Our current scheme and its overbearing credentialism is out of date and cannot keep up with a rapidly changing health care environment. Greater flexibility is needed for the well-being of patients and physicians alike.
Professional burnout and anticipated physician shortages continue to be highly debated topics. Indeed, the American Medical Association reports that 45 percent of physicians have symptoms of burnout, and the Association of American Medical Colleges anticipates a current shortfall of 64,000 physicians in 2024, which is expected to increase to 86,000 by 2036.
The prospect of fewer and unhappier physicians leads to a self-perpetuating state of malaise. While multiple external factors such as government regulations, corporatization of medicine, and changing public expectations are blamed for this funk, it is nevertheless necessary to take a hard look at the ways in which the profession might be contributing to its own misery by maintaining an antiquated medical education structure which is more rigid than ever and ill-adapted to a changing health care environment.
The dead-end job
The standards for medical school admission have never been higher, but we take extraordinary, multitalented individuals who have excelled at a variety of endeavors and corral them into an inflexible training program leading to a dead-end job. Is professional boredom contributing to our epidemic of burnout? The irritation with regulations and corporate didacts might be a symptom of a deeper problem.
Medical school, full of pregnant possibility, seems now to be the pinnacle of it all; it’s downhill from there. Once through our current front-loaded system, there’s not much room for change. The multitalented student becomes the disillusioned physician.
Some prospective medical students are opting to become physician assistants so as not to be pigeon-holed in one specialty. Similarly, nursing education is iterative: From associate degree through bachelor’s to master’s and doctorate, and all can be done part-time. Furthermore, advanced practice nursing is a very different career challenge than bedside nursing. An acute care nurse practitioner can readily move from critical care to cardiology, but a physician, with more baseline training, cannot.
A rigid system
The structure of medical training in North America has scarcely changed in the 125 or so years since the Flexner Report of 1910. No doubt, the standardized pathway of medical school and residency that followed greatly improved the overall quality of physicians. But this is a rigid system which has not evolved to meet the challenges of an increasingly complex and rapidly evolving medical environment.
Back then, there were a limited number of residencies and subspecialty training was less formal. Once trained in a base specialty, there was scope for a career focus to evolve more organically. As medicine has become more complex, however, the number of residencies and specialty and subspecialty training programs have continued to increase as medical and surgical practice continues to be broken down into narrower and narrower quanta of specialism.
While it is valuable to recognize expertise in a particular area of medicine, exclusive reliance on formal training programs slows knowledge translation as it takes years for trainees to roll through the system to meet the needs of a health care system that may have already shifted. Given the increasing debt burden, young physicians are increasingly reluctant to embark on additional training unless there is a tangible financial benefit, further compounding slow knowledge translation and creating shortages in lower-paying specialties.
Conversely, one may wonder how many more residents would consider primary care if there was a realistic option to gain specialty certification later through practice.
The demographics of medicine have also changed: Two-career couples mean that it is not always possible to relocate for training. It is often said that older physicians often sacrificed their families for their careers, but I suspect that many younger physicians are conversely sacrificing their careers for their families given the inflexible nature of medical training. This naturally affects women more than men given a system set up for a then-male-dominated profession and the social norms of 100 years ago. Unsurprisingly, female physicians are more likely to report burnout than their male colleagues.
As the opportunities to grow within the profession dwindle, it is not surprising that 35 percent of physicians are eyeing leaving the profession and seeking challenges elsewhere. More insidiously, the reliance on formal training creates the perception that only through formal training can expertise be obtained. Hard-earned experience is not validated, contributing further to decreased professional satisfaction. A nihilistic approach develops to career development. Physicians’ scope of practice narrows as they are pushed to stay in the lanes drawn by their area of certification. Medicine becomes increasingly siloed as specialties become their own echo chambers, further eroding collegiality. Evolving interests are discouraged, further leading to burnout.
A solution in board certification?
How do we get out of this rut which we have created for ourselves? The solution might be in an increasing source of irritation for many physicians, namely board certification.
Board certification, like structured training, is a valuable aspect of physician career development which has become seemingly less valuable and more burdensome, paradoxically as it has become mandatory. When the various specialty boards were formed starting in the 1930s, the intent was to recognize excellence for physicians in practice and not to be certification to practice. Board certification is now tied primarily to completion of training, and maintenance of certification leaves little room for career growth beyond the defined parameters of the given specialty. Instead of an honor to be proud of, board certification and its maintenance is seen by many now as a burdensome yoke, something that is necessary to do but without much perceived benefit.
Perhaps it is time for board certification to evolve beyond its current role as a capstone examination at the end of accredited training. While is it hard to envisage a pathway for base specialization other than formal training, certainly it should be feasible to develop practice pathways for subspecialties. Indeed, these already exist for a period of time when a new specialty is established, but this is always time-limited.
Let’s leave them open and strengthen the parameters to certification via this pathway by requiring case logs and proof of a significant amount of relevant CME. This would allow the profession to better respond in real time to evolving specialty shortages. It would also democratize the spread of medical knowledge.
This process is already upon us as artificial intelligence and the wealth of virtual educational opportunities continue to grow, making expert knowledge and education far more available. With the shackles of our rusting training system loosened, physicians could once again grow professionally in meaningful ways throughout their career and meet the evolving workforce needs in a more responsive manner. Learning and doing new things is a great antidote to the vicissitudes of work and might be just what the doctor ordered to put a dent in burnout for the long-term benefit of the profession and the public they serve.
Ravi Agarwala is a critical care physician.
