Can Bedside Manner Be Taught? : The Traditional Medical School Glacier Begins to Melt

On the night before the operation, one of the doctors visited the cancer patient and his wife in the hospital room and related a message as sure and chilly as a scalpel:

“It’s going to be a tough operation, and we don’t know if you’ll make it,” John Sterle says the doctor told him. “And even if you do make it through, you’re going to go home with tubes coming out of you, you’ll need a nurse, you’ll have to be fed by an IV. . . .”

Today, a year after the surgery, Sterle is glad to be living proof of the error of the doctor’s pessimism. But his happiness is tempered by the memory of the doctor’s cold bedside manner.

Though such uncaring treatment at the hands of a caregiver is probably unusual--and, indeed, interviews with other patients indicate that supportive, comforting physicians seem to be more the norm--the prospect is real enough to have prompted some changes in the education and training of the doctors who take our health and well-being into their hands.

Under scrutiny in recent years has been the entire medical education system--from the intense competition for admission, to the highly technical, scientific courses that make up the bulk of the pre-medical and medical school curriculums, to the punishing, boot-camp-like years of internship and residency.

With a system so inhumane, critics wonder, can the doctors it produces be anything but?

“There’s a selection bias in the process in favor of people who may not have the human characteristics you’d want in a doctor,” says John Gryder, a Johns Hopkins University chemistry professor and adviser to pre-medical undergraduates. “It’s like a hazing ritual.”

Defenders of the traditional system, however, say it is necessarily rigorous--that it is how physicians-in-training develop the tough-minded, decisive qualities needed by someone entrusted with life-and-death matters.

Change is coming slowly and subtly to medicine and to medical education--but it is coming, pushed along in part by changes from outside.

Once viewed as a prestigious and lucrative profession, medicine has been battered by the threat of malpractice lawsuits and the high rates for insurance needed to protect against them.

In addition, a combination of demographic trends and the waning appeal of medicine as a profession have shrunken medical school applicant pools. As a result, it is not as difficult to get admitted to medical school today as it has been.

This year, 25,825 people submitted applications to the nation’s medical schools, according to statistics compiled in March by the Assn. of American Medical Colleges. While that represents a small increase--348 more than in 1988--it is still far below the 42,624 applicants of 1974, when medical school applications began declining.

“When you look at what’s happening, what we’re experiencing now and will be for the next decade is the demographic downturn of birthrates in the ‘70s,” says Dr. Norman Anderson, dean of admissions at Johns Hopkins School of Medicine. “That’s the same thing that’s closed down elementary schools and high schools.

“And at the same time, careers in science are losing favor. Fewer of the students with the high grade point averages and MCAT (Medical College Admission Test) scores are applying to medical school. Now, one of the most prestigious majors is business. (The top students) are moving into business or the legal profession.”

As a result, medical schools are beginning to look at other criteria for admission.

“As the pool gets smaller, the individual with a non-science background . . . gets looked at more seriously,” says Dr. Murray Kappelman, dean for medical education and special programs at the University of Maryland School of Medicine. “There’s been a shift away from just using numbers and beginning to look more at the individual.”

“Because (medical schools have) had to go down to people whose grades are lower, they have a better, more well-rounded group of people,” Gryder says. “I think there’s more to medicine than just being smart and being able to take a test.”

Johns Hopkins, accordingly, no longer uses a person’s MCAT scores as a qualifier for admission. “We’re more interested in whole people who can do more than a standardized test,” explains Dr. Richard Ross, medical school dean.

Although only one other U.S. medical school has joined Hopkins in rejecting the test, other schools also may see a change in applicants when the admissions test changes formats in two years. Scores from the revised test should reflect more balance between science and the humanities. Rather than having four sections testing science knowledge and two testing verbal and quantitative skills, the new test will have two science sections and two on writing and verbal reasoning.

Still, medical schools can end up sending mixed messages along the grueling path.

“The funny thing about medical education is you take someone who is multidimensional, a good student, someone who was involved in a lot of activities, but, subtly, they reward you for being one-dimensional, a workaholic,” says Dr. Russell Brown, chief resident at the University of Maryland medical school. “You’re rewarded for staying late. By the middle of medical school, you’re not as well-rounded as you used to be. You get meaner, more jaded. There’s a certain amount of thick skin that develops. The nature of the beast is that you have to develop it.”

The rigors of medical school--the heavy load of science and medicine that needs to be learned and then practiced on human beings--require compressing a lot of information into a small amount of time.

“I don’t believe in these rites of passage, I don’t worship that, but I don’t know an alternative,” Seidel says of the long hours and pressure-cooker atmosphere of medical school. “There is so much that can be done if there were more time, but time is money.”

For the most part science still dominates, but medical schools have responded to the call for adding more humanities to the curriculum. Many schools, for instance, require students to take issues courses, such as ethics.

But educators say that’s not necessarily the answer to the call for more humane doctors.

“I really don’t believe you make humane physicians by making them take humanities courses,” Ross says. “What my philosophy has been is that the time to get humanities is before you get to med school.”