Medical Education 2005

Abstract

IN HIS ALLEGORICAL SERIES OF PAINTINGS, THE VOYAGE OF Life, Thomas Cole portrayed the challenges people encounter during 4 stages of life. The painting Youth on the cover of this issue of JAMA launches the 2005 Medical Education issue, which contains articles bearing on challenges facing physicians through the stages of their profession, from the comparatively youthful medical student years, through residency, and into the time of establishing their careers and maintaining excellence. Youth depicts a young man focused on moving toward his ideals, which seem to be directly ahead of him. Unfortunately, out of his view but visible to us, the river will take an unexpected turn leading to rapids and a ravine. Similarly, many unexpected (and sometimes unperceived) challenges to ideals are faced by students as they travel toward their established career. Examples of this are addressed in 2 articles in this issue. The first involves developing the ability to have an appropriate “clinical detachment” from patients while still maintaining the human connection, a skill that must be achieved during a physically and psychologically stressful period. Many invoke “medical humanities” as a component to aid in successfully navigating through this process. In his essay, Campo reflects on incorporating humanities into medical education and the difficulties in even defining the concept of medical humanities, much less agreeing on the proper approach to their integration into medical curricula. The second article is a study of the relationships between pharmaceutical companies and medical students by Sierles et al. This article first reviews evidence that interactions between drug companies and physicians can lead to nonrational prescribing that may be inconsistent with evidence-based guidelines and that this prescribing occurs despite denial by the physicians that promotional contacts influenced them. If one believes that the effects of this influence are not in the best interest of patient care, it is important to understand its roots. Previous studies have documented that residents accept the appropriateness of these interactions. Sierles et al show that medical students have a heavy exposure to these drug company interactions; they report a correlation between an increased exposure and a decreased skepticism, an “ego-bias” belief among students that their colleagues are susceptible to these influences but that they are immune, and a perception that sponsored lectures are simultaneously likely to be biased and educationally helpful. Sierles et al also provide suggestive evidence that the more role modeling of acceptability that students witness, the less skeptical they become. It thus seems that efforts to promote independence from these influences will need to be initiated at the beginning of medical education and will need to be consistently maintained throughout the educational continuum. Five articles in this issue of JAMA focus on the stage of residency training. Fletcher et al review the literature on efforts to limit work hours and the impact this has had on residents’ quality of life. Arnedt et al measure neurobehavioral performance after a period of heavy night call and demonstrate a level of impairment in specific tasks comparable with or greater than that caused by significant alcohol consumption. In their editorial, Dawson and Zee provide a context for the findings of both of these studies and present important cautionary considerations for applying the results of these and related studies when determining policies aimed at reducing risks associated with resident fatigue. Two additional articles are related to residency. Weissman et al show that at the end of residency, self-reported competency in cross-cultural care is low across all measured specialties, even in programs that have specific curricula devoted to the topic. Most telling is that few programs are perceived by residents to overtly evaluate their abilities in this area; whether intended as such, this is a signal sent by the programs that these skills are not important. More broadly, Ludmerer and Johns review the history of the development of graduate medical education programs, which they see as a promise unfulfilled. They present their views of current structural flaws and their rec-