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    Training system-based physicians

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    On September 1, I started work as Dean of the College of Medicine and Vice President for Health Sciences at The Ohio State University. While I have truly enjoyed my 161/2 years chairing ob/gyn departments at NYU and Yale, I believe this new post will allow me more say in how healthcare reform affects the practice of academic medicine, our research enterprise, and most important, the training of the next generation of physicians. Fortunately I still will be able to care for obstetrical patients and to continue to serve as editor of this wonderful magazine. I thought you might be interested in reading my first "address" to the new OSU medical students at the time of their White Coat Ceremony in early August.


    Charles J. Lockwood, MD, MHCM
    Today I would like to talk to you about how medicine has changed over the course of my career and at least where I think it is headed in the future. You are starting your training at a time of great change and at a crucial inflection point in the history of our country's healthcare system. However, I strongly believe that the future of our chosen profession has never been brighter and that this is the very best of times to begin your medical training.

    The "old medicine"

    Thirty years ago almost to the month, I was starting my internship. Medicine was very different then. Our patient's charts were paper, not electronic. "PC" meant neither personal computer nor politically correct; it meant nothing. Patient imaging consisted of a simple x-ray, taken on a piece of celluloid film, which could only sometimes detect even major abnormalities. There were no MRIs or PET scanners to reliably detect microscopic lesions. Heart disease was epidemic, and not much could be done about it; there were no statins to lower cholesterol, no angioplasty to open clogged coronary arteries. DNA was something new you learned about in college but it had virtually no practical medical applications. Cancer diagnoses were usually made late, and treatments were relatively crude and largely ineffective. There were no targeted therapies, no designer drugs.

    The way we were taught was also very different. Thirty years ago if a medical student or resident had the temerity to question an attending physician on rounds as to why he engaged in a particular practice, he would be lucky if he were brushed off with a dismissive "because that's the way we do things around here." In 1981, you were expected to carry the presentations and workup of virtually every common disease in your head, and maybe on some index cards in your pocket. We had no iPads or PDAs to search the planetary literature. Residents were on call every third night if they were lucky, and every other night if they weren't, and all of us were expected to stay late for an interesting case. The thought of an 80-hour work week would have brought literally howls of laughter. After all, aren't there 168 hours in a week?

    After residency, our careers were also entirely different from today and nothing like what you will experience. Most private practitioners worked alone with only a small office staff. They would round by themselves early in the morning and rush back to a busy office. If they were lucky, they would be able to have dinner with their families. In teaching hospitals, faculty were expected to be triple threats: equally good at teaching, research, and clinical practice. At morning rounds, the attending physician would be accompanied by an entourage of medical students and residents, and he would ask endless questions to test a protégé's knowledge of arcane facts and often irrelevant medical trivia in front of patients who often served more as stage props than as the appropriate focus of everyone's attention.

    In operating rooms, the primary surgeon was an absolute dictator. All manner of disruptive behavior was to be tolerated. Instruments could be tossed around the room like Frisbees. I remember being rapped over the knuckles—really hard—multiple times for tying a knot the wrong way or not exposing the anatomy well enough with retractors. We were expected to just grin and bear it.

    For medicine in the 1980s, failure was not an option, and every patient was subjected to our maximal exertions, no matter the cost or futility of the treatment. In fact, in 1981 physicians rarely considered the absolute cost of a test or procedure or its effectiveness. Insurance companies and the government didn't pay much attention to cost either. We were paid per procedure and so we found more and more justifications for performing more and more procedures. The fact that healthcare costs were rising at twice the inflation rate mattered not at all to us.

    Worse, we convinced ourselves and the public that we were Godlike and, if given enough resources, we could cure any disease and literally perform miracles. Then we were shocked when we found ourselves mortal and fallible and embittered when we were sued for less than optimal outcomes or for an honest mistake.

    By the way, your first homework assignment is to read the book Why Hospitals Should Fly, by the patient safety expert John Nance.1 Nance argues that for most of medical history, physicians acted like the hero of the original Star Trek series, Captain Kirk: swashbucklers who would dash alone into dangerous situations, react instinctively, and issue streams of orders without explanation. To ask advice, except maybe from Spock or McCoy, was a sign of weakness. On the other hand, any mistake was always our fault entirely and the resultant guilt and anguish was, of course, to be silently borne.

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    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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