Practicing Physicians: The Intern & Resident Experience in the Shaping of American Medical Education, 1945--2003.

다국어 초록 (Multilingual Abstract)

Spanning from 1945, when internships and residencies had become requisite to independent medical practice in the U.S., to 2003, when major reforms of graduate medical education were codified by its accreditation system, my dissertation focuses on the experiences of housestaff with the aim of understanding what they found problematic .about their training, and how they sought to change it.. Activist housestaff believed that graduate medical education, which was key to physicians' professional formation, fostered a professional identity which was at odds with the compassionate, socially responsible medicine they hoped to practice.
Sociological research on medical trainees in the 1950s and 1960s, by articulating medical education's impact on professional formation and suggesting its contingency, laid the groundwork for decades of efforts by housestaff to transform their own training.
Would-be reformers stayed persistently focused over time on the implicit values that were being transmitted by a training system they believed was grounded on the exploitation of themselves and their patients. It was a truism to these housestaff that American physicians trained on the poor and treated the rich. They thus argued that the process of becoming competent practitioners of medicine was concomitant with a loss of the pre-existing human values that had led them to medical school in the first place, and a gain of troubling professional values.
Despite the constancy of reform targets over time, successive cohorts of housestaff activists deployed strikingly different reform strategies, enabled by the multiple dualities they embodied within the health care system (student and employee, professional and laborer, physician and layperson).
The reform targets and strategies were seen by some in the medical profession as self-serving, and therefore as skirting the principles of professional ethics. Early activists were particularly vulnerable to these charges because their tactics were outside the norms of traditional professional behavior—various subsets of reformers coopted "rights" language from marginalized peoples, formed labor unions for physicians, and wrote mass market exposés of the medical training system. Later activists adopted a very different tactic—they self-consciously embraced traditional professional values and venues. Patient care and professionalism became central to the argument for reform.
Graduate medical education reform had been sought by housestaff activists for decades, and by the late 1990s, the focus was on achieving regulatory changes. The question was whether regulations should be imposed externally, via legislative or judicial decisions, or internally, by the professional bodies which oversaw the graduate medical education system. Facing the prospect of housestaff- and patient-supported legislation that would externally impose reform in the name of patient care, in 2003 the accreditation agency overseeing internships and residencies instituted major changes. For the first time, duty hours were to be limited and monitored on a nation- and specialty-wide level. This development was far from encompassing the full range of changes that had been sought by generations of housestaff activists, but it nevertheless represented significant reform.
My research demonstrates that successive generations of housestaff in this era of modem graduate medical education were troubled by the same types of problems in medical training. This lack of change over time is remarkable. It suggests continuity within American medical education—of entrenched deficiencies within the system, and of rhetorical commitments to an established set of idealized professional values and ethics. With ongoing debates regarding the breadth and efficacy of the 2003 reforms, graduate medical education is very much a work in progress, and I hope that this dissertation will contribute to that conversation. The sources for this research include diaries, sociological field notes and publications, my own oral histories, published memoirs, the archived papers of a number of individuals, and internal documents from organizations ranging from the bastion of the medical "establishment," the American Medical Association, to the first housestaff union, the Committee of Interns and Residents.