it’s reliably been compared or national pride, that the Kollegstufe is at least equivalent to a lot of lower-quality US colleges, so any pupil that finishes Gymnasium successfully with the Abitur - the official sign that he is deemed qualified to study at a university - is comparable to an US pupil who finished college.