Troubled Times for Med School Teachers
By Mary Ellen Miller | Illustrations by Wiktor Sadowski
With clinicians pressured to see more and more patients, and hospitals coping with colossal budget cuts, what’s being shunted aside at academic medical centers is the education of tomorrow’s doctors.
essica Bienstock has found her calling. Her choice may never bring her fame or glory—it may not even bring her an associate professorship—but she can’t help herself. “It’s the reason I stay,” says the 37-year-old obstetrician and assistant professor who came to Hopkins four years ago. “I love my patients, I do research because it’s the way I’m going to stay in academics. But I definitely like teaching the best, that’s for sure. I just have fun every single day. You never get to rest on your laurels and say, Okay, I’m done learning. Because constantly you have medical students and residents on your case, saying, Why, why, why, why, why.”
Her teaching award for restructuring the Gyn/Ob resident curriculum hangs directly above the picture of her 2-year-old daughter, Hannah, and her letters from students occupy a special place on her filing cabinet.
“When I get letters from patients, they go up on my wall. But the ones that I never let go of ,” she whispers, “are the ones from medical students that say, ‘You know what? You really taught me something. You not only taught me information, but you taught me how to care for people.’ Those are the ones that make a huge difference in your life.”
Yet sometimes she questions whether the long hours spent after clinic preparing lectures and the extra effort she puts into role modeling how to be a good, caring doctor are worth it. She hasn’t read a novel in years, she doesn’t watch television, go to the movies or even read the newspaper. “I essentially don’t do anything else but work and go home and play with my daughter at night. That’s it. In theory, I have protected time [to teach], although, quite honestly, it gets gobbled up by patient care. And if I’m seeing 15 patients in a half-day, I can’t bring a student or a resident to my office hours with me. It just slows me down too much!
“So I teach in my spare time, essentially. My husband refers to it as my hobby.”
Catherine DeAngelis, M.D., who last month left her position as vice dean for academic affairs and faculty at the School of Medicine to become editor of the Journal of the American Medical Association, has served as the guardian of education at Johns Hopkins for nearly a decade and sees a major problem brewing as patient care and research crowd out academic medicine’s third mission. She worries about junior faculty like Bienstock, whose schedules are so full of clinical work that they find time for little else. “Our attendings are spending two to three hours a day dictating or filling out forms or on the phone with managed care people fighting to keep their patients in for an extra day,” says the outspoken DeAngelis. “All that time is taken away from teaching. They’re asked to work twice as hard to make the same amount of money in clinical practice. The question is, Are we going to wait until people die of exhaustion? Or are we going to address the issue from the beginning as we see these gigantic cracks forming?”
Coming up with solutions to the teaching crunch consumed much of DeAngelis’ time during the last months of her deanship. And it’s a problem that’s hardly particular to Hopkins.
“People worry a lot about how managed care has impacted the quality of care and the freedom to do research,” states Edward Benz, M.D., director of the Department of Medicine. “I’ve noticed in just going around the country that one of the real victims of managed care is the quality of teaching. But it clearly shouldn’t be a stepchild. We’re the School of Medicine, not the Clinic of Medicine, not the Institute of Medicine. And that implies that teaching and education should be prominent. In an academic environment, there have to be times when students and teachers can interact at a somewhat slower, more measured and more thoughtful pace. This sort of constant high-tech corporate lifestyle we’re all being forced to adopt is creating an environment that does not foster teaching. It doesn’t foster learning, which is more important.”
Of Time and Money
Medical education is no money -maker. Despite the fact that the tuition bill for four years of medical school in this country totals roughly $100,000, that amount doesn’t begin to cover the true costs of the time-consuming mentoring required of faculty.
Furthermore, a physician’s education hardly ends with graduation from medical school. Residency programs, where newly minted physicians spend years learning the intricacies of their medical specialties, take place at more than 1,000 “teaching hospitals” nationwide. Whereas once there was sufficient margin left over from clinical revenues to support this teaching, those funds have shriveled from the squeeze of managed care. But the biggest blow to graduate medical education came last year, when as part of the Balanced Budget Act the federal government slashed the Medicare budget by $220 billion. These funds for the most part had gone directly to teaching hospitals to support their residency training programs. An Association of American Medical Colleges (AAMC) analysis concluded the average teaching hospital stands to lose $45.8 million between 1998 and 2002. With one hit, many residency programs have been threatened with extinction.
In fact, some longtime teaching hospitals have recently backed out of the residency-training business altogether. Last spring, both Manhattan Eye, Ear & Throat Hospital and Mount Sinai Medical Center in Cleveland (the latter, disconcertingly, on Match Day) announced that they would terminate their residency programs on July 1. “Now that all the slack is going out of the system, the thing that’s getting pushed into secondary status is teaching,” says Benz.
When Teaching Was King
It was not always thus. Although the modern American medical school always has held fast to its tripartite mission, each component has had its heyday. Teaching was paramount during the early part of the century, when the nation’s research-oriented, university-based system of medical education was created. According to Kenneth Ludmerer, who recently published Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (see box, p. 33), “Teaching was the end in itself, and patient care was pursued only insofar as it was needed to facilitate teaching.”
Johns Hopkins is a prime example. In the early days of the Hospital, as many as 90 percent of patients were charity cases, cared for by an army of house staff and private voluntary staff. The small faculty treated these patients with the most advanced medicine of the day but also used them to teach medical students and residents the nuances of disease. “They didn’t have this push to see patients for the sake of revenue,” explains Ludmerer, who holds an M.D. from the School of Medicine (1973) and an M.A. from Hopkins’ History of Science, Medicine and Technology Department. “They saw patients because they chose to see patients, because of an education or research interest.”
Still, “there was always a tension,” says Ludmerer. “In the 1920s, research became the gauge by which schools measured their reputation relative to other schools. In fact, many schools were already promoting faculty much more readily for research accomplishments than teaching accomplishments. The ‘publish or perish’ phenomenon had already begun.”
So by the time the National Institutes of Health expanded at the end of World War II, research was already primed to take the spotlight. “There was this huge expansion of funds which allowed faculty finally to do what they wanted to do all along—spend their time on research.”
It wasn’t until 1965, with the passage of Medicare and Medicaid, that the third, and perhaps most perilous, era arrived at academic medical centers—what Ludmerer calls “the age of clinical practice.”
According to him, the seeds of the current dilemma were sown during this time. With cash pouring in from the government and from fee-for-service medicine as private health insurance spread, medical centers grew exponentially. From 1965 to 1990, the number of full-time faculty nationwide increased from 17,000 to nearly 75,000; during that same 25-year period, income from clinical practice at U.S. medical schools rocketed nearly 200-fold.
“In my opinion, Medicare and Medicaid were the single most important turning point,” states Ludmerer, a professor of medicine and of history at Washington University in St. Louis. “Because overnight, with the stroke of a pen, all of these tens of millions of patients who had been seen as charity patients at teaching hospitals like Hopkins, all of a sudden were private patients. And immediately, hospitals and medical faculties could begin billing for services that historically they’d provided free. Much good came from this, no question. But much of our current dilemma, inadvertently, started here, when we became economically dependent on, and vulnerable to, third party payers.
“You cannot have maximum productivity and quality education,” Ludmerer continues. “Because everything that teaching requires demands that fewer patients be seen. Learners cannot see patients and reflect on them as quickly as faculty can. I would say that if Johns Hopkins or Washington University are genuine about wanting to maintain excellence in education, they’ve got to be willing to see fewer patients.”
One of the Best
It is easy to understand the pull of medicine in the presence of Charlie Wiener, an associate professor of pulmonary medicine.
“I think he’s probably one of the best teachers here,” says Cynthia Boyd, M.D., a third-year resident. “He’s very good at making things clinically relevant, and, to me, that’s by far the most interesting kind of teaching. He so clearly loves medicine and loves having conversations about it. He’s just incredibly enthusiastic.”
On this humid late-summer day, Wiener ushers his patient into the cramped, graded classroom for monthly grand rounds for the Longcope Firm, for which he serves as faculty leader. “I present her to you today as a complete MICU success story,” he says of the young woman in her mid-20s who sits in a yellow hospital gown facing the audience.
The patient has cystic fibrosis and underwent a double lung transplant nine months before. After an initial rapid recovery, she was hospitalized again and again. She developed pneumonia six months postoperatively (the cause was never determined), and she has just finished 75 days on a ventilator in the Medical Intensive Care Unit.
Wiener takes the roomful of medical students, interns and residents through her history, then gives the floor to the young patient, who has the classic, translucent CF complexion, as well as features so fine they evoke a Vermeer painting.
“What do you remember about your stay here? What do you last recall?” Wiener asks her.
“I remember them telling me they were going to intubate me,” she says in a breathy, clearly articulated voice, “and I was happy, because it was so hard to breathe and the oxygen was turned all the way up, and I just wanted to go to sleep. But I can’t believe I slept for two months.”
“What do you first remember?” Wiener asks.
The patient pauses. “I had a lot of bad dreams. I remember them all perfectly. People dying. I remember, in my dreams I was living in another house, and I was about to be killed. Then I said, you know I think it’s time for me to go home now. And that’s when I woke up.”
“How long did you think you’d been asleep?” asks Wiener. “About three or four days,” she answers.
“Is that typical for patients in the MICU who are intubated not to recall a lot of what we do?” a resident asks Wiener.
“It’s the absolute rule,” he states. “The amnesia effect is so prevalent, so pervasive. It’s the power of benzo [the tranquilizer, benzodiazepine]. From my perspective, it’s definitely a good thing. So interns, when you’re putting lines in these folks, we all try to minimize the discomfort. But sometimes you know you’re causing pain at some level. But these folks, thank God, they don’t remember this stuff. And that’s so reassuring to me as a MICU physician.”
Wiener goes on to give a brief lecture on lung transplantation, passing out an article, discussing how candidates are selected and laying out the risks of transplanting this remarkably sensitive organ. But once the patient leaves the room, what everyone wants to talk about is her dreams. “It’s fascinating when people tell that kind of stuff,” Wiener says later. “I’ve talked to many people after they’ve recovered from the MICU, and none of them remembers anything. I’ve never heard a story like this about vivid dreams, and feeling like it was time to go home, and waking up at that moment. That was kinda cool. It reinforces the point that there’s more goin’ on here that nobody really understands.”
Wiener is 43, a solid man with a broad face and such a commanding presence that he manages not to look silly despite the Winnie the Pooh tie, the blue, pink and yellow multicolored glasses he twirls and chews, the wooden ornament made by his daughter when she was 6 that is pinned perpetually to his long, torn white coat.
Wiener always thought he’d be a teacher, an economics teacher actually, before he veered into medicine and became enamored of physiology and internal medicine. He came to Hopkins in 1987 as a pulmonary critical care fellow and joined the faculty in 1991.
“I suspect if I wasn’t a physician taking care of patients, I would be a teacher in something other than medicine,” says Wiener, who won the coveted Professor’s Award for teaching at graduation last spring. “It’s what I love to do. And one of the glories of being [at Hopkins] is the quality of the learners here. They’re constantly pushing you, testing you, challenging you, so you can’t be complacent. You can’t find a more stimulating environment than this place.”
Wiener realizes, however, that he is one of the lucky ones. As associate director of the Department of Medicine’s house staff training program, and faculty leader of its Longcope Firm, he is freed from part of his clinical load specifically so he can spend time teaching house staff and medical students. “My department chief and division chief applaud what I’m doing. So I’m living off their largesse. Trouble is, they can’t allow too many people to do that, because frankly, teaching is not revenue generating.
“I’ve always thought it would be very nice if the dean or your department chair could buy 5 percent of your week and say to you, ‘During that time, I want you to teach.’ It’d be nice if there was some endowment for that.”
Funding through New Avenues
Endowment may not exactly be the term DeAngelis would choose for the pot of money she identified to support teaching. It’s more like entrepreneurship. Over the last year or so, she embarked on a crusade to broaden the School of Medicine’s continuing medical education outreach into lucrative new avenues that could support its educational mission. Through a venture called the Center for Distributed Continuing Education, M.D.s around the nation will be able to register and pay to hear Hopkins physicians teaching classes and giving lectures on the Internet. If the dollars earned are sufficient, the money will allow the School to buy time to lighten the clinical or research loads of faculty who want to concentrate on teaching.
One of the first such offerings to reach the Internet is a weeklong series called “Review of Medicine for the New Millennium.” Featuring 75 lectures by members of the Department of Medicine, with digitized slides and audio, it is meant to act as a refresher in the field or as a preparation for the internal medicine boards. The cost for the whole course, $750, is a bargain compared to that of similar products, according to David Heaphy, Ph.D., director of Continuing Medical Education.
One more potential source of funding for teaching could well come from pharmaceutical companies who increasingly are providing School of Medicine faculty with educational grants to teach specific continuing medical education courses. Finally, fees totaling several hundred thousand dollars have flowed into the dean’s office from the successful Business of Medicine course that Johns Hopkins teaches on the Internet. Some of that windfall has gone directly into grants to faculty for developing courses and computer programs for teaching.
“Hopkins is trying to solve a problem that is national, created by managed care,” DeAngelis says. “It’s trying to earn the money to solve that problem by spreading medical knowledge. There’s nothing wrong with this kind of exchange.”
Edward Miller, M.D., dean/CEO of Johns Hopkins Medicine, has been kicking around another idea to support the beleaguered educational mission—establishing a specific teaching bequest with contributions from donors. But it’s a slippery issue, Miller says, because of the difficulties in calculating the true costs of teaching. “I think personally what will happen in the future is that people will look more closely at separating the various missions to get a better handle on costs. Then we’ll be able to demonstrate to donors that this is an unmet need and we could use their help to support it.”
The Hardest Way to Get Promoted
Finding a way to recognize and reward good teachers is one more problem that Miller and other medical school deans are grappling with. In October, the AAMC’s Group on Resident Affairs tackled the topic at its annual meeting. And next spring, the Accreditation Council for Graduate Medical Education is hosting an invitational symposium to brainstorm on the subject.
Part of the problem lies in the fact that the intricacies of teaching are not fertile ground for scholarly papers that are supposed to add weight, and renown, to a physician’s curriculum vitae. “Most major medical schools with international reputations, like Hopkins, expect their faculty at the senior ranks to be respected and recognized beyond their own campus,” says Benz. “Teaching is very local.”
“The hardest way to get promoted at Hopkins is as an educator,” admits DeAngelis. “You can do it, and the School is getting better at it, but we’ve had to do a fair amount of fighting.”
But Fred Sanfilippo, M.D., Ph.D., who directs both the Department of Pathology and the School of Medicine’s Professorial Promotions Committee, makes clear that “promotion to professor at Johns Hopkins is based on excellence in a range of areas.” These include research, clinical service, program development and education. “Over the past three years, several individuals have been promoted to the rank of full professor with tenure at Hopkins based almost entirely on their achievements as educators and mentors,” Sanfilippo emphasizes. (See his letter to this magazine on page 3.)
Some academic medical centers, like Harvard, have actually opted for teaching tracks through which faculty could choose to be evaluated on their pedagogical contributions, rather than published laboratory research. And Hopkins has considered hiring “nonacademic” faculty whose sole responsibility would be to treat patients (thereby lightening the clinical load for faculty who want to teach and do research). Still, DeAngelis doubts that separating out the missions will work at Hopkins. “There’s one track here, an equal track, and people are rewarded on each of the forms of scholarship.”
And because that is the Hopkins way, department heads are coming up with creative solutions to buy time for harried clinicians to teach. A year ago, George Dover, M.D., director of pediatrics, felt so stretched trying to fulfill both his clinical and teaching duties as an attending physician, that he introduced the “teaching attending” to work with medical students. The position carries no clinical responsibilities, and Dover made it an honor to be asked, but according to John Andrews, M.D., director of medical student education for pediatrics, “even though faculty are flattered, I have trouble filling the schedule.”
In the long run, medical education will survive. It has to, DeAngelis says, because without teaching, the other missions at academic medical centers would collapse like a house of cards. And in fact, she believes that because the tradition of teaching runs so deep at Hopkins, it will continue to define the institution.
“Because people who love to teach are here, they will find the time [to teach] and we will make sure it gets done,” she says. “There are some people who are absolutely essential to this place, who will never get an international reputation as researchers, but they are vital because they are devoted teachers. People get paid for clinical work, and people get paid to do research. Why not pay for teaching?”