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FALLACIES OF MEDICAL EDUCATION
839 FALLACIES OF MEDICAL EDUCATION
SIR,-What a strange compound of downright common sense and swingeing emotional prejudice is the article by Professor Dornhorst and Dr. Hunter (Sept. 23, p. 666). Their contention that preclinical teaching is often insufficiently orientated towards medical needs will probably be sympathetically echoed by the profession, as will their proposal to adopt the approach of the Newcastle school and integrate preclinical and clinical experience from the outset of the undergraduate medical course. They might even consider the proposal of Popper1 that the time is ripe for medicine to withdraw altogether from the crippling influence of the university campus. But is the central discipline of science-assisted clinical practice really backed up against the wall fighting for its life, as they picture, against the onslaught of a hoard of barbarian " amateur psychoanalysts ... all manner of cranks and faddists ", generalists, psychotherapists, sociologists, and " for opportunist reasons, by some professional specialties " ? The hugely defensive tone of the article suggests that in some quarters there is powerful criticism that modern, technologically complex medicine as practised in our hospitals is not enough. To devalue those who visualise medical care in its wider psychological and social setting, and those who would wish to avert certain diseases through control of xtiological factors, as " no longer able to keep abreast " of technical progress is unworthy. In the inevitable rivalries of opinion which, rightly and necessarily, characterise the progress of medicine it is surely essential to avoid this sort of discourtesy. Complementary differences of approach to ’the many-sided problems created by ill-health should be welcomed. I believe, contrary to the views of Professor Dornhorst and Dr. Hunter, that most doctors and the non-medical public are tremendously impressed by the rapid technical development of modern medicine. But can we ignore the oft-heard expressions, by patients and their relatives, of resentment and even detestation of the aloof impersonal manner of the hospital doctors who have given them back their lives ? The technological breakthrough has rather gone to the profession’s head, resulting in a distasteful arrogance towards all and sundry, as has been noted before in history in those who hold the power of life and death. Those in our care would wish us only to humanise our approach; the sick prefer a combination of technical and pastoral care. I hope indeed there is substance in the happy assertion of Professor Dornhorst and Dr. Hunter that most newly-qualified doctors are now " fully aware of the importance of social and emotional factors in illness ". Incidentally, something like 93% of marriages avoid the divorce courts, against 97% forty-five years ago.2 I can understand that the prospect of sonic booms might just provoke some reaction against scientific endeavour, but by what process of loeical association is the divorce-rate involved ? Department of Clinical Research, Crichton Royal,
J. C. LITTLE.
Dumfries, Scotland.
THE BRAIN DRAIN AND MEDICAL EDUCATION SIR,-Iwould agree with Dr. Naidoo (Sept. 23, p. 670) in his use of the word exemplary as applied both to medical education and to medical practice. The word, however, should be qualified by and appropriate ". Nowhere in my writings is there an advocacy of inferior medical education or inferior practice by the physician. It is rather to protect the status of the profession, and the standards of medical education and practice, that I advise the development of an auxiliary medical-care worker. Only by this means can one, in the circumstances of the poorer countries, protect the quality of the physician, whilst at the same time rendering the immediate quantitative needs for medical care to the many. If the "
"
"
1. 2.
Popper, H. Ann. N.Y. Acad. Sci. 1965, 128, 473. Fletcher, R. The Family and Marriage in Britain. 1966.
Harmondsworth,
engineer performs the functions of the plumber, does he become identified with the
plumber,
not
only
but he is the
plumber. In the industrialised countries the medical-care programmes organised on the basis of an educated urban society. Much of the common illness is self-diagnosed and self-medicated. For the more serious ills medical care is based upon the large urban hospitals with their specialised units. The ills are mostly those of stress, degeneration, and urban hazards. They are more difficult and more expensive to treat. Both medical research and medical education have changed, and are changing, to meet these needs-including the trend of the teaching schools to move into the community, a trend that will no doubt be adopted by non-teaching hospitals. A greater reliance has to be placed upon advanced medical technology. Conversely, in the poorer countries medical programmes need to be organised to cater to the needs of a semiliterate, uninformed, rural population. The urban societies of such countries are catered for on much the same patterns as elsewhere, with a relative plentitude of physicians and hospital beds. Rural areas still remain isolated by poor communications, and, often, an inability to afford public transport where it exists. The pattern of disease is that of Western countries during the nineteenth and early twentieth centuries: diseases of childhood, and infectious and vector-borne diseasesdiseases for which we already have the answers, but not the manpower and the money to secure their demise. Medical care is based on the rural health centre, organised and staffed to cope with patients with the daily ills, others being referred to larger centres. Diagnosis and treatment depend mostly on clinical acumen, with minimal technological investigations. The medical-care worker needs to be a generalist, well versed in the skills of meeting medical, surgical, and obstetric emergencies. He needs to be much more self-reliant. He needs to have the knowledge and skills to treat the ills of his people For it is as a group as well as their individual sickness. true that for medicine is based on faith in patently respect curative medicine. Prevention may be better than cure; but that is little consolation to a sick person. So the concept of the practice of integrated, or comprehensive, medicine demands the production of able self-contained general practitioners with a thorough knowledge and understanding of managerial medicine, social and preventive medicine, communicable diseases, child care, nutrition, and fertility/infertility, and with vocational skills. Medical education in the poorer countries needs to stress these aspects. Medical research needs to veer towards solving their problems of today. So, I wonder how appropriate is the training which foreign students seek in the Western world. How far does it suit them to meet rural requirements ? Or do they merely return to aggravate the urban-rural imbalance ? Both Westand Livingston2 are of the opinion that the special training sought by many is not consonant with the priority needs of their countries, or with their country’s ability to support them in the specialty roles they have chosen. This latter aspect is of course one of the reasons which induce such foreign medical graduates to remain in the Western world. But on the whole the exodus is a temporary one, some nine out of ten returning to their home country. Most stay a year or two, but many much longer. If the postgraduate training received in foreign countries is appropriate to the home country’s needs, then I cannot understand why there is the fuss. For the graduates return, presumably much enriched in knowledge, and spend the next 30-40 years contributing more competently to progress in medical service, education, and research in their own country. Surely, on balance, there is a profit not a loss ? If on the other hand such foreign postgraduate training is inappropriate, then it is perhaps a valid comment that undergraduate education should endeavour to inculcate into students a greater desire to be generalists rather than specialists, and to study those aspects which are most pertinent to their own are
1. 2.
West, K. M. J. med. Educ. 1965, 40, 119. Livingston, K. E. New Engl. J. Med. 1966, 275, 1288.
SIR,-What a strange compound of downright common sense and swingeing emotional prejudice is the article by Professor Dornhorst and Dr. Hunter (Sept. 23, p. 666). Their contention that preclinical teaching is often insufficiently orientated towards medical needs will probably be sympathetically echoed by the profession, as will their proposal to adopt the approach of the Newcastle school and integrate preclinical and clinical experience from the outset of the undergraduate medical course. They might even consider the proposal of Popper1 that the time is ripe for medicine to withdraw altogether from the crippling influence of the university campus. But is the central discipline of science-assisted clinical practice really backed up against the wall fighting for its life, as they picture, against the onslaught of a hoard of barbarian " amateur psychoanalysts ... all manner of cranks and faddists ", generalists, psychotherapists, sociologists, and " for opportunist reasons, by some professional specialties " ? The hugely defensive tone of the article suggests that in some quarters there is powerful criticism that modern, technologically complex medicine as practised in our hospitals is not enough. To devalue those who visualise medical care in its wider psychological and social setting, and those who would wish to avert certain diseases through control of xtiological factors, as " no longer able to keep abreast " of technical progress is unworthy. In the inevitable rivalries of opinion which, rightly and necessarily, characterise the progress of medicine it is surely essential to avoid this sort of discourtesy. Complementary differences of approach to ’the many-sided problems created by ill-health should be welcomed. I believe, contrary to the views of Professor Dornhorst and Dr. Hunter, that most doctors and the non-medical public are tremendously impressed by the rapid technical development of modern medicine. But can we ignore the oft-heard expressions, by patients and their relatives, of resentment and even detestation of the aloof impersonal manner of the hospital doctors who have given them back their lives ? The technological breakthrough has rather gone to the profession’s head, resulting in a distasteful arrogance towards all and sundry, as has been noted before in history in those who hold the power of life and death. Those in our care would wish us only to humanise our approach; the sick prefer a combination of technical and pastoral care. I hope indeed there is substance in the happy assertion of Professor Dornhorst and Dr. Hunter that most newly-qualified doctors are now " fully aware of the importance of social and emotional factors in illness ". Incidentally, something like 93% of marriages avoid the divorce courts, against 97% forty-five years ago.2 I can understand that the prospect of sonic booms might just provoke some reaction against scientific endeavour, but by what process of loeical association is the divorce-rate involved ? Department of Clinical Research, Crichton Royal,
J. C. LITTLE.
Dumfries, Scotland.
THE BRAIN DRAIN AND MEDICAL EDUCATION SIR,-Iwould agree with Dr. Naidoo (Sept. 23, p. 670) in his use of the word exemplary as applied both to medical education and to medical practice. The word, however, should be qualified by and appropriate ". Nowhere in my writings is there an advocacy of inferior medical education or inferior practice by the physician. It is rather to protect the status of the profession, and the standards of medical education and practice, that I advise the development of an auxiliary medical-care worker. Only by this means can one, in the circumstances of the poorer countries, protect the quality of the physician, whilst at the same time rendering the immediate quantitative needs for medical care to the many. If the "
"
"
1. 2.
Popper, H. Ann. N.Y. Acad. Sci. 1965, 128, 473. Fletcher, R. The Family and Marriage in Britain. 1966.
Harmondsworth,
engineer performs the functions of the plumber, does he become identified with the
plumber,
not
only
but he is the
plumber. In the industrialised countries the medical-care programmes organised on the basis of an educated urban society. Much of the common illness is self-diagnosed and self-medicated. For the more serious ills medical care is based upon the large urban hospitals with their specialised units. The ills are mostly those of stress, degeneration, and urban hazards. They are more difficult and more expensive to treat. Both medical research and medical education have changed, and are changing, to meet these needs-including the trend of the teaching schools to move into the community, a trend that will no doubt be adopted by non-teaching hospitals. A greater reliance has to be placed upon advanced medical technology. Conversely, in the poorer countries medical programmes need to be organised to cater to the needs of a semiliterate, uninformed, rural population. The urban societies of such countries are catered for on much the same patterns as elsewhere, with a relative plentitude of physicians and hospital beds. Rural areas still remain isolated by poor communications, and, often, an inability to afford public transport where it exists. The pattern of disease is that of Western countries during the nineteenth and early twentieth centuries: diseases of childhood, and infectious and vector-borne diseasesdiseases for which we already have the answers, but not the manpower and the money to secure their demise. Medical care is based on the rural health centre, organised and staffed to cope with patients with the daily ills, others being referred to larger centres. Diagnosis and treatment depend mostly on clinical acumen, with minimal technological investigations. The medical-care worker needs to be a generalist, well versed in the skills of meeting medical, surgical, and obstetric emergencies. He needs to be much more self-reliant. He needs to have the knowledge and skills to treat the ills of his people For it is as a group as well as their individual sickness. true that for medicine is based on faith in patently respect curative medicine. Prevention may be better than cure; but that is little consolation to a sick person. So the concept of the practice of integrated, or comprehensive, medicine demands the production of able self-contained general practitioners with a thorough knowledge and understanding of managerial medicine, social and preventive medicine, communicable diseases, child care, nutrition, and fertility/infertility, and with vocational skills. Medical education in the poorer countries needs to stress these aspects. Medical research needs to veer towards solving their problems of today. So, I wonder how appropriate is the training which foreign students seek in the Western world. How far does it suit them to meet rural requirements ? Or do they merely return to aggravate the urban-rural imbalance ? Both Westand Livingston2 are of the opinion that the special training sought by many is not consonant with the priority needs of their countries, or with their country’s ability to support them in the specialty roles they have chosen. This latter aspect is of course one of the reasons which induce such foreign medical graduates to remain in the Western world. But on the whole the exodus is a temporary one, some nine out of ten returning to their home country. Most stay a year or two, but many much longer. If the postgraduate training received in foreign countries is appropriate to the home country’s needs, then I cannot understand why there is the fuss. For the graduates return, presumably much enriched in knowledge, and spend the next 30-40 years contributing more competently to progress in medical service, education, and research in their own country. Surely, on balance, there is a profit not a loss ? If on the other hand such foreign postgraduate training is inappropriate, then it is perhaps a valid comment that undergraduate education should endeavour to inculcate into students a greater desire to be generalists rather than specialists, and to study those aspects which are most pertinent to their own are
1. 2.
West, K. M. J. med. Educ. 1965, 40, 119. Livingston, K. E. New Engl. J. Med. 1966, 275, 1288.