The role of socio-behavioural scientists in health care practice

SOC.Sci. Med. Vol. 25, No. 6, pp. 6799687, 1987 Printed in Great Britain. All rights reserved

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1987 Pergamon Journals Ltd

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THE ROLE OF SOCIO-BEHAVIOURAL SCIENTISTS IN HEALTH CARE PRACTICE F. M.

HULL*

Free University, P.B. 7161, Amsterdam, The Netherlands and University of Birmingham Medical School, Birmingham B15 2TJ, England Abstract-This paper attempts to analyse some of the complex problems that face primary health care practice in the developed world today. These are shown to be a degree of depersonalisation, that has come with greater efficiency, and a reduction in the quality of the doctor-patient relationship, which has accompanied increased medical effectiveness. These changes are in turn related to changes in diagnostic methods in primary care, to changes in the

organisation of primary care and to change in the stress laid on interventive, preventive and rehabilitative care. All these inter-related problems have to be viewed against a background of shortage of resource which demand a far more stringent system of accountability than has been common until now. A possible solution lies in redefining the traditional medical role and the philosophical basis which underlies that role at a time when primary health care is confronted by the special problems of the AIDS pandemic. This would require major alterations in medical attitudes and in established medical education which may be impossible for the doctors to achieve by themselves. It is suggested that a most important role of socio-behavioural scientists lies in helping the medical profession to remove the attitudinal and educational barriers which prevent the realisation of the concept of a new sort of doctor who may cope with the demands of primary health care as we approach 2000.

INTRODUCTION

the gross deficiencies of primary care reflecting perfunctory care given by perfunctory men. In America a tendency begun by Flexner [2], who in 1910 had reorganised medical education, led to the virtual demise of the family doctor as immortalised in Hertzler’s “Horse and Buggy Doctor” [3]. All this came about because of the explosion of medical knowledge. It was no longer respectable to be jack of all medical trades; mastery of a single speciality grew to be the norm. With maldistribution between generalism and specialism there was also spatial maldistribution with doctors concentrating around centres of excellence in the big cities where academic hospitals fostered what Harold Wilson called the white heat of modern technology. Doctors, burdened by a huge amount of factual information, felt increasingly insecure and, in self protection, moved further towards specialisation. The doctor, who looked after people, became in succession an organ doctor, a tissue doctor, a cell, and finally, a molecule doctor. It was a long time before this was seen as the disaster that it is (in fact it is still not universally recognised as such). Ironically when the lesson came it was from the third world where, anxious to show that something was being done in the face of appalling health care statistics, emergent governments imported western ideas. New multi-million pound tertiary care hospitals began to spring up in countries with disastrous neonatal and infant mortality. Still the children died because, it was cheap primary, not expensive secondary or even tertiary care, that they needed.

Once upon a time a large piece of truth was placed at the centre of a round table. A group of people sitting round the table were each asked to write what they saw. Each described something different; but it was the same truth, for so much depends on the angle from which one studies it. The point of this story is that the way a subject is treated must vary according to where an author sits on that round table. I am a general practitioner and an itinerant academic who finds himself surprised at being asked to prepare a background paper for an International Conference on Social Science and Medicine. When one of my students says, in reply to a question, “I don’t know” I always reply: “splendid, after that disclaimer you can now start thinking”. The following paper resulted from just such an exchange with this Journal’s Editor. It analyses the origins of problems now facing primary care and suggests ways in which socio-behavioural scientists may help doctors to solve them. FACING PRIMARY CARE

ANALYSIS OF PROBLEMS HEALTH

Over the in primary practice in rating fast.

last 40 years there has been a revolution care. After the second world war general Britain was of poor quality and deterioBy 1950 Collings [l] was to report on

*Address for correspondence: Lucy, Warwick

Jasmine Cottage, CV35 8BE, England.

Hampton

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Useful though examples from the third world may be this paper is concerned with the state of primary health care in developed countries. Appreciation of the need for simple medicine, even among sophisticated nations, has produced a renaissance of primary care throughout the world. This rebirth became apparent in several countries after the second world war. In Britain it started in the late 1950s and it grew internationally during the next two decades. After a slow start in America primary care accelerated there during the Kennedy administration [4] and grew so explosively during the 1970s that now family medicine is the first choice of many new medical graduates. Similar changes have occurred or are taking place throughout Europe, in Australasia and increasingly in the developing world. These changes in attitude towards primary care took place against a background of even more profound change in the understanding and management of disease, of new approaches to diagnosis and in the organisation of health care aimed at increasing its efficiency. Ironically, in its attempt to meet the challenge of these changes, primary health care has produced new problems. Change in attitudes

to diagnosis of disease

In Britain after the war there was still a great deal of infective disease which accounted for the bulk of the family doctor’s huge workload. Attitudes to infective disease were still related to the pre-antibiotic era which stressed isolation and bed-rest. It followed that a large proportion of the doctor’s work was domiciliary which, beside being time-consuming, made it less necessary for him to maintain a well appointed office or surgery in which to see patients. Though there were plenty of chronic conditions and an increasing mortality from heart and malignant diseases, general practitioners saw themselves as interventionists who waited until their patients presented symptoms which they then attempted to diagnose and manage. Certainly there was little attempt to go out and seek disease among one’s patients and prevention was limited to immunisation and ante-natal care. Diagnostic methods were those of traditional medical school teaching: indeed where doctors abandoned accepted ways for more pragmatic methds they felt guilty of lack of professionalism which re-inforced a misplaced sense of inferiority [S-7]. Gradually new ideas about diagnostic pathways led to the acceptance of hypothetico-deductive methods [8-l I] which were more appropriate to general practice [12]. At the same time the concept of the practitioner’s responsibility for those people on his list who rarely complained or never saw him began to grow and with it the need to seek out those with asymptomatic disease. This need for screening is not universally accepted since some doctors hold that screening for asymptomatic disease infringes the individual’s right of autonomy but it is difficult to see how this is in accordance with the Declaration of Lisbon which defines the patient’s right to accept or refuse treatment after receiving adequate information. It is clearly impossible to be adequately informed if no attempt has been made to discover detectable but symptomless disease.

Changes in the organisation

of primary

care

The doctor’s charter of 1965 brought about a further change in British general practice which hastened the tendency of doctors to coalesce into groups working from purpose built premises. Such groups could afford to buy new equipment: minor operating rooms, electrocardiograms and other diagnostic and therapeutic tools allowing general practitioners more scope in recognition and management of illness. These groups, often housed in local authority buildings were encouraged to have nurses, health visitors and social workers from the local authority assisting them in their practices. Other doctors who had built their own surgery premises soon followed suit, either making similar arrangements with their local authorities, employing their own staff, or both. The idea of a team of different disciplines working together in primary care was to grow steadily over the next two decades though it was often hampered by inter-professional rivalry and territoriahsm [13-l 71. Revolution is never all good. Though these changes were enormously beneficial they also produced problems. As general practice moved from the cottage industry of the immediate post-war period and became organised it lost a very great deal in the process. One can see this in present day Dutch general practice [ 181 which, in its frequency of single-handed doctors working from small lock-up surgeries with little or no ancillary support and very frequent referral to hospital [ 191 closely resembles the state in Britain in 1955-60. But these Dutch doctors have maintained a close relationship with their patients resembling the guide philosopher and friend of Hertzler in America or Pickles in England [20]. A recent thesis presented at Nijmegen [21] has shown that the average consultation time among Dutch general practitioners is 9.9 min, nearly twice that of their British counterparts. The same thesis demonstrated that quality of the consultation, as judged by somatic and psycho-social performance, improved with consultation length up to 8 min after which time there was little further improvement in quality. Between 1950 and 1980 British practice has become efficient but it has also become officious. There is abundant evidence from many sources showing that general practice has somehow lost its ability to relate properly to the people it serves [22,23]. This deterioration in the doctor/patient relationship has been analysed by Shorter [24] who shows that as doctors have become more effective over the last century so they have lost the warmth of relationship that they had in former days when they were therapeutically impotent. (This observation is important because it suggests a way of resolving the problems that I am describing and I shall return to this later.) That this has happened despite Bahnt’s [25] contribution to whole person medicine, to the appreciation of illness in the context of the person suffering from it and the importance of the relationship between doctor and patient, showed that high technology medicine has exerted a very profound influence on primary care. So today we have in Britain a general practice that has become efficiently interventionist, which has moved from a home-visiting, home-delivering, supportive of home-dying position to one which argues

Socio-behavioural

scientists in health care practice

from impeccable statistics that home-visiting is uneconomic, home-delivery unsafe for both mother and baby and home-dying unacceptable to the patient, his relatives and medical attendants. These changes are in marked contrasts to other European countries: visiting is much commoner in Belgium [26] and home delivery in Holland [27,28]. Such a change is not without its critics; there is a growing tendency for consumers to complain, not so much at medical management as at the brusqueness, the lack of courtesy, the unkindness of doctors [23]. Or as Wilkes puts it “the comparatively ill-equipped doctor of half a century ago was more beloved and respected than his modern high-technology counterpart” [29]. That this tendency is more marked in Britain than elsewhere is often revealed to me when teaching on videotaped simulations of British consultations which, though perfectly accepted as normal in Britain are seen as being impossibly short, brusque and uncaring by Dutch general practitioners. There is thus a discrepancy between what the providers and consumers of health care expect from late twentieth-century medicine. This attitude is reflected in the ever increasing volume of litigation against the profession in many western countries, and the consequent meteoric rise in insurance premiums. Doctors, listening to this rising tide of complaint, react defensively though denying the reason behind the unrest, they find the situation increasingly untenable. The growing acceptance of unorthodox medicines is another indication of consumer dissatisfaction and a survey in Belgium suggested that the reason for increasing use of ‘fringe’ medicine lay in the fact that non-allopathic practitioners gave patients more time [30]. Time and courtesy, important to us all, are essential to the sick who may be afraid or embarrassed at the possible significance of their symptoms. A survey in Britain showed that many people, especially women aged 15 to 45, leave the doctor without having completely told him why they had come [31]. Morrell and his co-workers also showed that doctors identified fewer problems when surgery appointments were short [32]. This question of access to doctors requires further study. We boast of the ease of access that the National Health Service provides but is this more illusory than real? As Smith and Churchill point out in their thought-provoking book on Professional Ethics in Primary Care [33] accessability subsumes availability, attainability and acceptability. These qualities are often lacking and increasing evidence from consumer societies must make us question the sacred cow of accessability. In some areas it is difficult for patients to register with general practitioners, particularly if they have problems which are likely to make them unusually demanding. When a patient falls out with his doctor for any reason it may be quite difficult for him to change to another practitioner [34]. In some cases appointment systems are overloaded making it difficult for a patient to see the doctor and when he succeeds consultations tend to be very short [35,36]. In Britain general practitioners spend less of their time in face to face consultation than family doctors in ten other countries in North America, Australia and Europe [26]. The hallowed 6min of the average British consul-

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tation, despite its defence by eminent general practitioners like Norell [37] is simply not enough even though, as Howie points out [38]: “each consultation is a single frame in the long-running film of the patient’s life”. This brevity is made infinitely worse in large practices where it may be difficult for a patient always to see the same doctor and so preserve continuity. Difficulty of access is not solely of medical making but there is a need to make it easier for patients to change doctor when there is good reason. We also need to make information about practices and their staff available to patients in order that they may be in a position to make informed choice of their general practitioner. This may be particularly important where religious or ethical considerations might affect medical decision making [33,34]. The outcome for a young woman with an unwanted pregnancy may vary with her chance selection of the doctor whom she consults. Whatever the rights and wrongs of termination of pregnancy it should not be influenced by chance. Such ethical differences are not the only problem; there are huge gulfs between patients and their doctors such as fear, class, education and culture. Communication, difficult at the best of times across such barriers, is made all the more impossible by the patient’s dis-ease. We urgently need new solutions to these communication difficulties and most of these turn upon, or involve, radical changes in current medical opinion and attitude. Many of the problems which are brought to doctors are very simple; how often do we hear the disclaimer: “I hope I’m not wasting your time doctor” and this reveals the patient’s frequent need of some means of finding out whether or not a given symptom should be taken to a doctor. This is why we need a different type of ‘medical’ consultation in primary care which could so easily be provided by the use of specially trained nurses. Experiments in Birmingham [39] have shown conclusively that the nurse is acceptable as an adviser on many simple medical problems especially with a host of minor worries and anxieties, in prevention and in maternal and child care. In some cases the nurse is actually preferable to the doctor, particularly for women of child bearing age, those very individuals that the previously mentioned survey [3 1] indicated as having difficulty in telling doctors their troubles. Doctors have traditionally taken a paternalistic attitude towards patients, expecting blind obedience to their orders and describing such behaviour as compliance. But compliance is increasingly recognised as existing more in the minds of doctors than in fact. Patients often do not understand or forget what the doctor has told them [40,41]. Again this may well be a side-effect of the doctor’s perennial shortage of time so that he issues orders rather than explaining; sometimes he even uses his prescription pad instead of talking to the patient for it is so much easier to write a script for Valium than to explain why it is not necessary! But old habits of paternalism die hard [42] and indeed often provide a shield for the doctor’s insecurity. A recent challenge to medical paternalism involves a person’s access to his own records [43]. The advantages and disadvantages of this are many and complex so that feelings run very

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high on the subject. In some cases this may be because medical records are simply not fit to be shown to those whom they most intimately concern and who might be able to check their accuracy. There are undoubtedly some cases where medical secrecy is justified but in the majority it is likely that more good than harm would come of sharing records with patients. However while there is a minority who for any reason should not see their records one is faced with either selective sharing of these documents or the traditional secrecy and allowing selected patients to read their notes would be impossibly divisive. Another pressure upon modern primary care is economic: governments increasingly protest at the size of the health bill. In impoverished Britain we spend half as much of the G.N.P. on health as do our neighbours across the North Sea in The Netherlands [28], but our bill is still enormous. This demand for economy from our paymasters has led to two attacks upon escalating costs: the finding of a cheaper way and secondly the examination and justification of costs. So governments look towards cheap prevention, rather than expensive intervention, and to audit. Prevention Much of today’s disease is preventable. Ramalingaswami [44] in his opening address to the Ninth International Conference on the Social Sciences and Medicine pointed out that in the industrialised world 50% of mortality from ten leading causes can be related to long-term patterns of behaviour and behavioural risk factors such as cigarette smoking, alcohol, dietary habits, physical activity, noncompliance with therapeutic and preventive regimes and maladaptive responses to social pressures. Though, since the war, infective disease has been enormously reduced there is still much morbidity and considerable mortality from preventable conditions such as measles, rubella, gastro-intestinal and sexually transmitted disease. Following scares about whooping cough there has been a fall in the level of immunity against this disease and with its reduction in levels of immunisation against diphtheria, tetanus and poliomyelitis. About one fifth of children in Britain are not immune to poliomyelitis, diphtheria and tetanus and two fifths have not been immunised against whooping cough or measles [45]. If Finland, where primary health care immunisation policies are so efficient, can have an epidemic of poliomyelitis in 1985 how safe are we in Britain or in other countries of the western world? But infection has been demoted from captaincy of the men of death and in its place we have heart disease and cancer, much of which is also preventable. Glasgow is the capital city of myocardial infarction for the whole world and other British cities are not far behind. Yet we know that much heart disease is avoidable-or at last postponable from the fourth or fifth decade to the seventh-by relatively simple means such as control of smoking and blood pressure. Cancer too, in many cases, may be either prevented or detected at a curable stage: but many unnecessary deaths still occur. It is splendid to see that at last something is being done about the dreadful statistics in Scotland; the ‘Good Hearted Glasgow’ project is a determined

effort to attack the problems of heart disease in that city [46]. Doctors however are not good at prevention, perhaps because they see themselves as intellectuals whose proper function is to diagnose and manage disease rather than patiently to follow the algorithms required by good preventive care. There is increasing evidence to show that nurses are very much better at these tasks than doctors [47-501 and are also better able to influence people’s behaviour patterns. Interference with an individual’s lifestyle, which may be involved in many of the preventive measures that have been mentioned, raises questions of ethics. How far are doctors justified in such interference? We now have conditions under which individuals are penalised because of risks that they expose themselves to (it is an offence in many countries not to wear a safety belt when driving and cigarette-smokers are liable to increased insurance premiums). Such penalties have become accepted though they are infringements on the autonomy of the individual [51,52]. In some countries it is argued that any form of preventive care unless requested by the patient himself is also an infringement of his autonomy and may cause him anxiety. This view of the morality of screening not only makes it virtually impossible to implement but also provides a convenient excuse for the inefficient or unenthusiastic doctor. The question of autonomy is involved with that of informed consent. The decision by an individual to refuse or consent to a procedure such as blood pressure measurement or the taking of a cervical smear, if it is to be autonomous, must be based on an understanding of the risks and benefits involved. Not to offer the clearly explained advantages of screening precludes the patient’s right of informed refusal as well as potentially putting him or her at risk. Different attitudes to the ethics of prevention are likely to impede the development of screening in some places. It is interesting to note that some doctors are suggesting that the absence of appropriate screening should be grounds for legal action, for example if a patient suffers a stroke and his doctor has NOT recorded his blood pressure then the doctor should be liable. Audit The other economic need is accountability. Doctors, in and out of hospital, must begin to think of themselves as high spenders of public money. They must learn to accept control of their profligacy and to justify their costs. This means the widespread introduction of methods of auditing and examining the quality of the structure, process and outcome of medical care [53]. Such audit will involve increased scrutiny of medical management, of the need to pursue unlikely diagnoses to the last and most expensive investigation and questioning of the relative priorities of treatment. There is an increasing need that time as well as money must be carefully audited. This will be particularly necessary if increased numbers of primary health care workers lead to a lengthening of the time available for each consultation. Some doctors will use that extra time for their patients, some for themselves. Such a challenge implies a huge shift in the beliefs and attitudes

Socio-behavioural

scientists in health care practice

of doctors and a re-examination of medical goals and the whole ethical, philosophical and ethological vision of medicine. Crombie [54] has shown that variation in performance depends more on the attitudes of doctors than on characteristics of the patient. It is in these areas that we really begin to see the major problems which face the profession in the last decade of the twentieth century. But this is not the end of the problem for a new factor now impinges on the development of medicine generally and primary care in particular and that is the “doctor mountain” [55]. Britain is overproducing doctors to a significant degree; the situation is worse in The Netherlands, worse still in France and disastrous in Italy where many young doctors dispense nothing but alcohol in cocktail bars. All these medical graduates, since they belong to nations signatory to the Treaty of Rome are free to move between the countries of the EEC. Competition for patients is not healthy: it leads to a form of unprofessional gratification of the patient aimed at giving him what he wants rather than what is best for him. Such short-term pleasing of patients is all too common anyway (how much easier and quicker it is to write a prescription than to lend the sympathetic ear that is really required). This form of treatment, which may maintain goodwill and allegiance in the short term leads to sharp professional practice by a minority of unscrupulous doctors. This is all too obvious in countries where there are already too many doctors. Yet, in such places, there is the paradox that medical excess co-exists with unmet need. The problem jizcing primary care can be summarised 1. There is a tendency

towards

officiousness

and

depersonalisation. is questionable. 2. Accessability leaves much to be desired. 3. Time management 4. The ethical base of primary care needs examination. skills are deficient. 5. Communication is common. 6. Paternalism 7. There are too many barriers to preventive care. 8. There is need for greater accountability with regard to both cost and quality control. 9. There 10. There

are too many doctors. is much unmet medical

THE CHANGES

NEEDED

IN PRIMARY

need.

HEALTH

CARE

So much for the muddle that we find ourselves in: now we must look at possible solutions and barriers which prevent improvement. We begin to see that we need to re-define the task of primary care in order to correct the balance between intervention, prevention and rehabilitation. We need what Tudor Hart describes as a new type of general practitioner [56] who, as Stott [57] puts it will be “concerned with health and ill health and with strengthening the independence and resourcefulness of the public without removing a refuge”. The patient needs to be reinstated at the centre of medicine,

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shifting responsibility on to him for his own health. At the same time we should provide employment for well-educated doctors who maintain their ability to fulfill their functions through continuing education and who subject their work to detailed audit. As Teeling Smith has said [%I: “the doctor of the 2lst century must be a superb diagnostician, must provide long term support for his patients both in a purely medical context and in a socio-medical sense as well and must provide health education for the patients in his practice persuading them to accept a healthy life-style and watching for early signs of deviation from good health.” To this Katherine Whitehom adds: “The challenge of the future, as I see it, is how to combine the efficiencies of things like group practice and health centres, sophisticated testing, computer diagnosis and so forth, with that autonomy which a patient wants and needs in his own care; to combine competent medicine with that respect and certainty of respect that we will never be able to count on getting from a stranger; with that involvement in our own illness and health that comes from not only knowing we can trust the doctor, but more importantly still, knowing that the doctor will trust us to do the best we can with our own lives” [59]. In short the doctor must learn to meddle less, to interfere less. He must learn more respect for patient autonomy, handing back responsibility to the individual so changing the attitude of primary care from one of paternalism to one of fraternalism. This implies that he must relearn the true meaning of the word ‘doctor’, as teacher, and return to the Hippocratic tenet “primum non nocere”. Many of the problems which have been described will require political solution but that is only democratically achievable when the profession is in agreement. The achievement of professional agreement to change does not require new knowledge, we have enough already and often do not use what we have [44], it may need new skills but it will certainly require enormous shifts in attitudes of both doctors and those they treat. Changing attitudes is the hardest thing in education. It is in this modification of attitude that the socio-behavioural scientists have a very great role to play. Then, when they have helped to bring about this change in attitudes they must begin to lead doctors, teachers, into implementing the new philosophy. I believe that possible ways of achieving the changes which I have suggested are necessary lie in medical teaching, moral philosophy and in opportunities offered by that recent challenge to medicine the Acquired Immune Deficiency Syndrome. Medical education First we must examine the new generation of doctors and how they are trained. For many wouldbe doctors the decision to study medicine is taken very early in life. Some follow, or are made to follow, parents who have been in the profession. There are some arguments for this, largely based on the contention that the young will at least know what they are in for. There are also counter arguments: many children, growing up in a medical household, see a glamourised, materialistic picture of the doctor’s lifestyle, some drift thoughtlessly in the wake of a

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parent and a few may be driven by parental ambition. An even greater argument against selection by reason of medical parenthood derives from the tendency to stereotype a single kind of doctor. Success in science O-levels may lead to a choice of chemistry, physics and biology for pre-university entrance examinations where high scoring may allow the student entry to medical school. There is nothing, however, to show that academic success in scientific subjects correlates in any way with the production of good doctors in later life. The interesting experiments in Australian universities such as Flinders and Newcastle, New South Wales [60,61] where different entry criteria are applied may provide reason to question these time-honoured standards. In Adelaide at Flinders admission to the medical school is offered to school leavers who have matriculated in nonscientific subjects. Though these art students themselves find the course very tough going they bring a new dimension to the student body. At Newcastle there is relaxation of the normally strict Australian observance of matriculation results; application for entry to the medical school is open to all who will long before the results of school leaving examinations are known. Would-be students are invited to Newcastle where its philosophy and problem-based teaching is explained. At this stage many applicants withdraw and the remainder are subjected to a wide range of psychometric tests and undergo a structured interview. The results of these tests are stored to be considered in relation to the results of the school leaving examination before offers of places are made to students. This method is probably too cumbersome to appeal to admission deans of many medical schools but I have observed similar methods in the United States at, for example, Mercer in Macon, Georgia. The Newcastle experiment will be watched eagerly since it is controlled by the simultaneous admission of students according to traditional Australian selection methods so allowing a comparison of selection criteria (Engels, personal communication). Once the academic screening of preuniversity entry has excluded those thought to be intellectually unlikely to survive the rigours of the course then the gamble of selection is begun. In Holland it is openly admitted to be a sweepstake. All who will may apply for medical school, with preferential chances for those who have done particularly well in school leaving examinations. Selection is then made by lottery. In France selection is by attrition: 1000 students are admitted where there are 100 places and after the first year there is a swingeing examination with rejection of 90%. In Britain selection is based on the results of school leaving tests with the addition of competitive structured interview. Unfortunately objective evidence that any one way is better than another is lacking. However as students are selected a stereotype emerges: the new entrant to medical school is likely to be highly intelligent, biased in favour of high social class, deeply grounded in science and trained to absorb and retain (at least as far as the nearest examination-room) huge quantities of factual information. He or she is not required to think very much and any tendencies towards artistic appreciation, though lip-service is paid to them, tend to be discour-

aged. Spare time is likely to be dominated by hearty sport and alcohol. SO our students embark upon medicine; on entry they are nice warm cuddly human beings with 18 or more years experience of life, of human relationships, communication and behaviour-which they tend to refer to as common sense. Sadly, during their years in medical school this innate quality often dwindles away under the burden of the huge amounts of factual information that they are expected to cram into memory. Though many schools purport to teach subjects such as ethics and ethology, which may challenge attitudes and behaviour, the gesture is largely to satisfy regulatory bodies and is rarely regarded very seriously and seldom assessed. The reason for this lack of assessment is easy to find: one can tell if students do not know facts but it is not so simple to measure their abilities in ethical or behavioural fields. But there is increasing evidence that doctors are poor communicators [62], especially with regard to bad news [63,64] and that they may actually get worse during their sojourn in medical school. (There has recently been a suggestion that things have improved in medical schools but that this deterioration has been moved forward to the preregistration year.) At Birmingham we have devised an examination technique which uses a television case to assess students’ ability to communicate, relate to and appreciate the significance of a patient’s behaviour. We set this test to schoolgirls, to third year medical students and to vocational trainees in general practice. In many of the questions the schoolgirls did better than either the students or the young doctors. This brings to mind the gibe, made by an American professor of family practice, that medical schools did not produce doctors but human floppy discs! The tendency to dehumanise medical students is only partly explained by the mass of facts that they are expected to absorb. Much more lies in the attitude of their teachers. Visiting and teaching in medical schools in Europe, America and Australasia, talking and listening to academic doctors one has the feeling that the common practice, as Pickering [65] puts it, is that of filling the pot rather than lighting the fire under it. Medical teaching is fact-stuffing rather than thought inducing. The common method is by means of the didactic lecture, when as many as 250 or more students painstakingly write down every word that the great man says, even copying his punctuation marks from the overhead transparencies! Doctors, themselves oppressed by the magnitude of their subject, are insecure and to ease their sense of insecurity retreat ever further into specialism. In so doing they not only expand knowledge but also increase their expectations of the student’s ability to learn even more detail. In all this there are few teachers who attack the central issue of how a would-be doctor may come to terms with and live with his own insecurity. So medicine tends more and more to be for doctors rather than for patients. Increasingly it is about the realisation of personal ambition; research for research sake aimed at erudite publication becomes more important than teaching or the care of patients. The obsession, in some universities, with the Citation Index and just how many times one’s published work has been quoted would be laughable were

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scientists in health care practice

it not so pitiable. Given teachers like this is it surprising that students are as they are. Pickering [65] observed in 1944 that the Royal College of Physicians Committee on Medical Education, of which he was secretary, concluded that “the average medical student has defects which are to be attributed chiefly to the manner of his training. He tends to lack curiosity and initiative; his powers of observation are relatively undeveloped; his ability to arrange and interpret facts is poor; he lacks precision in the use of words. In short his training, however satisfactory it may have been in the technical sense, has been unsatisfactory as an education.” If he were writing today Pickering would have to refer to the increased proportion of women students who were many fewer in 1944 than now. There is the suggestion in many quarters that the increased number of women students may have improved the gloomy picture painted by that committee and this may be because they seem to survive medical school training with more of their humanity intact. Nevertheless the huge burden of fact that we require students to absorb makes Pickering’s observation as true today as 40 years ago. This is a disaster because continuing education, which must persist throughout a doctor’s professional life, “depends entirely on those qualities in which his training has left him defective” [65]. Many of Pickering’s criticisms are met by medical schools such as Newcastle NSW, Maastricht, Beersheva and McMaster which adopt a problem based approach to medical education but these innovations require more time before their full impact can be judged. It is interesting also to reflect on the stage in a student’s career at which he is exposed to nonmedical aspects of practice. In many British medical schools an early exposure is common. For example at Birmingham we provide a programme in which students are attached to families with problems in their first weeks in the course and have an examined course in behaviour and communication at the end of the second year when they begin clinical medicine. We provide these programmes so early in the belief that exposure to the harsh realities of medical life demand that students develop a thick skin and lose their sensitivity. In some American schools, Harvard for example, it has been found that medical practitioners are most receptive to behavioural aspects of their calling after they had been practising for some years [66]. One way in which this might be resolved lies in interdisciplinary teaching. In Britain there is very little combined teaching of doctors, nurses and other health care workers. There are occasional dramatic clashes of opinion between members of the caring professions which might have been prevented by the establishment of common goals and ethics through combined teaching. Such teaching could also be extended to include students in social sciences which would not only help to educate doctors and nurses but would provide basic medical knowledge in the training of socio-behavioural scientists. Moral phdosophy We can now see that there is a need upheaval within medicine itself [67]. We back to personal care where the patient of interest. This patient must be seen

for a need is the as a

major a shift centre whole

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person, the sum of whose parts is greater than the whole. That is the true meaning of Smuts’ term ‘holism’, not the debased meaning introduced by some of the practitioners of alternative medicine (though a few of them come much nearer to holism than many an allopathic practitioner). This implies a need to change from our present obsession with interventionist medicine towards prevention, rehabilitation and the provision of dignified palliative care when cure is no longer possible and we need the wisdom to know when that point has been reached. The achievement of these aims require a fundamental change in medical attitude which in turn must be based on firm medical ethics. Increasingly ethicists in Britain and America are relying on the ethical framework proposed by Beauchamp and Childress based on balance between the four ethical principles of Autonomy, Beneficence, Non-maleficence and Justice [51, 52,681. Unfortunately moral philosophy tends to be another underregarded subject in medical schools where teachers either pontificate because they think they know all the answers or abstain from thinking about moral questions because they are all too difficult [52]! The changes that are needed are fairly obvious but their implementation is incredibly difficult. Medical opinion is monolithic and changes, in Professor Eric Wilkes’ immortal phrase, with all the agility of a melting glacier. Before it can alter attitude the profession must be made aware of the need. This is probably the most important single task facing socio-behavioural scientists in health care practice in the last years of the twentieth century. Medicine needs your help: some of the profession even realise it but can you save us from ourselves before, like the dinosaurs, we fail to adapt our outmoded specialism towards the requirements of the coming new millennium. The challenge of AIDS The new pandemic caused by the Human Immune Virus (HIV) has all the potential of the plague, cholera, typhus and the threat of nuclear holocaust in altering the course of history. It is spreading with increasing rapidity, it is invariably fatal and there is no immediate prospect of cure. In the face of this it is indeed strange that some immunologists are beginning to speak of the ‘blessing’ of AIDS for such a blessing has to be exceptionally disguised. The response is partly due to an optimistic belief that nothing can be wholly bad and also because the HIV is causing scientists to rethink and re-examine aspects of immunology and this may have far reaching beneficial results. Though I cannot subscribe to the idea of so disguised a blessing I do see that AIDS challenges us in a way we have grown unused to. Edward Shorter [24] in his recent book “Bedside Manners” suggests that the change in the relationship that has occurred between doctors and patients over the last century has come about because of the increased therapeutic power of the doctor. AIDS puts us back to the age of medical impotence. We know enough of its epidemiology to believe that if we are to limit its spread we can only do so by modification of human sexual behaviour. We also know that for every person who develops the syndrome there will be

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many whose lives will be made unbearable by fear of the condition. Already primary care physicians in many countries are being consulted by very concerned people, some of whom have good reason for their concern. For those increasingly numerous individuals unfortunate enough to suffer the full blown syndrome medicine only has symptomatic treatment to offer while they await the inevitable end. This means that the under-regarded aspects of the doctor’s work implied in the word caring are once again to become essential and what’s more recognised as such. In summary socio-behavioural scientists have several very important roles which they could play in the reshaping of health care practice: (1) In service to the consumer they could help by altering attitudes of both doctors and patients towards preventive medicine, encouraging a shift of responsibility for health back towards the individual so making him realise the long-term importance of denying himself short-term gratification. Within primary health care teams, consisting of various medical para-medical and allied workers, we need socio-behavioural scientists to help find a way to smooth difficulties, soothe inter-professional rivalries and break down the demarcation disputes of territorialism (or, as one disgruntled non-medical member of the team commented: “to stop the doctors peeing on trees!“). More than anything else socio-behavioural scientists could help doctors to find a way to reduce the professional paranoia which so effectively prevents the introduction of quality control and audit. (2) The larger, infinitely more difficult but, in my view, essential task of socio-behavioural scientists lies in the modification of medical education so that it produces a new sort of doctor who thinks rather than knows, who realises the limits of his capability but works to them, who understands how to use the skills of his colleagues, who can cope with his own insecurity and who places the care as well as the cure of his whole patient at the centre of his medicine. (3) In the task of coming to terms with the concept of the new sort of doctor we need help in examining our behaviour and motivation. In this task we need help from many sources outside the medical profession, from economists, from moral philosophers as well as behavioural scientists. (4) The challenge of AIDS demands of us a return to the caring which was so much commoner when we were as impotent in the face of most illness as we are today with AIDS. These goals require vast structural and attitudinal changes which, I believe, are far beyond the capability of the medical profession in the foreseeable future because they are blinkered by tradition, habit, entrenched ideas and vested interest. The last time such radical change occurred in Britain it was brought about by politicians who introduced the National Health Service in the face of medical opposition. The change I suggest must come from within medicine itself with the help of behaviourists. Perhaps I ask too much of them, but, having watched the persuasive effect of the former Stuart Fellow of the Royal College of General Practitioners upon a group of examiners for the college, I am tempted to believe

that the best chance of achievement socio-behavioural scientists.

lies with

the

Acknowledgemenrs-I am most grateful to many people with whom I have discussed the ideas presented in this paper and particularly to Dr Sheila Greenfield Ph.D., Dr John Horder C.B.E., P.P.R.C.G.P., Mrs Barbara Stilwell S.R.N. and Dr Gerrit van Staveren for their patience and time spent reading and criticising its various drafts. REFERENCES 1. Collings J. S. General practice in England today. Lancet 1, 555-585, 1950. 2. Flexner A. Medical Education in the United States and Canada. Carnegie Foundation for advancement of teaching, New York, 1910. 3. Hertzler A. E. The Horse and Buggy Doctor. University of Nebraska Press, 1938. 4. Kennedy E. In Critical Condition: The Crisis in America’s Health Care. Simon & Schuster, New York, 1972. 5. Hull F. M. Diagnostic pathways in rural general practice. J. R. CON. Gen. Pratt. 18, 1488155. 1969. 6. Hull F. M. Diagnostic pathways in general practice. J. R. Coil. Gen. Pratt. 22, 241-258, 1972. 7. Hull F. M. The consultation process. In DecisionMaking in General Practice (Edited by Sheldon A., Brooke A. and Rector A.). Macmillan, Basingstoke, 1985. 8. McWhinney I. R. Problem-solving and decision-making in primary medical care. Proc. R. Sot. Med. 65, 934938, 1972. 9. McWhinney I. R. Decision-making in general practice. J. R. CON. Gen. Pratt. (occasional paper) 10, 31-33, 1980. 10. Elstein A. S., Kagan N., Shulman L. S., Jason H. and Loupe M. Methods and theory in the study of medical enauirv. J. med. Educn 47. 85-92, 1972. 11. Elsiein A. S., Shulman L. S., Sprafka S. A. er al. Medical Problem -Solving: An Analysis of Clinical Reasoning. Harvard Press, Cambridge, Mass., 1978. 12. Sheldon M., Brooke J. and Rector A. Decision-Making in General Practice. Macmillan, Basingstoke, 1985. 13. Marsh G. N. and Kaim-Caudle P. Team Care in General Practice. Croom Helm, London, 1976. 14. Pritchard P. How can we improve team working in primary care? Practitioner 228, 1135-l 139, 1984. 15. Brooks D. Teams for tomorrow-towards a new primary care system. J. R. CON. Gen. Pratt. 36, 2855286, 1986. 16. Bowling A. Delegation in General Practice. A Study of Doctors and Nurses. Tavistock, London, 1981. 17. Cumberledge J., Carr A., Farmer P. and Gillespie E. Neighbourhood Nursing-A Focus for Care. DHSS, HMSO, London, 1986. 18. Es J. C. van. The Netherlands. In Primary Health Care 2000: Global Challenges (Edited by Fry J. and Hasler J.). Churchill Livingstone, London, 1986. 19. Hull F. M. and Westerman R. F. Referral to medical outpatients department at teaching hospitals in Birmingham and Amsterdam. Br. med. J. 293,31 I-314, 1986. 20. Pemberton J. Will Pickles of Wensleydale. Geoffrey Bles, London, 1970. 21. Tielens V. C. L. M. G. Consultations of general practitioners. Thesis, University of Niimeaen, - _ The Netherlands, 1987. 22. Cartwright A. Patients and Their Doctors. Routledge & Keegan Paul, London, 1967. 23. Cartwright A. and Anderson R. General Practice Revisited. Tavistock, London, 198 I. 24. Shorter E. Bedside Manners. Viking, Harmondsworth, 1986.

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