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Evolution of a Physician In Training: Effects of the medical education pipeline on personal and professional development.

Daniel M. Williams, MD, First Draft: July 11, 2009

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ABSTRACT

Discussions of physician burnout and job dissatisfaction have historically focused on workplace pressures, the impact of managed care, and increased governmental oversight. This approach fails to put the individual physician’s perspective in proper context and, therefore, doesn’t get to the root of the dissatisfaction. The author describes 5 stages in the personal and professional development as experienced by the physician-in-training, includeing the reemergence of physician priorities that cause job satisfaction to return. The emphasis is on the holistic impact of the current U.S. medical education pipeline, as drawn from the scientific literature and success of a model physician wellness program – a hybrid of the mastermind group. This paper serves as a framework for discussing physician maturation that focuses on learner-centered teaching approaches, which may assist in the planning of future physician wellness initiatives.

INTRODUCTION

Physicians undergo a massive transformation during their training which prepares them to be healers. From the early premedical years, personality characteristics have been described for decades, which provide insight into the mindset of the bright, ambitious, altruistic premedical student (19,22,24,25). These characteristics are seen in Phase 1 “Standing at the Precipice”, wherein future physicians’ idealism is untainted and pure. What happens next in the pipeline of  medical education is nothing short of phenomenal.

Phases 1-3 describe the important stressors and circumstances that lead an idealistic, altruistic hero to become ambushed by system problems, sustain personality changes from difficult work-loads coupled with lack of support, and face severe penalties for even asking for help (49,50,51,68,71).

Discussions of physician burnout and job dissatisfaction have historically focused on workplace pressures, the impact of managed care, and increased governmental oversight (180-181,183). These workplace pressures are important, but fail to put the individual physician’s perspective in the proper context of life experience, therefore the root of the job dissatisfaction is frequently missed (182).

While these 5 phases in the evolution of a physician-in-training occur in sequence, each individual may experience them multiple times throughout their career. The various medical education pipeline stressors affect people with great variability.

Phase 1: Standing at the Precipice

Premedical students engaged in the early medical education pipeline frequently share similar goals and ambitions. The most commonly described premedical student traits are hard working, competitive, motivated, goal-oriented, altruism, and prestige-seeking (22-24). Fairly early in their premedical experience they begin to learn of the imperfection in the system.

A number of frustrations faced by these bright, enthusiastic students begin before even entering medical school. The challenges face by these future physicians can be categorized as follows:

1. Selection Bias. Learning that affirmative action exists without understanding the need for diversity can be a shock (143,145,156).
2. Academic Preparation. Realizing their undergraduate premedical and M.C.A.T. preparation may not actually predict how competent they will be as physicians can be disheartening (46,45,48).
3. Premedical Advising. Many students encounter premedical advisers, though wonderful guidance has been published for decades (11,15,17).
4. Admissions Criteria. The paradigm shift being birthed in premedical curriculum, which seeks to broaden one’s humanities background and foster empathetic relationships, is taking a surprisingly long time (4,6,27,28,30,31). The transition period as more medical schools are changing their admissions criteria and interview process can leave the premedical student confused about what is important in their preparation (184).

Because these sytstem-wide messages that contradict their altruistic nature, it is not surprising that the majority of students matriculating into medical school already have a well established ethical framework that is difficult to mold (26).

Further, two of the most historically trusted sources of information flat fail the premedical student attempting to learn about medical education. First, institutions of higher learning remain hyper-focused on grade point average though is associated with mere surface learning in medical school and the “MCAT Myth” of requisite rote memorization had been debunked by the mathematical application of Bloom’s Taxonomy (46). Second, nationally syndicated journalists yield influence in the ranking of “top medical schools”, but their method are ill-conceived; are unscientific; are conducted poorly; ignore the value of school accreditation; judge medical school quality from a narrow, elitist perspective; do not consider social and professional outcomes in program quality calculations; and fail to meet basic standards of journalistic ethics (32).

Sadly, the more idealistic and altruistic the nature of the unsuspecting premedical student, the greater the expectations in their career, and the greater the disappointment that comes in later phases in their evolution.

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