Wheezing is common in small children — around a third of all children will have an episode of wheezing before they are three years old. Although it’s common, we still don’t quite know the best thing to do about it. The problem is that wheezing, like fever, is a symptom of a disease, not a disease itself. It’s not one thing. Every physician who treats small children in the office, the emergency department, or the pediatric intensive care unit is often faced by the dilemma of what to do with a wheezing small child.

In such children wheezing is often triggered by a viral illness. When it happens in infants it is often caused by a virus we call RSV (short for respiratory syncytial virus) and causes a disorder called bronchiolitis. For those children, we know that not much of anything helps the symptoms — all we can do is provide supportive care and wait for the illness to run its course. What about wheezing children who don’t have bronchiolitis? Can anything help them?

The problem facing the doctor is that all the treatments we’ve tried over the years for small children who wheeze are taken from how we handle older children who have chronic, frequent wheezing — what we call asthma. These treatments work for asthma, yet they often don’t for wheezing that isn’t. A certain number of children who have their first spell of wheezing will go on, over years, to develop true asthma. But most wheezing toddlers won’t progress to asthma — they will have an episode or two (or three) of wheezing and then “grow out of it.” If you bring your infant or toddler to the doctor for a first (or second) episode of wheezing, the doctor has no way of knowing which of these two things will happen. There are a few clues, such as a family history of asthma, which will increase the chances of future asthma, but there’s no good way to tell.

How do most doctors handle this problem? Most will try a dose or two of asthma medications (inhaled albuterol and/or budesonide, or oral prednisolone are commonly used) just to see if it helps. If the child gets better, they can be continued.

My point is that you should understand that for this problem — wheezing in an infant or toddler — your doctor is handicapped by not being able to predict the future. Only time will tell. It’s a frustrating, but common medical scenario.

In spite of all its scientific underpinnings, medicine is not really a science; rather, it is an art guided by science. Medical students spend long hours learning about the science of the body, but they really do not become doctors until they have learned the art at the bedside from experienced clinicians. Medical practice is called practice for a reason; we learn it by practicing it in a centuries-old apprenticeship system, which is really what a residency is. As we do so, and again, in spite of the scientific trappings, we imbibe ways of thinking, of talking, and of doing that are as old as Hippocrates. The rest of this chapter will show you that aspect of medicine. Seeing it is fundamental for your understanding of what doctors do and why.

Although physicians learn at the feet of their elders — the experienced practitioners — a young doctor’s peers also heavily influence his training, and through that, his outlook; resident culture is important. Residency is an intense experience that comes at a time in life when most new doctors are relatively young and still evolving their adult characters. In a manner similar to military training, residency throws young people together for lengthy, often emotion-laden duty stints in the hospital. Not surprisingly, and also like military service people, residents often form personal bonds from this shared experience that last for the rest of their lives. Most physicians carry vivid memories from their residency for the duration of their careers.

Recent regulations have limited the maximum number of hours a resident may work each week. These rules came from two sources. One was the common-sense observation that tired residents cannot learn or work well. Common sense, however, cannot change hidebound traditions; what really changed resident work hours was a famous court case in New York (the Libby Zion case), involving a girl who died under the care of overworked residents. The particulars of that case did not clearly establish that resident fatigue caused Libby’s death, but the uproar started a sea change in how residents are trained.

The mandated maximum of an eighty-hour workweek is still long by any standard, but it had been much longer, and many of today’s doctors (myself included) trained under the old system when 110 hours or more per week was not uncommon, with perhaps the gift of every third Sunday off. My own residency program director told us, intending no irony: “The main problem with being on-call only every other night is that you miss half the interesting patients.” So, like garrulous ex-Marines, doctors swap tales of the time that, although brief in comparison to a lifelong career, was extraordinarily important in forming their professional behavior. Generalizations are tricky, especially when applied to such a diverse group of people as resident physicians. This caveat aside, parents who understand something about resident culture will gain useful insights into why many physicians think and act the way that we do.

Residents have come through a pathway that generally fosters intense competition and that values academic achievement above all else. In recent years, medical schools and residency programs have, to varying degrees, tried to emphasize the importance of more humanistic skills like empathy and compassion, and the specialty of pediatrics has been among the leaders in doing this. However, it remains true that physicians are the products of a system that rewards those who excel at competing with their colleagues at how much information one can learn, remember, and then produce when asked for it by a superior.

Resident culture encourages young doctors to appear and act all-knowing and self-confident even when they are not. This skill is often called “roundsmanship” and is inculcated from early on in their training. Residents get much of their teaching during the time-honored ritual of rounds, in which a team of residents and their supervising physician walk around to their patients’ rooms, pausing at each doorway to discuss the case. The discussion typically begins with the resident presenting the patient’s problem and the resident’s plan to deal with it to the assembled group, following which the supervising physician often grills the resident about the case. Residents adept at roundsmanship are quick thinkers and have rapid recall of pertinent facts. Master roundsmen, however, are best characterized as fearless when clueless—they appear assured and in control of the situation even when they are not.

I am exaggerating a little for effect, of course, but my point is to show you how years and years of this kind of environment affect most doctors to some extent. Such a background can cause doctors to seem defensive when questioned, for example by a parent, because doctors spend their formative years defending what they are doing to both their peers and to their exacting teachers. It can also make it difficult for a doctor to admit he does not know what to do with a patient, since physicians are conditioned to regard that admission as a real defeat. This attitude is encapsulated in the saying, often applied to surgeons but relevant to all physicians: “Seldom wrong, never in doubt.”

So how does one train to be a physician? The first step is to obtain a four-year undergraduate degree at a college or university. This was the most fundamental change in post-Flexner medical training; before that time, many medical schools had little or no requirement for previous education, some not even demanding a high school diploma. Today the prospective physician’s baccalaureate degree can be in anything (mine happens to be in history and religion), but all medical schools require premedical course work in biology, chemistry, biochemistry, physics, and often mathematics. As a result of these science-heavy requirements, most premedical students choose to major in one of the sciences.

The next step is to gain admission to medical school. This traditionally has been a difficult thing to accomplish, although admission statistics for individual schools are hard to interpret because virtually all students apply to several schools, often more than ten. In general, a medical school applicant’s overall chances of being admitted to medical school has fluctuated between 25 and 35 percent over the last several decades. One thing that has changed is drop-out rate. Fifty years ago, many students did not complete the course; these days, drop-out rates are extremely low.

Medical school generally lasts four years, at the end of which time the graduate is properly addressed as “doctor.” However, the new doctor is one in name only, because no state will allow her to practice medicine independently without further training. Medical licenses are in fact granted by the individual states, and their requirements vary, but all demand at least one year of supervised on-the-job training beyond medical school. Fifty years ago, many physicians stopped their training after doing that single year of training — called an internship — because that was all a physician needed to obtain a medical license and begin working as a general practitioner. These days virtually no one stops after one year, because nearly all physicians require more training just to find a job. You will still hear doctors in their first year out of medical school referred to as interns, but the term does not mean much now.

Medical students receive a standard training curriculum that varies little between the various medical schools; this is enforced by the organization that accredits medical schools. Toward the end of their four years, however, students generally do get some freedom to select courses geared toward what specialty they choose for their residency, the term for the several years of practical training they get after medical school. The usage comes from the fact that medical residents once actually lived in the hospital; these days, even though resident workweeks average eighty hours or so, no one literally lives in the hospital.

Residencies come in the standard broad categories of areas of expertise like internal medicine, pediatrics, surgery, and obstetrics and gynecology, as well as specialties like radiology, neurology, dermatology, and psychiatry. There are in total twenty-four recognized medical specialties, each of which sets its own requirements for the residents training in their respective fields. (You can read more about each individual specialty here.) Medical science has expanded sufficiently that a medical student who wishes to specialize in not being a specialist — that is, who wants to take care of all sorts of patients — must do a residency in family practice.

Residency lasts from three to five years after medical school, depending upon the specialty. At the end of training, the resident takes an examination. Passing it makes her “board-certified” in the field; someone who has completed the residency requirement but has not yet passed (or has failed) the examination is called “board-eligible.” Some physicians choose to continue their training even further beyond residency, to subspecialize in things like cardiology, infectious diseases, or hematology.

The person you encounter when you bring your child to her doctor’s appointment has thus spent at least eleven years getting ready to meet you: four years in college, four years in medical school, and three to five years in residency. That person has also spent much of that time being initiated, perhaps indoctrinated, into a culture, a worldview, that is shared by most physicians. It is a culture foreign to that of many nonphysicians. Its attributes come primarily from the way physicians have been trained since Flexner’s reforms of medical education a century ago. Knowing about this time-honored system will help you understand your child’s physician, and understanding improves communication. More about that in later posts.

A couple of conversations I’ve had with patients’ families over the past month have made me realize that many folks don’t know how our system produces a pediatrician, a radiologist, or a surgeon. And a lot of what people know is wrong. Physicians are so immersed in what we do that we forget that the process is a pretty arcane one. Just what are the mechanics of how doctors are trained? Understanding your physician’s educational journey should help you understand what makes him or her tick. As it turns out, a lot of standard physician behavior makes more sense when you know were we came from. This post concerns some important history about that.

Most physicians in the nineteenth century received their medical educations in what were called proprietary medical schools. These were schools started as a business enterprise, often, but not necessarily, by doctors. Anyone could start one, since there were no standards of any sort. The success of the school was not a matter of how good the school was, since that quality was then impossible to define anyway, but of how good those who ran it were at attracting paying students.

There were dozens of proprietary medical schools across America. Chicago alone, for example, had fourteen of them at the beginning of the twentieth century. Since these schools were the private property of their owners, who were usually physicians, the teaching curriculum varied enormously between schools. Virtually all the teachers were practicing physicians who taught part-time. Although being taught by actual practitioners is a good thing, at least for clinical subjects, the academic pedigrees and skills of these teachers varied as widely as the schools — some were excellent, some were terrible, and the majority were somewhere in between.

Whatever the merits of the teachers, students of these schools usually saw and treated their first patient after they had graduated because the teaching at these schools consisted nearly exclusively of lectures. Although they might see a demonstration now and then of something practical, in general students sat all day in a room listening to someone tell them about disease rather than showing it to them in actual sick people. There were no laboratories. Indeed, there was no need for them because medicine was taught exclusively as a theoretical construct, and some of its theories dated back to Roman times. It lacked much scientific basis because the necessary science was itself largely unknown at the time.

As the nineteenth century progressed, many of the proprietary schools became affiliated with universities; often several would join to form the medical school of a new state university. The medical school of the University of Minnesota, for example, was established in 1888 when three proprietary schools in Minneapolis merged, with a fourth joining the union some years later. These associations gave medical students some access to aspects of new scientific knowledge, but overall the American medical schools at the beginning of the twentieth century were a hodgepodge of wildly varying quality.

Medical schools were not regulated in any way because medicine itself was largely unregulated. It was not even agreed upon what the practice of medicine actually was; there prevailed at the time among physicians several occasionally overlapping but generally distinct views of what the real causes of disease were. All these views shared a basic fallacy — they regarded a symptom, such as fever, as a disease in itself. Thus they believed relieving the symptom was equivalent to curing the disease.

The fundamental problem was that all these warring medical factions had no idea what really caused most diseases; for example, bacteria were only just being discovered and their role in disease was still largely unknown, although this was rapidly changing. Human physiology — how the body works — was only beginning to be investigated. To America’s sick patients, none of this made much difference, because virtually none of the medical therapies available at the time did much good, and many of the treatments, such as large doses of mercury, were actually highly toxic.

There were then bitter arguments and rivalries among physicians for other reasons besides their warring theories of disease causation. In that era before experimental science, no one viewpoint could definitely prove another wrong. The chief reason for the rancor, however, was that there were more physicians than there was demand for their services. At a time when few people even went to the doctor, the number of physicians practicing primary care (which is what they all did back then) relative to the population was three times more than it is today. Competition was tough, so tough that the majority of physicians did not even support themselves through the practice of medicine alone; they had some other occupation as well — quite a difference from today.

In sum, medicine a century ago consisted of an excess of physicians, many of them badly trained, who jealously squabbled with each other as each tried to gain an advantage. Two things changed that medical world into the one we know today: the explosion of scientific knowledge, which finally gave us some insight into how diseases actually behaved in the body, and a revolution in medical education, a revolution wrought by what is known as the Flexner Report.

In 1910 the Carnegie Foundation commissioned Abraham Flexner to visit all 155 medical schools in America (for comparison, there are only 125 today). What he found appalled him; only a few passed muster, principally the Johns Hopkins Medical School, which had been established on the model then prevailing in Germany. That model stressed rigorous training in the new biological sciences with hands-on laboratory experience for all medical students, followed by supervised bedside experience caring for actual sick people.

Flexner’s report changed the face of medical education profoundly; eighty-nine of the medical schools he visited closed over the next twenty years, and those remaining structured their curricula into what we have today—a combination of preclinical training in the relevant sciences followed by practical, patient-oriented instruction in clinical medicine. This standard has stood the test of time, meaning the way I was taught in 1974 was essentially unchanged from how my father was taught in 1942.

The advance of medical science had largely stopped the feuding between kinds of doctors; allopathic, homeopathic, and osteopathic schools adopted essentially the same curriculum. (Although the original homeopathic schools, such as Hahnemann in Philadelphia, joined the emerging medical mainstream, homopathic practice similar to Joseph Hahnemann’s original theories continues to be taught at a number of places). Osteopathy maintains its own identity. It continues to maintain its own schools, of which there are twenty-three in the United States, and to grant its own degree—the Doctor of Osteopathy (DO), rather than the Doctor of Medicine (MD). In virtually all respects, however, and most importantly in the view of state licensing boards, the skills, rights, and privileges of holders of the two degrees are equivalent.