Empty Credentialism is Hurting Medicine
By over-emphasizing papers and grants, elite teaching hospitals forget what medicine should actually be about.
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– The editors.
As an attending physician at one of the “best” (i.e. highest-ranked) hospitals in the United States, I work with a good number of residents (medical school graduates who are now completing their clinical training). They are, in short, amazing. Their schedules are onerous, their pay meager. On top of that, the practice of medicine has become dizzyingly complex, with a vast array of drugs and devices and an aging patient population whose health needs are greater than ever. Every day, I’m impressed at how our residents—intelligent and hardworking—meet these challenges head on.
But I also wonder: how much “better” are residents these days compared to when I began training, some fifteen or so years ago? When it comes to the day-to-day, unglamorous work of learning how to take care of people, how much has changed over the past few decades? Residency training has always been a crucible—the setting where one “becomes” a doctor. True then, and true now.
There is, however, one key difference. There has been an explosion in the qualifications, almost exclusively in the form of research credentials, that our residents exhibit “on paper.” When I applied to an internal medicine residency and, subsequently, to a cardiology fellowship over a decade ago, I had one middling abstract and one publication in a low-tier journal to my name.
Nowadays, the arms race in qualifications has reached a fever pitch. Interviews begin and sometimes end with asking about research. So what do you want to do, goes the question, where the clearly wrong answer is “take care of patients,” or, even worse, “learn how to take care of patients.” Residents at the highest-ranked medical centers often have ten-plus papers before they even begin their training. They have, in some cases, begun to secure grant funding. They are somehow already fluent in the language and folkways of academia, having begun to master the gamesmanship intrinsic to academic success.
How did things get this way? When did students cease to be doctors-in-training, something that’s difficult enough, and start advertising themselves (and that’s what it often seems to be: advertising, or a sort of self-entrepreneurship) as nascent “thought leaders,” using the customary “new paper alert” tag to let everyone know about their latest accepted manuscripts?
To an extent, this phenomenon is undergirded by certain material dynamics, macrostructural features of the economy. Health care is big business, now comprising nearly 20 percent of GDP. In the current “fee for service” environment, the operative term is “productivity,” which translates to just how many patients a health system can churn through in a given year; the more the better. A consequence of this is that the work of being a doctor—for so long regarded as a calling, something greater than oneself to which the healer feels drawn—has been proletarianized, reduced to a labor-wage activity.
The exception would appear to be academic medical centers, or “teaching” hospitals, which had (until recently, at least) been somewhat insulated from this brute financial calculus, largely due to their prominence as educational and research institutions. They receive substantial federal subsidies for their role in training residents and are awash in billions of dollars of research funding. Doctors there are paid less than their counterparts in private practice but receive a different sort of wage—the wage of prestige. But this has its own compromises, and as a result, I’ve begun to question the assumption, so ingrained among many trainees and faculty, that cultivating a stratum of Brahmin physicians should at all be the “purpose” of even the most decorated and storied of America’s hospitals.
Because, U.S. News and World Reports rankings notwithstanding, the care of a patient with a heart attack is really not that much different at Man’s Greatest Hospital than in, say, a hospital in Wichita Falls. (I say this with reasonable confidence, as someone who practiced in a non-academic setting for several years, before taking my current job). For common ailments and routine procedures—which, by definition, constitute the majority of medical care and therefore constitute the majority of what most trainees are likely to end up seeing—the care one receives at any decent-sized metropolitan hospital, it seems to me, is very likely to be the same.
The problem, I’ve found, is that many people working in elite teaching hospitals don’t quite regard things this way. On the contrary: they fashion themselves the sort of vanguard of medicine, where care for even run-of-the-mill illnesses is leagues better than that which one might encounter elsewhere. Attending physicians at the Big House—and this attitude, I think it’s fair to say, then trickles down to their trainees—might look down their noses at these outlying hospitals, not even deigning to refer to them by name, instead lumping them all together under the vaguely dismissive heading “outside hospital,” or “OSH” (rhymes with “nosh”).
Seen in this way, then, it makes a certain amount of sense that trainees at elite medical centers will adopt this same stance, even unconsciously. Some are not even training to become doctors, per se—that, after all, is the easy part, the part that even a hospitalist at a 200-bed facility in Twin Forks can do. They are, rather, training for a medical career in which the goal is not to see patients, but instead to do something else. The process occurs slowly, insidiously. It may start with a sincere desire to be a “clinician-investigator,” though, just as often, it may end with an earnest desire for fame and acknowledgement.
And in the moral economy of academic medicine, much like in the academy as a whole, the coin of the realm is papers and grants. The goal is to amass the greatest quantity of this very specific type of capital, independent of quality, relevance, or readership. CVs are stuffed with line after line of low-quality, observational analyses, which can, at best, be described as “hypothesis generating”—and, at worst, as duplicative and meaningless. All too commonly, the goal seems to be to form small, close-knit networks of similarly-situated colleagues and collaborators, such that these networks can then function in processes of social closure and opportunity hoarding, whereby scarce resources (i.e., prestigious non-clinical activities that are nevertheless compensated—“protected time,” in the argot of academia) are doled out among the privileged few.
This goes against what I think is probably the prevailing view of medicine as being somehow more demotic in its orientation compared to other white-collar professions—a sort of anti-elite elite. Sure, it’s a relatively small pool and it’s difficult to reach its rarefied air; but, once you’re there, the popular conception goes, it’s largely mission-oriented people who’ve devoted their life’s work to care for the sick.
Perhaps. But despite the egalitarian values that many teaching hospitals profess to hold, in the insular world of academic medicine, the same few institutions, and the same few people within them, continue to fight among themselves for who gets to be at the top of the pile.
With this being true, I suppose one of my aims in writing this essay is to dispel the widely-held notion that the medicine practiced at our most illustrious institutions is in any way better than the medicine practiced elsewhere, from the perspective of most patients, for most conditions. (As an aside, I remember a supervising physician in medical school once saying how lucky a patient was that she “got to be operated on” by the then-chief of surgical oncology, an esteemed physician-scientist, something that rubbed me the wrong way, even as a relatively clueless medical student all those years ago).
The fact is, those qualities that made for the best medical trainees a generation ago and continue to do so today—conscientiousness, trustworthiness, an ability to find information and communicate it effectively—these are qualities that have precious little to do with one’s academic footprint, and also happen to be found in a lot of people occupying a lot of different jobs, many of them in far less well-paid sectors of the economy.
Medicine, in other words, should be democratized, in the broadest possible sense. To achieve this, I might humbly suggest that we begin to rethink what medical training is for, and how to allocate training slots based on social need. The late healthcare economist Uwe Reinhardt’s idea of forgiving a portion of a physician’s medical school debt for every year he or she works full-time in primary care is one possibility. Another possibility is simply to address the glaring mismatch of supply-and-demand. Our population is getting sicker and older, and we’re facing a massive shortage of doctors to take care of them. (According to the Association of American Medical Colleges, there will be a shortfall of 86,000 doctors by 2036.) Expanding the number of slots and instituting a lottery system of admission to medical schools and residencies would be another logical response.
Fostering among our brightest aspiring physicians a sense of superiority mixed with an implicit message that it’s everything but patient care that truly makes one’s career does little to help address this pressing social need. It’s becoming increasingly hard for me to see a way to deal with this problem that doesn’t involve breaking the guild of the medical “elite”, dismantling the credential economy, and uncoupling empty CV desiderata from the necessary work of training competent and compassionate doctors.
Akshay Pendyal is a physician and writer living in North Carolina.
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The problem that this thoughtful essay identifies also extends to education in general. What is the purpose of education? I shall have to give this much more consideration, but the preparation of young people to be thoughtful, productive, and useful members of society springs immediately to mind. What then should they learn? I personally lean towards a classical education followed by technical education in one’s chosen field.
I do not believe that education should be trade school and I lament the decline in the humanities, even though much of that decline is merited. Nonetheless, we are churning out bright and energetic graduates that have gaping holes in their educations. Neither are they great citizens or fully developed people.
Back when I read the paper version of The Wall Street Journal, they would periodically list the famous alumni of the « best » B-schools. Always, convicted felons and notorious rogues made the top ten. The schools either rewarded those lacking in the best qualities of humanity or it erases whatever was there. Probably both.
The implications for society and for public policy are immense. Credentialism is rampant everywhere at universities. We have entire departments and platoons of PhDs that are specialists in nothing. If knowing little is bad, then specializing in the untrue is worse. Veritas has no meaning. It should be no surprise that the recent antisemitic protests mostly confined themselves to selective schools. Their purpose is not to produce as many meritorious citizens or doctors as possible, but to produce the next generation of the elect.
Everyone should be worried that science and medicine are now infected.
Another key take away from empty credentialism is it convinces those that seek the credentials they will mean something. When they don't it hurts. Resources and time were wasted. Unfortunately I have experience tho not in the medical field.