The plane in which I’m flying to New Zealand is at 35,000 feet — cruising altitude over the Pacific, three hours out from Los Angeles. The cabin is dark and, other than the dull roar of the engines, all is quiet. Then the announcement that physicians hope not to hear comes over the PA system, “Is there a doctor on the plane?”
I catch the attention of the flight attendant and identify myself as a physician. She tells me that a passenger fell in the back of the plane and hit her head. Could I help?
As I move to the rear of the plane, I see a middle-aged woman sitting on the floor of the galley. Someone else is with her. He introduces himself as a pediatrician and, when I volunteer that I am a lung doctor and a critical care physician, he sighs in relief, says “She’s all yours,” and returns to his seat.
I sit on the floor beside the woman and, as we both bounce with the turbulence, ask her name. “Angela,” she responds (not her real name).
“How are you? What happened?” I ask. She tells me that she got up to go to the bathroom, slipped, and fell, hitting her face and forehead on the counter in the galley. I follow with questions about loss of consciousness and history of seizures and try to gauge her clarity of thought. “What medical problems do you have?” and “What medications are you taking?” She mentions aspirin, which I note as a possible risk for bleeding after an injury.
This scenario, being asked to care for someone who is ill or has been injured on a flight, occurs routinely for doctors. Over the years, I have been asked to assess pregnant women as well as individuals with seizures, acute intoxication, and other maladies that are often outside of my specialty (pulmonology). In these circumstances, I fall back on my early training in medical school — training that was broad and comprehensive, the medical equivalent of a liberal arts education.
Unfortunately, this type of general education is becoming less common in medical schools across the country. Responding to students’ desires to focus only on their career aspirations to become specialists, some schools let students take multiple courses and seek clinical experiences in a particular track or pathway rather than ensure they acquire knowledge and skills in a broad range of areas.
Despite the explosion of medical knowledge in recent decades, many medical educators are questioning whether medical school really needs to be four years long. Why not speed things up, save money, and get into your specialty sooner? Why would one spend time in that fourth year embracing areas of medicine you won’t be needing in your post-graduate training? After all, isn’t the goal of medical school to prepare you for residency training?
This approach, which emphasizes early specialization and views medical school as a hurdle to be cleared in the most efficient way possible, risks transforming medical schools into vocational rather than professional training: “Just learn how to do these skills and take care of this narrowly defined list of problems and you are all set.” Furthermore, people trained in this way may be more likely to make mistakes because of their limited knowledge and experience.
Back to Angela. I perform as much of a physical examination as I can under the circumstances. Using equipment from the plane’s small medical kit, I check her blood pressure and heart rate, her eye movement, and how her pupils respond to light. I also assess her for entrapment of muscles (failure of the eye to move in a particular direction), which could indicate a facial fracture.
“How is she?”
I look up. The captain has come to the rear of the plane from the flight deck. He’s interested in Angela’s condition because he is responsible for the passengers on his plane. He also needs to make a decision: “Do we need to turn the plane around?” he asks me.
I explain what happened and my give him assessment of Angela’s status. Trying to be aware of the possibility that my judgment might be affected by a desire to continue to our destination, I force myself to carefully go through all the possibilities and probabilities of what might have happened and what could happen as a consequence. I think she will be okay, but we will need to watch her for the rest of the flight.
We arrive in Auckland hours later; Angela is fine.
As a physician, faculty member, and educational leader at Beth Israel Deaconess Medical Center and Harvard Medical School, I was recently involved in the development of a new curriculum spanning all four years of medical student education at Harvard. There were hours of discussion with dozens of faculty members over several years about the content and teaching methods we thought were best for laying the foundation for the next generation of doctors.
In these conversations, we often talked about the kind of doctors we hoped would emerge upon graduation from Harvard Medical School. Would they be compassionate with good communication skills? Would they be able to think and reason analytically? Would they be aware of cultural differences in our diverse population and understand the effect of societal factors on health and disease? And would they be knowledgeable about electronic medical records?
There are many things that go into being a great doctor. But I would muse from time to time: “I want them to be able to do more than the flight attendant when called to help a passenger at 35,000 feet.”
Richard M. Schwartzstein, M.D., is professor of medicine and education and director of the Carl J. Shapiro Institute for Education and Research at Beth Israel Deaconess Medical Center and Harvard Medical School.
My daughter and I were on a flight from Houston to Seattle. The call for a Dr. came out. Although I am a radiologist, I had two years of general surgery training and two years as a general surgeon in the Air Force from 67 through 69. The problem was a huge black Nigerian male who had passed out in his seat. When I arrived, there is an EMT and a family physician applying an oxygen mask to the sitting patient. I am mediately had him removed from his seat laid down on the floor and put in Trendelenburg. With difficulty we took him back to the Galley. since he was unconscious, there was no way to ascertain a medical history. He had a rapid week pulse. He was breathing normally. We kept him in Trendelenburg and gave him oxygen. Slowly he recovered . When he woke up, he complained of abdominal pain. On physical exam, he had acute right lower quadrant pain with rebound. We advise the captain that we thought he had acute appendicitis and we landed in Denver so that he could be taken to the hospital. I provided my name address phone number etc. I got absolutely no feedback from the airlines. I hope the patients OK. I’m glad I had a very general education in medicine, and was able to Intervene in the patient’s behalf. It would be nice if the airline would you have a physician feedback on the results of the decision.
In my daughter and I were on a flight from Houston to Seattle. The call for a Dr. came out. Although I am a radiologist, I had two years of general surgery training and two years as a general surgeon in the Air Force from 67 through 69. The problem was a Nigerian male who had passed out in his seat. When I arrived, there is an EMT and a family physician applying an oxygen mask to the sitting patient. I am mediately had him removed from his seat laid down on the floor and put in Trendelenburg. With difficulty we took him back to the Galley. since he was unconscious, there was no way to ascertain a medical history. He had a rapid week pulse. He was breathing normally. We kept him in Trendelenburg and gave him oxygen. Slowly he recovered . When he woke up, he complained of abdominal pain. On physical exam, he had acute right lower quadrant pain with rebound. We advise the captain that we thought he had acute appendicitis and we landed in Denver so that he could be taken to the hospital. I provided my name address phone number etc. I got absolutely no feedback from the airlines. I hope the patients OK. I’m glad I had a very general education in medicine, and was able to Intervene in the patient’s behalf. It would be nice if the airline would you have a physician feedback on the results of the decision.
Refreshing to read an article that speaks to the escalating pressure on physicians to overspecialize. This emphasis has been at the expense of a broader grasp of how symptoms are often only a piece of a larger puzzle. What does treating “the whole person” actually mean given today’s healthcare realities? While marketing trendsetters promote holistic treatment, technological “progress,” along with government and insurance documentation have pushed professionals in the opposite direction, toward fragmentation of information, and decline of clinical judgement. The less we see and confer with colleagues, the less we learn, post residency.
We have become overly dedicated to discovery and dissection of diseases, down to the last molecules, but with less reflection. Because I am a psychiatrist, this trend has become most evident to me in psychiatry. Here the series of DSM’s have grown in descriptive categories, but without insight into what they imply. One thing I observe, is that classification of illnesses, such as depression, do not imply common etiologies or treatments, but merely a constellation of symptoms. Same for ADHD and Anxiety. No, I can’t prove this with a double blind study, but only point out we would have a far better batting average of successes if all depressions and anxieties were the same. Classifying them is not equivalent to understanding them, and what to do about it.
Like the author, I also rely on earlier training to supplement what I must do today. Ironically, the trend toward specialization has made specialists less available and sometimes not particularly appreciative of how a lab’s low normal may be normal for their specialty but not for psychiatry. I have needed to keep up with how to treat, at least initially, medical illnesses that first show up with psychiatric symptoms. Depressed hypothyroid patients with normal or borderline normal labs, women with mood instability and hormone secreting IUD’s, borderline psychotic young women with PCOS, are just a few examples.
Twenty years ago, I routinely called and spoke to a colleague, a neurologist . We referred to each other and shared patients. Those days of talking to colleagues, meeting at drug company sponsored lunches, and curbside consults are long gone, at least for now.
All this progress and efficiency have isolated the Docs in the trenches, especially those in private practices. Yes, we need to be a Jack of many trades, and try to master our own. For this we should at least be upgraded to “Provider Plus and Prescriber Plus.”
Peggy Finston MD
This story is very well said and very important. I am Board Certified in both Psychiatry and Neurological Surgery, but in over 50 years of being a physician, I am most proud of being able, willing and confident, to evaluate any person who is in need of help. I am grateful and proud of my medical school, the University of Cincinnati Collge of Medicine who prepared to be a complete physician. I graduated in 1966 when internships were still necessary. I took a straight medicine internship, followed by 4 years in the military, a year of general surgery, a requirement for entering a 5- year Neurosurgical residency. Much later I took two years of General psychiatry residency followed by a fellowship in Addiction Psychiatry. I still see veterans. I can say without reservation I loved my medical education, all of it, and benefited from every minute. Young medical students today may think I need a Mental Status Examination, but I would be very, very careful shortening medical school. I can still remember cases that I saw in the Emergency Room while a medical student that influence how I evaluate patients today.
I graduated in 1966 when internships were still necessary.
They’re not still necessary? When did that happen?
I am pleased to read this article by Dr. Richard Schwartzstein on the importance of having a broad foundation of medical education for physicians, to support basic competency outside their speciality. Not only is this important for physicians, it is also essential for other healthcare providers, especially for nurses. Being able to critically assess a patient, using basic tools and your knowledge allows the health care provider to be effective no matter the location or situation. In the air at 35,000 feet or at the local shopping mall or restaurant, all of us may be called on to step in a provide help in an emergency to people who we would not care for in our usual clinical roles. When that happens, we fall back on these basics, and the broader skills of communication and observation to be able to provide the needed care. Dr. Schwartzstein, you articulated why heart care education needs to have a basic generalist foundation. Thank you! Linda Godfrey-Bailey, MSN, ACNS, BC
I suggest that airlines arrange to have available one or more physician specialists in emergency medicine to consult by telephone, assuming a radio link is available, with whatever in-flight medical or non-medical personnel happen to be available when someone needs to be checked by a doctor. All doctors are accustomed to consulting with colleagues who have specific relevant experience.
I think that’s already done. I saw a show on PBS about medical emergencies during air travel, and they showed a call center with physicians for exactly that. It might be helpful to have a more comprehensive medical kit, like one with telemedicine tools like an EKG and some basic pharmaceuticals like epinephrine, nalaxone, and insulin autoinjectors, and nitroglycerin. Maybe some mechanism for the remote doctor to unlock compartments containing prescription drugs after he’s authorized dispensing them.
A wonderful article about the breadth and depth required in medicine today. I would be interested to know more about whether, when discussing the kinds of doctors you hope would emerge, your team emphasized how neophyte physicians will recognize limitations of their field and trainings, and how to embrace and foster an Interprofessional collaborative approach to care?