The Long View on Residency Training

Kenneth Ludmerer is a professor of medicine and history, and the Mabel Dorn Reeder Distinguished Professor in the History of Medicine at Washington University School of Medicine in St. Louis.

Photo by James Byard

Interviewed by Rachel Wallach.

Kenneth Ludmerer ’73 has devoted decades to studying the intellectual, social and cultural context of American medicine, in particular medical education. His latest book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine (Oxford University Press), describes how the residency system evolved, why it’s important to patient care and what aspects lead to excellence—and mediocrity—in medical practice. Given the current challenges facing U.S. health care, the lessons Ludmerer shares in Let Me Heal are particularly timely. We asked him to tell us about his book—and offer some advice on where residency training should go from here. 

Why did you write Let Me Heal?

I’ve had a lifelong interest in medical education. Recently, I served on a committee at the Institute of Medicine that published a report in January 2009 on resident work hours. Serving on the committee, I came to understand two things: Doctors spend more time in training after they receive their M.D. than in medical school, making it the dominant influence on the knowledge, behavior, values and skills of today’s doctors, and I realized that no one had written about it.

Second, I thought the recommendations from the committee missed their mark. What is needed are not rigid restrictions about work hours, but to try to understand the system better so we can come up with improvements to better prepare future doctors.

What should readers take away?

First, if our goal is to understand the residency system so it becomes better and better serves patients, the most central aspect is not hours of work, but conditions of work. The goal is to create a total environment of learning in which work has meaning. This depends on having responsibility, close personal relations with inspiring senior faculty, a manageable workload, the opportunity to think and reflect, a stimulating environment, and an environment of appreciation.

Secondly, the residency system has dual origins. It rose in part from the university system as exemplified by Germany in the latter part of the 19th century, which had a strong academic and scientific footing. It also derived in part from the apprenticeship system. The academic and practical blended into the current system. Johns Hopkins was the first institution to do this.

Because of its dual origins, the central tension in residency training from the beginning has been between education and service, meaning the economic exploitation of residents as cheap labor. That tension plays out today. It’s best for patients when we do a better job of emphasizing education and de-emphasizing exploitation, which goes beyond the question of hours.

You point to Johns Hopkins as a model for effective residency training. Why?

Johns Hopkins did two great things for American medicine. It is where the residency system was invented and put into operation, and where graduate medical education was put on a firm university basis. Johns Hopkins’ second contribution was that it had a specific model of not just what residents should do, but how they should think. The idea was that residents should be problem solvers; they should use a scientific method of thinking. So if the patient has chest pain, you develop a hypothesis and design an experiment to test it, obtain empirical information, then modify it if necessary and proceed. The power of that approach is thinking about the patients and doing tests and procedures only as they are indicated. It’s a method that clearly results in better and less expensive care; this is in our nation’s interests.

What are the most important fixes for our current system of residency training?

One, we need to relax residents’ work hour restrictions and add flexibility. When their shift ends, let them finish their work before they go home.

Two, medical schools and training facilities need to do a more effective job of rewarding teaching, because the environment of learning is what matters. Medical faculty are promoted and get tenure and salary increases if they bring in big research grants or see lots of paying patients. Teaching has always been relatively underappreciated, to the point that today it’s difficult for residents to interact with faculty and develop the personal relationships that help them cultivate their own professional identities.

Three, the single biggest problem in residency training today is that the patient workload is too great. Residents today see three to four times the number of patients they did in the recent past. This is the modern form of economic exploitation of residents. Residents need a manageable patient census so they can be thorough, reflect and pay attention to detail—all of which are necessary for learning and for good patient care.

Two economists calculated how much a more manageable patient load would cost: $1.6 to $1.7 billion nationwide. In late July 2014, another Institute of Medicine committee recommended that we do away with indirect medical education payments to hospitals and use the money to create a fund for education innovation. I recommend that we use 25 percent of this fund to improve the learning environment by hiring additional personnel to take the pressure off residents.