FALLACIES IN MEDICAL EDUCATION

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Points of View FALLACIES IN MEDICAL EDUCATION A. C. DORNHORST M.D. Lond., F.R.C.P. PROFESSOR OF MEDICINE

ALASTAIR HUNTER Cantab., F.R.C.P.

M.D.

DEAN

ST.

GEORGE’S

HOSPITAL MEDICAL

SCHOOL,

LONDON

S.W.1.

MEDICAL education is news. The General Medical Council has revised its recommendations on the undergraduate curriculum, a Royal Commission is deliberating, and there is a shortage of doctors. Universities with ambitious departments of biological science are eager to take medical students and some have already made bids for them. The medical profession has become so obsessed with the possession of a degree as a touchstone of respectability that it has hardly stopped to inquire whether the universities will inevitably meet its needs. It is time to look warily for myths and fallacies. Medicine is a scienceusing technology directed to the identification and analysis of disease by methods which form the essence of a doctor’s training. This analysis logically precedes treatment and prevention. The role of the biological sciences is primarily to enable medical students to study disease rationally rather than to turn them into scientists. Medical education therefore differs from the general run of undergraduate education in that it is necessarily vocational, and must aim to produce educated doctors and not merely educated men. Two fallacies commonly vitiate thinking about medical education; we shall call them the scientistic and the pastoral. The chief tenet of the scientistic fallacy is that medical students must be fortified against the potential corruption of clinical teaching by requiring them to take a science degree in the early stages of their course. That of the pastoral fallacy is that medicine has become too scientific and, consequently, inhumane; medicine must be humanised by removing students from the influence of specialists, and by apprenticing them instead to generalists, psychotherapists, and sociologists. THE SCIENTISTIC FALLACY

Scientistic fallacy flourishes in universities, especially where preclinical and clinical teaching are physically separated. It originates in the historical situation which enabled departments of anatomy and physiology, and later biochemistry, to become established in university faculties of science; and from the idea that medicine is a traditional craft, and that clinical education is still based upon rule of thumb imparted by practitioners distinguished solely by financial success. Before the introduction of academic clinical units, preclinical teachers had some justification for being conscious of a mission to teach medical students the principles of science as a protective armour against the supposed evils of clinical practice. But as their academic interests have diverged increasingly from those of medicine, they have tended to allow what is really a subsidiary purpose to take precedence over their task of preparing students for clinical work. The myth of the basic medical sciences has been created, and with it the belief that a degree in science is the only proper foundation of a medical course. Of course, it is natural and admirable that scientists should feel that experimental investigation is the most worthy form of activity, but to assume that it is the only

respectable way of training the mind, or that the study of general problems is necessarily intellectually superior to the handling of particular problems, is to display a ludicrous intellectual parochialism. The situation created by belief in the scientistic fallacy is well exemplified at Cambridge where an honours degree in biological science is so dominated by the tripos requirements of anatomy and physiology that subjects such as biochemistry, pharmacology, pathology, and psychology have a relatively minor role. The traditional prestige of the course, and the high academic standing of the departments concerned, have largely distracted attention from its limitations as a preparation for medicine. The obvious inadequacy of courses based largely upon anatomy and physiology has given a new twist to the scientistic fallacy. Degrees in human biology, designed sometimes as much for social scientists as for medical students, have been proposed as a means of broadening the syllabus by the inclusion of a variety of subjects ranging from mathematics to sociology. As yet, none has been tried in practice; but, even if their curricula succeed in being something more than a hotch-potch, they give little promise of improving the present system. Closely involved in the scientistic fallacy is the notion that physiology and other biological sciences must be studied exhaustively during the early stages of the course, because these sciences will receive no serious consideration during the clinical period. This convention has already run into practical difficulties because of the addition of new subjects to the curriculum, and will undoubtedly become unworkable when others are introduced. To adherents of the scientistic fallacy the solution is simple and logical; to lengthen the preclinical course by encroaching on clinical time. A long experience of elementary clinical teaching has given us opportunities denied to many preclinical teachers of assessing the effectiveness of the preclinical course. We have found little advantage in science degrees on the Cambridge pattern, and we have been impressed with the serious limitations of the system as a whole. Few students begin clinical work with any broad understanding of human structure and function, and many of them seem to have forgotten their preclinical work amazingly quickly. This low educational efficiency is not so much the fault of preclinical teachers as a consequence of the students’ educational background and of the structure of the course. By the time they begin preclinical studies, students are experienced and successful examination passers. They learned medieval history, perhaps, for ’0 ’ levels. They forgot it promptly, but by then it had served its purpose. They have since dealt similarly with the anatomy of the earthworm and the commercial production of ammonia. To them the preclinical course presents no essential novelty, nor calls for any change in the proven technique. The subjects will be memorised, the examinations passed, and the registers cleared for the next task. Indeed, the transition from learning for reproduction to learning for use takes place painfully-and too often incompletelyonly during the clinical course. The purpose of undergraduate medical education is to produce doctors who can understand disease, and who will be capable of practising medicine scientifically. Only a minority of medical students are primarily interested in science as such; the majority are committed to becoming doctors and will try to master a science only when convinced of its relevance to their purpose. The modern

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doctor increasingly needs

a good working knowledge of and pharmacology if he is to biochemistry, physiology, come to grips with the ever-expanding technical aspects of medicine, and especially if he is to maintain a critically

informed attitude to the flood of new information and therapeutic claims which he will meet after qualification. But medical students will apply themselves effectively to these subjects only when they have enough clinical experi-

appreciate their application to medicine. Failure to recognise this is the educational error of the scientistic fallacy. Mere extension of the preclinical course will leave the students’ attitude unchanged, and is likelier to augment the amount forgotten than to increase understanding. And ence to

if the clinical course is eroded there will be less oppvrtunity to make good the deficiencies in these subjects. THE PASTORAL FALLACY

The pastoral fallacy is a creation of a section of the profession, and probably arises as a reaction, by those no longer able to keep abreast, to the technical complexities of modern medicine. Its proponents emphasise the distinction between the patient and his disease, and claim to treat the whole man, and to regard the patient as a person. They stress the frequency and educational importance of the more trivial disorders and their interrelation with emotional factors. There is an implication that much of the elaboration of modern investigation and treatment could be dispensed with, if doctors were trained to acquire wisdom rather than to accumulate technical knowledge. Pervaded by an excessive belief in a unique therapeutic relation between doctor and patient, they aim to substitute a pastoral role for technical care, which is assumed to be necessarily impersonal or even inhumane. This approach is often sympathetically received by laymen who are alarmed by various features of modern life, from divorcerates to sonic booms. They believe that all would be well if doctors would turn their attention to prevention rather than cure, and that medical students should learn more about health than about disease. The fallacy is a favourite with the amateur psychoanalysts who figure so prominently in left-wing journalism, and is also supported, for opportunist reasons, by some professional specialties, and by all manner of cranks and faddists. The essential superficiality, and indeed dishonesty, of this attitude is revealed when one of its advocates is faced with illness in himself or in his family. The call then is not for the wise father figure, but for the man who knows most about so-and-so. THE

CONSEQUENCES

Despite the apparent incompatibility of their beliefs, adherents of the scientistic and the pastoral fallacies are united in their lack of regard for the rapid technical development of modern clinical medicine. Scientists seem unaware of it, or at best see it as a faintly disreputable technology: pastorals oppose it as contrary to the art of medicine. The effect of their combined views on medical education would be to devalue its essential disciplines by substituting a degree in human biology and a diffuse professional apprenticeship for a thorough training in methods of diagnosis and treatment. We share the scientists’ desire to increase the part played by the biological sciences in the medical course, but we believe that to be fully effective they must be taught in the most relevant parts of the course, and not solely at the beginning, when their potential importance cannot be fully appreciated. We in no way depreciate the importance of social and preventive medicine, especially as postgraduate studies, but we believe the

pastoralists err in giving them a central role in the undergraduate course. The traditional alignment of preclinical teachers with science instead of with medicine prevents the course being treated as a whole and separates it artificially into " scientific and non-scientific parts---or even in some people’s minds into university and non-university parts. Physical separation of the university and the teaching hospital aggravates the problem and makes it difficult for some preclinical teachers to contemplate changing their allegiance. Their reluctance is likely to be shared by pastorals and laymen who are apt to confuse learning with culture, "

and to see the campus as a source of social and aesthetic civilisation for those about to enter a barbarian professional world. Under the present system, most newly qualified doctors acquire a sound grasp of clinical method, and a humane concern for their patients’ welfare. Contrary to what is sometimes stated, they are fully aware of the importance of social and emotional factors in illness. But their performance as candidates for higher qualifications, and their difficulties in independent practice show a lack of ability to evaluate and handle new information critically, which suggests that their knowledge of medicine is not as solidly based as it should be. THE REMEDY

The only remedy which will avoid the errors of the scientistic fallacy is to integrate science more adequately into the medical course instead of teaching it separately. The distinction between preclinical and clinical subjects is now educationally obsolete, and medical students ought to begin clinical work as early as possible. The preclinical period will therefore have to be shortened, although the total time allotted to science will be increased. Scientists who wish to teach medical students must be prepared to sacrifice some departmental convenience to make their teaching fully effective by concentrating on those topics most relevant to medicine, and by deploying it throughout the whole undergraduate course. Those who feel that their scientific integrity would thereby be compromised should leave the teaching of medical students to others.

In

England Now

A Running Commentary by Peripatetic Correspondents I’VE often thought I should like to read fast. Not a word at a time, as I do now, but at least a line, a paragraph, or a page. Useful, profitable, evidence of an agile brain. But a man who can do it tells me that, at least for him, words are what alphabet letters are for me, useful symbols which together make something significant but themselves without meaning or flavour. Nothing less than a sentence counts and the sentence conveys only its meaning. Ergo, at least for him, no Keats, no Blake, no Coverdale’s psalms, no David’s lament for Saul, no best bits " of Shakespeare. " Nothing for nothing," said my father, and precious little for sixpence." This may not be the necessary price, but if it is, " nothing doing." I will never regret my plodding again. Furthermore, to teach a child to read fast-supposing it can be done-seems a doubtful kindness. *

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America, bread, fit for humans and not for robots, costs 2 cents an ounce; ready-mix fruit pie, with top crust, costs less than 1 -5 cents. Ah, Marie Antoinette, you prophetess! In

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The academic’s family holiday Sunday morning in the North of France; car won’t go and garages shut; camp site flood and tent is leaking; D and v in the

sleeping-bags.