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In the seventh and final part, Prof. Ashoka tells us about the challenges in the formation of physicians, in his erudite research paper. A Different Truths exclusive.
Along with attention to medical students’ “training for uncertainty,” any attempts to improve their social, cultural, psychological, and ethical education should be mindful of the “training for detached concern” process that they undergo as they are carried along by the curriculum toward their formation as physicians. Ideally, physicians are expected to bring “objectivity and empathy, equanimity and [sympathy] into a supple balance with one another – combining and recombining them in ways that are compatible with the delivery of competent, sagacious, and humane patient care,” as I have emphasised elsewhere illness and medical work are not only “serious,” but also physically, and existentially evocative, in ways that are inherently perturbing.
… students undergo their “training for detached concern” – struggling to attain the sort of dynamic equilibrium between composure and compassion that will enable them to function professionally without (to use their word) becoming too “dehumanised.”
Young women and men en route to becoming physicians are initiated into these features of the profession they are entering through a series of rites of passage: medical school experiences associated with such events as their dissection of a cadaver, their participation in autopsies, their neophyte efforts at taking medical histories from patients and performing their first physical examinations, their contact with disease-inducing pathogens in laboratories and with the spectrum of maladies that beset the patients whom they encounter in their clinical clerkships, the first births that they witness, and the first deaths of patients with whom they have had contact. It is through the impact of such experiences that students undergo their “training for detached concern” – struggling to attain the sort of dynamic equilibrium between composure and compassion that will enable them to function professionally without (to use their word) becoming too “dehumanised.” In response to these shared experiences, medical students develop common defence mechanisms that help them to cope with the most psychologically, socially and ethically difficult and emotive dimensions of their preparation for assuming the physician’s role and responsibilities for the care of the patients-defenses that not infrequently are tipped in the direction of self-protective detachment.
Finding ways to transmit more successfully relevant social science and ethical knowledge, reasoning, and insights to medical students not only requires informed awareness of the training for uncertainty and for detached concern that they are undergoing but also thoughtful inclusion of these aspects of their professional socialisation into what is implicitly and explicitly taught.
Kenneth Ludmerer describes, analyses, and deplores what he characterises as the progressive “erosion of the intellectual atmosphere” of medical schools throughout the 1990s
It may prove even harder to achieve excellence in this sphere of medical education than it has in the past because of the problems that American medical schools and academic health centers are presently facing and the manner in which they are responding to them. In his book Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, Kenneth Ludmerer describes, analyses, and deplores what he characterises as the progressive “erosion of the intellectual atmosphere” of medical schools throughout the 1990s, and the waning relevance of medical education as a “mission and raison-d-etre” of academic health centers.
A series of interlocking factors, both internal and external to medical academia, have precipitated this decline. Foremost among them is the wave of concern about escalating health costs and the associated development of a competitive market place for medical care that emerged in the 1980s, bringing in their wake an “era of cost containment”, and the eruptive growth of predominantly for-profit managed-care organisations on the American medical scene. Academic health centers, with their teaching hospitals and medical schools, have been severely threatened by these and other new forces that have catapulted them into an ongoing struggle to remain financially solvent in a health-care market that has diverted patients and clinical revenues away from them. The financial pressures of managed care have been augmented by the phased-in reductions on Medicare spending through the year 2001, mandated by the 1997 Balanced Budget Act, which sharply decreases the substantial direct and indirect subsidies for medical -school teaching, for residency training, and for indigent as well as paying patients that academic health centers have received from this source for more than thirty years.
More and more clinical faculty members’ time is spent in medical practice, which has become the chief source of their salaries and of the income of the academic health centers and medical schools with which they are affiliated.
One of the ways in which academic health centers have responded to this situation is to greatly increase the number of full-time clinical faculty whose principal, often exclusive responsibility is to see patients rather than to teach or do research. It could be said that many of these clinician-non-teachers are faculty in name only. More and more clinical faculty members’ time is spent in medical practice, which has become the chief source of their salaries and of the income of the academic health centers and medical schools with which they are affiliated. In this business – and money-oriented atmosphere – enhanced by the growing number of managed-care contracts under which academic health centers now operate in order to acquire and maintain a sufficiently large patient base-physicians are under intensifying pressure to see as many patients as fast as possible. The length of in-patient hospital stays has been drastically shortened not only as a consequence of biomedical advances (such as the development of less invasive surgical procedures and new forms of anaesthesia ) and by the increased prevalence of chronic diseases that can be well cared for on an outpatient basis, but also by the economically driven rules of managed-care organisations that restrict the number of days patients are allowed to be hospitalised and the financial coverage for those days. Attempts to move more of clinical education to ambulatory, extra-university settings have not proven to be easy, because community physicians- like their academic colleagues-“are under increasing pressure to be more productive in-patient care and may, therefore, not have the time to…take students into their practices. ” These practice conditions have also begun to curtail the time that community physicians feel they can afford to spend as volunteer faculty teaching medical students and university hospital house staff. Furthermore, patients being cared for in private practice are reluctant to be used for medical education purposes. And medical schools have only begun to tackle the difficulties of being sufficiently cognizant of what kinds of learning experiences students are having in the array of doctors’ offices to which they are being sent for training, and of controlling the quality of the education the students receive there.
… medical students are being taught by a small percentage of the members of massively large and continually expanding medical-school faculties.
As a consequence of these deep changes in the organisational, financial, and practice circumstances under which medical education is taking place, and the social and psychological ambiance surrounding them, medical students are being taught by a small percentage of the members of massively large and continually expanding medical-school faculties. Their teaching and learning are occurring in a context where – because of clinical practice, time, and financial pressures-faculty members generally do not have enough contact with students to become their advisors, role models, or mentors. Further, many faculties are demonstrably demoralised by these conditions, and by what they view as their adverse effects on the quality of patient care and research, as well as on teaching. It has also become harder for students to observe the phase-movements of disease and the unfolding of its diagnosis and treatment, or to have meaningfully sustained contact with the declining numbers of hospitalised patients-the majority of whom are either admitted for procedures that, under the new health-care ground rules, are considered to warrant no more than overnight stays, or are gravely ill in intensive-care units. This has pushed both faculty and students away from the bedside as a locus of clinical education and made the conference room, distanced from patients, their primary meeting place. Although ambulatory settings have become both more logical and more significant as milieu x for medical education, they, too, are beset with what Kenneth Ludmerer has characterised as the high-volume and-speed “throughput” of patients that subverts the scientific, intellectual, and humanistic excellence of medical education.
It is still unclear what the consequences of educating future physicians under these circumstances will prove to be. But emerging data suggest, for example, that today’s medical students and residents may be less skilled in conducting physical examinations, in making clinical observations, and in distinguishing between normal and abnormal physical signs than their predecessors. There is also evidence that negative attitudes toward managed care prevail among them, allegedly influenced by the implicit and explicit “messages” about managed care that they receive from medical-school faculty.
… any effective plan to better integrate social science and ethics into the teaching of medical students will have to not only take these problems into account but make them a part of its curriculum.
It could be said that the most serious and important social and ethical problems facing medical education are those that originate in the transformations that medical schools and academic health centers have weathered throughout the last two decades. If this is the case, then any effective plan to better integrate social science and ethics into the teaching of medical students will have to not only take these problems into account but make them a part of its curriculum. In the present context, however, the long-standing tendency of medical educators to attach “magic-bullet” significance to the power of designated courses to positively influence and professionally shape the attitudes and behaviour of medical students and young physicians seems unduly optimistic, and somewhat misdirected. As Bernard Lown, emeritus professor of cardiology at Harvard School of Public Health has provocatively put it, “Talking of medical curricula and teaching about human interactive skills” is akin to “living in a Never Never Land…. What is the value of interactive skills,” he asks, “if you can only spend eight minutes with a patient? “
In conclusion, I do not consider it a denial of the intellectual and attitudinal importance of teaching to state that unless medical academia recognizes the social and moral as well as the economic nature of the intricately entwined educational and health-care delivery issues it is facing, and tackles them systemically, one more set of attempted “non biomedical ” curriculum reforms-this time emphasizing courses that interrelate bioethics, medicine, and social science will fail to make a deep and enduring difference.
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