AAMC Reporter: November 2008

The Future of Medicine: Today's Challenges

Nancy H. Nielsen, M.D., Ph.D., President, American Medical Association, Senior Associate Dean for Medical Education, University at Buffalo School of Medicine and Biomedical Sciences

I recently had the honor of delivering the inaugural O.P. Jones lecture at my alma mater, the University at Buffalo. I remember Dr. Oliver "O.P." Jones, a renowned anatomy professor, very well, although he had reached emeritus status by the time I began medical school. He was the mainstay of the first-year experience, unflinching in his discipline toward unprepared medical students, and a devoted teacher and mentor. One of Dr. Jones's legendary teachings was "the prostitute's whisper"— what a way to remember that tertiary syphilis can cause an aneurysm of the ascending aorta, which then compresses the left recurrent laryngeal nerve and paralyzes the left vocal cord, resulting in a low, throaty whisper.

Oliver Jones taught at least 4,000 medical students during his 36-year career at our school. If one estimates that after graduating, each of those physicians saw 5,000 patients over a career, then O.P. Jones influenced those who have cared for 20 million patients. Such is the reach of a medical educator.

But today, while the lessons of Dr. Jones still resonate, there is much more to the education of a medical student than rigorous preparation and careful study. There is more required than spew-it-out memorization and risqué mnemonics for complex anatomical structures. Today's education increasingly emphasizes training in evidence-based medicine and evaluation of the scientific literature. Today's medical students and young physicians must develop the ability to access information in ways our teachers could not even consider because the technologies did not exist. Today, students Google or use UpToDate®, yet their memories are still tested when "pimped" on rounds (more delicately referred to as the Socratic method).

In Dr. Jones's time, there was only a limited number of drug categories—now we have an overwhelming number of medications and worry about antibiotic resistance and drug interactions. We used to trust the published scientific evidence; now we know that science can be tainted by commercialism and conflicts of interest. The powers of careful clinical observation and deduction are still taught in medical schools, but the temptation we all face is to "pan-scan" the patients first, maybe even before examining them, because it is more "efficient."

So as we look to the "Future of Medicine," let's first consider a few challenges our medical students must face. After learning anatomy, physiology, and all the other scientific necessities, third-year students go to the wards, clinics, or private offices and discover that patients are not all the same, and that health insurance is the privilege of the wealthy, the very poor, and those who are fortunate enough to have an employer who still offers it. They quickly learn that the system does not treat all patients equally.

Today, only 60 percent of employers offer health insurance to their workers, and that number decreases each year. We have world-class science, but the delivery mechanism is so expensive that health care costs actually threaten our global competitiveness. Medical expenses remain the number-one cause of bankruptcy. It is unconscionable that we, the richest nation in the world, have left 46 million people uninsured through benign neglect. It is unconscionable that thousands of patients die each year because care is delayed until it is too late.

Recently, I joined lawmakers on both sides of the aisle to announce a bipartisan commitment to solve this critical problem. Our nation spends 16 percent of its gross domestic product on health care, but we lag way behind many other developed countries in health status. A recent Commonwealth Fund study ranked the United States dead last overall among six developed countries in health care safety, efficiency, and equity. Our nation—which trains the world's best doctors—ranked next to last in coordinated care and patient-centered care. This is an "illness" every bit as concerning as malignancy or obesity, and every bit as worthy of our search for a cure.

As medical educators, we are in a unique position to influence the system. We must be leaders in that process, and we need to train our students to be leaders as well. We can commit to a thoughtful societal debate that leads to courageous and principled decisions. We can hold our elected leaders to their promises and work with them to translate policy into legislative and privatesector solutions. We must be sure our medical curricula and residency programs address these systemic problems and search for answers to them. The AMA encourages your partnership. I welcome your input on ways we can work together.

The task of today's medical educator is to prepare the next generation of physicians to be advocates for their patients, activists for reform, scientifically prepared, ethically driven, and optimistic about the future of our profession. These issues may not sound as sexy as the prostitute's whisper, but they are every bit as important.

As we prepare to pass the torch to the next generation of clinicians, researchers, and educators, we must also prepare our students to take charge of crafting the solutions for our sick health care system. This is still the best, most satisfying profession in the world. Let's "cure" our health care system and teach our students to care about doing so as well.

Editor's Note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.