Reimagining medical training for the twenty first century [PODCAST]

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Inner medication doctor Robert C. Smith discusses his article “Why medication wants a second Flexner Report.” On this episode, Robert explores how trendy medical training has fallen behind the science it was constructed on, leaving immediately’s physicians unprepared to handle psychological well being, power illness, and prevention. He examines how the historic “mind-body break up” continues to form curricula and care supply, calling for a brand new nationwide investigation—akin to Abraham Flexner’s 1910 report—to make sure medication as soon as once more aligns with essentially the most present scientific understanding. Viewers will achieve perception into how reforming doctor coaching may restore medication’s scientific integrity, enhance well being outcomes, and cut back the staggering prices of inefficiency.

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Transcript

Kevin Pho: Hello, and welcome to the present. Subscribe at KevinMD.com/podcast. At present we welcome again Robert C. Smith, inside medication doctor. His newest article is “Why medication wants a second Flexner report.” Robert, welcome again to the present.

Robert C. Smith: Kevin, thanks for having me. I get pleasure from speaking with you.

Kevin Pho: All proper, so let’s leap proper into your newest KevinMD article. Simply give us some context. For many who aren’t accustomed to medical training, simply outline what was the Flexner Report?

Robert C. Smith: Certain. The Flexner Report happened, it was printed in 1910, however the investigation started within the late 1800s. On the time, the American Medical Affiliation, which was the principle pressure in medical training, was involved that there have been some 155 medical faculties again then. The AMA was involved that they weren’t educating what all of us immediately perceive as scientific pathological correlation. Reasonably, they have been involved that the medical faculties have been persevering with to show the previous 4 humors concept of illness.

Mainly, meaning there have been 4 humors: black bile, yellow bile, blood, and phlegm. This dates to the time of Hippocrates within the fifth century BC, so we’re speaking about two and a half millennia for this 4 humors concept. The concept was that an imbalance of those 4 humors led to illness, or was the illness, and it led to signs.

Again in the course of the 1700s, scientific pathological correlation had been found in pathology. That had permeated all through Europe and have become the principle focus of educating, nevertheless it had not permeated but into medical faculties within the U.S. apart from Johns Hopkins. With the Hopkins mannequin of scientific pathological correlation, the AMA was involved that every one medical faculties needs to be educating scientific pathological correlation, not the 4 humors. If you happen to keep in mind, within the 4 humors, in the event that they have been out of stability, that was illness. They put them again in stability by doing bloodletting, placing leeches on to rebalance the humors.

Effectively, that units the stage. The American Medical Affiliation commissioned the Carnegie Basis to research to find out if this was the truth is the case. That started again within the mid-1800s. There was a several-year research. Again at the moment, Flexner, who was head of this, and his group needed to actually exit to all of the medical faculties and examine what they have been doing, speak with individuals, take a look at information, and the like.

After they did that, and once more by all 155 medical faculties, got here the Flexner Report in 1910, which mentioned in impact that these faculties have been persevering with to show the 4 humors concept and have been blatantly non-scientific. Additionally they weren’t requiring any prior training to get into medical faculties. The medical faculties solely lasted one 12 months, and it was all lectures. The medical doctors would then merely discover a practitioner to preceptor with, and they’d then go into observe.

The AMA not solely insisted that the Hopkins mannequin of scientific correlation be adopted, however that coaching with precise sufferers by educated college be applied and the college be elevated first to 2 years, after which later they bought it as much as 4 years, a lot of what you and I’ve immediately, Kevin. With that, there was this dramatic change in the best way medication was practiced, and this was an absolute revolution in what happened.

However that was the unique Flexner report. It rooted out unscientific practices and insisted that trendy medical training comply with them. They closed one thing shut to at least one hundred, I believe it was about ninety-three faculties have been closed. The rest have been required to make the adjustments that I’ve simply described.

Kevin Pho: Your article requires a second Flexner report. For many who didn’t get an opportunity to learn your article, inform us what it’s about.

Robert C. Smith: Certain. What has occurred is again on the time of Flexner, over 100 years in the past, essentially the most scientific method to medication within the medical faculties was scientific pathological correlation centered on bodily ailments. That’s what the AMA wished instituted and efficiently did.

What has occurred then is that mannequin that we now have immediately in medical training has continued, and it was extremely profitable. There’s no query about that. Medical pathological correlation on this remoted concentrate on bodily illness was profitable. Within the final century, life survival doubled, from 40 years in 1900 to almost 80 by the tip of this century. So it labored, nevertheless it largely was clearing out surgical issues, acute medical issues, epidemics, and the like. That’s why they’d the huge enhance in life survival.

However come the tip of the final century and now into this century, medication’s inhabitants has modified. It’s not acute surgical and epidemic ailments. Reasonably, it’s psychological sickness, which is now the commonest well being situation within the U.S. It’s power ailments. It’s prevention. New issues arose, however medication nonetheless adhered to remoted scientific pathological correlation centered simply on bodily ailments. They excluded the psychological and social.

If you happen to exclude the psychological and the social, you’re clearly ignoring psychological sickness in your coaching, and actually, that’s the case. Psychological well being coaching in medical faculties is not any totally different now than it was on the time of the Flexner report. 2 p.c is the utmost period of time dedicated to psychological well being throughout 4 years of medical college and three to 5 years of residency. That is what accounts for the psychological well being disaster immediately.

The second drawback with this remoted concentrate on bodily illness is medication’s forte: bodily illness. We simply mentioned how profitable. However with power illness, the excluded psychological and social elements have to be included to deal with it. Right here’s an instance.

Continual bodily ailments are prevalent immediately. One thing like 85 p.c of individuals over 65 have a power bodily illness. Half of them have two or extra power bodily ailments. The psychological and social elements that medication ignores are essential on this respect: these power ailments have comorbid psychological issues in 17 p.c of the instances. That’s some 30 million People.

The comorbid psychological dysfunction must be handled if the bodily illness is to get higher, however we don’t do it. Solely 12 p.c of those comorbid psychological issues ever get handled, and that’s why untrained individuals such as you and me, Kevin, we’ve not been educated on this. It’s not our fault. We merely haven’t been educated.

Right here’s one other manner through which excluding psychosocial elements jeopardizes care in power bodily ailments: We don’t practice our medical doctors in so-called life-style elements. Cigarette smoking, alcohol use, chubby, not exercising, stress. All of those are psychosocial elements that trigger most power bodily ailments. 80 p.c of coronary heart illness, strokes, and diabetes are attributable to these elements and thereby are preventable, however we don’t educate that.

When a affected person is available in, say they’ve bought diabetes, they’re in coronary heart failure, they’re smoking, they’re chubby and never exercising, and so forth. Medical doctors do no extra with them than say, “Effectively, you must reduce weight and stop smoking.” Medical doctors should not taught the labor-intensive and difficult-to-learn motivational interviewing expertise required to deal with this, and accordingly, little or no occurs.

Let’s take this concept a bit bit additional. 80 p.c of coronary heart assaults, strokes, and diabetes will be prevented. 40 p.c of cancers will be prevented if we handle these psychosocial elements, however medication doesn’t try this. If you happen to return and take this particular person sitting in your workplace proper now, they’ve bought diabetes, peripheral neuropathy, possibly have some imaginative and prescient bother from it. They’ve possibly had a coronary heart assault, possibly had a stroke, and are disabled. They’re retiring now. They’re 65 years previous, however they’ve bought all this medical morbidity.

That’s not a contented retirement. They spend most of their retirement going to the physician. Don Berwick has raised this challenge. Why don’t we now have our sufferers have a contented, wholesome retirement, so that they don’t have any of these items after they retire? Drugs may try this by going again 40 years earlier in that particular person’s life and stopping these items from ever occurring or interdicting them as soon as they’ve begun. These ailments, 80 p.c are preventable, however medication doesn’t do it.

Kevin Pho: Now should you have been in command of the Flexner report or the revision of the Flexner report, what sort of adjustments particularly would you make?

Robert C. Smith: The Flexner report would do precisely what the one in 1910 did. You’ll type an unbiased fee. It might be a presidential fee, congressional fee, Nationwide Academy of Drugs, Carnegie Basis, someone unbiased of medical training. They’d merely examine medical training for his or her present practices with the aim of: Are they coaching competent physicians to look after the commonest well being situations immediately, psychological well being and power bodily ailments? Quantity two, this hyperlinks again to the unique Flexner report: Are they educating essentially the most scientific method immediately? They are going to be discovered wanting on each counts.

Now a touch upon what’s scientific. This scientific pathological correlation centered on bodily illness was essentially the most scientific method again within the 1900s. What has occurred, and once more, all sciences again at the moment have been reductionistic like that. Drugs centered simply on bodily ailments and excluded psychological and social, however so did arithmetic, physics, ecology, and many others. All of them have been reductionistic. That was essential again when trendy science started. It was in an embryonic state, so that you centered simply on one half.

However come the 1900s, all sciences modified from a reductionistic focus to a so-called techniques view. Which means you take a look at all components of the issue and their interactions like this, somewhat than only one half like medication does. Drugs is the one science amongst all sciences that continues to observe in a reductionistic manner, and also you’ve already heard of the downsides from this.

This new Flexner report will discover medication’s present practices are non-scientific, and they’re producing clinicians who should not competent to handle the commonest well being situation they are going to discover and who’re additionally jeopardizing the care of their power bodily illness sufferers.

I’d add one other factor they are going to most likely discover. In a $5 trillion annual well being care expenditure that the U.S. has, consider what may occur if we prevented 80 p.c of all coronary heart assaults, strokes, and diabetes, and 40 p.c of all cancers. You’d save two to $3 trillion a 12 months. That’s $20 to $30 trillion in ten years. That is how the deficit is addressed. That is the way you present well being care for everybody freed from cost.

This fee is essential to getting a change proper now. The general public doesn’t understand how derelict medication is. They assume their psychological well being care and power bodily care are good due to their previous successes. However medication has not saved up conceptually. It has didn’t undertake a techniques method. That’s the fundamental drawback.

The general public will hear this from this federal fee. They are going to change into enraged and infected, as they rightly needs to be, and can insist on change. The primary a part of that change will probably be to alter medical training in order that they’re educating psychosocial in addition to biomedical illness points in parallel and the way they combine. However it is going to go greater than that. This fee, a federal fee, will now supervise all medical care. This consists of not simply medical training, however how it’s practiced and the way it’s researched. That will probably be a model new manner we should go.

Kevin Pho: All proper, so we’re speaking to Robert Smith, inside medication doctor. His article is “Why medication wants a second Flexner report.” Robert, let’s finish with some takeaway messages you need to go away with the KevinMD viewers.

Robert C. Smith: Sure, let’s be hopeful about this. Issues have modified up to now. The car business was derelict. Alongside comes Ralph Nader. Unsafe at Any Velocity is his e-book. He blew the whistle, because it have been, on the auto business. They’d seat belts however wouldn’t put them in vehicles, despite the fact that they knew they labored, as a result of it could price an excessive amount of, and a number of different issues. His e-book got here out, infected the general public, and we had the Site visitors Motor Automobile Security Act, which is why we now have all these protections in cars, together with seat belts.

Rachel Carson’s e-book got here out and knowledgeable a beforehand uninformed public concerning the chemical business. DDT was in our ingesting water. They weren’t cleansing up after themselves. Her e-book, Silent Spring, got here out, infected the general public. You’ve bought to have an knowledgeable public. It infected the general public, they usually then insisted their politicians do one thing, which is the Environmental Safety Company we now have immediately. That’s why we don’t drink DDT in our water and have a thousand and one different protections. My e-book hopes to do this.

In case you are interested by doing one thing proper now, go to my web site. It’s RobertCSmithMD.com. Don’t neglect the MD; it’s too frequent a reputation in any other case. RobertCSmithMD.com. Once you click on on that, you instantly see one thing that claims “Act now.” Click on on that. Up comes a web page with the e-mail addresses of the president, the legal professional common, the Nationwide Academy of Drugs, your congressperson, and your senator. Beneath that could be a pattern letter. Plug that pattern letter into the e-mail and ship it. It’s recommending a federal fee of the type I’ve simply described that may examine medication.

That’s the leverage level we’d like now. The general public should change into knowledgeable about this, and in order that, in my view, is hopeful. There’s gentle on the finish of the tunnel, nevertheless it’s going to take some work.

Kevin Pho: Robert, thanks a lot for sharing your perspective and perception. Thanks once more for coming again on the present.

Robert C. Smith: Oh, thanks for having me, Kevin. I actually respect speaking with you.