Quest For The Holy Grail Of Competence
When I emigrated from South Africa to the United States in 1976, I was unaware of stirrings among medical schools in this country, and became pre-occupied with my work in a junior faculty position at the University of Minnesota. The challenge of establishing a meaningful career was heightened by suddenly finding my small family in the icebox of America where, at first, the only person we knew was the blue-haired realtor to whom we had been steered. The previous decade had seen, among other things, the introduction of health care legislation aimed at increasing the number of physicians in the USA. I had been accustomed to a medical school class of about 130 students, and was astonished to find myself in the Fall of ’76 engaging 242 of them. The Association of American Medical Colleges (AAMC) now anticipates a shortage of physicians over the next one to two decades (http://www.aamc.org/meded/cfws/enroll.pdf), a conclusion based on the results of a Fall 2005 survey of 116 allopathic medical schools. Allopathic schools teach conventional Medicine, as opposed to homeopathic schools, which teach alternative approaches. By 2010-11, total enrollment increases from existing and new allopathic schools are projected to be 5.3% to 8.6% above the 2005-06 levels, short of the AAMC goal of 15%. To overcome the predicted physician shortage, several new medical schools are in the pipeline. One at Hofstra University on Long Island will be clinically integrated with the North Shore University Hospital-Long Island Jewish Medical Center, and expects to see its first class commence in 2011.
Approximately three months after settling in Minnesota, I was pleasantly surprised at being appointed co-director of the pathology teaching course. Surprised, because my experience with the U.S. health care system and training programs was non-existent. I imagined that I was being rewarded (prematurely) for showing an active interest in the teaching of pathology to undergraduates. The University of Cape Town (UCT), where I had obtained the MB.ChB. degree and had graduated as a pathologist (M. Med. [Path]), was imbued with a teaching tradition that had been passed down by the almost legendary figures who had emigrated from England and Scotland to establish the institution in the early 1900s. Teaching at close quarters came naturally, because of strong pedagogical instincts embedded at all levels of the school and hospital, Groote Schuur. In the United States, however, the 1970s and 1980s were periods when academic success came to be measured increasingly by publication and research. It did not take long for me to conclude that my enthusiasm for teaching threatened the prospect of promotion and advancement, and that I had been drawn into that role because most peers at my level shunned intense teaching activities that might interfere with the rollout of publications.
Again, Ludmerer, p310: “At medical schools everywhere, instructors demonstrated by their actions and inactions that student teaching was a low priority to them. Medical school records from prestigious and nonprestigious schools alike demonstrated a widespread lack of concern for student matters: the difficulty in recruiting faculty to serve on admissions committees or to help with interviews, repeated complaints from students that they were neglected, reports on the unavailability of faculty advisors, the behavior of faculty who resented their lecture duties…the refusal of departmental chairpersons to sit on curriculum committees, the conversion of student teaching laboratories into faculty research laboratories, the unwillingness of some faculty to write letters of recommendation for students, and poor faculty turnouts at commencement exercises.”
After leaving Minnesota, I became much more involved with resident training, for sixteen years in Washington, D.C., and more recently in the New York metropolitan area. During this period, my impression has grown that new pathology residents seem to know less about basic anatomic pathology than used to be the case. This correlates with Ludmerer’s remarks about the diverse curricular experiments that were introduced by medical faculties soon after the passage of Medicare and Medicaid (“The greatest deviation from the ideals of medical education occurred in the basic science teaching.”). The examples that he chooses from the clinical world are mirrored in the instructional changes that affected the pathology curriculum. Although the central role of pathology in Medicine has always been acknowledged (the language of pathology is entrenched in all clinical discourse), many schools began to dilute the exposure of students to this discipline.