ALIEM Bookclub – Let Me Heal: The Opportunity to Preserve Excellence in American Medicine

As a practicing Emergency Medicine physician, I have spent almost the last decade of my life immersed in a culture of medical education. Actually, not quite accurate, as I have spent my life since middle school years either studying for one standardized test to another, or buffing my CV with medical related volunteering experiences in pursuit of my medical aspirations. Even prior to beginning medical school, I was drawn to the culture of medicine, what I saw as a commitment to altruism, and dedication to preserving patient health and quality of life.

In my actual training, most apparent during those grueling residency years, I was exposed to another culture of medicine; this period of my life was composed of fatigue, imposter syndrome, fear that my actions or ineptitude could directly cause patient harm or death. These emotions and feeling were just as present as my desire to heal and serve. I know that my experience is not unique, but what I didn’t know was the fascinating history of how this culture of medicine, and medical education has evolved since before the original establishment of residency education at Johns Hopkins in 1889. As the famous quote states, “those who don’t know history are destined to repeat it”, which underlies the importance of reading and reflecting upon Let Me Heal: The Opportunity to Preserve Excellence in American Medicine by Dr. Kenneth M. Ludmerer [Link].

Introduction

Let Me Heal by Dr. Ludmerer is dedicated to the “ideals of the Johns Hopkins Medical School and Hospital” which is appropriate given that Johns Hopkins Residency was unique, and an American answer to the previous traditional of Americans traveling to Europe for medical training. The focus of these residencies was to provide a blend of clinical medicine with basic science research. According to Ludmerer, what Johns Hopkins did differently was to:

1. Provide resident staff with full responsibility for patients, under the supervision of faculty
2. Instill in their learners an attitude of inquiry and investigation
3. Encourage residents to educate students, nurses, and their peers
4. Require multiple years for training

If this sounds familiar, this is because these are the same values that are inherent to graduate medical education today, almost 125 years later. And this is a testament to have strong these values were woven within graduate medical education.

Synopsis

Like any other history book, Dr. Ludmerer thoroughly documents the historical origins of the founding of graduate medical education. He then goes through the timeline of how important world events such as World Wars I and II impacted this. With great attention to detail, the use of primary resources such as personal letters and correspondences, and quotations from medical giants such as Sir William Osler, Let Me Heal paints a vivid portrait of the educational system, the day to day life of residents, and impact on patient care. The final chapters of the book give an excellent overview of current issues impacting graduate medical education such as work hour restrictions, burnout, and patient safety.

An interesting and recurrent theme in the book is what Dr. Ludmerer describes as the dual origin of graduate medical education: basic science research (originates from the German University system) and medical practice (apprenticeship). Over the course of the last 125 years, the two branches have intertwined to create our current system which views residents as both graduate level medical learners and as an important member of the patient care team. Today, we see a reference to the dual roots used in a work versus education debate. There is divide between those who advocate for a work hour reduction as means to improve patient safety, and those who lament that limited hours makes it difficult to residents to gain enough clinical exposure to become excellent clinicians.

Another interesting theme arises from the detailed description of the work life balance of residents. In the early days of medical education, residents lived in the hospital, which is where the term “house officer” came from. In fact, they were forced to live in the hospital. And yet, Dr. Ludmerer describes that these young doctors, who were in the prime of their years apparently loved these experiences. And in fact, he credits this forced confinement to setting the stages for life long friendships, that were often sealed over midnight meals and late night teaching sessions over complicated patients admitted to the hospital. At that time, in the early stages of graduate medical education, these doctors were even forbidden from marrying, because of the fear of distractions. Burn out apparently was a nonissue during those days.

But this changes over time, as Dr Ludmerer describes over the chapters how economic changes, increased administrative aspect of hospitals, the adaption of wide spread insurance, the decreased usage of “charity” patients essentially lead to a decrease in the average length of stay for patients, increased patient load per resident, and increased illness severity of these patients. Residents of today probably are not looking back fondly at midnight meals shared with their colleagues, rather given the combination of reduced work hours and increased patient load, they are working hard just to keep up with their work load. All the while, lamenting over the lack of actual learning experiences. And this is the reality of today’s medical education system.

Application to Medical Education

This is an excellent book for any one who is interested in medical education and the history of medicine. This is applicable for anyone, of any specialty, but in particular those in leadership positions. It is truly fascinating to understand that many of the current issues in medical education either were inherently there from the beginning, or stem from decisions made at critical junctions in the development. This is a great book also to learn about the history of medicine, and to go beyond the commonly quoted Osler, and to learn about the other leaders who shaped graduate medical education.

Criticisms

As one reads this book, you cannot help but notice the lack of information about the issues that minorities and women have gone through in medical education. While, minorities and women did not make up a significant number of doctors at that time, it would be worthwhile to learn more in depth about their struggles and successes. Additionally, while the paternalistic nature of medicine in the early stages is noted, it is not detailed either. This is important as so many tend to immortalize the “fathers” of medicine including Dr. Osler without understanding the full extent of how medicine was practiced in those times, especially on “charity” patients.

Bookclub Questions

1. Do you agree with Dr Ludmerer’s assessment of the origin of Burnout? What are solutions that you feel would be helpful to combat this?
2. Many argue that restricted work hours actually makes graduate medical education more difficult for residents to learn, what are ways that we can current implement solutions to increase the educational value of residency education?
3. What are your thoughts on the current attitudes of Work and Life in graduate medical education?
4. How do you envision the future of graduate medical education?

Further Reading

• Andolsek KM. Chasing perfection and catching excellence in graduate medical education. Acad Med. 2015 Sep;90(9):1191-5. [Link]
• Goitein L. Training Young Doctors: The Current Crisis. 2015. New York Review of Books. [Link]
• Sorensen MJ. Let’s Heal Ourselves. JGME. 2014. Vol. 6, No. 3, pp. 449-450. [full commentary link]

* Disclaimer: We have no affiliations financial or otherwise with the authors, references or hyperlinks listed, the books, or Amazon.

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