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A senses of context
The last word
A sense of context John A Lee Department of Pathology, University of Sheffield Medical School, Beech Hill Road, Sheffield S10 2RX, UK
Near the entrance to the medical school where I work, there are some impressive words set in tablets of stone. Carefully carved in sandstone blocks, 3 feet high and 20 feet long, is an aphorism of Hippocrates translated into Latin. Ars longa vita brevis, it says, reminding us of how much there is to learn in such a short time and thereby (hopefully) inspiring us to be humble, scholarly, and better doctors. Over the last few years, with the aid of innumerable tutorial groups at all stages, I have tested whether or not this seems to be working. The first problem is that 70% of the students claim never to have seen the carving, which makes me worry about their powers of observation, if nothing else. Almost as bad is the fact that of those who have managed to spot some of the largest writing in the country, none of them know what it means. When I suggest that this indicates a certain lack of curiosity (especially given that there is an explanatory placard to one side) I am met with grins or shrugs. Undeterred, I try to elicit suggestions for what it might mean. We don’t usually get very far. The most memorable proposal was that it represented an ancient comment on obesity – the translation offered was “having a big bottom shortens your life”, though why this should be inscribed in Latin at the medical school entrance the student couldn’t say. Sensitised by this experience, I’ve undertaken a bit more exploration of how much modern medical students know about the context of what they are learning. The answer isn’t “not much”, which is what you might expect. The answer is “virtually nothing”. Who, in fact, was Hippocrates? “Didn’t he do the Hippocratic oath?” Who was William Harvey? – fewer than 1 in 20 have heard of him. OK, so roughly when did he describe the circulation of the blood? – “1910”. When were antibiotics discovered? - “1820”, “1900”, “1750”. Who were William Withering, Edward Jenner, Lord Lister? – “don’t know”. Who invented the microscope? – “don’t know”. When was it? – “1800s”. When were anaesthetics discovered? – “1930”. Oh dear! In the above list, I have not exaggerated at all, and I also don’t think Sheffield is exceptional in the almost complete contextual ignorance of its medical students. There are, in fact, a few exceptional medical schools, which do make an 458
effort to ensure that this void is filled, but most seem to have taken in a rather simplistic message about facts. There are too many of these in medical curricula, they were told, so pruning was carried out. Out with everything unnecessary. Apparently, that includes context. The culture of the current learning environment comes across pretty clearly when you suggest to students that they may be missing out on something important. More grins and shrugs. No, they don’t know and they don’t care. It’s as if they’ve all been taught about and agreed with Hegel’s view that “what experience and history teach us is this – that people and governments have never learned anything from history, or acted on the principles deduced from it”. Maybe in the big scheme of things this has an element of truth. But in medicine, which is at root about a relationship between just two people – one with a problem and one with specialist knowledge – I disagree completely. In medicine, I think we should apply the definition of Dionysius. “History is philosophy from examples”. Sure, we have lots of scientific facts these days. Sure, we do clever tests and trials to try and figure things out. But once the facts are in, the art of medicine (the ars longa bit) is about interpreting this information in the context of an individual patient. Is this treatment right at this time, given her other medical problems, taking into account what I know of her as a person, and the fact that her husband has angina and her son graduates in three weeks? Standard everyday stuff. The point is, context is hugely important in medicine, and it always will be, in spite of the rather control-freaky, top-down agenda of evidence-based medicine. Doctors will always try to interpret for their patients; that is their job, but it also means that they will always be susceptible to fashions and fads, to making mistakes, to being overcautious or overconfident, and to doing stupid things for intelligent reasons. History gives us plenty of insightful examples, so leaving history completely out of the medical curriculum is something we do at our peril. Tomorrow’s doctors will be unable to use even the best evidence sensibly without a much fuller context to work in than medical schools are giving them now. THE LANCET Oncology Vol 2 July 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
A sense of context John A Lee Department of Pathology, University of Sheffield Medical School, Beech Hill Road, Sheffield S10 2RX, UK
Near the entrance to the medical school where I work, there are some impressive words set in tablets of stone. Carefully carved in sandstone blocks, 3 feet high and 20 feet long, is an aphorism of Hippocrates translated into Latin. Ars longa vita brevis, it says, reminding us of how much there is to learn in such a short time and thereby (hopefully) inspiring us to be humble, scholarly, and better doctors. Over the last few years, with the aid of innumerable tutorial groups at all stages, I have tested whether or not this seems to be working. The first problem is that 70% of the students claim never to have seen the carving, which makes me worry about their powers of observation, if nothing else. Almost as bad is the fact that of those who have managed to spot some of the largest writing in the country, none of them know what it means. When I suggest that this indicates a certain lack of curiosity (especially given that there is an explanatory placard to one side) I am met with grins or shrugs. Undeterred, I try to elicit suggestions for what it might mean. We don’t usually get very far. The most memorable proposal was that it represented an ancient comment on obesity – the translation offered was “having a big bottom shortens your life”, though why this should be inscribed in Latin at the medical school entrance the student couldn’t say. Sensitised by this experience, I’ve undertaken a bit more exploration of how much modern medical students know about the context of what they are learning. The answer isn’t “not much”, which is what you might expect. The answer is “virtually nothing”. Who, in fact, was Hippocrates? “Didn’t he do the Hippocratic oath?” Who was William Harvey? – fewer than 1 in 20 have heard of him. OK, so roughly when did he describe the circulation of the blood? – “1910”. When were antibiotics discovered? - “1820”, “1900”, “1750”. Who were William Withering, Edward Jenner, Lord Lister? – “don’t know”. Who invented the microscope? – “don’t know”. When was it? – “1800s”. When were anaesthetics discovered? – “1930”. Oh dear! In the above list, I have not exaggerated at all, and I also don’t think Sheffield is exceptional in the almost complete contextual ignorance of its medical students. There are, in fact, a few exceptional medical schools, which do make an 458
effort to ensure that this void is filled, but most seem to have taken in a rather simplistic message about facts. There are too many of these in medical curricula, they were told, so pruning was carried out. Out with everything unnecessary. Apparently, that includes context. The culture of the current learning environment comes across pretty clearly when you suggest to students that they may be missing out on something important. More grins and shrugs. No, they don’t know and they don’t care. It’s as if they’ve all been taught about and agreed with Hegel’s view that “what experience and history teach us is this – that people and governments have never learned anything from history, or acted on the principles deduced from it”. Maybe in the big scheme of things this has an element of truth. But in medicine, which is at root about a relationship between just two people – one with a problem and one with specialist knowledge – I disagree completely. In medicine, I think we should apply the definition of Dionysius. “History is philosophy from examples”. Sure, we have lots of scientific facts these days. Sure, we do clever tests and trials to try and figure things out. But once the facts are in, the art of medicine (the ars longa bit) is about interpreting this information in the context of an individual patient. Is this treatment right at this time, given her other medical problems, taking into account what I know of her as a person, and the fact that her husband has angina and her son graduates in three weeks? Standard everyday stuff. The point is, context is hugely important in medicine, and it always will be, in spite of the rather control-freaky, top-down agenda of evidence-based medicine. Doctors will always try to interpret for their patients; that is their job, but it also means that they will always be susceptible to fashions and fads, to making mistakes, to being overcautious or overconfident, and to doing stupid things for intelligent reasons. History gives us plenty of insightful examples, so leaving history completely out of the medical curriculum is something we do at our peril. Tomorrow’s doctors will be unable to use even the best evidence sensibly without a much fuller context to work in than medical schools are giving them now. THE LANCET Oncology Vol 2 July 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.