The Sword of Damocles, Redux

It has been some time (two years) since I last posted in this forum.  I wanted to share comments published recently in the POMA Newsletter.


The title of April’s Another Voice, “ACGME Sword of Damocles Poised to Strike a Devastating Blow”(POMA Newsletter, April 10, 2014), well describes the current state for osteopathic graduate medical education (OGME), but not for the reasons the author intends.  Please see the link to the meaning of the legend of Damocles’ sword.

One reason for my support for moving to a unified accreditation system is that the OGME system currently exists in a state “of foreboding engendered by a precarious situation, especially one in which the onset of tragedy is restrained only by a delicate trigger or chance.”  In the current state, multiple swords hang over OGME.  These include:  graduate medical education (GME) financing, governance of OGME by a membership organization, lack of reliability, relevance to graduates of colleges of osteopathic medicine (COM), lack of positions for future COM graduates, and yes, the actions of the Accreditation Council for Graduate Medical Education (ACGME), who is the provider of the majority of GME for COM graduates.  A unified system removes many of these swords hanging “from a single horse hair” above the head of OGME.  Other swords may remain, but they are better tethered.  I’m confident that these can be removed by the future educational leadership of the osteopathic profession having a governance stake in GME within the United States.

Reliance on the status quo leaves all swords hanging over OGME’s head.  While I do not possess a crystal ball, I believe that one or more of the noted swords will fall within the not-too-distant future.  This would result in a GME system where the osteopathic profession has no governance stake.  If that happens, there will be no opportunity to teach osteopathic philosophy.  This would guarantee the fulfillment of Still’s admonition:  “unless you teach, neither you, nor osteopathic medicine will survive.”

It is a false interpretation that a unified system with shared governance precludes teaching osteopathic philosophy and tenets.  In fact, the unified system perpetuates osteopathic principles by explicitly including them in the accreditation standards.  One has to ask themselves:  is it more likely to have osteopathic philosophy taught in a system where the osteopathic profession shares a governance stake or a system where the osteopathic profession has no governance stake?  I recognize that all do not share my concern for the swords hanging over our heads which are “poised to strike a devastating blow.”  They would say that the status quo is acceptable and a full governance stake in a fraction of GME is preferable to shared governance of entire United States GME system.  I addressed this topic in the April JAOA.

The professional exploration of this topic is quite valuable.  The scientific method stipulates that the first step in any evaluation is to define the question.  This question is not the worth of osteopathic values.  The question is:  what is the most likely path to ensure that those values continue to be taught?  The evidence points to a unified system of GME accreditation being the answer.

Originally published in the POMA Newsletter, April 25, 2014

Who wants to live forever?!?!

On a recent flight across the United States, a familiar song played on my iPod, Queen’s Who Wants to Live Forever.  While the song clearly asks a question about mortality and immortality, that question has two derivations.  The two questions are:

1.       Who wants to win the prize of immortality?

2.       Why would anyone want to live forever?

Some further context may help.  The song was written and performed by Queen for the movie Highlander.  The movie follows Connor MacLeod who was born in 1518 in Glenfinnan near the shores of Loch Shiel.  He is one of Earth’s immortals who fight for the ultimate prize of omniscience.  The person who wins the prize must behead all of the other immortals on the planet.  As each immortal succumbs, the victor gains the strength of the fallen.  That sounds pretty simple, thus, who wants the prize?  Who wants to live forever?

The problem is that Connor does not always like being immortal.  In the movie’s opening scene he is almost killed in battle by another immortal in a Scottish clan skirmish.  Just as he is to be beheaded his clansmen stop the rival – the Kurgan.  Connor, who will surely die, is taken back to Glenfinnan, but inexplicably lives.  It is now his clan that wants him dead figuring that he must be possessed by the devil.  He is eventually banished from the village.  After this he meets a woman, Heather, who becomes his wife.  He cannot have children, he’s immortal, and this is a lifelong sorrow for he and Heather.  Worse, Heather grows old over the years and he does not.  She eventually dies in his arms.  He learns that immortals should have transient bonds.  So, why would anyone really want to live forever?

OK, now you are asking what this has to do with OGME.  Well, there was a recent article in the Wall Street Journal entitled "Why Doctors Die Differently."  The article reported on the differences between physician’s end of life decisions versus those of the general public.  There were some striking differences.  Who wants to live forever?  Physicians were more likely to choose conservative and palliative management when faced with low cure or survival rates.  The question posed is whether physicians unique perspective, they clearly have both knowledge and experience dealing with end of life issues and watching other people die, changes their view of the question.  To the general public, the prize is immortality.  The medical community – doctors, nurses, researchers, pharmaceutical companies – has been in search of this prize since the beginning of time.  Clearly that resonates with the public – why else would they be willing to pay so much for so little?

Some may say that medicine hasn’t furthered the immortality notion.  Think for a second though about Queen’s voice Freddie Mercury.  Freddie died far too young of AIDS.  All one has to do is watch a Queen concert on YouTube and they will see one of the most alive people ever known.  Freddie could command entire stadiums across two continents (as he did at Live Aid).  Listening to him sing Who Wants to Live Forever and another poignant song, The Show Must Go On, make me wonder what his view of certain death must have been.  He contracted HIV in the late 1980s and died in the early 1990s.  Everyone who got HIV at that time died of AIDS or an AIDS associated illness.  We all know, Magic Johnson knows quite well, that that doesn’t happen now, at least in the “developed” world.  HIV is only one death sentence that has been pardoned.  There are many more each year.

They lesson for physicians, physicians in training and physicians that train physicians is that the end of life is many times as important as life itself.  It is also important to share the lessons of our previous patients with our current patients.  It seems clear that physicians head those lessons when they make their own decisions regarding death and dying.  We need to ask patient both:

1.       Do you want us to do everything to make you better?

2.       Are you sure that you would like to suffer more?

The answers are a matter of perspective…

Everything flows...nothing stands still...the final installment

I know that you have all been on the edge of your seat for part 3, so without further adieu, here it is, the last facet, organizational flows…

·         The AODME is in the midst of a strategic planning process.  This has entailed using proven methodology to flesh out our goals and aspirations as an organization.  The board held a planning retreat in July (in conjunction with the AOA House of Delegates) and there were surveys of membership before and after this retreat.  One large move is the decision to focus on excellence in Clinical Osteopathic Medical Education.  This includes the undergraduate, graduate and continuing medical education spheres, with an emphasis on OGME.

·         As many of you know, the AODME has purchased management services from the AOA since 2003.  This contract has been automatically renewable on a yearly basis.  The AODME shares a close working, teamwork relationship with the AOA and recently had Susan Sevensma, DO appointed as the liaison from the AOA Board to the AODME Board.  This is a first for both organizations.

·         Finally, the AODME underwent a by-laws change in December of 2011.  This change culminated four years of discussion on the topic, through three annual meetings, multiple surveys and drafts of the changes.  The by-laws were ratified by a 90% positive vote of two thirds of the members.  This was not small accomplishment for a small and diverse organization.  The changes brought the AODME in line with the current structure of OGME, including the realization that most DMEs commune as OPTIs.

Everything flows…nothing stands still.  The AODME and OGME are certainly proof of this.