Bernard M. Jaffe, MD Professor of Surgery Department of Surgery Tulane University School of Medicine New Orleans, LA

As many of you may know from prior Surgical Rounds editorials, I am often tantalized by specific lines in beautifully written books. While on vacation last summer, I read Mary Reilly (a marvelous novel paralleling the Dr. Jekyll–Mr. Hyde story) by Valerie Martin, a former professor at the University of New Or­leans. In the book, several gentlemen of wealth discuss the possibility that a school for the impoverished, which they had financially supported, will be closed. One of Dr. Jekyll’s colleagues tells him, "They say we've only taught pickpockets to be embezzlers."*

What progress—a school that prepared petty criminals for a life of white-collar crime! I wondered about the curriculum. Was it an MHA or an MBA with a major in health insurance? Or perhaps it was a JD with an emphasis on plaintiff noncases. We live in an environment where many around us have something to take, but little to give.

After the brief wave of anger passed, precipitated by a lifetime of medical experiences (remember I was on vacation in the south of France), I became much more reasonable and the line "pickpockets to embezzlers" then took on a new perspective. Per­haps what Ms. Martin really meant was that a little knowledge was dangerous. There is certainly lots of evidence that substantiates this tenet. I need not re­mind any of you of the multiple wrong decisions hospital administrators have made based on a little knowledge, rather than knowing or learning all the facts. Or of the occasionally ridiculous authorization determinations health insurance companies make based on too little know­l­edge. My favorite example of this was an insurer's insistence that an abdominal peroneal resection for carcinoma of the rectum be performed as an outpatient procedure because all I was going to do was core out the rectum. Finally, there has been no end of fri­volous malpractice claims generated by plaintiff attorneys who have absolutely no understanding of the medicine or surgery involved.

Obviously, a lack of medical education does not stand in the way of poor decision-making. The problem is that many medical bureaucrats, legislators, insurers, administrators, and attorneys do not realize how little knowledge they actually have or how much more effective they could be if they relied on those of us practitioners who really understand.

Unfortunately, it's not only the doctor wannabes who want to practice medicine with only a little knowledge. There are a fair number of allied professionals with some of the same motives. You can list them as well as I can. The psychologists have earned the right to prescribe medications, and nurse practitioners are clamoring for the same opportunity. Physicians' assistants perform many of the activities of their employers, often without the license or education to do so. Nurse anesthetists have recently earned the right to practice independently in many states. While all of these groups play important roles, they are vying to be physicians without going to medical school.

Medical schools are themselves culpable for providing too little knowledge. The recent curricular changes that de-emphasize study and vigorous academ-ic standards in favor of electives and touchy-feely rotations are doing the next generation of physicians a clear disservice. There are no shortcuts to an effective medical database, and those with too little knowledge are likely to get themselves and their patients into trouble.

With the advent of the 80-hour workweek, residents are being subjected to similar educational limits. The mandated enforcement of these laws (I think you already know how I feel about them) coupled with attempts to shorten residency programs threaten the quality of postgraduate training. I am concerned that there may be a day in the near future when even specialists will have too little knowledge.

We live in a time of real paradoxes. One of the major priorities of the specialty boards, colleges, and the state medical societies is the documentation of the maintenance of competence by physicians. These organizations are responding to a variety of constituencies. For some time, the public has been pressing for a rating system for physicians and this is one satisfactory mechanism. Legislators, bureaucrats, and insurers are also seeking proof that their resources are being expended appropriately, and documentation of good results and passing exam scores fit the bill perfectly. Isn't it amazing that the group of doctor wannabes with no medical education or license and only a little knowledge has been successful in mandating that physicians continuously document their founts of knowledge, yet they ignore their input in health care decision-making?

Thus, while law school and health care graduate programs have not "taught pickpockets to become embezzlers,"* they have instilled a false sense that their graduates know more about medicine than they really do. In such cases, a little knowledge combined with a significant level of authority is both dangerous and destructive.

Reference
*Martin V. Mary Reilly. New York, NY: Pocket Books; l990:56.