Graduate Medical Education

Graduate medical education has become as important as attendance at medical school in the training of physicians. Up to 1970, most graduates of medical schools first took an internship in general medicine and then a residency in a specialty. After 1970, practically all medical school graduates entered residency training in a specialty immediately after graduation. Residency programs have been located in hospitals affiliated with medical schools and have been accredited by specialty boards, which have been controlled by medical school faculty members. This situation has led to insufficient breadth of training and lax regulation of the programs. The internship, which followed graduation from medical school until its elimination after 1970, consisted of one or two years of hospital training, usually unconnected with any medical specialty. It was designed to provide gradually increasing responsibility for patient care, supplemented by formal teaching in rounds and seminars. In practice, as George Miller observed in 1963, it was “virtually impossible to find an internship [program with] a graded and sequential course of study leading to relatively well-defined goals.” This was also the finding of several surveys of interns and physicians. A 1959 survey of 2,616 interns found that the two most frequently cited deficiencies of internships were lack of “sufficient review and criticism of your work with patients,” cited by 47 percent, and “adequate instruction in the application of scientific knowledge to patient care,” cited by 34 percent. A 1952 survey of 6,662 graduates of the medical school classes of 1937 and 1947 and a later survey of over 3,000 interns and residents produced similar findings. Formal instruction during the internship was usually casual and unsystematic. Stephen Miller's study of one university hospital found that interns spent only a few hours per week in formal lectures and conferences and on rounds. In teaching on rounds, “the visiting physician does not prepare a lecture or other teaching material. He simply walks onto the ward and responds to patients and their problems with opinions and examples from his own clinical experience.” The educational value of rounds therefore depended on the illnesses of the patients and the relevant skills of the physicians.