The American Scene; Daumier

The following program is brought to you in living color on WNVQ. The American Scene, a series of programs providing a closer look at those things which form our contemporary society, produced by the Illinois Institute of Technology in cooperation with WNVQ. Host on the series is Dr. Donald Smithberg, Associate Professor of Political Science at IIT. The guest for today's discussion, the Modern Hospital Medical Education, our Dr. George Miller, Director of Research and Medical Education, University of Illinois, and Dr. Hans Mouche, the Dean of Liberal Studies, Illinois Institute of Technology. Now here's our host, Dr. Smithberg. Good morning. This is Donald Smithberg for the Illinois Institute of Technology on the American Scene. This is the fifth in a series of programs that we've been doing on hospitals. The hospital is perhaps a

very great significance in Chicago, which of course is one of the great medical centers in the world today. But I think few laymen realize the extent to which hospitals have changed both in the way in which their functions are performed, in the extent to which they are used, the way in which people use them, the whole relationship of hospitals in modern society has been undergoing a major revolution in the postwar period. And in this series of programs, we've been trying to analyze the hospital from a variety of angles. First, we looked at the hospital as the general changes in patterns. How is it shifted around both in location, in organization, in personnel, in the Chicago area specifically? Secondly, we've concerned ourselves with some of the problems of the hospital as

a complex organization. Most of us, as I suggested on the program last week, for those of you who are watching, see the hospital from the viewpoint of a patient in a bed. And we sometimes wonder what only mysterious activity is that goes on behind the scenes. We're trying to look at this structure of the hospital as an interrelationship of people. Thirdly, we looked at the relationship between the variety of professionals, nurses, doctors, researchers, technicians, and other people who go to make up the component personnel and how they knit their work together. And on the fourth program, we took a look at the hospital as seen from the standpoint of the patient. What kind of a person is he, when he goes into the hospital, how does he react, what he gets there, what are the circumstances under which he is rehabilitated while he is in the hospital. Down this program, we want to consider still another aspect of hospitals, because hospitals are more than merely places where people go to get

well. There also centers for educational training programs of a very interesting and complex nature. And we want to consider today the medical educational aspect of the hospital, the role of the hospital plays in medical education, the way in which this medical training programs are reacting to the change in the hospital structure. I have today, as my guest, Dr. George Miller, who is the director of research and medical education at the University of Illinois. And Dr. Hunt's mouth, some of you may remember that Dr. Malk was on the second of our programs. And Dr. Malk was formerly director of patient care at Presbyterian St. Luke's, his sociologist who is now Dean of Liberal Studies at Illinois Tech. Welcome to the program, gentlemen. And who would like to start off with this? I think we might, if we can follow my lead question and suggest

what are some of the changes that are going on in medical training these days, particularly as related to the hospital. And Dr. Miller, can you jump on that one and we'll take it from there. The change has been very profound since the beginning of this century. At that time, most men who graduated from medical school immediately entered the practice of medicine. But since that time, the pattern has changed very profoundly. The present day, almost all who graduate from medical school and bark upon a further training program that has carried out in hospitals, spend a year in internship, which is the first year after graduation from medical school, and then most spend from three to five additional years in what are called residency training. All of this carried out within the walls of one or more hospitals, dealing with patients, gaining new skills, new insights, new information about the steadily increasing

complexity of medical care and medical research. So the hospital now assumes a major role in the education, not only of undergraduate students, but in fact today, there are more in graduate training, internship and residency than there are in medical schools. Well, what about these hospitals that are not connected directly with any medical school, Dr. Mark? Do they also have an educational function? Well, an educational function is, I think, associated with any professional function. And while one can debate on the degree to which it is fulfilled, and the debate on the degree to which it is actually present, all hospitals, to some extent, have an educational function, at least those, I would say, who are public who are hospitals that are... voluntary that are controlled hospitals. I'm trying to eliminate some of the proprietary

hospitals, I think you would agree, probably, that they might not always apply to them. The educational function here is, of course, one of several dimensions, Dr. Miller pointed out the residency and intern programs. I think one aspect that intrigues me as a sociologist, particularly, and that I might like to jump into and get your comments, is that very subtly sometimes, and sometimes in a more deliberate fashion, and certainly in particular in some medical schools, not only is there a different or a new form of education of the physician taking place, but also the role of the physician, his relationship with the other members of the health team, and with the patient, and with the entire hospital community, is undergoing change, and there's a real, real function of the hospital in assisting the new physician, the young physician, in learning how to

accommodate this new situation in the hospital. It's certainly true that the physician has always had to work with nurses, but in recent years, there have been a growing number of ancillary personnel, psychologists, sociologists, occupational therapy workers, social workers, and so on, who are professional persons, not only in an institution to assist the physician, but also to exercise certain needs. The physician, having in the past, assumed a role that was almost totally independent of other professions, as indeed, had to learn some new ways of dealing with others, particularly in the setting of the hospital. In a large university hospital does each practicing physician function as a teacher in the broadest sense of that term? In the university hospital, this

is true that every member of the staff is not only a professional member of the hospital staff, but is a member of the faculty of the medical school, and thus has responsibilities that are associated with his faculty status, teaching undergraduate students, interns, residents, often nurses, and these other ancillary personnel to whom we have referred. On the other hand, in community hospitals, unaffiliated with medical schools, if internship and residency programs are a part of the institutional responsibility, each member of the staff carries a responsibility to participate in this program, if he does not, he is not fulfilling his total role in commitment to this institution. The last time I was in a hospital, it was not a university hospital in the sense of buildings, it's a large research hospital, and I was in for a specific illness, and my specialist that was treating me would come down the hall, and he would be followed by residents,

interns, nurses, it would be a regular parade of people that would come into the room. I suppose that would be a teaching function, he's fulfilling when he examines me as well as anything else, or why would all these people be there? That is probably an intern's residence, and possibly even for the medical students who may be the hospital may have some arrangement for, I think, externships, as it is called in some places or clerks, and I think it is something of importance for the public to know. So, as certain as I have observed the teaching function as a researcher, that in the health professions, there's only one way of gaining that kind of expertness that entitles you to practice, and that is to learn in by actually doing, at least at one point, and to practice it under supervision, which is what we call the internship. And

patients who are in the hospital, I think it is, generally observed that they are very cooperative, but they have to understand what the real function is very often of being examined by more than one person by several people, or by a whole group of people at one time, that in that sense, as they are patients, they are also contributing to medical education, and to nursing education, and to the education of other people. I think the situation you have described is one which patients have often found difficult to understand, because they are inclined to regard this as being experimented upon, or serving as guinea pigs. It's very difficult sometimes to explain the difference between experimentation and learning, which also involves the rendering of an important service, because I think it, without question, the quality of medical care that can be rendered in an institutional, which has an educational program,

is higher than that of an institution, which is not. And so patients who have been admitted to those institutions, not only have the benefit of medical care that is potentially of a higher quality, but also are contributing to the development for the future of even better medical care, more generally throughout the community. Well, that's why they have what is known as an operating theater, isn't it, where the students sit around, you sit on television, the students sit around watching the surgeon perform his function. I think you sit on television more often than you sit on the hospital, but it is true, that this kind of observation of what the senior members of a staff do is one way in which learning opportunities are provided in the hospital. One thing that you suggested a few minutes ago, Dr. Miller, interests me as a

teacher and as a sociologist, and that is that you suggested that the growing need for the physician to have an understanding of a variety of related disciplines, which are ancillary or related to the medical function. I was wondering if this does mean that the undergraduate education, as well as the medical education curricula will be changed in the future, are they undergoing changes in terms of what the student is taught? Would you say the medical education today is more broad -gaged in pre -med, in medical school, in the rest of it than it used to be, or are any changes on the horizon? Many changes have occurred particularly since the war. The concept of comprehensive patient care is one of the most profound influences upon undergraduate medical education in the last decade. The concept of patient care is something more than simple identification of a disease

process and the selection of appropriate therapeutic measures to deal with that disease process. Instead, the longitudinal nature of health and disease as an interlude, which interrupts health, has profoundly influenced what we are attempting to do in medical schools to help students gain not only information about this whole concept, but attitudes which lead them to use the information they have in dealing, perhaps in a different way with patients, and physicians have ordinarily dealt with patients in the past. Dr. Talia Kuto, on the last program, was pointing out the way in which the patient himself becomes a part of a complex institution when he is in the hospital, because a different person, Dr. Lepper, brought up the same point. Well, this, to me, has some very profound implication for medical education, and

if Dr. Miller doesn't mind making a somewhat critical comment, I would say that medical schools, by and large, have not picked up that element too rapidly. But I'm referring to here is picking up your earlier comment about the physician recognizing that he now works with many people, many of them have independent functions. You might, in a somewhat glip fashion, compare the physician of 50 years ago into the physician of today with San George, who single handedly fought the dragon, and really was an expert swordsman, and that was important. And today, he is essentially the general who commands an army, and the skills that make a good general include, not only, still to know the skills of battle, but also to know the skills of what you might call in modern terminology, general general ship, to the skill of how to lead, how to coordinate, how to understand what others are doing, even though you do not yourself, presumably, more to be an expert in all of

these specialties. This is a new role of the physician. It is one for which the physician must be prepared, it is one for which involves, well, I'm being biased here, of course, involved sociology of complex institutions, of the hospital, of how to relate and integrate people, and which also may make one plea, which also means re -education of the public to permit the physician. To perform this function, because too often the physician is placed back into the position of being expected to be the sole magician, who can do everything by himself. I don't know whether you would care to make some comments on this. Go ahead, Dr. Well, I think you're quite right that the physician is often expected to be a magician, particularly, when the patient is sick, even if the patient is a sociologist. And inevitably, this is so, when we are

ill, we want to be made well. But at some point, the patient must have confidence in the physician that he is truly working to help the patient become well, often by means that are unfamiliar. And today, some of the unfamiliar ways deal with a whole new science that has not been a part of the training of physicians in the past. In the past, our focus has been upon biological science, understanding disease in its manifestations through the scientific investigations of biological and physical scientists. But today, the science of behavior has become not only sufficiently profound, reproducible, and reliable, but also has become respectable. And thus, as physicians, we are going to have to learn how to respect scientists whom in the past have not always

operated as scientists, but are doing so more present. I would like to ask another question. Maybe I'll just a little off the point, but one thing that is a great concern, I assume, and that is the forbidding length of medical education today, which can run up to 10 years or there about before a person can get into actual functioning professional relationship. At the same time, we have two problems that seems to me. One is that the necessity for the physician to operate as Dr. Mount put as a general, or a generalist, maybe, and relying on a whole series of specialists. On the other hand, we find the patient subjected to a series of specialists and treated as bits and pieces here and there. Now, I wonder if the what direction we're going to go in medical education as the knowledge expands, can we keep on adding to the length of time, or do we have to move more in the direction of having the position be the general,

or the director, or how are we going to solve this problem? I'm not sure whether I'm stating it right, I sure am not. Well, I'm sure this is another issue that the one we started out with, but I would respond by saying that this must be a subject of investigation that is as objective and dispassionate as the investigation we make of a biochemical system or a physiological system. We have not been inclined in the past to look as critically and analyze as closely the process of learning whether in a medical school or in a college as we have looked at other things. And I mention this because this is the focus of a new scientific breed in medical schools, those who are educational scientists and investigators of this process. It is our hope that as we begin to gather data about

learning rather than about the passage of time and teaching, we may find that it is indeed possible to make this whole process far more efficient than it has been in the past to accomplish even more than we have done in a lesser period of time. I think it's only proper to mention, incidentally, the Dr. Miller is one of the people and the forefront of this in really being in a position of taking this kind of hard look at the process of education itself. I would truly agree that we have not, we have assumed an awful lot about the educational process without really having asked just what takes place. I think it also should be pointed out that this is not a phenomenon that solely related to medicine is true in every other discipline as our knowledge, the increment of knowledge grows at an increasing pace. We have to find some way of absorbing it within a lifespan of an individual. And I'm afraid I agree with you that educational institutions have perhaps as

conservative as any world. I'd like to ask you another question, though, on the question of the hospital. And that is whether or not the hospital will continue to function more closely with the educational process or is its relationship changing in its relationship to the formal university? I don't know, I was wondering how hospitals in the future will be organized in this. I think it's important to point out that at the present time only 15 % of the hospitals in the United States have internship and residency programs that far more do not have such formal training programs than offer them. On the other hand, the hospital as an institution within which the physician works is probably the primary focus of continuing education for the physician. And thus represents the point about which in the future we will build

even stronger programs of continuing education than we have in the past. Medicine has, I believe, taken the lead in offering continuing education to members of the profession, but it is still not a very efficient process. And we must look even more in the future than we have in the past, the hospital as a center of this activity. I'm forgetting where I saw it, but I saw somewhere a statement that by some physician, five years out of medical school, if he hasn't studied this practicing out of date medicine these days. Well, again, medicine, as many of these comments should never forget that medicine probably of all professions with possibly the exception of the clergy is very much in the forefront and the limelight. And it is maybe less recognized or less commented upon that it is true for all of us. I think five years after taking the

PhDR's, most sociologists couldn't pass them any more. And I think this is probably true for the physicists, this is probably true for people in every field. And only with the one, one, a provider, that those who after graduation continue to occupy themselves with research are more likely to stay up with new developments than those who go into practice. But it is important to point out that research is a spirit. It is a way of life. It is not simply becoming involved with test tools and experimental animals. But this is simply a spirit of critical inquiry that a physician should bring every day to his patients and attempt to gather data in the same way that the scientist in his laboratory does. If we do not instill this attitude in our graduates of medical schools and reinforce this attitude in the course of internship and residency programs, it is unlikely that physicians will acquire this spirit after they begin to practice. But if they have acquired it before, it is unlikely

that they will lose it once they get into practice. Well, with the tremendous population explosion and the relatively limited number of medical schools were running into a shortage of physicians and each physician, most competent physicians and population centers at least is so overloaded with patients today. I wonder whether he has an opportunity to keep up even with the literature. Well, this also is a topic that could occupy another program, but there are different ways of looking at the relationship of physicians to population. It is true that for the last 40 years we have averaged one physician per 1 ,000 population roughly. But one wonders whether with the increment of the ancillary personnel who can provide now professional services that the physician was required to render in the past, whether this kind of ratio is still as appropriate as it was 40 years ago. That is one

other point coming back to your previous one. You mentioned the internship programs being unfortunately too few hospitals, but actually the existence of an internship program is one very important social force that makes the attending men, that makes the practicing physician more prone to have to keep up with modern development continuously because there is nothing that forces you to learn as if you have to teach. This is one factor and the other factor is certainly that in medical centers the increasing practice and nothing very prevalent practice of using other specialists in the appropriate areas as consultant. In other words, practicing medicine with a continuous eye to the specialist serves as a continuous resource of finding new information from those people who have made it a business to become particularly informed in a certain selected area. I think this is one way of by which the physician manages to

obtain and maintain knowledge. Is that generally true, Dr. Miller, that the increase in teamwork does allow the physician to move into a different area to concentrate his efforts in terms of the patient? Well, I wonder how this works. I hate to sound like an agramist, but I don't know. If you ask how it works, I must confess that it doesn't always work because as Dr. Malch pointed out earlier, we must begin to learn how to use people who have other professional skills and we haven't all learned how to do this yet. On the other hand, where we have learned to do it, the physician dealing with an emotional problem, for example, may very well make effective use of a psychiatric social worker rather than a psychiatrist, may make

use of a social worker trained in other areas to render services that otherwise he would have to render. And where these personnel are used efficiently, the physician saves immense amounts of time. I imagine he would, particularly in a hospital -centered situation or in a large population center where he can call on such people. He no longer is the horse and buggy duck, Dr. Miller. Well, I'd like to thank you, gentlemen, for coming down here. I'd like to try and summarize what we've done in this series of programs. We've looked at the medical profession probably from the angle of the hospital primarily, but that inevitably carries us out into the problem of the physician, the patient, the community, the entire social complex around which medicine is developing. Medicine itself is not an isolated thing. It's a part and parcel of the whole complex of the social structure of our time. And with this, I suppose we have

to conclude our review of the hospital situation and I want to thank you once again for coming in. This has been the American scene. Today's discussion, the modern hospital, medical education, had as guests, Dr. George Miller, director of research in medical education, University of Illinois, and Dr. Hans Mouch, the Dean of Liberal Studies, Illinois Institute of Technology. Post on the series is Dr. Donald Smithburg, Associate Professor of Political Science at IIT. The American scene is produced by the Illinois Institute of Technology in cooperation with WNBQ. Next week's topic, social implications of technology will be discussed by Mr. George Phillips and Mr. Paul Zimmerer, as we continue our investigation of the American scene, preceding programmers pre -recorded in color. How Nikita Khrushchev became the unquestioned ruler of Russia's millions in slightly more than five years.

Chair Huntley narrates the second in a special series on communism, on NBC White Paper, The Rise of Khrushchev.