Let Me Heal The Opportunity to Preserve Excellence in
American Medicine
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This landmark book should be read by all who are concerned with medical education
and patient care in America.
Renée C. Fox, Annenberg Professor Emerita of the Social Sciences, University of
Pennsylvania
In a most readable and engaging way, Ken Ludmerer traces the development of gradu-
ate medical education in the United States in parallel with the major developments in
the science and practice of medicine over the past century and a half. With his intimate
knowledge of and decades of personal experience with medical education, he brings to
this work a deep appreciation of the social value and moral purpose of physician train-
ing. If you’re concerned about the skills and dedication of tomorrow’s doctors—and
everyone should be—read this insightful and authoritative book.
Jordan Cohen, Immediate Past President, Association of American Medical
Colleges
Let Me Heal is as much an entreaty to the profession and the public to solidify the
future of graduate medical education in the United States as it is a historical treatise on
the evolution of perhaps the greatest and most efficient medical education system in
the world. While tracing and interpreting its evolution, Ken Ludmerer points out not
only the successes but also the failures of the system, past and present. The inescapable
conclusions to the challenges he outlines to the training and professional maturation
of physicians are a call-to-arms for those of us engaged in the education of the next
generation of doctors and a call for understanding and support from the public, whose
future care depends on our success!
Thomas J. Nasca, MD, Professor of Medicine and former Dean, Jefferson Medical
College, and Chief Executive Officer of the Accreditation Council for Graduate
Medical Education (ACGME)
Let Me Heal
The Opportunity to Preserve
Excellence in American Medicine
Kenneth M. Ludmerer
1
1
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Library of Congress Cataloging-in-Publication Data
Ludmerer, Kenneth M., author.
Let me heal : the opportunity to preserve excellence in American medicine / Kenneth
M. Ludmerer.
p. ; cm.
Includes bibliographical references and index.
ISBN 978–0–19–974454–1 (alk. paper)
I. Title.
[DNLM: 1. Internship and Residency—history—United States. 2. Education, Medical,
Graduate—standards—United States. 3. Quality of Health Care—United States. W 20]
R840
610.71′55—dc23
2014004264
135798642
Printed in the United States of America
on acid-free paper
To the Ideals of the Johns Hopkins Medical School and Hospital
CON T E N T S
Preface ix
Acknowledgments xv
1. Antecedents 1
The Search for Clinical Experience 2
The Quest for Specialty Training 8
The Passion for Discovery and the Birth of Clinical Science 12
2. Johns Hopkins and the Creation of the Residency 17
Graduate Medical Education Enters the University 18
The Scientific Practitioner and the Promise for the Nation 23
Work as Play 28
Diaspora 33
3. The Growth of Graduate Medical Education 37
Completing the Infrastructure 38
The Maturation of the Internship 42
The Spread of the Residency 49
In Search of a System 61
4. The American Residency 65
Educational Principles 66
The Moral Dimension of Graduate Medical Education 74
The Learning Environment 80
Cultural Influences 87
5. The Life of a Pre–World War II House Officer 95
Obtaining a Residency 96
Experiencing the Residency 102
Education and Service 112
6. Consolidating the System 117
The Second Reform of Medical Education 117
The Rise of the Specialty Boards and the Triumph of Residency 122
Graduate Medical Education and the Public Good 128
( vii )
( v i i i ) C o n t e n t s
7. The Expansion of the Residency in an Era of Abundance 135
From Privilege to Right 137
The Maturation of Clinical Science and the Creation of Subspecialty
Fellowships 146
The Ascendance of Specialty Practice 151
The Propagation of Wastefulness 156
8. The Evolving Learning Environment 161
The Decline of the Ward Service 162
The Preservation of Educational Quality 169
Maintaining the Moral Mission 178
9. The Life of a Post–World War II House Officer 185
Changes and Continuities 186
Quality, Safety, and Supervision 201
Education and Service, Again 209
10. The Weakening of the Educational Community 215
The Marginalization of House Officers 216
House Staff Activism 223
The Discovery of Burnout 231
11. The Era of High Throughput 239
The New Learning Environment 241
The Subversion of the Moral Mission 258
Changing Attitudes toward Work and Life 265
12. The Era of Accountability, Patient Safety, and Work-Hour
Regulation 271
Work-Hour Restrictions 273
Perpetual Dilemmas 287
13. Preserving Excellence in Residency Training and Medical Care 303
Challenges, New and Old 305
Aligning Education and Patient Care 317
Notes 335
Index 411
PR E FAC E
This book had its immediate beginnings while I served on the Institute
of Medicine’s “Committee on Optimizing Graduate Medical Trainee
(Resident) Hours and Work Schedules to Improve Patient Safety,” which
published its report in January 2009.1 However, this book would have been
impossible for me to conceptualize or write without my two earlier books
on medical education: Learning to Heal,2 which explores the creation of
the modern medical school and teaching hospital in America, and Time to
Heal,3 which examines the evolution of American medical education from
the early twentieth century to the era of managed care. Thus, Let Me Heal
builds on a lifetime of experience in medical education, both as a professor
of medicine who is practicing and teaching on the wards and as a medi-
cal educator and historian of medicine who is researching, thinking, and
writing about medical education in the United States. It discusses a subject
about which I have long been passionate, having for decades witnessed the
residency system’s achievements and failings as well as its fundamental
importance to the health of the nation.
While on the committee, I discovered the great need for an analytic
account of the residency system. In the making of a doctor, the residency
represents the dominant formative influence. It is during the three to nine
years that medical graduates spend as residents and clinical fellows that
doctors come of professional age—acquiring the knowledge and skills of
their specialties or subspecialties, forming professional identities, and
developing habits, behaviors, attitudes, and values that last a professional
lifetime. The four years of medical school, in contrast, provide only a gen-
eral introduction to medical practice. Yet, despite the growing historical
literature on medical students and medical schools, no history of the resi-
dency system existed.
This book represents an attempt to fill that void. It is intended to provide
a contextualized, interpretive account of the development of the residency
system in the United States. It is also meant to offer insight into our current
( ix )
( x ) Pr e fac e
dilemmas in residency training and medical care and to offer guidance for
improvement. Those who hope to improve the training of doctors and the
quality of patient care in America will find much to contemplate in these
pages. The book is written for doctors who wish to reconnect with the educa-
tional and moral roots of the profession, physicians of tomorrow who aspire
to understand the heritage of the profession they will be joining, individuals
and scholars of diverse interests who seek to understand the history and
meaning of residency training, educational and health care leaders who
strive to improve our systems of producing doctors and providing patient
care, and patients who desire to understand their own dilemmas in receiving
medical care and, perhaps, to work proactively to create a health care system
that more effectively focuses on their needs.
The residency system in America had dual roots. It arose in part from
the revolution in scientific medicine in the late nineteenth century and
the infatuation of American educators of the period with the ideal of the
German university. Thus, the residency system represents an important
chapter in the history of American higher education. It was no accident
that the first formal residency program was introduced at Johns Hopkins,
which also established the country’s first research university and first sci-
entific medical school. However, the residency system also had roots in
medical practice, particularly in the apprenticeship system. Accordingly,
it developed many characteristics of an institutionalized apprentice-
ship. These dual roots of the residency system account for its defining
dilemma: the tension between the responsibility of residency training to
provide high-level professional education and the desire of sponsoring hos-
pitals to extract as much inexpensive labor from their residents as possible.
The “education versus service” tension has shaped the residency system at
every moment of its development.
Throughout its history, the residency system was continually influenced
by evolving scientific and medical circumstances. These are explored fully
in the pages that follow. However, cultural conditions indelibly affected
the residency system as well. Changing attitudes toward work and poverty
impacted the ways doctors learned and practiced medicine, as did the civil
rights movement, feminism, the rise of consumerism, and the evolving
health care delivery system. These considerations, too, are included here.
At the core of the residency system are fundamental educational prin-
ciples: the assumption of responsibility by residents in patient manage-
ment, and the importance of providing residents sufficient time to reflect
and pursue subjects in depth. Also at the core are the moral principles of
residency training: thoroughness, attention to detail, and learning that
the needs of patients should come first. The subject includes a sociological
P r e fa c e ( xi )
dimension: Who are the residents? What was it like to be a resident? What
were the stresses and rewards? How did the experiences of residents shape
their attitudes and behaviors toward patients? How did the experience of
being a resident change over time? The topic also involves consideration of
the financing, administration, and regulation of graduate medical educa-
tion as well as the relation of residency training to public goals, such as the
quality of doctors produced, the geographical and specialty distributions of
physicians, and the ability of doctors to retain a caring, patient-centered
focus in an increasingly technological and commercialized health care sys-
tem. All these perspectives are explored in this book.
As I wrote this book, an emotional public controversy over resident
work hours was raging, fueled by the fear that tired house officers pose a
threat to patient safety. This is the most intense, divisive controversy in
medical education in generations. In one sense this debate is misguided.
The evidence is much stronger linking patient safety to the workload of
house officers and the quality of supervision than to fatigue from long
hours. Indeed, there is growing evidence that the current imposition of
rigid, highly inflexible work rules that often do not allow house officers
to complete their responsibilities is detrimental to both education and
patient care. Yet, as the following account demonstrates, more reasonable
work schedules have long been needed to make the residency experience
more humane. This book is sympathetic with current efforts to lighten the
back-breaking work schedules that residents have traditionally endured,
but it makes a strong plea for the provision of much greater flexibility in
constructing work schedules than the present system allows.
But that is only part of the story. The danger in the current controversy
over resident work hours is that attention will be diverted away from the
factors most essential to producing outstanding doctors. From the begin-
ning of the residency system, work hours were but one part of the much
larger issue of work conditions. This book examines the evolution of the
learning environment for resident training and thus speaks directly to the
challenge of establishing and maintaining excellence in residency educa-
tion. To achieve that goal, attention needs to be paid to the totality of the
learning experience. This includes the quality of the house officers and fac-
ulty, the characteristics of the teaching, giving residents the opportunity
to assume responsibility in patient management, the availability of time to
reflect and wonder, the opportunity for residents to establish meaningful
personal relationships with faculty, patients, and each other, the provision
of manageable patient loads, freeing residents from too many extraneous
chores, holding high expectations of residents, and conducting residency
training in an atmosphere of professional excitement. All these factors
( x i i ) Pr e fac e
influence the quality of training and the characteristics and capabilities of
our country’s doctors. It would do well for medical educators to heed this
lesson, particularly those who wish to see residency training continue as
professional education and not devolve into vocational training.
The most important factor affecting residency training is the quality of
patient care that house officers observe. Residents learn their specialty
by practicing, under supervision, in the real world of health care delivery.
Thus, the quality of residency training ultimately depends on the standards
of care maintained in the settings where residents learn and acquire pro-
fessional values. At the moment, the education of tomorrow’s doctors is
endangered by our country’s commercialized system of health care that,
despite lip service to patient-centered care, fails to deliver on that prom-
ise. Residents are acquiring habits and approaches to patient care amid a
culture of excess in which tests and procedures are often obtained because
they are there, not because they are needed. Residents are also learning
their specialties in a health care environment that encourages doctors to
see as many patients as possible as quickly as possible without necessar-
ily providing the time, caring, thought, and attention to detail that many
patients need. Patients are not consistently well served in such a system;
neither is medical education. These problems in America’s system of health
care delivery represent the greatest challenge facing residency training at
the present moment.
However, the relationship between residency training and the health care
delivery system is reciprocal; the fate of one affects the other. During resi-
dency, doctors acquire the habits and approaches that they carry with them
throughout their careers. Thus, there is much that good residency training
can do to make medical care in America better and more affordable. Medical
educators have the opportunity to teach a much more parsimonious approach
to patient care—one in which doctors evaluate patients thoughtfully and
proceed with only the tests or treatments that are dictated by the patient’s
particular circumstances. This approach—deemed the method of the “sci-
entific practitioner” by the original medical faculty at Johns Hopkins—has
long been the ideal of medical education and practice, if never even closely
approximated in reality. As this book points out, closer adherence to this
approach would both reduce costs and improve quality, thereby potentially
alleviating some of the major stresses in America’s system of health care.
This reciprocal relationship between residency training and the health care
delivery system, and the potential for residency education to contribute to
health care renewal, are the most important messages of the book.
With the health care delivery system rapidly changing, the 2010s repre-
sent an uncertain time for medical education and practice. Yet there is also
P r e fa c e ( xiii )
much for physicians to embrace. Developments in medical science bring us
to the brink of unparalleled opportunity in preventing and treating disease
and relieving suffering. The current turmoil in health care delivery offers
the profession and public the opportunity to redesign medical education
and practice in ways that more fully serve the needs of patients, present
and future. The opportunity is there to envision medical education and
practice as they should be, not as they are, and to work toward achieving
that end. Such opportunities are to be treasured, not feared. The country
will always need good doctors, and the medical profession has little to fear
in the changes ahead as long as it remembers that it exists to serve, that the
needs of patients come before its own, and that it always must be thinking
of improving the future as well as caring for the present.
AC K N O W L E D GM E N T S
One of the great joys of writing a book is the opportunity to thank those
whose ideas, encouragement, and support were so instrumental along the
way. Thus, it is a deep pleasure to acknowledge the many friends and col-
leagues whose contributions have facilitated and enriched this book.
Let Me Heal, like my two earlier books on medical education, Learning to
Heal and Time to Heal, is based on years of extensive research in archival
repositories throughout the country. The notes will serve as an index to
the staffs that proved so friendly and helpful. For this book, I am particu-
larly indebted to Carol Tomer (Cleveland Clinic), Steven Novak (Columbia
University Medical Center), Scott Podolsky (Countway Medical Library,
Harvard Medical School), Nancy McCall (The Johns Hopkins Medical
Institutions), Jeffrey Mindlin (Massachusetts General Hospital), and
Stephen Logsdon (Washington University School of Medicine). I am also
grateful to Thomas Nasca and Kevin Weiss for providing me access to the
records of the Accreditation Council for Graduate Medical Education and
of the American Board of Medical Specialties, respectively. I owe a special
thanks to Debra Weinstein for introducing me to the collection of Chief
Resident Letters in the department of medicine of the Massachusetts
General Hospital and to Jatin Vyas for granting me permission to examine
those letters.
Throughout the project I benefited from the encouragement and assis-
tance of many friends who were always available to discuss ideas and pro-
vide support. I would particularly like to thank Marcia Angell, Garland
Allen, DeWitt Baldwin Jr., Iver Bernstein, Henry Berger, Melvin Blanchard,
Timothy Brigham, Douglas Carlson, Ralph Dacey, Thomas De Fer, Bradley
Evanoff, Mark Frisse, Lara Goitein, Lee Goldman, Daniel Goodenberger,
David Hellmann, Michael Johns, Joel Katz, David Kipnis, David Konig,
Alan Kraut, Howard Markel, Thomas Nasca, Ingrid Philibert, Arnold
Relman, Walton Schalick, Dale Smith, Murray Weidenbaum, and Sankey
Williams. I am also grateful for the insights of those who have written about
( xv )
