Michael Opipari, D.O., was on his way to speak at the orientation of the second Authority Health teaching health center class in Detroit when he realized that 50 years ago he began his own training.
Of course, much has changed. The students tend to be smarter, yet more reliant on diagnostic technology than their own intuitive judgment. The medical economy has changed. Even the setting for medical training has changed — from Dr. Opipari’s internship at Detroit Osteopathic Hospital (DOH), to the community-based teaching health center program in Detroit.
Orientation, he says, “has always been something that’s meaningful to me because that is the beginning of a whole new phase in the life of a medical student. I consider the residency as a transition between your student classroom years and becoming a physician. You’re still a trainee. I guess that’s why I thought of it. I almost didn’t believe it to myself: Gosh it’s been 50 years since I did this myself. What’s happened during those 50 years?…I spent most of those 50 years, aside from my practice in 35 of those 50 years, involved in training residents and medical students.
Dr. Opipari served as a director of medical education, residency program director, and administrator of medical education programs, for the AOA and for the DOH hospital system. He had been retired for seven years when Chris Allen, CEO of the Detroit Wayne County Health Authority, told him that he was establishing the Authority Health graduate medical education program and that he wanted him to be associate director of Medical Education. The two worked together when Allen was an administrator at Detroit Osteopathic Hospital. He respected Dr. Opipari’s knowledge as a clinician and his skills as an educator, particularly his experience with the American Osteopathic Association as chair of the Council on Osteopathic Postdoctoral Training for 20 years.
“I wasn’t interested in coming back,” Dr. Opipari confides, “and I truly had no idea how this kind of program could function. … Now, after being here for a year and a half, I truly see the benefit. I understand what this program is all about. I think there is a place for it. We’re providing a benefit to the greater system of health care. I think we have a real opportunity to seed a community with type of physician that’s needed.”
“The trainees who are here are here because these are the specialties that they want, not because they couldn’t get into the other specialties. Most of the people in our training program want to make a difference. They’ve convinced me of that. They want to be in an area of need. They have a need to fill. They think that they can do something that makes a difference. That’s what we should be in education for — to make a difference.”
Dr. Opipari is impressed with the medical knowledge Authority Health residents bring to the program. “They know a lot more medicine than we did because of what’s happened to medicine; the escalation and evolution in medical knowledge through the years, and technology. Medicine is the same as it used to be and it isn’t the same. It’s changed significantly in many aspects, and it’s very much the same in many aspects as well.
“Although the trainees are smarter and better prepared with medical knowledge, I think they’re a lot less practical, in terms of understanding and approach to people and the patient. The Osteopathic philosophy has always been caring for a patient as a person: caring for a person as whole person, rather than a sick heart, a sick liver or a sick stomach. You care for a person, you don’t care for a sick organ because of the influences that that whole person has on that sick organ or sick system, and vice versa and the effect the sick system has on the whole person and their functioning and their behavior. I think there was a greater understanding of that philosophy in years past.
“I think that in years past we could understand a lot better the approach to the individual patient, to their family. We had little dependence on technology that today’s young trainees have. We were dependent on our senses of touch, hearing and sight. We made diagnoses most of the time by knowing what to ask, how to talk to a patient, how to listen to a patient, and by feeling and touching through physical examination, which to me created a connection between the doctor and the patient. The patient knew they were examined. They knew that the doctor paid attention and did something. They could feel the doctor’s hands. They could look in the doctor’s eyes as you ask them questions and as you listen for their response.”
Today’s trainees, he says are more dependent on ordering a diagnostic test or high level laboratory study to validate a diagnosis that he and his peers would be required to think through. To some extent, he says, “it has distanced the patient and physician. That’s not to say that technology has no role. Thank God for that technology. It’s there for when we need it, but it shouldn’t be needed all the time in every case. It’s used to confirm diagnoses. It’s also used for legal protection, unfortunately, in today’s world.”
The demands on residents have changed considerably since Dr. Opipari’s internship when he literally “resided” at the hospital. “Trainees, today, are protected in terms of not working excessive work hours. It was nothing for us to work 72 hours with little time off. There were no call restrictions. Sometimes we were on call three, four nights in a row, two or three weekends back-to-back, seven days a week. Trainees now have more (free) time. That’s good; they need the time. It’s a different world. Trainees have other interests, where our interests were primarily our work, our training program, caring for patients. Trainees now are interested in their families. They have social interests. Many of the people in my time should have had more of an interest in their families. There would have far less divorce and families would have stayed together.
“Our training was 100 percent in the hospital. It was all inpatient-based. It was all acute care based. Training today is significantly split between inpatient and ambulatory care, because that is the way that health care is delivered today and the way that health care is paid for today. Rather than acute care, today it’s significantly chronic care-based, rather than dealing with acute episodic flare-ups of chronic disease that brought the patient into the hospital.”
Medical practice is also more evidenced-based, he says. “My experience has allowed me to define for myself what works well for me under certain circumstances. Today… we have to train residents that they can only do what there a basis for in terms of evidence… if you want to treat an infection with an antibiotic you need evidence…that allows you to pick the best. In our time, we would say this is the drug were going to pick for you because it has worked extremely well almost all the time for me. I know it, I understand it, I feel comfortable with this drug. I think it’s safe in my hands because I’ve used it 90 percent of the time. Today that’s not good enough. Today we’re told that we have to practice evidence based medicine. You have to draw your evidence from scientific based studies”
Pay has also increased for residents. “My first contract at DOH was for $125 per month. (Residents in the Authority Health Teaching Health Center earn about $46,000 a year, plus benefits and a $3,000 signing bonus.) The work hours are better, the salaries are better.”
And there is much less stress. Dr. Opipari believes the hours and pressure of seemingly endless call was helpful in his training, but “in today’s healthcare delivery environment it is not at all helpful. It made a difference to have a total immersion in what you did. Your whole world was in the four walls of that hospital. We thought, we lived — we virtually ate and breathed what we were doing.”
To some extent, the value of immersion in the training environment is the same with the community-based teaching health center, which encourages residents to become involved in the communities where their patients live and work. “I think it provides as much benefit today in reverse, because the residents need to have the experience of being out in the community and being part of the community in which they’re practicing. “
What concerns him the most, perhaps, is that the decentralization of the modern training experience may diminish the possibility that today’s residents will share the peer support that Dr. Opipari had, and the lifelong friendships that have endured.
“I told some residents that there are some residents in their class they will not see again except at mandatory educational meetings where all residents are required to attend. … Our trainees go between four or five different hospitals and never cross paths with other trainees very often — if at all, especially trainees’ specialty programs other than theirs.”
The residency program needs to create opportunities for the residents to connect and develop professional and personal bonds. “There are few occasions for them to develop relationships. They don’t get to know one-another. We got to know each other’s families. When we were off, it wasn’t unusual for us to be invited to each other’s homes to have dinner with their families. Those who were married — there were very few in those days… those who were not married were invited to parents for dinner. That relationship endures. That doesn’t happen today. Everyone leads their own lives. When they’re through with their training for the day, they go their separate ways. The training program has so many variations it doesn’t lend itself to that kind of support system. We did it as a support system. If someone was in trouble for whatever reason, they came to their fellow residents for support.”
Dr. Opipari appreciates his return from retirement. “I truly enjoy seeing the evolution of a young physician throughout the three or four years of their training program, in terms of the development of their self confidence in themselves, their self-confidence in their approach to the patient and talking to the patient’s family, having the information to impart, being able to make decisions that they think are good decisions — good for that patient and that family, which may be a very different decision with a different patient. I still teach residents that part of it. Regardless of what the payment system says you can do or have to do or what they’ll pay for, some decisions are not good for some people.”
Above all, Dr. Opipari is encouraged by the movement toward community-based training.
“I really believe, after watching health care for 50 years, that this is absolutely the direction of the future. This type of training — ambulatory, preventive, community-based — this is where health care is going… It’s not going to stop suddenly. It’s not going to shift back. There’s no doubt about it.”
“When we talk about health care been accountable to the public’s need, this is what the public wants.”