Jordan J. Cohen, MD Delivers 2018 Marvin R. Dunn Keynote Address

4 April 2018

Dr. Jordan J. Cohen explored the evolution of medical education in his presentation, “Looking at the Road Ahead through the Rearview Mirror,” as the 2018 Marvin R. Dunn Keynote speaker at this year’s Annual Educational Conference, offering his unique perspective as graduate medical education (GME) leader.

Dr. Cohen is president emeritus of the Association of American Medical Colleges and former CEO and chairperson emeritus of the board of the Arnold P. Gold Foundation; is an emeritus professor of medicine and public health at the George Washington School of Medicine; served as Dean at the School of Medicine at the State University of New York at Stony Brook; served as Chair of Medicine at the University of Chicago-Pritzker School of Medicine; and held faculty positions at Harvard, Brown, and Tufts. He also recently completed his second tenure on the ACGME Board of Directors, for which he served as Chair.

GME’s Early Days

During the early 20th century, Dr. Cohen said, medical education was chaotic and without a formal system. In this time of “fly-by-night storefront” medical schools Dr. Abraham Flexner completed a comprehensive survey of undergraduate medical education, known as the Flexner Report. While instrumental in transforming undergraduate medical education, the report did not mention GME; there was nothing to report. Four years were considered sufficient for learning to execute the responsibilities of medical care, and few physicians pursued apprenticeships or went to hospitals for ad hoc training, Dr. Cohen explained.

In the 30 years following Flexner, medical education changed dramatically. Few ad hoc training sites survived, and new facilities, sponsored by universities, expanded. GME grew alongside scientific advancement, and medical school graduates were required to have at least an internship post-graduation.

Linking Personal Experience

Dr. Cohen reflected on his own residency experiences as medical education evolved through the 1960s. He remembered being on call every other night and every other weekend, working a minimum of 120 hours a week in the hospital, and receiving on average three or four admissions when on call. The average stay for a patient was two weeks, and the hospital’s pace was slow, he said.

“I can’t remember a single time when we asked the question about the cost of what we were doing,” reflected Dr. Cohen. “We were encouraged, in fact, to do everything we could think of to help the patient… Never a concern of what it might cost or what the resources demanded. We became complacent about the use of resources at that time that were not known to be scarce.”

Dr. Cohen remembered with fondness how he got to know his attendings. They invited residents to their homes; everyone felt part of a big family with a real interest in their education and as individuals in practice, devoting their time to medicine and education.

An Evolving World, An Evolving Practice

The arrival of Medicare in 1965 transformed how health insurance and hospitals were organized. At the same time, doctors saw increasingly sicker patients while providing shorter stays, Dr. Cohen said. Technology also affected patient care and training programs, creating a faster – and more stressful – hospital environment, he said. Residents were providing complex care while learning, and the demand for residents began to exceed the number of US medical school graduates, providing opportunity for foreign medical graduates to pursue residency positions in the US.

The result, Dr. Cohen posited, were high stress levels, the corrosion of physician comradery, and the beginning of the burnout epidemic.

Dr. Cohen discussed the tragic Libby Zion case in 1984 as a significant moment in the timeline of GME. Her death sparked outcry and concern about resident fatigue, leading to public policy turmoil and years of intense debate within the profession about patient safety issues resulting from resident work hours.

“Public trust clearly can be threatened by failing to meet societal needs,” said Dr. Cohen, adding, “If we fail to meet the public’s needs and the public’s expectations we are in danger of losing that fundamental trust between the patient and his or her doctor and between the profession and the society more broadly.”

The Road Ahead

Familiar challenges on the road ahead will continue affecting the medical profession, Dr. Cohen explained. There are too few general physicians, too many specialists and subspecialists, geographic distribution problems, climbing health care costs, and other roadblocks to meeting the needs and expectations of our increasingly diverse society.

GME must embrace these realities, and our programs must meet these expectations, Dr. Cohen said. We have to bolster the public’s trust in medical science and medical expertise, so the voice of physicians and others in science can influence public policy and its consequences.

This will require heightened political activism on the part of physicians and others, which Dr. Cohen suggests could be a new Competency for the ACGME to consider - the possibility of future physicians trained to be effective advocates for issues important to the health and welfare of the nation.

Beyond the Visible Road

The age of machine learning, artificial intelligence, and advanced robotics holds great potential significance for GME, Dr. Cohen predicted, including the automation of routine and error-prone tasks and administrative procedures, and seamless recording and retrieval of medical data. Greatly improved diagnostics, intricately personalized therapies, immediate access to genetic information, use of advanced simulators and robotics for surgery, and more could offer great benefits to medicine and society, maybe at a level equal in significance to the Industrial and Agricultural revolutions.

The culmination of such advancements could be the return to humanism for the physician, Dr. Cohen said. The physician’s intelligence, wisdom, moral judgment, experience, awareness of complex situations, and more cannot be replicated by artificial intelligence, and is a uniquely human facet of care – one that in fact drew many physicians to medicine in the first place.

“There’s one thing that is absolutely certain never to change," Dr. Cohen said. "People get sick. And they need help. And they prefer to have a doctor who cares for them.

But this vision is not guaranteed. GME must identify those with true passion and commitment to serving others. Students entering training must have clinical learning environments that prioritize and demonstrate humanistic care, providing access to well-being programs, embracing CLER requirements, and focusing on outcomes, all of which are championed through the work of the ACGME.

The ACGME, Dr. Cohen said, is in a unique role to support educators and enhance education to prepare physicians for this promising new age.

“We could return meaning and joy to the practice of medicine,” said Dr. Cohen, “and in the process, heighten public trust in the medical profession by truly caring for patients as our only obligation as professionals.”