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IF I WERE A DEAN
30
there is little evidence yet of any great competition for such plum postings in the medical empire. A straw poll amongst third-year students at a certain Scottish medical school uncovered a mere half-dozen who "might consider" general practice and none at all who foresaw any viable future in community medicine. Tom McKeown’s "engineering model" still seems firmly entrenched.
tely
Medical Education
IF I WERE A DEAN
GORDON HOROBIN* As the Irishman said, when asked the way to Dublin, "If I were you, I wouldn’t start from here". The trouble about choosing a method of selecting students for medical school is that the starting-point is far from an ideal one. Take, for example, the present medical curriculum, heavily weighted as it is in the preclinical years on the side of the physical sciences. Those most likely to pass their first M.B. will be, ceteris paribus, those who obtained A-grade passes in A-level physics and chemistry. It would not be particularly helpful to select those candidates who score A on "motivation" (however you define and measure it) and D on science if they never get beyond the preclinical stage. In one sense, then, that a science-based medical curriculum attracts the high fliers from the science sixth forms and that, in turn, medical schools demand better and better A-level performances is a self-fulfilling prophecy. Of course the trend also reflects a fairly realistic appraisal on the part of the candidates (and their advisers) of future job prospects. The massively increased uptake by industry of science graduates forecast in the 1960s never seems quite to have materialised and, so far at any rate, the medical trade unions have managed to restrict the supply of doctors sufficiently to maintain a healthy sellers’ market. Is it necessarily a bad thing to have high selection standards in science? There is, after all, a powerful section of the conglomerate medical profession which claims that medicine needs a firmer scientific basis than it has had hitherto. In this scenario, the medical enter-
prise is seen as an increasingly research-based, increasingly technical onslaught on the hitherto intractable problems of the aetiology and cure of the killing and degenerative diseases. This image of medicine, boosted by the media, strikes a responsive chord with the public too. How much nicer it would be, we fantasise, if we could all smoke, eat, and drink as much as we like because whatever illness penalties we incur can be cured just as easily as last week’s sore throat. health is everyone’s if doctors retain the business, monopoly of the treatment of illness. And, if we are to take prevention seriously, does this not have rather profound implications for the recruitment and training of future healthand-illness professionals? Just as in the nineteenth century the only measurable impact on disease came from the public-health sector, so in the past two decades it is perhaps to its modern counterparts, community medicine allied to a revitalised and politically weighty healtheducation corps, that we should look for aid. Just as important, I believe, is a new emphasis on the key role of primary care in the prevention of ill-health. Unfortuna-
But the less
palatable truth is that
even
*M.R.C. Medical Sociology Unit, Institute of Medical Aberdeen AB9 2ZE.
Sociology,
Health, I believe, now demands political and social action as much as, if not more than, biophysical intervention in the workings of the skin-contained individual, and medical education is still heavily weighted towards the latter. Modern illnesses are produced in, and sustained by, social action; their treatment or, more important, their prevention, are therefore necessarily social acts too. To label alcoholism a disease, for example, may help to reduce stigma, but it also creates the expectation that it can somehow be cured by medical intervention. Yet it is clear that drinking behaviour is firmly entrenched in our culture, and that a very subtle understanding of the complex social relationships in which the alcoholic is enmeshed is a necessary, though not sufficient, condition for counselling or "treatment". Medical schools vary a good deal in the extent to which they provide behavioural-science courses, but even the most highly developed of these scarcely affects the total portrait of the medical enterprise available to the students. I am not suggesting that clinical expertise is, or will become, redundant; I too will continue to expect the best, most elegant treatment when I am ill. Nor am I suggesting that medical sociology should replace anatomy or physiology. What I am suggesting is that health and illness are social as much as physical states and that knowledge of the environmental, social, and cultural conditions which produce them, together with the behavioural forms through which health and illness are acted out, should be fully incorporated into the medical curriculum. This is not, of course, a very revolutionary statement; it is, after all, no more than a paraphrase of some of the Todd recommendations. But there is no possibility of implementing these, other than on a token basis, while the sciences and clinical specialties dominate the schools. Alternative selection procedures are not likely to be very effective either, since change has to begin from the other end. Health-service priorities may be broadly determined at a national political level but their translation into practical action depends heavily on the professional trades unions and their shop stewards-i.e., the Royal Colleges and the hospital consultants and medical school professoriate. Training follows this alliance of tradition and power, and the career motivations of the students depend in turn on their perceptions of where the power and the
prestige reside. A modest start might just conceivably be made by requiring all candidates to have spent a post-school year in two or more practical placements-as an auxiliary helper, for example, to a district nurse or health visitor; in a mental hospital, a geriatric hospital, or old people’s home; in a field organisation like Shelter, a community rehabilitation project, or even a doss-house. At least the students would then be in a position to teach their teachers something.
there is little evidence yet of any great competition for such plum postings in the medical empire. A straw poll amongst third-year students at a certain Scottish medical school uncovered a mere half-dozen who "might consider" general practice and none at all who foresaw any viable future in community medicine. Tom McKeown’s "engineering model" still seems firmly entrenched.
tely
Medical Education
IF I WERE A DEAN
GORDON HOROBIN* As the Irishman said, when asked the way to Dublin, "If I were you, I wouldn’t start from here". The trouble about choosing a method of selecting students for medical school is that the starting-point is far from an ideal one. Take, for example, the present medical curriculum, heavily weighted as it is in the preclinical years on the side of the physical sciences. Those most likely to pass their first M.B. will be, ceteris paribus, those who obtained A-grade passes in A-level physics and chemistry. It would not be particularly helpful to select those candidates who score A on "motivation" (however you define and measure it) and D on science if they never get beyond the preclinical stage. In one sense, then, that a science-based medical curriculum attracts the high fliers from the science sixth forms and that, in turn, medical schools demand better and better A-level performances is a self-fulfilling prophecy. Of course the trend also reflects a fairly realistic appraisal on the part of the candidates (and their advisers) of future job prospects. The massively increased uptake by industry of science graduates forecast in the 1960s never seems quite to have materialised and, so far at any rate, the medical trade unions have managed to restrict the supply of doctors sufficiently to maintain a healthy sellers’ market. Is it necessarily a bad thing to have high selection standards in science? There is, after all, a powerful section of the conglomerate medical profession which claims that medicine needs a firmer scientific basis than it has had hitherto. In this scenario, the medical enter-
prise is seen as an increasingly research-based, increasingly technical onslaught on the hitherto intractable problems of the aetiology and cure of the killing and degenerative diseases. This image of medicine, boosted by the media, strikes a responsive chord with the public too. How much nicer it would be, we fantasise, if we could all smoke, eat, and drink as much as we like because whatever illness penalties we incur can be cured just as easily as last week’s sore throat. health is everyone’s if doctors retain the business, monopoly of the treatment of illness. And, if we are to take prevention seriously, does this not have rather profound implications for the recruitment and training of future healthand-illness professionals? Just as in the nineteenth century the only measurable impact on disease came from the public-health sector, so in the past two decades it is perhaps to its modern counterparts, community medicine allied to a revitalised and politically weighty healtheducation corps, that we should look for aid. Just as important, I believe, is a new emphasis on the key role of primary care in the prevention of ill-health. Unfortuna-
But the less
palatable truth is that
even
*M.R.C. Medical Sociology Unit, Institute of Medical Aberdeen AB9 2ZE.
Sociology,
Health, I believe, now demands political and social action as much as, if not more than, biophysical intervention in the workings of the skin-contained individual, and medical education is still heavily weighted towards the latter. Modern illnesses are produced in, and sustained by, social action; their treatment or, more important, their prevention, are therefore necessarily social acts too. To label alcoholism a disease, for example, may help to reduce stigma, but it also creates the expectation that it can somehow be cured by medical intervention. Yet it is clear that drinking behaviour is firmly entrenched in our culture, and that a very subtle understanding of the complex social relationships in which the alcoholic is enmeshed is a necessary, though not sufficient, condition for counselling or "treatment". Medical schools vary a good deal in the extent to which they provide behavioural-science courses, but even the most highly developed of these scarcely affects the total portrait of the medical enterprise available to the students. I am not suggesting that clinical expertise is, or will become, redundant; I too will continue to expect the best, most elegant treatment when I am ill. Nor am I suggesting that medical sociology should replace anatomy or physiology. What I am suggesting is that health and illness are social as much as physical states and that knowledge of the environmental, social, and cultural conditions which produce them, together with the behavioural forms through which health and illness are acted out, should be fully incorporated into the medical curriculum. This is not, of course, a very revolutionary statement; it is, after all, no more than a paraphrase of some of the Todd recommendations. But there is no possibility of implementing these, other than on a token basis, while the sciences and clinical specialties dominate the schools. Alternative selection procedures are not likely to be very effective either, since change has to begin from the other end. Health-service priorities may be broadly determined at a national political level but their translation into practical action depends heavily on the professional trades unions and their shop stewards-i.e., the Royal Colleges and the hospital consultants and medical school professoriate. Training follows this alliance of tradition and power, and the career motivations of the students depend in turn on their perceptions of where the power and the
prestige reside. A modest start might just conceivably be made by requiring all candidates to have spent a post-school year in two or more practical placements-as an auxiliary helper, for example, to a district nurse or health visitor; in a mental hospital, a geriatric hospital, or old people’s home; in a field organisation like Shelter, a community rehabilitation project, or even a doss-house. At least the students would then be in a position to teach their teachers something.