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To Teach Them This Art

Chief of Surgical Oncology Stanford University Medical Center

"To consider dear to me as my parents him who taught me this art...to look upon his children as my own brothers; to teach them this art if they so desire..."

from The Hippocratic Oath

The challenge to all of us involved in the practice of medicine is to deliver more health care to an ever-expanding population while using fewer of our nation’s expendable resources. In addition, we are asked to continue to do so in an environment that, with our nurturing and blessing, supports philosophically the creation of new knowledge—with an emphasis on advances in more sophisticated diagnostic techniques and expanded therapeutic options.

None of us who have chosen careers in medicine take issue with the priority of this public directive. In fact, I believe we as practitioners deserve credit for working to achieve rather significant gains toward the control of escalating health care costs. As scientists, we have also learned to do as much and often more with smaller grant awards and more competition for existing agency resources.

Admittedly, for those of us caring for cancer patients the realities of the new order of health care have not always been easy to navigate nor have they always been in the best interest of our patients. Nevertheless, we have fought extremely hard to protect our patients and to see that they always receive the best care—state-of-the-art cancer treatment by the very best cancer specialists. Often, this has required many hours on the telephone attempting to convince gatekeepers of the need and appropriateness of our therapeutic recommendations.

But the new order of health care creates another even more disturbing side effect: how do we carry out our mandate to be teachers as Hippocrates intended? The essence of that command is that we are to ensure the instruction of those who will someday take our place. This is a potent message, and the one which is probably most alien to the CEOs of for-profit managed health care providers and the management forces of so many of our medical institutions. I am often struck by the bewildered face of a student as I hurry through my day. I suddenly realize that during all the faithfully attended committee meetings rarely a moment has been devoted to how all this new-system-creating, merging, expense reduction, and bottom line preservation is going to impact on those to whom we must "teach this art"—the students, residents, and fellows.

The threat to our educational institutions, specifically our postgraduate training programs, is not simply a matter of finding more faculty time. It is a much more challenging task of maintaining the resources for salary support of faculty hours dedicated to teaching, for postgraduate trainee stipends, and finding resources to cover indirect expenses associated with the higher cost of running academic centers dedicated to training. Indeed, a daunting task in an atmosphere constantly seeking ways to reduce expenses.

The issue of graduate medical education (GME) is currently a major focus of debate in Washington, as Congress wrestles with the broader issue of health care funding. Pressures to reduce Medicare expenditures have placed the support for graduate medical education in a very vulnerable position, and the perceived need for a greater ratio of primary care providers to specialists has sparked proposals for government intervention through incentivising and direct legislation.

This past July I spent a day with two colleagues from the Society of Surgical Oncology, visiting several members of the House and Senate as well as key congressional staff, discussing our concerns regarding continued support of graduate medical education. The issues of who pays, the number of years of funded support that will be allowed, where training should take place, and the number of specialists to be trained are all being debated by our representatives on Capitol Hill.

During our visit we strongly urged that a formula be devised which would require all health care insurers to share in funding GME, that the length of training not be capped unreasonably but be based on the needs of individual specialties and that individual specialty boards, resident review committees, and the marketplace be the determinants of the number of training positions available in each specialty.

The good news is that an awareness exists on the Hill that this is an extremely important issue. Congressional members and their staffs understand the vital role existing GME support plays in maintaining the very core of our training programs and the facilities where this training takes place. While the debate on a resolution is temporarily on hold, it will certainly move rapidly to the front burner early in 1997. We can probably expect significant reductions in fiscal support and more governmental control of how those resources are used.

We need to take heart, however, in the willingness of our congressional representatives in both the House and Senate to listen to their constituents. Take, for example, the recent 6.9% increase in NIH funding. Without question, this vital increase is the direct result of an aggressive presentation of our case through personal visits, letter writing campaigns, e-mail, and phone calls. The scientific community rose to the challenge of protecting the national biomedical research agenda.

Our assignment is clear. The issues to be debated are understood by all of us and, more importantly, I believe that reasonable solutions which we can all agree to support can be articulated. We must therefore speak clearly with a forceful and unanimous voice on this issue. We cannot afford to have our Congressional leadership distracted from the importance of maintaining the best health care system in the world.

I believe we can all agree that it is imperative that congress reduce the federal expenditure for health care and we must accept that GME will participate in that reduction. I also firmly believe in the system of graduate education in the United States, recognized as the best in the world, and I strongly feel we should be committed to protecting its future and our patient’s right to the best health care anywhere. Together, working with Congress, we can accomplish both significant reductions in federal expenditures for GME while fulfilling our oath "to teach them this art."

John E. Niederhuber Chief of Surgical Oncology Stanford University Medical Center

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