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Douglas P. Zipes, MD, FACC, Indiana University School of Medicine, Krannert Institute of Cardiology, 1111 W. 10th Street, Indianapolis, Indiana 46202, USA.
In 1976, I sat on the dais during an American College of Cardiology (ACC) Convocation Ceremony for the first time. I was there because Dr. Gordon K. Moe had bestowed upon me the honor of being his marshal when he accepted an Honorary Fellowship Award from the College. Gordon had been my teacher a handful of years earlier, and he remained my friend and my scientific godfather for the rest of his life. He was one of the most brilliant electrophysiologists of his time but, to his students, he was a generous, loving man who cultivated roses and built furniture and chuckled at the practical jokes we sometimes played on him.
As Gordon’s marshal, my duty was to introduce him and give him the plaque that symbolized his award. I had worked on the introduction for some time, carefully selecting words from my heart. As I sat on the dais listening to the marshals who preceded me, I began to worry. Their introductions were precise litanies of the awardees’ accomplishments—recitations of manuscripts published, academic affiliations, and other honors. My presentation had no such details about Gordon’s many achievements, which everyone already knew; rather, it was a passionate recounting of the human side of this giant and the impact he had had on his many students. But the other presentations unnerved me, and I reached through my robe and into my jacket pocket and pulled out a pen, all the while searching my memory for such specific details about his academic career. I happened to glance into the audience, where my wife, Joan, sat in the front row. For a moment, our eyes locked, and she shook her head imperceptibly. She knew what I had been thinking, and I knew what she was telling me. I returned the pen to my pocket, waited my turn, and introduced my good friend and mentor as I had originally planned.
Many years later, I still recall those few moments with perfect clarity, just as I recall how touched Gordon was by my words. Few students get the opportunity to honor their teachers in such a public way, and I value that experience because it furthered our friendship and because it affirmed for me the value of teaching. (It also reminded me of something I already knew—to always trust my wife!)
Looking back on that evening and on more than three decades of my own experiences as a teacher, I am struck by the disparity between the incredible value and importance of teaching the next generation of physicians—the extraordinary impact that teachers have on young lives—and how little our health care system is willing to invest in it.
A recent study (1)examined the net reimbursement of full-time faculty members at a major teaching hospital and found that, excluding so-called fringe benefits, the net reimbursement rate for teaching medical students and house staff was less than $16 per hour. This study was published in the same general period as several others demonstrating that the care delivered at teaching hospitals is better than that of nonteaching facilities. For example, a study by Moore et al. (2)found that the adjusted odds of death among patients treated in major U.S. teaching hospitals was 19% lower than among patients treated at nonteaching hospitals. The same study noted that the risk-adjusted length of stay was 9% lower in teaching hospitals. In a third study, Allison et al. (3)examined care of elderly patients with acute myocardial infarction in teaching versus nonteaching hospitals. Using four quality indicators that included reperfusion therapy on admission; aspirin during hospitalization; beta-blockers and angiotensin-converting enzyme (ACE) inhibitors at discharge; and mortality at 30, 60, and 90 days and two years after admission, they found that teaching hospitals scored better on the latter three indicators (3). Another group of investigators speculated that, although teaching hospitals are recognized for treating rare diseases, they might be no better at caring for patients with so-called common illnesses than nonteaching facilities. They reviewed the medical records of Medicare patients with congestive heart failure (CHF) and pneumonia in four states, ultimately finding that their speculation was off target. Teaching hospitals received better quality-of-care ratings from physician reviewers, and explicit process criteria were more likely to be adhered to. For example, patients with CHF who were receiving ACE inhibitors or intravenous diuretics in teaching hospitals were more likely to have their potassium and creatinine measured on the third day of their hospital stay (4).
The irony is that teaching hospitals have been struggling to justify their existence, to ramp up their bottom lines so that they can compete with hospitals that can’t tout such impressive statistics. Physicians in academic medical centers are under increasing pressure to spend more and more of their time pursuing activities that generate revenue for the institution. Protected time for teaching is virtually nonexistent today. Physicians who make a conscious investment in teaching—taking time to develop innovative teaching methods and working with individual students, perhaps influencing their students’ careers as Gordon did mine—can find themselves under scrutiny from their center’s administration. Many physicians are now forced to account for their hours in terms of the dollars they earned that day, such as from reimbursements for patient encounters or from grants for their research. Despite the effort that goes into teaching, there are no dollar figures to report for hours spent with students—not even that miserly $16 per hour.
This suggests that time spent teaching could have been better spent seeing patients or conducting research. In the minds of some, teaching has nearly come to be viewed as time wasted. What an extraordinarily inaccurate reflection on reality! To the contrary, physician-teachers have made the best possible investment with their time. They have invested in the future of our profession. By training tomorrow’s doctors, they have ensured that we will continue to advance the field of medicine well beyond our current expectations and we will have safe hands into which to place the next generation of patients.
Certainly, our teaching methods have changed dramatically since I was a student. As I have noted in previous President’s Pages, the changes are driven in part by the technological information revolution. The speed and volume at which new findings are released into the medical literature are creating a challenge for medical teaching. Both teachers and students are caught in a relentless struggle to keep up—not only with reading but, more importantly, with sorting out what all the findings mean and committing the right conclusions to memory for day-to-day application in patient care. Related to the speed of transmission is the snowball effect of scientific progress. Medical science is not merely plodding along with one or two big discoveries a year. To the contrary, breakthroughs have become almost routine occurrences. Thirty years ago, we didn’t really need the vast data warehouse, ACCardio, that the College is building at this moment. At most, back then, it would have been a nice luxury; now, it is a necessity. It is also no coincidence that the new recertification process instituted by the American Board of Internal Medicine (ABIM) is called Continuous Professional Development or that it has found its place in medicine today. Many years ago, one of my teachers suggested that, instead of the consecutive years spent in fellowship training, perhaps we should head back into training for one or more days each month for the rest of our lives. At the time, I thought the idea was crazy, but now—when training in cardiovascular disease is already seven or eight years and probably should be longer—I’m not so certain that the idea doesn’t have merit.
Other new teaching approaches are being tested. Consider an innovative education tool the College will be sponsoring at ACC ’02. Rather than sit in a classroom and learn abouta new procedure, physicians can practice the actual procedurein an environment where mistakes hurt no one. Called simulation training, this creative use of technology centers around a sort of mannequin—I call it a patient in a box—whose response to the treatment is much like that of a human, without the risks associated with a life-threatening mistake. I recently performed a bronchoscopy on this box, and when I passed the bronchoscope through the vocal chords, the box “coughed”; when I bumped the wall of the colon doing a colonoscopy, the box said “ouch.” In the near future, from the first venopuncture a medical student performs to a complex angioplasty in the last year of cardiology training, procedural training will begin in such “virtual reality” settings. Furthermore, such technology will enable the ABIM or other organizations to accurately test individuals in technical skills. Finally, these approaches will have therapeutic implications. For example, an interventional cardiologist encountering a complex stenotic lesion of the anterior descending coronary artery will be able to download the cineangiogram to a simulator and try several approaches, pick the best one, and then turn back to the patient—all in real time—to complete the procedure. I predict that, in the future, simulation training will revolutionalize the way we teach, test, and treat.
As just these few examples demonstrate, medical education is galloping along, working earnestly to keep up with advances in medicine in general, cardiology in particular, and the demands of the new health care environment. While I support all of these innovations and more, I also hope that “progress” does not take a further toll on the value we place on teaching in its traditional sense. In terms of learning how to care for patients, working with real people is still without rival. Thirty years ago, we relied on ward rounds for learning. Today, most patient presentations occur in a classroom; the teacher and the students are there, but the patient is nowhere to be found. There are good reasons for this change—it’s more efficient and it doesn’t disturb the patients themselves—but there is also a significant drawback. Learning requires an emotional investment. When you are a student presenting a case to your peers and your teacher, and the patient whose care is in your hands is lying there, listening to every word you say, you will be emotionally invested. First, you don’t want to be embarrassed by being wrong and, second, you can’t help but empathize with the patient. You feel the patient’s nervousness and fear, and you want to get it right for his or her sake. It’s a valuable lesson from all angles—science, yes, but also the sacred patient–doctor interaction. In this case, teaching medicine the old-fashioned way may take more of the teacher’s time, but it is worth the investment.
Once during my research fellowship, when Gordon and I were sitting in his office chatting, he casually hypothesized that there must be some patients who have a concealed form of Wolff-Parkinson-White syndrome (i.e., no delta wave in the electrocardiogram but a bypass tract that nevertheless could be responsible for tachycardias). Years later, he probably didn’t recall that conversation, but he was so proud when a study we published proved that he had been right (5). In the years that followed, I have found myself in his position several times—humbled by the fact that offhand remarks I made influenced the careers and lives of my students.
Not long ago, I ran into a cardiologist who, as a medical student, had gone through a rotation with me. He reminded me of a day more than two decades ago, when I had arrived late for rounds after an exciting morning in the animal lab. My euphoria about that morning’s discovery was contagious, as I described the exhilaration of the new research chase and, when successful, of being the sole possessor for a time of that new bit of knowledge. That brief encounter helped to launch him into a career where he pursues similar thrills. “I always remember that day and how you described the incredible intellectual high that comes from fruitful research,” he said. I have no recollection of that day or what I said during rounds, but I am endlessly grateful that I took the time to invest in him and others who ended up as tomorrow’s physicians and scientists.
↵1 President, American College of Cardiology
- American College of Cardiology