Training doctors as therapists

Organisers of a new training course for doctors at St George’s Hospital in London have been accused of ‘dumbing down’ the medical curriculum by reducing it to four years (1).

But the real problem is not the duration of the curriculum now provided at most medical schools in Britain, but its content. Following a policy adopted by the General Medical Council (GMC) 10 years ago, training in medical science now takes second place to the cultivation of the values of the therapeutic society.

In Tomorrow’s Doctors, published in 1992, the GMC outlined the ‘goals and objectives’ of the new curriculum under the rubric of ‘knowledge, skills and attitudes’. Whereas in the past knowledge was crammed for exams, skills were picked up on the job, and attitudes (for better or for worse) unconsciously assimilated, now students were going to be taught formally in all three areas.

Knowledge would be reduced to a ‘factual quantum’ defined by a ‘core curriculum’: this would include the familiar basic medical sciences, but also unfamiliar subjects such as ‘human relationships’ and ‘the importance of communication’. The extensive and detailed attitudinal objectives reflected the values of the culture of therapy and the demands of political correctness (neither previously a major influence on the
medical mainstream).

Students would be expected to show respect for patients’ diverse identities and rights, they should be able to ‘cope with uncertainty’ and they should display an ‘awareness of personal limitations, a willingness to seek help when necessary and an ability to work effectively as a member of a team’.

One of the key concepts of the new curriculum is that of ‘problem-based’ learning: instead of acquiring a grounding in basic medical sciences before encountering sick patients, students begin from a clinical problem presented by a patient and organise their studies around this problem. The idea is that, by being relevant to the resolution of a real clinical problem, their study of anatomy, physiology, biochemistry and so on will be more interesting and better retained. The role of the teacher is no longer to transmit knowledge, but to facilitate the process of problem-solving by students, working collectively, in teams.

The defect of problem-based learning is that it assumes that defining a clinical problem is a straightforward matter, whereas in practice it is often profoundly difficult. According to Abraham Flexner, whose historic 1910 report promoted the reorganisation of medical education in the USA on the basis of scientific medicine: ‘[F]or the analysis of the simplest situation which the ailing body presents, considerable knowledge is required.’

Furthermore, for practical treatment ‘still another volume of knowledge and experience is requisite’. Flexner explicitly rejected the method of proceeding on ‘superficial or empirical lines’, which is what is implied by the notion of the ‘relevance’ of scientific inquiries to the problem that has been identified. It is commonplace that what appears to be relevant or important to the untrained eye is revealed by science to be merely a manifestation of some underlying phenomenon. If what appears to be relevant coincided with what is actually important, then there would be no need for science.

Flexner offered a definition of science as the ‘persistent effort of men to purify, extend and organise their knowledge of the world in which they live’. He particularly emphasised the word ‘effort’, insisting that students should ‘strive to transcend native powers, prejudices, limitations’. This approach stands in sharp contrast to that of the new curriculum, in which the preoccupation with ‘relevance’ means elevating
‘native powers, prejudices and limitations’ over the systematic process of ‘observation, inference, verification and generalisation’ regarded by Flexner as the essence of the scientific method.

For today’s medical teachers, according to one authority, students should find the course ‘enjoyable’ and be allowed to study at ‘their own pace and in their own time’ rather than being expected to make an effort to transcend their own limitations. More than a decade earlier in the USA, the eminent clinician Lewis Thomas had warned against ‘notions of relevance’ that were ‘paralysing the minds of today’s first year medical students’.

The very fact that the medical curriculum has been repeatedly criticised for more than a century on the grounds that it is overloaded with facts – a period in which the ‘facts’ have changed considerably – suggests that this is a misconceived criticism. It implies a conception of medical science as a vast corpus of knowledge that has steadily increased in volume. From this perspective, medical education is a process of cramming all these facts into the student cranium.

This approach confuses the process of scientific inquiry with its results: medical science is a method of understanding human health and disease, not a body of facts. The immunologist and Nobel laureate Peter Medawar dismissed problems arising from the apparently ‘oceanic volume of scientific knowledge’ as ‘essentially technological problems, for which adequate technological solutions are rapidly being found’. And this was before electronic databases, CD-ROMs and the internet. As Flexner wrote, ‘the teacher cannot provide the student with bits of information likely to be useful, nor can study be prolonged to include everything’.

The increase in the scale of medical knowledge over the past century makes no qualitative difference to this judgement. The key issue was not facts, but ‘habituation to method’; the role of the teacher was to select knowledge to exemplify scientific procedure. He insisted that ‘the facts in question cannot be passively learned and mechanically applied’. The object of medical education was ‘primarily the effort to train students in the intellectual technique of inductive science’. This required ‘an extraordinarily active and oft-repeated mental process, involving observation, sorting out, combining, inferring, trying’.

The real problem of medical teaching over the years has not been a surfeit of facts but a deficit of training in the intellectual technique of inductive science. Unfortunately, the promoters of the new curriculum have responded to popular criticisms of ‘overload’ by replacing inductive science with a vulgar empiricism. Medical science is disparaged as ‘knowledge’ and reduced to easily assimilated fragments of a ‘core’ curriculum, according to the criteria of relevance and enjoyability.

The main concern of medical schools has shifted towards the inculcation of what are considered to be the correct attitudes. The Oxford physician David Weatherall is one of the few leading medical figures to have pointed – in a strikingly tentative way – to the dangers of this approach: ‘While the motives behind these changes are admirable, it is essential that, while trying to improve the social, pastoral and communication skills of our future doctors, we do not dilute their scientific education.’

One of the most significant innovations of the new curriculum is the introduction of formal teaching for medical students in communication skills. Indeed such teaching has extended rapidly into the post-graduate domain and into the ‘continuing medical education’ of practising doctors. Inadequacies in communication skills are one of the most frequently cited problems of ‘poorly performing doctors’ and the provision of appropriate tuition in this area is one of the functions of the ‘assessment and support
centres’ proposed by the government.

To anybody who has encountered a doctor who was rude or patronising or who spoke in incomprehensible medical jargon (and anecdotal evidence suggests that these are all familiar experiences), it would seem a good idea that medical students should be taught how to communicate with their future patients. But is it possible to teach communication skills?

In one widely used set of guidelines on communication (produced by Robert Buckman) there is a striking combination of the most elementary ‘basic steps’ and suggestions about profoundly difficult matters such as ‘responding to patient feelings’. No doubt it is possible to instruct students in ‘basic
steps’, such as the importance of introductions, shaking hands, sitting down, listening attentively, etc. Perhaps in the past such conduct would have been regarded as simple good manners, which students might have been expected to acquire at home rather than at medical school.

However, it may be fairly argued that the manifest lack of such elementary civility towards their patients among many doctors justifies including such instruction in the curriculum. Nevertheless, it is difficult to imagine that it would be necessary to spend more than a few minutes in an overcrowded curriculum on such tuition.

When it comes to communications between doctors and patients at a higher level of subtlety, which rely on establishing a degree of empathy, and are heavily influenced by the past record of mutual experience and trust, it is doubtful whether formal instruction, whether in the form of books, videos or role-playing can be of much assistance. For the distinguished Dublin GP James McCormick, such skills fall into the category of things that can be learned by observation and reflection in clinical situations, not taught in a classroom.

Indeed, the very attempt to teach them in such a formal way underestimates the subtleties of doctor-patient communication which generations of doctors have painstakingly acquired through the sort of apprenticeship experience that is now so disparaged. The net effect of the promotion of comic-book communication skills is to elevate the banal while degrading what is profound in medical practice.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

(1) Medical training ‘dumbed down’, BBC News, 10 September 2002