A Missed Diagnosis:
Our Badly Broken Physician Education System
Seventy-eight-year-old Mr. S lay in his hospital bed, nearly comatose, having undergone a routine hip replacement the day before. I was the kidney specialist, consulted to evaluate his abrupt drop in urine output and kidney function. While examining him, my gaze settled on the balloon-like protrusion of his lower abdomen. Tapping or “percussing” over this area yielded a dull thud, instead of the usual hollow ring, indicating a very distended bladder. Mr. Sampson suffered from the common post-surgical complication, in older men, of an enlarged obstructing prostate and acute urinary retention, in which the building pressure within his bladder led to kidney shut-down. Placement of a urinary catheter would alleviate this plumbing problem almost immediately. How could the treating physicians, I wondered, miss this obvious diagnosis.
Spotting the harried orthopedics resident moments later, I inquired what he thought was the cause of Mr. Sampson’s renal failure. Looking at me blankly, he answered, “We have no idea. That’s why we called you.”
“Did you consider post-surgical acute urinary retention?” I asked, adding “Did you examine his abdomen?” Embarrassed, he shrugged, “Well…I’m not really good at abdominal examinations.”
Mr. Sampson’s problem should have been easy to recognize and treat, without elaborate or expensive testing – or even a consultation with a kidney specialist. Why did these talented, energetic, newly-minted physicians miss so obvious a diagnosis? The answer reveals a serious crisis in physician education.
Since its introduction in the 1890s, our system of medical education: except for the first two years of “preclinical” medical school classroom science has remained largely hospital-based, wherein lies the problem. Hospitals were ideal for clinical training in the early twentieth century. As a medical student in the early 1970s, I was assigned to follow a young woman with chronic anemia. She remained an inpatient for more than a week, during which she had a plethora of tests. Observing her during this period taught me about her symptoms, her physical findings, the biology of red blood cell production and diseases that cause red cell loss. It was a comprehensive and memorable lesson in hematology. I had time to chat with her at length and monitor her progress.
Nearly fifty years later, this patient would not have been admitted to a hospital but would have had her “workup” completed in office visits to her primary care physician or with a hematologist. Hospitalizations have been in decline since the 1980s and lengths of stay have shorted by nearly half. Treatments such as intravenous antibiotics and chemotherapy are now administered in outpatient centers.
With alarms sounding, pagers beeping, and respirator machines grinding, today’s teaching hospitals have become noisy and distracting places. Medical students and residents spend most of their time in front of screens, looking at laboratory and imaging studies and writing orders, while, largely overlooked and untouched, the patient is shuttled from test to test and then rapidly discharged. Overwhelmed with this avalanche of “data,” medical trainees easily lose perspective, the capacity to empathize with patients, and basic bedside skills. In short, today’s hospital is too chaotic an environment to foster learning.
The consequences of our outmoded hospital-based medical education system are profound. Missed diagnosis and medical errors are rising in prevalence largely owing to a lack of basic clinical skills in physical examination. Overutilization of tests, particularly imaging studies such as MRIs and CT scans accounts for much of the excess in health care costs. And medical students, residents and young physicians are suffering from a rising prevalence of burnout, depression and suicides.
Medical education needs major reform and a relocation of clinical training from hospital to office. The principal barrier to reform is the that funding for residency training is provided mostly by Medicare to hospitals – not to medical schools. The powerful hospital association lobbying groups will strenuously resist this change but change must come if we are to save ourselves and our doctors.