The following excepts are transcribed from a speech delivered by Dr. Eugene A. Stead in Durham, NC in October 2002 on the occasion of his 93rd birthday. They represent the extemporaneous musings of a true medical pioneer who was perhaps the foremost American clinician of the second half of the 20th century. Although William Osler is generally credited with defining the state and practice of clinical medicine earlier in last century, few would dispute Dr. Stead's subsequent importance as a pre-eminent medical educator. He was responsible for training more heads of medical departments than any other physician of his day, and is also credited with conceptualizing and creating the Physician Assistant Program while Chairman of Medicine at Duke University Medical Center. Ultimately, Dr. Stead's trainees, as well as the younger PA graduates, served to influence the diffusion of many present clinical paradigms across the entire United States.
The following remarks reflect the speaker's frustration with the present state of the very system of medical education on which he thrived and to which he contributed so much. Dr. Stead challenges us to move beyond the status quo and risks inviting the criticism of the profession he so proudly served for over 50 years. Perhaps, as Dr. Stead intimates, it's time for another Flexner-style report to recommend reforms to medical education. By doing so, we may create opportunities to correct some of the shortcomings in the contemporary health care system, to better serve our patients, as well as to change medical education for the better.
Robert L. Bloomfield, M.D., M.S., F.A.C.P., Collection of E.A. Stead, Jr. Annals for Medical Education, Evergreen Clinic, Winston-Salem, NC.
"...There hasn't been one medical school that has failed since the publication of the Flexner Report. I think this is an interesting fact, that either demonstrates medical schools are so wonderful, or the situation is so critical that nobody wants to examine it."
[The Flexner Report was a monumental study of the medical education system in the United States. Published in 1910 and funded by The Carnegie Foundation, was conducted by a well-known educator, Abraham Flexner. The Flexner Report made recommendations regarding the structure of medical education, and complemented the system established at Johns Hopkins Medical College which was under the direction of a great physician/educator, Sir William Isler, at that time]
"If you look at other businesses, that is, other prominent "big businesses" at the time of The Flexner Report, you'll find that only about 5%-7% are still in business. That an interesting comparison to the history of medical schools which number in the hundreds...That occurrence should make you somewhat suspicious, since major medical schools have a rather rigid system, which doesn't allow them to change with the changing times. They must be protected in some unusual way; of course I think they are.
You cannot practice without a four-year medical degree you cannot become a medical doctor unless you pass two qualifying examinations. These exams are not based entirely upon what we know about caring for patients, but mainly upon questions of whether we have a MD degree from an accredited medical school; it often doesn't matter how good of a medical school it is.
In order to sit for these qualifying exams, you are required to have a medical school degree. That piece of parchment is relevant, indeed. In our country, therefore, we have an exclusive dominion on the creation of skilled medical manpower in the hands of schools which are mostly in the mode they were during the Flexner Report.
The questions at issue then are, "are there medical schools that are interested mainly in the care of the patients" and "Is it in our best interest to continue with the present medical school [system]?" [Under the present system], you [probably won't] have a reduction of cost in medical education, and you [probably won't] have a distribution that allows us to provide care for the entire patient population in this country. So, I think that time has come that we begin to raise the questions, "Shouldn't medical schools change their purpose?"
"You must appreciate the fact that amount all of the present and affordable online education [options available], we now have a private school marketplace [that is] no longer asking for charity [alone to fund their initiative, but [is clearly suggesting to the public] that medical education is worth spending money for. The online educational institutions advertise: "You want to come to our school, we will charge you some money and give you a good education conveniently - while you are at home or work. You do not have to go to a college campus of a fancy school, a place where people enjoy exploring the grounds."
I predict that he medical school of the future will be in a little building, and will not have a a great campus; it will be online. There's not a medical school in this country that will allow you to take courses online toward a medical degree. Not a single one.
Most people don't notice a monopoly, or that medical schools do not have a major interest in serving rural areas, the underprivileged, or those underserved. Many people know very little about medical education, and most do not know that the first two years of medical school are predominantly a matter of have a good memory. Medicine is thought of as a very illustrious profession yet, it's not that difficult to learn. Thus, the commonly associated arrogance of physicians has always irritated the heck out of me. "
"[During] World War II, health establishments began to let people spend two years at the institutes of health, due to previous health experiences in the armed services. Up until that time, doctors never talked to anyone else but other doctors, and never learned anything new because, it was just a perpetual circle [of knowledge]. Whatever one doctor knew, the other would converse with hi about it. The young people who had been in the National Institutes of Health atmosphere discovered there weren't many doctors left at the medical school-affiliated hospitals, so if they wanted to talk to anyone there, they had to talk to the non-doctors; engineers, mathematicians, geneticists, and a whole range of people that the medical schools knew nothing about. When they returned they said, "Look, theres a whole lot more to medicine than what you guys learned in school."
Financially, this change did not make the medical schools different but, they did begin to introduce the non-physicians [consider, for example, the Duke University Medical Center MD/PhD program-co-author's note]. You do not always have to talk to an MD. You can converse with a PhD, or you can talk to a Physician Assistant and the situation has improved tremendously because of this [broader perspective]. "
"I wonder in truth if medical schools are not passe. Could the first tow years of medical school possibly be learned at many fine undergraduate colleges, since these early years rely heavily on memory, predominantly? These colleges can bring you up to date on the present state of medicine. I consider the rest of medical school to be mainly "apprenticeship." Medical schools now tend to operate in specialized areas, the apprenticeship is no longer concerning the general care of the patient; it is, presently, quite narrow. In a university hospital, you carry orders from department to department; most of the time these orders are not fully carried out, so it's sort of an operation fraught with inconsistencies. I don't think many people have honestly looked at medical schools the way that I have. I am a product of one of the best; I had a great career in spite of my criticisms.
However, I was not particularly interested in providing general service to all people. I never was particularly interested in providing general service to all people. I never thought about that until my later years; I knew the medical school wasn't that interested in that goal either. Now that I have grown older, I know how ignorant I was for most of my career, and I am a little of ashamed of what a slow learner I was."
Eugene A. Stead, M.D., Former Chairman, Dept. of Medicine, Duke University Medical Center, Distinguished Professor of Medicine [VA system], Originater, Physician Assistant Programs. [1908-2005]
One goes to an older physician, in part, for their wisdom, but doctors spend much of their formative years working on memory enhancement; trying to recall long lists of differential diagnosis, studying for tests, etc. As physicians age and pursue their practices, they have to rely less on their memory and more on their underlying wisdom; their ability to think. The quote from Nietzsche above has given me perspective as both a thinking patient and a thoughtful practitioner of Medicine; now I'm lucky if I can remember how to spell N-i-e-t-z-s-c-h-e. He is responsible for many memorable and insightful quotes; actually, many quotes have been attributed to fictitious individuals with a misspelling of his last name [...tsche, ...tzche, etc., etzc., etsc.].
More important than his quotes, however, is the pervasive philosophy of the man; the sharp wisdom behind the numerous quotes. This philosophy has been referred to as 'THE WILL TO POWER': the driving force in humankind; inspiration, striving ambition, achievement. Here rests the omnipresent inspiration framed and propped up on the doctor's desk or hanging up on the examining room wall. But, let me play the devil's advocate, and suggest a terser and less ambivalent message to patients and doctors- 'JUST DO IT!' Enough of the quotes and philosophies; I've reached the conclusion that slogans trump quotes.
'NIKE NOT NIETZSCHE!'