Training Young Doctors: The Current Crisis

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Osler Library of the History of Medicine, McGill University
Dr. William Osler (second from left) at the Johns Hopkins Hospital, Baltimore, where, in the 1890s, he created the first residency program for training physicians after medical school

In the 1890s, Sir William Osler, now regarded as something of a demigod in American medicine, created at the Johns Hopkins Hospital a novel system for training physicians after graduation from medical school. It required young physicians to reside in the hospital full-time without pay, sometimes for years, to learn how to care for patients under the close supervision of senior physicians.

This was the first residency program. Despite the monastic existence, the long hours, and the rigid hierarchy, Osler’s residents apparently loved it. They felt exalted to be able to learn the practice of medicine under the tutelage of great physicians who based their teachings on science, inquiry, and argument, not tradition. And far from bridling at being at the bottom of the pyramid, they virtually worshiped their teachers, who in turn generally lavished great attention and affection on their charges. Osler’s innovation spread rapidly, and the residency system is still the essential feature of teaching hospitals throughout the country.

Residents are young doctors who have completed medical school and are learning their chosen specialty by caring for patients under the supervision of senior physicians, called attendings. Residents in their first year are called interns. As in Osler’s time, residents work long hours, although they no longer live in the hospital and are now paid a modest salary. The time this training takes varies—three years, for example, to complete a program in internal medicine. Following that, many go on to a few more years of training in subspecialties (for example cardiology, a subspecialty of internal medicine), and at this point they are called fellows.

Together residents and fellows, who now number about 120,000 across the country, are called house officers, and their training is termed graduate medical education (GME). The teaching hospitals where most of this takes place are often affiliated with medical schools, which in turn are often part of universities, and together they make up sometimes gigantic conglomerates, called academic medical centers.

Despite the fact that Osler’s idea lives on, there have been enormous changes over the years, and this is the subject of Kenneth Ludmerer’s meticulous new book, Let Me Heal. Ludmerer, a senior faculty physician and professor of the history of medicine at Washington University in St. Louis, sounds a warning. The Oslerian ideal of faculty and residents forming close relationships and thinking together about each patient is in trouble. Instead, residents, with little supervision, are struggling to keep up with staggering workloads, and have little time or energy left for learning. Attending physicians, for their part, are often too occupied with their own research and clinical practices—often in labs and offices outside of the hospital—to pay much…


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