WI: 1970s counterculture — successfully! — de-professionalizes both medicine and law

In this ATL, about two-thirds of U.S. doctors have worked as nurses. Of course, they have. How else would you learn medical practice? Just like most auto sales managers have worked as sales people.

Medicine as a career has very much become multi-path. Some young people who want an early start still go to straight to medical school. But that's a little outside the norm and constituted just 29% of newly minted doctors in the year 2015.

Law's a tougher nut, because it is literally hard-wired in! But let's say the counter-culture successfully de-professionalizes this field as well.

Please tell me more.
 
Law is actually the softer nut, since until rather recently it was possible to become a fully licensed lawyer by 'reading' (i.e. studying & practicing under the supervision of a fully licensed lawyer) law, whereas medical schools have been around for the better part of three centuries.
 
So, the route to law was through an apprenticeship, right? Surprised this is still not somewhat available.

And medical schools have been around probably even longer than several centuries. But I think the dominant U.S. model traces itself to the 'Flexner Report' of 1910, with both good and bad effects.

Again, what I wished would have happened was multi-path, not single path.
 
As I understand it, a lot of medicine is trial and error in a respectful sense. For example, if someone has a tricky kind of pneumonia, hit it with one narrow-spectrum antibiotic, and if that doesn't work, hit it with another. You might be running a culture at the same time, but in the several days it takes to get back an answer, you can try your best guess antibiotic. And whether a particular antibiotic works or not, is itself diagnostic.

I saw a doctor with a cough, sore throat, and maybe a chest cold. I came back to see him about a week later still having the cough. The guy was a little put out to see me. Well, these are the cases you want to embrace. The hard cases are the good cases.

Or, with antidepressants, something like zoloft or wellbutrin might work great for a particular person, and not do a thing for another. Just that everyone's biochem is a little different. I've read that it takes four to eight weeks to tell and the point is to be willing to roll and try a series of antidepressants. Also, if you're going to stop, phase down in a series of medium steps, even if it doesn't seem to have been working, just that your body may have gotten used to it.

Again, trial and error in a respectful sense. Which is kind of the opposite of the school skill where you really focus on "being right." or maybe school serves as a proxy for a generalized IQ test, even though we now know that intelligence is multiple dimensions and these tests aren't near as good as we once thought.

And the defining characteristic of a profession is supposed to be the self-policing aspect. Which occasionally does happen in the punitive sense of suspending a doctor's license, but not in the more positive sense of coaching people up. Not like it should be. The norm is that doctors go it alone. You can't criticize another doctor even if you're 90% sure he or she is doing something seriously sub-par. It's like the profession lacks the medium social skills and the medium courses of action.
 
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And the legal profession does a poor job on both counts. Both on failing to send people to prison who need to be there, and on sending people who don't need to be there. And it seemingly can't even acknowledge really bad conditions in jail and prison.

Alright, there's One L by Scott Turow first published in 1977. The first part is exciting because he's learning new intellectual approaches and concepts. That part maybe lasts into October. Then it just becomes a long slog where it affects people's home lives and everything else. And I'll use the word brutalizing. The brutalizing effect of legal education where being "right" and being "first" easily overshadows anything even approaching justice. Scott was of the opinion that the second and third years of law school were largely unnecessary.

What this whole complex, regimented approach does is to separate the law from the people it's trying to serve. And yes, law should be the servant of people rather than vice versa.

And people agree with Scott and other critics from time to time. But then all they do is nimble at the edges and slightly change the curriculum.
 
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Full disclosure: I am a practicing physician.

First off, can you clarify what you are intending "de-professionalization" of medicine to entail? Are you looking more "non-traditional" physicians? Or are you looking to change the underlying structure of the profession of medicine, i.e. the fiduciary relationship between and physician and their patient? That is such a vague term I'm not sure what you're actually asking.

In this ATL, about two-thirds of U.S. doctors have worked as nurses. Of course, they have. How else would you learn medical practice? Just like most auto sales managers have worked as sales people.

Couple of intrinsic faults to this logic.

First, being a physician is not just being a manager of a group of nurses (there are actually nurse managers whose job that is). Nursing and medicine (defined here as physicians) are fundamentally different professions. The overall goal (patient care) is the same, but the approach and mindset are distinctly different. In western medicine these approaches are synergistic and overall care would be markedly poorer if only one approach was dominant.

Second, physicians are not the only "professionals" in the medical field. Nurses, therapists, audiologists, psychologists, techs etc all have professional organizations and significant educational barriers to entry. So this is really just one professional becoming a different one.

Lastly, if you're looking for "non-traditional" physicians, you don't have to look very far. A small but significant percentage of doctors come from many previous careers from both inside and outside the allied health professions. I have colleagues whose previous careers include a paramedic, economist, musician, and combat engineer.

As I understand it, a lot of medicine is trial and error in a respectful sense. For example, if someone has a tricky kind of pneumonia, hit it with one narrow-spectrum antibiotic, and if that doesn't work, hit it with another. You might be running a culture at the same time, but in the several days it takes to get back an answer, you can try your best guess antibiotic. And whether a particular antibiotic works or not, is itself diagnostic.

I saw a doctor with a cough, sore throat, and maybe a chest cold. I came back to see him about a week later still having the cough. The guy was a little put out to see me. Well, these are the cases you want to embrace. The hard cases are the good cases.

In general, that's an outdated view of medicine. As recently as 20 years ago, the majority of treatment decisions were based on physician experience and anecdote. So yes, educated guesses and a form of tailored trial and error. However, there has been an explosion of data on evidence-based best practices since then which has transformed medicine. For the preponderance of diseases that affect most people, for example diabetes, high blood pressure, high cholesterol, we know the ideal treatment (at least at the population level).

True trial and error, empiric medicine is reserved for the so-called "zebras," rare diseases where we either don't understand the pathophysiology or have an available treatment. These are the diseases you see on all the medical shows, which skews perceptions of how physicians practice. In the real world, the few physicians who practice like a Dr. House charge cash up front and sure as hell won't take people with Medicaid/Medicare. Your average primary doc needs to see 25-30 patients a day just to stay afloat financially (the Medicaid reimbursement from a standard clinic visit is about $25-50 depending on time/complexity).

In regards to your experience, it sounds to me like you just had to deal with a physician who was overworked, uninterested or both. If he/she truly just threw a random antibiotic at you for a week of cough and sore throat then honestly, they're not doing a very good job. Most of those symptoms are viral in nature, so an antibiotic is ineffective. Even if it is a bacterial pneumonia there are specific antibiotics that are first-line, and we usually start broad and narrow our antibiotics as we get culture and sensitivity data (other way around is a prime driver of antibiotic resistance). Obviously I don't know the details, but it sounds to me like you had the misfortune to deal with a doc with poor bedside manners and mediocre clinical acumen.

I can damn sure say there are plenty of bad or middling doctors in this profession! :)

Again, trial and error in a respectful sense. Which is kind of the opposite of the school skill where you really focus on "being right." or maybe school serves as a proxy for a generalized IQ test, even though we now know that intelligence is multiple dimensions and these tests aren't near as good as we once thought.

And the defining characteristic of a profession is supposed to be the self-policing aspect. Which occasionally does happen in the punitive sense of suspending a doctor's license, but not in the more positive sense of coaching people up. Not like it should be. The norm is that doctors go it alone. You can't criticize another doctor even if you're 90% sure he or she is doing something seriously sub-par. It's like the profession lacks the medium social skills and the medium courses of action.

Agree that school performance is an unreliable indicator of both intelligence and success as a physician. Problem is it's hard to test for the social skills and emotional intelligence necessary to make a truly excellent doctor. Also, plenty of medical students start out bright and altruistic but sucumb to burnout and dissatisfaction.

Self-policing is a bit of a mixed bag. There is some, but there is unspoken etiquette in the field that puts up significant barriers to physician-physician criticism. It's certainly an area for improvement. However, you're quite off the mark about the lack of coaching. Almost all physicians undergo a prolonged apprenticeship (residency and fellowship) where this exact process occurs - it ranges anywhere from 3 to 9 years depending on the specialty of the physician.

Finally, I'd argue that the true marker of a profession is the fiduciary relationship, i.e. the responsibility of the physician to subordinate his or her interests to that of the patient. At least, that's what attracted me to it! :)

Anyways, kind of a massive post. Would love to hear specifically what aspects of medicine you're looking to change - there's plenty of room for improvement.
 
Full disclosure: I am a practicing physician.
...

I'm an attorney and can say many of the same things about analogous aspects of the legal profession. What I really agree with is the fiduciary aspect of a profession and, if you remove that in law, you've gutted what it is to be a lawyer. Also, the idea of de-professionalizing the practice of law raises the specter, as it does in medicine, of a Wild West environment in which the consumer is very much put into a "buyer beware" position with respect to any doctor or lawyer they deal with. Professional licensing at least sets a standard of competence. Whether it is through medical boards or the bar exam, the licensing process does ensure some basic level of competence and vetting of the individual. If anyone can hold themselves out as a physician or lawyer, there are bound to be people doing so who are not in the least bit qualified to do so.
 
And the legal profession does a poor job on both counts. Both on failing to send people to prison who need to be there, and on sending people who don't need to be there. And it seemingly can't even acknowledge really bad conditions in jail and prison.

I heard that public defenders (sometimes called public pretenders) aren't so hot. There was this one guy my friend knew who got arrested for something he didn't do. Because of the public pretender, though, he ended up spending two years in jail while they figured out what to do with the case or something. All because of the PP.
 
I don't think it's possible, because both fields deal with people's lives in a direct and life threatening way.

If we take programming (my profession) it's largely unregulated and "unprofessional" (of course there are software engineers, certifications, designations and so on but anyone can call themselves an architect or programmer or developer without legal repercussions). Why is that? Part of it is the personality of the people involved which I won't talk about ("lone wolf" programmers, libertarians) but it's just not as important as a physician, lawyer or engineer (don't actually say that to any computer programmer we think the world runs on our code!). If a bridge collapses or a surgery is performed wrong or a case is done wrong, a person's life is lost or ruined. That's just not the same if there's a bug in some website or even the most serious problems -- missing money with your bank statement or a database somewhere -- it can always be fixed with little effort and some apologies or a Mk. I eyeball audit, but for regulated professions what's done is done and if it's done wrong people die or worse. Sure there's exceptions in every field for example if the C++ code in an F35 is bad it will cause the whole plane to shut down (actually happened) but we are talking in general.

So really to leave law and/or medicine unregulated, you would have to have a breakdown of the world in general like nuclear war. But soon after, expect people to demand quality when a life depends on the work, and expect the professions themselves to self-regulate to weed out the quacks. Another possibility is to make doctors and/or lawyers employees of the government. Then instead of a self-regulating professional association, you might have large unions which might fulfil the OP technically (but not in spirit, where anyone can just call themselves a doctor / lawyer).
 
I'm not talking about unregulated. I'm talking about where professional associations consciously adopt multi-path. For example, where only, say, 45% of doctors have been to any kind of formal medical school.

So, more formal training, less apprentice time required.

Another example, an army medic can learn some solidly useful information in a relatively short amount of time.
 
Full disclosure: I am a practicing physician.

First off, can you clarify what you are intending "de-professionalization" of medicine to entail? Are you looking more "non-traditional" physicians? Or are you looking to change the underlying structure of the profession of medicine, i.e. the fiduciary relationship between and physician and their patient?
elektro, thank you for a very thoughtful response. I read it in its entirety and will probably read it again. And I kind of like your version of the central core of a profession, that the well-being of the patient trumps money (qualified with that we still need to collect from patients to have a viable practice, etc, etc, and the reason for the heavy patient load).

I wish you would have responded to my example of antidepressants. That one is right now 2016, at least as far as I understand. That Zoloft for example might significantly help one person, work so-so for another, and not do a thing for a third. And no doctor in the world can tell in advance. From brain biochem to metabolism time, just too complex and too individual.

And here's my key point: Someone who's head of psychiatry at Harvard, actually works against the person in this regard because their ego's more wrapped up with being "right," at least potentially, it's an occupational hazard type of thing. Whereas a country doctor who's more of a tinkerer, that's exactly what's needed in this regard.

People ought to have realistic ideas about antidepressants, just like they should know basic first aid, the warning signs of a stroke, etc, etc. The first antidepressant may not work, but the third, fourth or fifth might. Or even later ones.

Also have read that it typically takes four to eight weeks to tell. And, a little bit surprises me, important to phase down in steps even if the medication doesn't seem to be working.

I wouldn't dream of asking you to practice medicine online. But just as general health information, is the above largely accurate? PS I think middlebrow sources like Mayo Clinic and WebMD are often pretty alright.

On another website, I got in the habit of coaching people struggling with depression. Someone is really suffering. No one else is responding, it's very sparse, either I respond or I don't. Not being a doctor, I think it was easier for me. And I said, "I am not a doctor." put it there as outfront as I could. Just showed care as a human being, and referred the person to what I thought was some credible, middle-of-the-road sources.
 
I'm an attorney and can say many of the same things about analogous aspects of the legal profession. What I really agree with is the fiduciary aspect of a profession and, if you remove that in law, you've gutted what it is to be a lawyer. Also, the idea of de-professionalizing the practice of law raises the specter, as it does in medicine, of a Wild West environment in which the consumer is very much put into a "buyer beware" position with respect to any doctor or lawyer they deal with. Professional licensing at least sets a standard of competence. Whether it is through medical boards or the bar exam, the licensing process does ensure some basic level of competence and vetting of the individual. If anyone can hold themselves out as a physician or lawyer, there are bound to be people doing so who are not in the least bit qualified to do so.

I think you're spot on - the fiduciary relationship is key, both from the feeling it gives the patient/client that their interests will be prioritized as well as the ability to seek recourse and recompense if those interests are violated either willfully or by negligence. Agree that licensing is necessary to ensure at least a basic minimum standard of competence in the professions. There are enough quacks and ambulance chasers as it is, no need to lower the barriers for more! :D


Very nice post, thanks! I agree that society is going to push for increased "quality assurance" in the professions - the history of medicine in the US shows that. GeographyDude mentioned the Flexner Report, which lead to implementation of actual standards in medical education and an oversight/licensing organization (AAMC).

I'm loathe to say that medicine is more important that another career or field. As you point out, programming errors can have serious and life-threatening consequences. However, in medicine the duty of care and responsibility for mistakes is much clearer and direct than say, programming. A physician practices independently and directly interacts with the patient. If I, for example, am taking care of your family member with a brain bleed and operate on the wrong side it is obvious who breached their duty to the patient (me) and who caused harm to the patient (me, again!). In programming, for example, the F35 code is probably a produced by a team which diffuses the individual responsibility, especially from the legal standpoint.

I'm not talking about unregulated. I'm talking about where professional associations consciously adopt multi-path. For example, where only, say, 45% of doctors have been to any kind of formal medical school.

So, more formal training, less apprentice time required.

Another example, an army medic can learn some solidly useful information in a relatively short amount of time.

Ah, okay.

First, without medical school what do you propose to be the entry requirements for physicians, either from and educational or work experience standpoint?

Second, if you want to promote "non-traditional" physicians you should be emphasizing apprenticeship and de-emphasizing formal education, not the other way around. That army medic may very well make an excellent physician, but the personal, academic and financial requirements for 4 years of college, 4 years of medical school, and 3-7 years of residency training may be too much of a barrier. Honestly, formal education is probably over-emphasized as it is. You need just enough to teach you the mindset to think about problems. Plenty of the information you learn is either outdated or plain wrong by the time you are a practicing physician.

Third, this is de facto happening already with the explosive rise of nurse practitioners and physicians assistants. In many states they can practice independently and even where they cannot they can do many things previously only physicians did like prescribing drugs, seeing patients in clinic, or assisting in surgery. I don't know the specifics, but with economics set to push to trend to continue, you could very well see 50% of licensed independent practitioners in medicine having NOT gone to medical school 10-20 years from now.

Lastly, one of the reasons that the multi-path model is unlikely is that physicians have a strong economic incentive to limit access to the field. It is very difficult to get accreditation to start a new medical school here in the US. This limits the number of physicians who can train and keeps salaries high for physicians. Additionally, the sub-specialties further limit their numbers by limiting the number of residency spots available. The counter-culture is intrinsically limited in political clout, and they'll need a lot of it to break down the barriers physician organizations have put up to protect their economic interests.
 
elektro, thank you for a very thoughtful response. I read it in its entirety and will probably read it again. And I kind of like your version of the central core of a profession, that the well-being of the patient trumps money (qualified with that we still need to collect from patients to have a viable practice, etc, etc, and the reason for the heavy patient load).

I wish you would have responded to my example of antidepressants. That one is right now 2016, at least as far as I understand. That Zoloft for example might significantly help one person, work so-so for another, and not do a thing for a third. And no doctor in the world can tell in advance. From brain biochem to metabolism time, just too complex and too individual.

And here's my key point: Someone who's head of psychiatry at Harvard, actually works against the person in this regard because their ego's more wrapped up with being "right," at least potentially, it's an occupational hazard type of thing. Whereas a country doctor who's more of a tinkerer, that's exactly what's needed in this regard.

People ought to have realistic ideas about antidepressants, just like they should know basic first aid, the warning signs of a stroke, etc, etc. The first antidepressant may not work, but the third, fourth or fifth might. Or even later ones.

Also have read that it typically takes four to eight weeks to tell. And, a little bit surprises me, important to phase down in steps even if the medication doesn't seem to be working.

I wouldn't dream of asking you to practice medicine online. But just as general health information, is the above largely accurate? PS I think middlebrow sources like Mayo Clinic and WebMD are often pretty alright.

On another website, I got in the habit of coaching people struggling with depression. Someone is really suffering. No one else is responding, it's very sparse, either I respond or I don't. Not being a doctor, I think it was easier for me. And I said, "I am not a doctor." put it there as outfront as I could. Just showed care as a human being, and referred the person to what I thought was some credible, middle-of-the-road sources.

A caveat, psychiatry is not my specialty and it's been a bit since I did my psych training in med school.

Generally, the first line treatment for major depressive disorder (most common form of depression) is one of the SSRIs, of which zoloft/sertraline is one. There are a bunch of SSRIs which work with the same general mechanism but have different bio-availabilities and pharmacokinectics (i.e., drug metabolism). There are definitely marked individual responses to the drug, and usually you give a drug a couple of months of therapy before switching agents.

I don't think a patient would be at too much risk from the "occupational hazard" you describe, at least with respects to SSRI therapy because the vast majority of psychiatrists would agree with you that response is variable and even successful responses take time. There definitely is the potential for that "occupational risk" in medicine, but I'd argue it's more likely in the surgical/procedural fields.

Depression is a real bitch to treat. Drugs can help, but there are commonly deep underlying interpersonal and societal factors playing into it. Hugely important field but too messy for me, hence why I didn't become a psychiatrist. :D

Re: WebMD and other online medical sources. The info seems generally fine from what I've seen, but the difficulty is putting it into context if you're a layperson. Physicians aren't important because they control access to medical information (at least not anymore), it's more about knowing how to apply it.
 
Thank you for the overview about clinical depression. And I particularly like your last point that the real art of a practitioner is putting the information in context.

On the question of the counter-culture multi-pathing (verb!) the professions:

A small POD might be if nurse practitioners were called 'senior nurses.' When I first heard the term, I must admit that I confused it with licensed vocational nurses. Then I caught on that the person was talking about quite a bit more training, in fact, more than RNs.

Maybe rolling with the book Our Bodies, Ourselves by the Boston Women's Health Collective. Or, if the civil rights movement had talked about how the medical profession hadn't always done right by African-Americans.

In general, if the country had turned to the left during the '70s, instead of the right. and that would have taken some doing, or maybe some mid-sized PODs rolling
 
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Much of this whole idea came from another thread where I asked people to help me come up with a third economic system. I envisioned the Soviets loosening up and doing well. The U.S. doing well. Okay, so what would be a legitimate third system. Well, you could envision a system that's 70% capitalism and 30% socialism, getting the regulation right, and getting the feedback mechanisms right. And that might be a great country to live in and be a citizen of, but is it really a third system?

And then I came up with the idea of a balance between the formal and informal economies and getting that right. And that might actually qualify as a third system.

Capitalist countries do well, Soviets loosen up, + third interesting economic system?
https://www.alternatehistory.com/Discussion/showthread.php?t=376035

. . . I want my indigenous society to maintain its informal economy, including subsistence agricultural, and then it can be a lot choosier about trade. And that makes a big difference.

And yes, my society will have hierarchical features. I don't want to make my people some kind of 'noble savages.' It's much more humanizing to allow them to be full human beings, flaws and all. And later on, somewhat with what we call 'jobs' but as much with activities and occupations, . . .
 
I am also a physician, although now retired and getting PhD in history with a thesis in an area that required a detailed exploration of the development of medical professionalism in the USA. "Deprofessionalization" is going to be a disaster. Who will regulate the "doctors" that did not go through the current process? While there has been expansion of the practice scope of NPs, PAs, and midwives those folks have their own fairly rigid educational and "apprentice" training, requirements for passing competency exams on a periodic basis, and continuing medical education requirements for licensing just the same as regular "doctors" do. If you do away with all that, it will be the wild west. If you simply add new categories, then somebody is going to regulate who can do what and how they qualify etc. No real change in terms of professionalization.

My surgery professor in med school made the point that to do a simple uncomplicated appendectomy could be learned easily. The real skill was when you got in there and found something way worse (the example he used was a perforated cecal carcinoma) that's when years of training, experience and skill were needed. The point being made was there are times when what you think is going to be a simple problem turns out to be much, much worse. Believe me that is true. Pilots flying the large commercial airliners do the long training, thousands of flight hours, simulator time etc
etc not for the easy flight in beautiful weather but for when everything turns to sh@t.

Not every physician is a good one, and there is room for improvement in many areas. Going back to the system that existed until the late 19th century in the USA is not the answer.
 
You may want to at least see where I'm coming from. I'm not necessarily against professions, but I am skeptical. And that is not so common.

So, for the United States, could it really work if becoming a doctor was multi-path, including for people not so great at written tests?

People have different preferred cognitive styles. There's math-abstract, there's story-narrative. Science classes heavily emphasize math-abstract, but actual clinical practice, at least to the outsider, seems like it would very much be story-narrative, which I'm guessing is the most common preferred style anyway.
 
Or, what about what I suggested above about developing countries? Typically, there's the informal economy and then there's the formal one and never shall the 'twain meet. But what if a country well integrated them. More than that, what if they respectfully started with the informal economy and ramped up from there.

And so, as an older physician with a goodly number of years of experience, let's just suppose a couple of middle-aged doctors from a developing country occasionally visited your hospital. They rounded with younger physicians, they asked and answered questions. Heck, they even presented one or two seminars and summarized studies presenting an aspect of practice. And when you told your younger colleagues how these visiting doctors became doctors, you always got a kick how they were absolutely blown away by the fact that some of these seemingly highly competent physicians had never been to medical school.

I think there's been studies about different approaches to oral rehydration solution. Atul Gawande has written how Bangladesh has really been ahead of the curve in this regard.

If our imagined developing country has a system where you can casually stop by and be seen by a medical professional on your way to work, not only might they be ahead of the United States given their income level. In some ways, they might be ahead of the U.S., as well as France, Germany, etc, in absolute terms. That would be the really interesting alt history. (I'm very aware my United States is way behind the curve on infant mortality and other very basic health measures. But even some of the best systems in the world, they're not perfect and we can imagine things where the occasional third world country really gave them a run for their money.)

And some of these nonwestern doctors may also practice social medicine. For example, some low-income families in developing countries spend 30% or more of family income for infant formula. Of course, they water it down. You or I would do the same. So, the baby ends up somewhat malnourished and more prone to diarrhea from dicey water. We can talk about Nestlé in the 1970s and the political campaign against their highly questionable marketing methods. Well, there are battles to be fought and won today in 2016. For example, I have heard the phrase "white gold rush" in regards to companies moving into China.

So, what if some of these developing nations doctors got political and got involved in some of this work? As well as being able to discuss the occasional Nature study which really catches their eye. Well of course!
 
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You may want to at least see where I'm coming from. I'm not necessarily against professions, but I am skeptical. And that is not so common.

So, for the United States, could it really work if becoming a doctor was multi-path, including for people not so great at written tests?

People have different preferred cognitive styles. There's math-abstract, there's story-narrative. Science classes heavily emphasize math-abstract, but actual clinical practice, at least to the outsider, seems like it would very much be story-narrative, which I'm guessing is the most common preferred style anyway.

I was interested when I saw this thread pop-up, but I'm still not sure what the goal is in "de-professionalising" or adopting other training paths?

I'm sure it would be practical to have a path to qualifying as a Doctor or Lawyer (or any other profession) which involves a majority of time being spent in apprenticeship style training through practice and part time study, with a few years full time at university. Such a path might lead to a greater mobility within the medical hierarchy, with more people starting in other health-care roles first, and then moving on to become doctors by topping-up their experience with the appropriate academic training.

However guilds had most of the negative features of professions... and I can't see an alternative world in which being a really good doctor isn't an incredibly demanding job that only a few people who have a high level of ability across a wide range of fields can do.
 
'Listening to the Heart: Dying Art?
DENISE GRADY, New York Times
Published: September 3, 1997

http://www.nytimes.com/1997/09/03/us/listening-to-the-heart-dying-art.html

' . . . The new doctors, residents from 31 training programs in internal medicine or family practice, made the correct diagnosis only 20 percent of the time when asked to identify common heart abnormalities by listening to recordings of patients' heartbeats. Residents who knew how to play a musical instrument scored a few points higher than those who did not, but the overall rate of correct diagnoses was still ''disturbingly low,'' said the researchers, whose study is being published today in The Journal of the American Medical Association. . . '
Alright, so this is a summary and discussion of a study that was published in a '97 issue of JAMA (Journal of the American Medical Association). Somewhere else I read that it wasn't quite as bad as it appeared, although it appears to be rather devastating.

And the clear response should be teaching a much smaller volume of material in medical school, but coming at it from different directions and teaching it well. In fact, I'd say this would be the cautious approach, this would be the conservative approach.
 
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