As a teacher of medical students and residents in an academic medical center hospital, I am more and more concerned about the increasing distance placed between patients and those who are learning to be doctors. This results in large part from forces that, taken together, place a disproportionate premium on efficiency in our teaching hospitals.
THE TYRANNY OF EFFICIENCY
The managed care emphasis on efficiency has led to an iniquitous celebration of "rapid through-put," in which the contact time between patients and physicians-and especially student physicians-is markedly diminished. This is evident both on the wards and in ambulatory care settings. Economic pressures, such as those created by the requirement that teaching faculty generate as much clinical income as possible, decrease the time these physicians are able to spend with patients and students. Expanding regulatory mandates for medical school and residency training curricula (and objective documentation of knowledge and skills by written or practical examinations) increase the time demands on students, residents, and their teachers.
Finally, perhaps the biggest obstacles to achieving efficiency in medicine are the patients themselves. Any system works most efficiently when all parts of the system behave as expected. The unfortunate reality is that sick people and their families are notoriously likely to be complex, emotional, time-consuming, and unpredictable. They are unlikely to correspond exactly to the abstract "patient with X affliction" described in textbooks and on examinations-or even to the "representative" average patient of the carefully analyzed cohort-based studies that are evidence-based medicine. Patients are not "efficient."
WHERE ARE THE PATIENTS?
Attempts on the part of educational institutions to respond to these forces have led to a flurry of "innovative" educational programs that circumnavigate the very objects of medical education-the patients. Both care facilities and medical education increasingly emphasize the use of representative avatars (laboratory results, images, echocardiograms, and so forth), what I call "virtual patients," as data sources superior to the patients themselves, with all their disturbing unreliability and changeableness.
"Standardized patients" (actors), or even mannequins, are used to teach and evaluate the students' history taking and physical examination skills. In addition, the very structure and content of a patient's history and physical examination may be determined more by the programming of hospital or office electronic information systems than by the patient's own words, findings, and needs. Bedside teaching in busy centers is close to nonexistent. Discussions of interesting cases are now held in small rooms; it is far more efficient.
Physical diagnosis is an atavism, supplanted by technology. Most highly trusted are images (MRI and CT scans, sonograms, etc). This is something of a puzzle to me, since these images are read by radiologist diagnosticians in much the same expert way that an experienced bedside clinician used to "read" the body of the patient-yet the images have much more credibility. Why? Modern imaging interpretation is, in fact, physical diagnosis l'intrieur, except that it is done in dark rooms without the benefit of integrative histories and knowledge of the patient as a person.
At the heart of my disquietude with the "virtual patients," particularly their use in teaching medical students, is the unspoken but clearly evident implication that real patients are less valuable in medical education than are these many reflections, paraphenomena, and simulations. How shall my students experience the things that cannot be taught but only learned through the sometimes inconvenient, potentially time-consuming, often uncertain, emotionally disquieting, and generally non-remunerative interactions with real patients: the subtleties of historical exploration, physical finding integration, the clues offered by verbal and nonverbal communication, and the immense value of the physician himself or herself as a diagnostic and therapeutic instrument?