Breaking The Rules Of Healthcare: Selecting The Best Doctors

At a leading academic hospital in greater New York, a patient who I’ll call John has just undergone complex neck surgery. Though the operation went flawlessly, the patient is having trouble breathing. The attending physician and senior resident look down John’s throat to see his vocal cords are nearly closed, restricting airflow and creating a potentially deadly crisis. After ruling out the possibility of nerve damage, the doctors are stumped. Neither has encountered this type of problem before.

Thankfully, it’s 2022 and there’s an app for that. Without delay, the senior resident reaches into her pocket, pulls out her iPhone and, with a few taps, finds a case report identical to John’s. Reading the article, both physicians realize his problem is self-limited and will resolve when the local anesthetic wears off. Half an hour later, the patient is breathing normally and ready to go home.

John is fortunate to live in this century. At any point in the last, his doctors would’ve searched their memories (not the internet) for a solution and come up blank. Alarmed, they’d have no choice but to intubate the patient and wheel him to the ICU where he’d suffer, restlessly, until morning.

As John’s story illustrates, technology can help doctors avoid medical mishaps and deliver superior care—far better than when physicians rely on memory alone to make difficult decisions.

Knowing this, why do medical-school deans and residency directors continue to select future doctors based on standardized test scores, which—more than anything else—measure one’s ability to memorize thousands of arcane facts? The answer to this question lies in the “rules” of the medical profession.

Breaking the rules of healthcare

All doctors adhere to two different sets of rules. There are the written rules, covering everything from human anatomy and physiology to the current laws and regulations that govern the profession.

Then there are the unwritten rules, which dictate the “right way” to act. These rules, which heavily influence clinician behavior, aren’t taught in textbooks or lecture halls. They are observed and subconsciously absorbed by medical students and young doctors whilst trying to learn the ropes and earn the respect of physician leaders.

Most of healthcare’s unwritten rules were established long ago, prior to 21st-century advances in science, technology and medical practice. Many of them are now outdated—obstructing clinical excellence and holding our nation back.

Although healthcare professionals object, vocally and appropriately, to a lot of medicine’s written rules, they rarely question or even consciously think about the unwritten ones. Our nation is suffering the consequences of this oversight. Independent research confirms that Americans receive the most expensive and least effective care in the developed world. Medical spending now exceeds $4.1 trillion annually and accounts for 19.7% of the GPD. Despite how much we spend, the quality of U.S. healthcare ranks dead last among wealthy nations. Americans have the lowest life expectancy, worst infant and maternal mortality rates, and highest incidence of chronic disease compared to people in peer countries.

As a nation, we won’t solve medicine’s cost or quality problems by tinkering at the edges or making small modifications here and there. Instead, we must reject and replace the dozens of rules that prevent doctors and others from delivering great care at reasonable prices.

This article, the first in a new series called “Breaking The Rules Of Healthcare,” looks at the outdated ways we select and train future doctors. Each subsequent story will highlight an unwritten rule—explaining why it exists, why it’s harmful or wasteful, and what can be done about it. ?

Rule 1: The best doctors are the ones with exceptional memory

Each year, roughly 50,000 graduating seniors apply for 20,000 medical-school openings. For those fortunate enough to get accepted, the chances of landing a residency spot at a top academic medical center are even slimmer.

Now, imagine you’re the dean of medicine at a prestigious university or a residency director in a highly competitive specialty. With far more applicants than available positions, your job is to decide which skills and qualifications separate the best from the rest. If you’re anything like your peers, you’ll lean heavily on standardized-test scores. As a rule of thumb, candidates who score below the 80th percentile on the MCAT or STEP exams need not bother applying to top medical schools like Harvard or Stanford. They also won’t land an interview for a coveted residency position like neurosurgery or cardiac surgery.

The problem with this process for weeding out applications isn’t merely the reliance on standardized tests. The problem is what these tests measure.

The ability to hold and recall facts was vitally important in the 20th century. Back then, a doctor wanting to access the totality of medical information would need to lug around a 100-pound backpack stuffed with textbooks and journals. Conducting a “quick search” for an obscure case report (like the one that saved John) was impossible. So, as a rule, the “best and brightest” doctors were the ones with the encyclopedic memories. And the most effective instrument for finding those physicians was national standardized testing.?

Selecting the best doctors for tomorrow

With easy access to smartphones and terabytes of digitized medical information online, memorization is no longer the profession’s defining skill. To kickstart healthcare’s transformation, we must break and replace the outdated rule that the best doctors are the ones with the best memory.

To find the ideal doctors for the 21st century, a better rule would be to identify candidates who can (a) use modern technology to access reliable information, (b) synthesize medical data into a coherent treatment plan and (c) effectively communicate that information to patients from diverse backgrounds. Physicians who do these three things, consistently, can deliver far better care than doctors of the 20th century ever could.

To help medical schools and residencies identify and train the ideal doctors of tomorrow, here are two initial steps:

Modify standardized testing. Today’s MCAT and STEP 1 exams are day-long marathons of applied memorization where test takers must summon obscure facts without the assistance of smartphones. A more useful exam would require participants to employ 21st-century tools to solve 21st-century medical problems, the kinds of complex challenges doctors encounter in real life. Rather than banning phones from testing centers and peppering students with multiple-choice questions, exam writers would require the use of mobile tech to source and apply clinical information. This approach would most closely simulate future clinical practice.

Change the curriculum. Medical students know their performance on the STEP exams will determine their ability to compete for the most desired specialties. That’s why second-year students spend an average of 10.6 hours per day cramming for the exam, leaving little time for classwork. This obsession among students drives school administrators and faculty bonkers, which is why STEP 1 will become pass/fail in 2022. But that change, alone, won’t alter the rule that residency directors use to identify the best future doctors. In fact, most directors with whom I’ve spoken plan to substitute STEP 1 with another test that overvalues memorization, STEP 2, as their basis for measuring a doctor’s potential.

The foundational skills doctors need for tomorrow include technological competence, complex problem-solving abilities and effective communications. The ability of doctors to master these skills will determine, among other things, whether a patient like John spends a hellish night in the ICU with a plastic tube jammed down his larynx or goes home fully recovered 30 minutes after surgery. ?

Breaking the outdated rule for selecting medical students and residents is only a first step toward transforming American healthcare. There are many more rules left to break. To receive future articles on breaking the rules of healthcare, subscribe to this newsletter.

Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s a Forbes contributor, bestselling author, Stanford University professor, and host of two healthcare podcasts. Pearl’s newest book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” is available now. All profits from the book go to Doctors Without Borders.