The Degradation of Medical Education
Discussions of lockdown consequences have all but ignored the changes in medical education. Once this generation of trainees graduates into licensed practice, the results may be devastating.
*This article was shared by The Ideas Institute, a Canadian professor-initiated thinktank.
By now, the consequences of heavy-handed lockdown policies have become self-evident. Even the most pious Covidians have begun to admit that lockdowns were not the answer. The collateral damage spans everything from food shortages to childhood suicide. However, the quality of medical education has not received as much attention.
Coincidentally, the drawn-out scream that is this blog started with an exploration of how we arrived at the problems currently plaguing medicine.
While you read this, remember the quality of your experiences with the healthcare industry prior to 2020, for better or for worse.
Before we explore the changes specifically affecting medical training, let us recap the consequences of lockdowns on the general population—as they also apply to people who happen to be in the medical field.
Social isolation—leading to a whole host of consequences
Increased anxiety and depression
Increased alcohol and drug abuse
Loss of income & livelihood
Lost follow-up for a variety of medical conditions
Loss of friends or family to widespread malpractice
You may think that medical students & trainees may be more resilient (or have access to greater support) in the face of psychological stress or uncertainty. Unfortunately, this is not always the case. Even before 2020, medical professionals suffered from some of the highest rates of burnout and suicidality. Additionally, the practice of coddling young adults within the confines of the college campus have also made tremendous inroads into medical education.
The Coddling of Future Doctors
In their book The Coddling of the American Mind, Jonathan Haidt and Greg Lukianoff have done a terrific job of laying out how we have coddled our young generation into a life riddled with anxiety & aimlessness.
It may surprise you to hear, that medical students are being coddled in the hospitals. According to colleagues at Mount Sinai Hospital, medical students who are on a general surgery rotation are not required to present their patient on morning rounds. It's just far too anxiety-inducing. Effectively, the institution has decided that students need not learn to discuss their patients in the presence of their colleagues.
One may argue this is justifiable, because surgeons are notoriously tough. First, surgeons have justifiably high expectations as their specialty concerns cutting people open and removing body parts. Second, this merely began with surgery rotations. I would be surprised if it hasn't already spilled over into other fields. If it hasn't, it will. Trends speak for themselves.
In effect, a medical student may graduate and become an intern, without having sufficient practice in effective communication of patient information.
Let that sink in.
This is the background, pre-covid psychological resilience (or lack thereof) that we are dealing with.
The Disruptions of 2020
You would think that a medical emergency would be a unique opportunity for students and trainees to learn, however rare the event in question. No time like the present. Furthermore, you may think that a medical emergency would qualify as an 'all hands on deck' scenario. Apparently not.
The first thing we did in early 2020 was send the students home. The young healthy medical students who will be interns in a matter of months were better suited to spend time at home. Secondly, we cancelled outpatient services (at tremendous cost to the patients) – which means there was no outpatient clinic for the medical students & trainees to rotate through.
Finally, we decided to provide medical students with virtual rotations. As if classroom based learning in the first 2 years of medical school was not sufficient, the 3rd and 4th year medical students could now learn clinical medicine from the comfort of their laptops.
I remember interviewing the first cohort of students applying for training in late 2020 – kept seeing 'virtual rotation' on their applications…
Needless to say, they got very little out of these Zoom rotations. Not surprising, as this does not qualify as clinical exposure. No matter how you massage the wording.
What about the trainees?
When I say trainees I mean residents and fellows. Residents are trainees within a given field of medicine (e.g. general surgery, internal medicine, radiology). Fellows are trainees who elect to undergo subspecialty training within their field. Trainees have limited practice licenses, can diagnose, treat, and dispense prescriptions.
The effects of the restrictions on trainees is a little more complicated.
First, the new trainees begin their exposure in the midst of covid-hysteria. Which means that they began their year (July 2020) with an extremely low-volume of cases. If you recall, we mentioned that outpatient services were turned down. Without outpatient services, there is no follow-up (continuity of care) and there are less new referrals (low case-volume). This was particularly troublesome for the Radiology residents, as more complex and follow-up cases tend to be performed on an outpatient basis.
What was left for them? Anything that came through the emergency department. Which went something like this:
Patient enters the ED – gets a covid test
If test is negative, proceed with normal management protocol
If test is positive – isolate the patient, figure out how covid could possibly cause knee pain, and withhold early treatment options
God forbid you were in a traumatic incident, and you tested positive for covid. You received the benefit of delayed and unnecessarily cumbersome care, which by now seemed normal for the otherwise unaware new trainee.
Second, the post-covid hospital environment is not what it used to be. People are afraid to speak. They are afraid to speak about the idiotic measures that continue to this very day. They are afraid to speak about the potential side effects of mandated clinical experimentation. Likewise, they are afraid to say masks don't work - despite the fact that the overwhelming majority of people in the hospital either don't wear masks properly or take them off at any given opportunity. Nevertheless, fear of expressing your thoughts also has insidious downstream consequences for the training period.
Third, with the introduction of mandated vaccinations – several people had to seriously consider just how badly they wanted to work in these academic centers. Those that were fired for refusing to get jabbed did not just leave their patients behind. These were the very thinkers that the trainees needed to hear from the most - thoughtful, critical, brave. Those that remained provided little viewpoint diversity.
Finally, the educational conferences.
Almost every training program has protected educational time at some point in the day – typically an hour or two – during which the trainees attend a conference on a topic relevant to their specialty. These conferences are usually held in small rooms. A rather intimate environment, and a nice break from the daily rush of hospital and administrative tasks that trainees have to navigate. The conference provides an opportunity to engage with faculty, colleagues, and an interesting topic.
Unfortunately, these educational conferences were also buried in the Zoom cemetery.
With the introduction of Zoom conferences came more unintended consequences. The trainees lost the engaging and intimate break from the daily hustle. They lost the opportunity to have extended discussions with colleagues and faculty. Without this daily ceremony, each new year of trainees has become more isolated from their department. They have not had the opportunity to build rapport with faculty and potential mentors. They have not been put through sufficient on-the-spot testing to gauge their progression through training.
Proof is in the Pudding
These changes in the hospital work environment have had tremendous impact on training. For example, we now get regular complaints from faculty that a proportion of the new trainees have not demonstrated the capability to take independent overnight call. There are more instances of under-prepared residents in 2022 than there were in 2021.
The academic performance of the new residents is also slipping across the nation. In radiology, the junior residents take a nationally administered exam that gauges preparedness for call. The highest scoring institutions achieved over 70% on this exam, in prior years. In 2021, the highest score was in the mid-50%. A massive shift.
Unfortunately, most of these 2020-era implementations are still in place. Our radiology department still holds Zoom conferences. Don't ask me why. But, let's consider the two major consequences, which themselves are inter-related.
First, the trainees are exhibiting substandard proficiency. It is blatant. The trainees themselves are conscious of this reality – as well as the factors which have led to it. They are not happy about it. After all, they are ostensibly at the training program to develop proficiency in their chosen field of specialization. They want to learn!
For the second year in a row, our department has singled-out trainees who must undertake supplementary 'training' or academic preparedness before they can progress in their responsibilities. Furthermore, there is increasing concern that these residents may not pass the board exams that await them in their third year.
Second, and most importantly, these same students and trainees will be the doctors of tomorrow. Whether they fulfill the examination standards is, sadly, irrelevant. Anyone will tell you that the standardized tests we take are poor reflections of the real world. Regardless, the overall lack of preparation will have knock-on effects on the ability of these trainees to provide appropriate care to their future patients.
If you thought the current doctors you interact with have shortcomings…just wait.
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