Training physicians—new ways of teaching in a changing medical landscape

For the past 32 years, Yale faculty from the Department of Internal Medicine have taught at 10 hospitals throughout Connecticut through the Yale Affiliated Hospitals Program (YAHP). Begun in 1975, YAHP is currently the largest consortium of internal medicine training programs in the United States. Its goal has always been to improve the quality of medical education throughout the state. With 446 full-time faculty among nine residency programs and more than 6,500 attending physicians, the program trains more than 450 residents in internal medicine each year. It also provides opportunities for collaborative clinical and educational research as well as selected subspecialty clerkships at Yale for affiliated medical residents. Each year 100 residents from other hospitals take electives at Yale-New Haven Hospital. Member hospitals include the Hospital of St. Raphael in New Haven, Bridgeport Hospital, Waterbury Hospital, Greenwich Hospital, Norwalk Hospital, Griffin Hospital in Derby, St. Mary’s Hospital in Waterbury, Danbury Hospital and Lawrence & Memorial Hospital in New London.

“This is a very robust relationship,” said Silvio E. Inzucchi, M.D., professor of medicine (endocrinology) and director of the program, speaking at YAHP’s 30th annual symposium in November. “After 30 years, the program is still evolving—it is clearly of mutual importance to both the department and our affiliates.” Asghar Rastegar, M.D., professor of medicine (nephrology) and associate chair for academic affairs, called it a “unique network.” Yale’s collaboration with smaller, community-based hospitals, he said, allows them to attract better faculty as well as trainees to their programs, enhance training of their residents and maintain academic links that serve as a resource. And, noted Peter N. Herbert, M.D. ’67, HS ’69, vice president and chief of staff at Yale-New Haven Hospital, a vigorous educational program strengthens the overall enterprise. “Training programs are critically important to the retention of our faculty,” he said.

But all is not well in the training of new doctors. More than a dozen speakers cited new challenges to medical education, not only in Connecticut but also in other parts of the country. Among those challenges are young doctors’ desires for a less stressful and demanding lifestyle, lack of financial support for education and the shrinking emphasis on the hospital as the primary training setting. As Herbert noted, patient contact typically takes up an hour or two of a resident’s day, while another six to seven hours are spent “doing largely clerical things that, in a practice setting, would be done by someone else.”

Dean Robert J. Alpern, M.D., Ensign Professor of Medicine cited inadequate funding for education as a major problem, observing that tuition covers only half the cost of a medical education. Clinical practice, which has traditionally brought in money to fill that gap, is increasingly under financial pressure itself. “The ability of the clinical practice to subsidize education is going away,” he said. “You can’t run a medical school without a clinical practice, but what is optimal for education is not necessarily optimal for clinical practice.”

Also of concern, said Jack A. Elias, M.D., the Waldemar Von Zedtwitz Professor of Medicine and chair of medicine, is the aging of the physician-scientist population, whose unique perspective bridges the lab and the bedside. Ten years ago, he said, 57 percent of the physician-scientists who received grants from the National Institutes of Health were 45 or older. “We are losing ground in this area at a time when translational research is blossoming.”

Panelists also cited the importance of mentorship for medical students and young doctors. Mary E. Tinetti, M.D., the Gladys Phillips Crofoot Professor of Medicine (geriatrics) and professor of epidemiology and public health, said that in the past students of either gender were linked with experienced older men, because the majority of available mentors were men. Today, however, there are women who can mentor other women and members of minority groups who can guide others from their respective backgrounds—even from afar—because they are “people who share many life experiences.”

Despite their concerns about the future of medical education, speakers also noted cause for optimism in efforts to address the challenges. Elias cited a one-year master’s program in public health at Yale that is geared to practicing physicians. Alpern said that while the financing of medical education is built on a shaky foundation, “each school figures out a way to get around it.” And Rastegar, in an interview after the symposium, said that the education at Yale rests on a core belief shared by faculty.

“Everyone feels that there are significant structural challenges we are facing,” said Rastegar. “A great deal of education depends on an environment that nurtures the trainees. Yale’s power has always been that.”