The residency director for the medicine-pediatrics (Med-Peds) program at Tulane Medical School was recently suspended from her role after she filed a racial discrimination suit. That suit arose, in part, because of disagreements over ICU training. The internal medicine department felt their residents needed more ICU training than Med-Peds residents. The Med-Peds residency director disagreed. The disagreement escalated, and charges of racism followed. One reason this charge was leveled was because there were more African-Americans in the Med-Peds program. Hence, when their access to ICU training was limited, the Med-Peds residency director attributed it to racist motives.
Scheduling conflicts are common in residency programs. These conflicts are made worse when overlapping residency groups compete for the same territory, as Med-Peds and internal medicine often do. Overlapping residency programs may have been beneficial in years past, but this recent lawsuit offers an example of how detrimental it can be today.
The tragedy at Tulane shows that the structure and culture of academic medicine have not caught up with the times. By eliminating excessive residency program overlap and an “us versus them” mentality between programs, we can improve medical training and avoid major conflicts.
The case for structural reform
In the 1990s, I opposed a proposal to begin a Med-Peds program at the medical school where I worked for three main reasons: The Med-Peds base was already covered by family practice; it would lead to scheduling conflicts; and I didn’t agree with the way certain subjects were taught in pediatrics, so I worried that Med-Peds residents might bring inapplicable teaching into internal medicine. The idea that a pediatrics education and an internal medicine education would complement each other was little more than a romantic notion. Applying clinical approaches used in children to adults was often inappropriate.
When I made these objections, the proponents of the program argued that students who chose Med-Peds residencies were better than other students. Since family practice was considered their main competitor in the primary care world, I was shown figures about how Med-Peds residents had higher test scores and class rankings than family practice residents, and sometimes even higher test scores than internal medicine residents. Test scores have a lot of appeal to residency directors.
The data was accurate – Med-Peds residencies were attracting “better” students. But day-to-day care of patients is different from test scores. Once the Med-Peds residency was formed, I was able to assess their day-to-day care of patients. It was not significantly better than that provided by internal medicine residents. As time went on, it seemed to become worse. This likely happened because the profession of medicine became more complicated over time. New procedures, new medications, and even new diseases stacked up. Information overload posed a greater challenge to disciplines, such as Med-Peds and family practice, which purported to master more than one specialty. At times, this information overload, made worse by misinformation overload, led to confusion and lack of competence in the day-to-day care of patients.
Yet, even when the reality of day-to-day care changes, attitudes and myths remain rigid. Hence, the “I am better” attitude remains fixed. This can pose problems and conflicts when the reality is different from the attitude. Some are quite sensitive to being told they are not as good as they think they are.
The pitfalls of the “us versus them” mentality
Tribalism – the “us against them mentality,” which is a natural tendency of the human mind – can contribute to hurt feelings. Academic medicine, the home of medical education, has a long history of tribalism. As a medical student, I was indoctrinated into tribalism through the put down games played between internal medicine and surgery. Internal medicine doctors called surgeons “mental midgets” and surgeons called internal medicine doctors “fleas” because they were the last to leave a dying body. The joke goes: “A patient is dying of cancer and kidney failure. The internal medicine doctors keep hammering away with futile care. Then the patient dies. But that does not stop them. The cancer doctor goes to the grave, chemotherapy in hand. He is going to treat the dead patient with chemo. He digs down to the coffin. He opens the lid. There is a sign inside that reads, ‘Patient has been taken for dialysis.'” These jokes and putdowns were heard in hallway conversations on many a day.
The “my tribe” versus “your tribe” mentality is common in academic medicine, not only did academic medicine never address its tribalism culture, but it also created more tribes. For subspecialty training, some of those tribes made sense – for example, interventional radiology as a subspecialty of radiology. But other times they didn’t make good sense. We have nurse practitioners, whose scope of work overlaps with physician assistants; we have assistant physicians, general internists, Med-Peds doctors, doctors of osteopathy, and family practitioners who all compete for primary care. We don’t need all these overlapping groups. As they compete for the same territory, tribalism can rear its ugly head.
Med-Peds was established in the late 1960s. It started as a romantic notion that doctors would care for children and then care for those children as adults. They would therefore know the patients very well. Like family practice, it was also developed to serve primary care needs in underserved areas. But neither of those romantic notions played out. Many Med-Peds doctors do not go to underserved areas to practice primary care. One reason for the conflict at Tulane was that the Med-Peds doctors wanted more ICU training. That is not primary care. When it comes to “knowing patients from childhood to adulthood,” that is not realistic. Most young adults don’t need to see doctors on a regular basis. To encourage such a notion is to encourage waste of resources and to encourage an unnecessary, and even a pathological fixation, on “health.”
Times have changed
As I look back on my opposition to the Med-Peds program when it was first proposed and put in place at the medical school where I worked, I feel fortunate that the times were different. It never crossed my mind to look into the racial status of Med-Peds before I voiced my opposition. Had it been predominantly African-American, I could have been accused of racism. Yet, my opposition had nothing to do with race. Of course, the circumstances of the Tulane incident are different, but similarly reflect the issues with overlapping residency programs and tribalism.
There is no excuse for racism or sexism and the times have changed to reflect that. Racism, particularly in the era of Trump, has become a greater threat to our society. Police killings of innocent African-Americans has raised calls for justice and has heightened racial sensitivity.
Times have changed. The loose talk of tribalism, the games of this medical specialty versus that medical specialty, sets the stage for racism and sexism. We need to do a better job eliminating racism and sexism, and the threats they pose, in our profession.
Times have changed. Information overload is a growing challenge each day. Misinformation overload is a growing hazard each day. Piling on more and conflicting information is not a good way to handle these challenges.
Times have changed. Rural areas are not what they used to be. They are now crisscrossed with highways. Helicopters fly critically ill patients to medical centers. What medicine needs is not a plethora of overlapping primary care doctors to treat minor medical problems, but doctors who can handle complex information and take appropriate care of patients.
The present structure and culture of academic medicine has not caught up with the times. That structure and that culture contributed to the tragedy at Tulane. It contributes to poor medical training. It needs to change.
W. Robert Graham, MD, completed medical school and residency at UTHSC-Dallas (Parkland Hospital) and served as chief resident. He received a National Institutes of Health fellowship at the Salk Institute for oncogene research in 1985, and was a professor of medicine at Baylor College of Medicine from 1998 through 2016. In retirement, he enjoys writing and ranching.
Source: MedicalNewsToday.com
