Clichés in Medical Education

802

Clichés in Medical Education People in my position have a problem. Though we are medical teachers in that we have taught medical students for many years, we are not experts on medical education. Though we cannot explain in educational terms, we have developed an instinct for those approaches in medical education that might work and those that might not. It is this instinct that makes us react so negatively to the dichés used by people who work in theory rather than practice of medical education. In the past year I have visited medical schools in many countries and have been struck by the widespread concern that damage might be done to medical education by ill-considered acceptance of new ideas. There is the fear that the neo-educationalists may not accept evolution as the normal process for change, but press for revolution to exercise their theories. This experience has given me the incentive to jot down some of the replies I oughtto have made when the following dichés

were

first put to me.

In an ideal world, medical education would be a totally integrated and multidisciplinary experience ONE feels rather lonely when attacking motherhood, patriotism, religious zeal, or integrated medical education because of the

widespread belief that they are good things. in My cynicism these matters of faith may stem from my country of origin. Though we are encouraged by the General Medical Council green book to introduce "integrated and ’interdisciplinary teaching throughout the undergraduate curriculum",1 I do not find the advocacy for this very convincing. In my experience, integrated teaching is difficult to plan and to mount, is extremely time-consuming and timewasting for the organisers and for the teachers, is confusing 1. General Medical Council Education Committee. Recommendations

on

basic medical

education. London: GMC, 1980.

10. Brewerton DA. Inherited susceptibility to rheumatic disease. J Roy Soc Med 1978; 71: 331-38 11 Gedde-Dahl T, Fagerhol MK, Cook PJL, Noades J. Autosomal linkage between the Gm and Pi loci m man. Ann Hum Genet 1971; 35: 393-98. 12. Cox DW, Markovic VD, Teshima IE. Genes for immunoglobulin heavy chains and for &agr;1-antitrypsin are localized to specific regions of chromosome 14q. Nature 1982;

297: 428-30 13 Larsson C. Natural history and life expectancy in severe alpha-1-antitrypsin deficiency,

PiZ. Acta Med Scand 1978; 204: 345-51.

DA, Webley M, Murphy AH, Milford Ward A The &agr;1-antitrypsin phenotype MZ in acute anterior uveitis. Lancet 1978; i: 1103. 15. Arnand P, Chapuis-Cellier C, Souillet G, et al. High frequency of deficient Pi phenotypes of alpha-1-antitrypsin in non-atopic infantile asthma. Trans Ass Am Phys 1976; 89: 205-14. 16. Hodges JR, Millward-Sadler GH, Barbatis C, Wright R. Heterozygous MZ alpha-1antitrypsin deficiency in adults with chronic active hepatitis and cryptogenic cirrhosis. N Engl J Med 1981, 304: 557-60. 17 Geddes DM, Webley M, Brewerton DA, et al. &agr;1-antitrypsin phenotypes in fibrosing

14. Brewerton

alveolitis and rheumatoid arthritis. Lancet 1977; ii: 1049-51. P, Galbraith RM, Faulk WP, Ansell BM. Increased frequency of the MZ phenotype of alpha-1-protease inhibitor in juvenile chronic polyarthritis. JClin Invest 1977; 60: 1442-44. 19. Beckman G, Beckman L, Liden S. Association between psoriasis and the &agr;1-antitrypsin deficiency gene Z. Acta Dermatovenereol (Stockholm) 1980; 60: 163-64. 20. Whittingham S, Mathews JD, Schanfield MS, Tait BD, Mackay IR Interaction of HLA and Gm in autoimmune chronic active hepatitis. Clin Exp Immunol 1981; 43: 80-86. 21 Whittingham S, Mathews JD, Schanfield MS, Tait BD, Mackay IR. Effect of gene interaction on susceptibility to disease. Tissue Antigens 1981; 17: 252-54. 22. Kagnoff MF, Weiss JB, Brown RJ, Lee T, Schanfield MS. Immunoglobulin allotype markers in gluten-sensitive enteropathy. Lancet 1983; i: 952-53. 23 Kagnoff MF, Brown RJ, Schanfield MS. Association between Crohn’s disease and immunoglobulin heavy chain (Gm) allotypes. Gastroenterology 1983, 85: 1044-47 24 Demaine AG, Vaughan RW, Behn AR, Myles AB, Panayi GS, Welsh KI. Immunoglobulin allotype frequencies in patients with giant cell arteritis and polymyalgia rheumatica J Immunogenet 1983; 10: 343-48. 25. Pandey JP, Johnson AH, Fudenberg HH, Amos DB, Gutterman JU, Hersh EM HLA antigens and immunoglobulin allotypes in patients with malignant melanoma. Hum Immunol 1981, 2: 185-90 18. Arnand

for the students who have to grapple simultaneously with the different intellectual approaches of a variety of individuals and a variety of disciplines, and is harmful for departments since it removes from them their strongest stimulus and raison d’etre, the responsibility for their own teaching. I think the time has come to face reality. So much effort and time has been given by so many medical schools to promoting complete integration with so little success that the onus of prooffor its viability must lie now with its protagonists. Until they can demonstrate an acceptable model of the system working satisfactorily with the resources available and over a period which outlives the enthusiasm of the launchers, academic staff should -not have their time needlessly dissipated in attempting the impossible. If what I’ve said is correct, what can explain this pervasive drive towards an illusory goal? Part of it may be our natural wish to meddle in the affairs of others and exercise power over them. We are all victims of fashion, and integrated medical education is certainly fashionable. Another factor may be the suspicion that the other fellow is using too much of the students’ time telling them about his subject when it could be better spent learning about ours. All the natural forces work against integration and schools with integrated teaching tend to revert slowly to teaching by discipline. This tendency is recognised by medical schools which advocate integration and some of them fight vigorously to combat what they refer to as "the regrettable tendency to revert towards the mean". My experience suggests, despite the views of many educationalists, that the best people to decide on what is appropriate to teach to medical students about a discipline are the experts in that discipline. I cannot prove that I am right in this, but such is the stuff of educational debate that they prove I am wrong. The harmonious and balanced teaching that we all seek will not be found just by setting up yet another curriculum review committee. It requires the constant dialogue and consultation

cannot

26. 27.

Pandey JP, Goust J-M, Sailer J-P, Fudenberg HH. Immunoglobulin G heavy chain (Gm) allotypes in multiple sclerosis. J Clin Invest 1981; 67: 1797-800. Nakao Y, Matsumoto H, Miyazaki T, et al Gm allotypes in myasthenia gravis Lancet

1980; i: 677-80. 28. Demaine AG, Vaughan RW, Welsh KI. Immunoglobulin (Gm) allotype frequencies in patients with renal failure. Transplantation 1982; 34: 153-54. 29. Whittingham S, Mathews JD, Schanfield MS, et al. Interactive effect of Gm allotypes and HLA-B locus antigens on the human antibody response to a bacterial antigen Clin Exp Immunol 1980; 40: 8-15. 30. Nakao Y, Matsumoto H, Miyazaki T, et al. IgG heavy-chain (Gm) allotypes and immune responses to insulin in insulin-requiring diabetes mellitus N Engl JMed 1981; 304: 407-09. 31. Nakao Y, Matsumoto H, Miyazaki T, Farid NR. IgG heavy chain allotypes (Gm) in atrophic and goitrous thyroiditis. J Immunogenet 1982; 9: 311-16. 32. Farid NR, Newton RM, Elke PN, Marshall WH. Gm phenotypes in autoimmune disease. J Immunogenet 1977; 4: 429-32. 33. Farid NR, Newton RM, Elke PN, Barnard JM, Marshall WH. The operation of immunological networks. Tissue Antigens 1978; 12: 205-11. 34 Leder P. The genetics of antibody diversity. Sci Am 1981; 246: 72-83. 35. Honjo T. Immunoglobulin genes. Annu Rev Immunol 1983; 1: 499-528. 36. Rabbitts TH. The human immunoglobulin genes. Biochem Soc Trans 1983; 11: 119-26.

37. Riches PG. Structure and function of

immunoglobulin genes. J Roy Soc Med 1984; 77:

249-53.

38 O’Brien

SJ, ed. Genetic maps. Frederick, Maryland: National Institutes of Health, 1982. 10, 15, and 17. 39 Yanagi Y, Yoshikai Y, Leggett K, Clark SP, Aleksander I, Mak TW. A human T-cellspecific cDNA clone encodes a protein having extensive homology to immunoglobulin chains. Nature 1984; 308: 145-49. 40 Marx JL. More progress on the T-cell receptor. Science 1984; 224: 859-60. 41. Marrack P. More on the T-cell receptor. Nature 1984; 309: 310-11. 42 Talal N, Dauphinee MJ, Ahmed A, Christados P. Sex factors in immunity and autoimmunity. In: Hayashi, Yamamura Y, Tada T, eds. Progress in immunology vol V. New York, Tokyo: Academic Press, 1984. 43. Ohno S. In: O’Brien SJ, ed Genetic maps. Frederick, Maryland: National Institutes of Health, 1982: 18. 44 Ohno S. The original function of MHC antigens as the general plasma membrane anchorage site of organogenesis-directing proteins. Immunol Rev 1977, 33: 59-69

803 between staff and students in different disciplines that stem from mutual affection, trust, and respect and a common concern to foster the knowledge, skills, and mental attributes needed for a life-long career in medicine. Merely talking and listening to one another should rid teaching of the most glaring examples of repetition, lack of balance, omission, and mutual incomprehension that creep in when teachers and students fail to communicate. In the last analysis, each student has to integrate his or her own knowledge and experience drawn from many sources in a way that is helpful and satisfying for the individual. What better integrator is there for this than the individual’s own brain?

We should have

more

mature students

WHY? Because it is fashionable? Perhaps. Because being older and wiser they do better in their examinations? No, they do less well. Because they use their earlier specialism as an adjunct to their medical practice? No, they usually become general practitioners and do not use their earlier speciality. Because it makes economic sense? No, it doesn’t make economic sense since they can spend fewer years in medical practice after qualifying. Because they give a mature point of view and variety to an otherwise rather homogenous class of eager school-leavers? Yes, certainly. I don’t know how to draw up a balance sheet for these arguments and I suspect nobody else does either. Perhaps that’s why we admit about 10-15% mature students to our schools, while we wait for more evidence on the matter to build up.

Students should not be

taught; it makes them discover their own areas should mentally lazy. They and respond appropriately of ignorance reason I find this so hard to accept is my of debt and gratitude to the splendid teachers who shared with me the accumulated wisdom they had built up from years of experience. I don’t think it made me mentally lazy; in fact I think it opened my mind to all forms of curiosity and adventure. I really enjoy listening to someone who knows his subject intimately. No matter what his subject may be, ifhe loves it (and I can tell ifhe loves it) he can give me an insight into how his mind works and what the subject is really about. If I’m lucky I can share his excitement in it. No matter how outlandish it may appear to be, if he loves his subject that much, I feel it can’t be all bad. One of my daughters had a rather bad time with selfdiscovery in lenses. She was given lenses, mirrors, and light sources and encouraged to recapitulate the discoveries of Galileo as part of her course in ’A’ level physics. Though she was acutely aware of her ignorance in lens matters, she lacked Galileo’s genius for seeing solutions. What she needed was someone like Galileo to explain lenses to her with the knowledge, confidence, and enthusiasm that comes from years of thought applied to a difficult problem. I accept that this might have made her mentally lazy but, on the other hand, it might have so excited her and fired her imagination that she would have devoted the rest of her life to laser technology. As it turns out she still doesn’t know much about lenses and I don’t think she even likes them very much. But then she has a wonderful teacher for chemistry and that is the subject she really loves.

PERHAPS the

enormous sense

Department of Physiology, Queen’s University of Belfast, 97 Lisburn Road,

Belfast BT9 7BL

IAN C. RODDIE

Round the World From

our

Correspondents

United States HEALTH ISSUES AND THE PRESIDENTIAL CAMPAIGN

SOME fundamentalists and Roman Catholics have managed to inject a public health issue, abortion, into the current US presidential campaign. They want it outlawed. So strong is their influence within President Reagan’s Republican party that they were able to get a plank into the party platform that directed the President to appoint only judges who oppose abortion. Whether Mr Reagan would go that far in the event of his reelection, which Republican leaders comfortably regard as a certainty, is unknown. There is no question, though, that he warmly embraces the anti-abortion cause. He has deplored abortion as a procedure which inflicts excruciating pain on the fetus. He has favoured a constitutional amendment banning abortion. The President’s Democratic opponent, Mr Walter Mondale, and his running mate, vice-presidential candidate Geraldine Ferraro, are on the other side of this issue. Ms Ferraro, a Roman Catholic, was singled out by anti-abortion pickets along the campaign trail even before the scandal broke over her admitted violations of campaign spending rules as a member of the US House of

Representatives. However, for all the emotion the idea arouses, it is hard to see that outlawing abortion ranks high on the Government’s agenda. A poll shows that most of the women in the President’s own party believe they should have a choice if the problem arises. That, unfortunately, is the way campaigns work. The really important health issueshealth care and environmental health-tend to get the brush-off treatment. They are too hard to explain to voters, who are usually bored with politics anyway. Mr Mondale himself has called the rescue of Medicare, the Government’s health insurance plan for the elderly, a major campaign issue. He said he had a plan to put things right but declined to disclose the details. The President’s budget director, Mr David Stockman, considered Medicare so politically volatile that he declined to provide details in the President’s budget for 1985 on how the administration plans to cope with the financial crisis. The President’s environmental plans are more specific. One of them, a proposal to ban, from Jan 1, 1986, about 90% of the lead in gasoline, astonished the environmentalists. It is a far bolder proposal than the approach his Democratic predecessor, Jimmy Carter, ever took. In announcing the proposal, Environmental Protection Agency administrator, William Ruckelshaus, said the evidence was overwhelming that lead in the air was a particular health danger to children and pregnant women. There is always the possibility, environmentalists say, that the lead proposal will turn out to be another forgotten election year promise. So much of the remaining EPA performance record is about what one would expect from an administration which caters for industry. The high-priority programme to clean up hazardous waste dumps barely moves. Mr Ruckelshaus steadfastly refuses to believe the many scientists who tell him to act now to curb acid rain. Similarly, action to protect the health of workers is bogged down. The Occupational Safety and Health Administration’s enforcement record shows a dramatic decline since Mr Reagan took office. OSHA cannot seem to get around to establishing standards for such workplace carcinogens as formaldehyde and ethylene dibromide. Whether Mr Mondale would, if elected, improve on Mr Reagan’s performance in protecting the public health is a matter for speculation. He complains that the rich "made out like bandits" under Mr Reagan’s administration. The president tells a story involving a jackass in attacking Mr Mondale. But after all the namecalling and sloganeering are cleared away, the plans of both candidates for the important daily business of governing often look remarkably alike.