SPECIAL ARTICLE

Uncritical Lovers and Unloving Critics Comments on Subspecialty Education in Gastroenterology D. M. Switz, MD, and W. H. J. Summerskill, MD

The orientation, nature, and duration of training programs in gastroenterology are in flux. Although the direction gastroenterology and its associated training programs should take has been discussed at length by the teachers and practitioners, none of the content of these conversations has appeared in print. Moreover, the "silent generation," now in training, has never been heard. "Uncritical Lovers and Unloving Critics," in this issue, is the first of a series devoted to comment by'those now receiving training in our subspecialty. The appellation "trainee" embraces several individuals in training, including research assistants and senior residents in gastroenterology. The article attempts to convey some of the current concerns of those receiving training and to balance these statements by appropriate modifying faculty comments. We hope the present offering may stimulate discussion locally and, via Letters to the Editor, in the pages of this Journal. We will attempt to have specific questions answered by the most knowledgeable party. We solicit your response. --Editor

Twelve trainees in gastroenterology met to discuss subspecialty programs. Tile majority convened again and were joined by 3 faculty members for an informal discussion. We report extracts and appropriate quotations by faculty and trainees from both meetings. Tile trainees attended I 1 medical schools; 4 received undergraduate medical education abroad. All had completed 2 or more years of general medical residency before beginning subspecialty training. Seven elected to obtain both forms of training in the same institution. T h e participating trainees are planning careers comprising one or more of the following components: From the Mayo Clinic, Department of Internal Medicine and Gastroenterology, Rochester, Minn. Address for reprint requests: Dr. D. M. Switz, Gastroenterology Unit, Mayo Clinic, Rochester, Minn 55901. Digestive Diseases,Vol. 15, No. 2 (February1970)

clinical practice, teaching, and research. T h e y are embarked upon programs, funded from a variety of sources, yielding experience in the disciplines of the medical scholar2 T h e majority are attracted to academic medicine; indeed, the 4 participants who have completed training since these discussions have all taken full-time positions in medical schools. T h e two discussions concentrated on five areas of concern: (I) difficulties involved in choosing a training center, (2) contents of the "ideal" program or programs, (3) overall program orientation, (4) funding problems, and (5) job opportunities. We report the results of these meetings in the hopes of promoting discussion of the various aspects of training programs by faculty and trainees and to record, for the first time, some trainees' viewpoints. 127

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Choice of a Training Center T h e trainees desired more reliable information with which to judge available programs. After writing or visiting various centers, several noted disparities between the stated aims and the apparent content of programs. (Trainee: "Directors should outline their program in greater detail; what is taught and what is expected." Faculty: "Programs need to be flexible, rather than rigid, since the majority seeking training are uncertain of their abilities and, sometimes, interests. It is important for a trainee to be able to change direction as his education progresses.") Contents of the Ideal Program

All trainees agreed that training must be appropriate to long-term career goals, and most therefore believed that two or three varieties of program would be appropriate. T h e faculty believed that an advantageous program would begin with a core of research experience, educational responsibility, and clinical exposure from which trainees could proceed to further training in their specific area of interest in the same institution or elsewhere. Programs of differing content were judged necessary for the three different types of career identified. A discussion of these careers and programs follows. Academic medicine. H o w should an individual be prepared for an academic position that includes geographic full-time activities with variable clinical, teaching, and research components? Trainees believed the program should last between 2 and 3 years, whereas the faculty firmly stated that 3 was a minimum. All concurred that 2 years of medical residency were usually prerequisite, and training in all three components was necessary. For clinical training, selected patient128

care experiences were believed essential; they should be obtained in an inpatient hospital setting and last approximately 1 year. Trainees and faculty, recalling their experience in a variety of centers, felt that outpatient duties were too often unrewarding. (Trainee: " T h e r e is simply too much work, too little worthwhile clinical material, and hardly an)' time for teaching in the outpatient department; the ratio of work to experience is too heavily weighted towards work. More effort should be devoted to developing the academic aspect, perhaps by encouraging the collection of diseases in organ-oriented special clinics.") Teaching responsibilities (with supervision), both formal and informal, were unanimously given high priority in an academic program. Additional teaching activities were then examined. Fellows did not believe course work should be fixed and obligatory, but urged that appropriate elective courses (computer technics, biostatistics, physiology, biochemistry, etc) be taken. T h e y believed that a lack of specific instruction in research technics and the basic sciences relevant to gastroenterology existed in most programs and thought this a major flaw. T h e faculty, while supporting the concept of comprehensive surveys related to gastrointestinal pathophysiology and methodology, pointed out that the hinds and personnel available for ~uch responsibilities were limited. It was precisely this lack of funds and faculty for teaching (as opposed to research) that disturbed trainees. ("What is the money supporting the training programs for, if much of the teaching comes from xour peers? We'd like to have professors spend more time passing on their accmnulated knowledge, even if this must be clone by taped lectures." '% race horse doesn't learn to race in the pasture; he needs a trainer Digestive D}seases,VoL 15, No. 2 (February 1970)

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a, well as a track." Faculty: "At the post.graduate level a considerable proportion of the learning process must be sought through initiative--by discussions with preceptors and colleagues and recour,e to ]ibraries.") T h e trainees had diverse views of tlm character of the research experience that should be included in an academic program. Assignment of the trainee to a project of interest to him which led to education in e x p e r i m e n t a l methods was felt to be ideal. But some doubted the need for a mandatory research project, especially if the trainee assumes only teclmical responsibilities for an ongoing projbct in a professor's lab. (Faculty: " I n d e p e n d e n t research represents a necessary reality of academic life. Relative emphasis on research training and execution is essential. T h e majority of trainees have had no experience in such discipline during the previous 8 years of medical education and have no way of judging their abilities.") Several trainees b e l i e v e d c l i n i c a l l y oriented projects best suited the needs of society and the t e m p e r a m e n t of young physicians: tlmughffnl studies of disease, as outlined by Feinstein in Clinical Judgment,* were given as an example. (Faculty: " T h e design and execution of a superior clinical study differs little from that of more 'basic' investigations, but usually involves more time and money than are available.") All agreed that research, whether at the bench or with patients. should bear an evident relationship to the elucidation of disease mechanisms and instill an approach thereafter applicable not only to a variety of research areas but also to other intellectual processes in medicine.

Full-time trainees

clinical practitioner.

believed

that

All man}" individuals

*~A;illiam~ & XVilkins, Baltimore, Md, 1967. Digestive Diseases, Vol. 15, No. 2 (February 1970)

seeking subspecialty education, whatever their ultimate decision, were initially attracted to a career in internal medicine with a subspecialty interest. Faculty and trainees depIored the paucity of welldesigned programs leading to such a career. (Trainee: " W h o wants to train a person for private practice? W h e n I thought this was what I wanted, I wrote to 20 centers; all said they were training tile academic doctor.") Currently, most individuals considering a purely clinical career gain subspecialty experience in relatively loosely structured senior residencies of varying durations. Better coordination, with greater emphasis on edncation, was urged in the training of such individuals. (Faculty: " W h o will---or s h o u l d - - s u p p o r t the additional educational c o m p o n e n t s of such training?") T h e r e was divided opinion regarding the necessity of research experience in a clinical program. (Trainee: " T h e p r o g r a m should contain no experience not useful in patient care: why overtrain such a m a n in esoterica?" Another trainee: " B u t he certainly should be taught the intellectual approach and the tools of tile specialty, including diagnostic methods and their interpretation.") Some trainees nnd all faculty believed such individuals should have the option of u n d e r t a k i n g a research project. (Trainee: "Even if you plan on full-time clinical work in a small town, I still think you need to feel you have the ability to do some clinical research if you so wish.") It was agreed that such a program should be of 2 years' duration following 2 years of general medical residency.

Laboratory investigator. A different type of training was felt to be a p p r o p r i a t e for the full-time laboratory investigator who would have no patient responsi129

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bility and a small teaching load. All agreed that such individuals are u n c o m m o n and, as soon as their career decision is made, their need for further clinical experience is dubious. Rather, their need to take courses in relevant basic sciences was stressed; it was believed that such individuals were better p r e p a r e d in a P h D prog r a m than in a clinical setting, regardless of the need to take a degree. (Faculty: "The p a r a d o x that worries me is that somebody should get his training in a clinical unit when he plans to be a 'basic scientist'; it is better to get experience in a biochemistry laboratory. Yet, on the other hand, if you go directly to a biochemical lab that is working on histones, when you come back to a medical school you're not a desirable candidate . . . they just d o n ' t have anybody who's got sick histones at that m o m e n t , and they d o n ' t know what to call you. So it is usually more practical to attach yourself to a subspeciahy, learn a b o u t several diseases in which x'ou are interested, then go to a basic science dep a r t m e n t that has some relevance to these diseases, and finally return to the subspecialty you left. Now you can teach more usefully as well as apply new technics to this subspeciahy.") Overall Program Orientation

T h e majority of trainees sensed that the extent of research orientation in m a n y programs distorted the balance of training. (Trainee: " T h e best and most sought-after programs often have heavy research components and m a y try to make laboratory investigators out of clinically oriented physicians because the m o n e y that builds these progTams calls the t u n e - - a n d the m o n e y says that you will do research, and not clinical research either." Faculty: " T h e s e programs are the best and most sought130

after because they integrate relevant research with superior teaching a n d clinical responsibilities. T h e y are clearly not designed for individuals motivated only towards clinical practice, and such individuals should not deceive themselves and others by applying for them." Another trainee: " N o b o d y wants to produce teachers, although everybody says they are needed. Congress seems not to recognize tlrat it is training teachers in a r o u n d a b o u t fashion in programs funded to do research rather than in programs that include training in educational methods.") The trainees equated their dissatisfaction with similar concerns expressed by college students (and faculty) regarding the impact of research pressures on the caliber of the educational process. T h e extent of research orientation was believed to be the result of a continuing (and deplorable) academic proclivity to llnk a d v a n c e m e n t and tenure to research productivity, with less emphasis on excellence in other areas. (Facu.Ity: "Excellent research does not preclude excellence in teaching or p r a c t i c e - - i n fact, one might argue to the contrary. However, ability in research is admittedly more susceptible to evaluation.") All trainees considered a career in academic medicine attractive and potentially fulfilling, b u t feared increasing restrictions in selecting proportions of teaching, clinical, and research responsibilities in relation to their personal interests and abilities. T h e faculty also regretted the relative absence of recognition and funding for m a n y of the teacMng activities essential to all aspects of highquality subspeciahy education. Funding Problems

T r a i n e e s associated the current heavy research orientation with federal funding Digestive Diseases, Vol. 15, No. 2 (February 1970)

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policies ~ and considered the~e policies unduly influenced by certain groups. Ahernatively, these funding policies could be interpreted as indicating public dissatisfaction with current medical practice and a belief that improved care will most quickly and economically stem from novel ideas developed through basic research. A third position was enunciated: "For years the public and Congress have been told that all that is good stems from basic research. T h a t is all right, but it is not the only point of view. We now have to teach Congress that the only way to get new ideas from the bench to the bedside is through careful clinical studies. We've got lots of research; now we need some development. It is a question of salesmanship." During some spirited exchanges, drawbacks and difficulties relating to funding were discussed. All agreed th'at greater efforts should be made to solicit the private and industrial sector to support areas presently rated as inadequately funded, since federal funds will clearly decrease during the next few )'ears. Discovering Job Opportunities

Many trainees rem'arked on the absence of a centrzdized information system through which relevant details of available positions could be obtained upon completion

Digestive D;sease3,Val. 15, [;-. 2 fl:cbruary 1970)

of training. At present, p e r m a n e n t appointments are sought in a variety of ways, but most trainees investigate possibilities suggested by faculty or heard by word of mouth, especially at national meetings. A national "data bank" of available positions and applicants would not be difficult to set up; the N I M P and A F C R have already started similar programs. SYNOPSIS

A group of faculty and trainees at a Gastroenterology T r a i n i n g Center discussed the current state of subspecialty education in their field. \Ve report their conclusions with appropriate quotations. Choice of training center, the "ideal" program, program orientation, funding problems, and job opportunities were considered. No single conclusion was reached. We hope to stimulate discussion by the variety of opinions presented. REFERENCES

l. KiasxE~, J. B. NIH-supported Training and Research in Gastroenterology, 1968. Some observations from an NIAMD Advisory Council member. Gastro.tenteroIogy 57:95-98, 1969. 2. SCHEELE, G. A., and KITZES, G. Analysis of academic training programs in Gastroenterology for the 10-year period 1957 to 1967. Gastroenterology 57:203-212, 1969.

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