Map of life expectancy at birth from Global Education Project.

Friday, October 27, 2006

I have little to add to this .. .

But people who are physicians, want to be physicians, or expect to be patients, might want to read it. I believe I referred to this when it came out, but it's highly relevant here. The editors of NEJM used excellent judgment when they made this essay by Molly Cook and colleagues available to the public:American Medical Education: 100 years after the Flexner report. Let me pull out a couple of quotes that I think are particularly cogent:

From the early 1900s to the present, more than a score of reports from foundations, educational bodies, and professional task forces have criticized medical education for emphasizing scientific knowledge over biologic understanding, clinical reasoning, practical skill, and the development of character, compassion, and integrity. . . .

Theoretical, scientific knowledge formulated in context-free and value-neutral terms is seen as the primary basis for medical knowledge and reasoning. This knowledge is grounded in the basic sciences; the academy accommodates less comfortably the practical skills and distinct moral orientation required for successful practice in medicine. However, Flexner had not intended that such knowledge should be the sole or even the predominant basis for clinical decision making. Within 15 years after issuing his report, Flexner had come to believe that the medical curriculum overweighted the scientific aspects of medicine to the exclusion of the social and humanistic aspects. He wrote in 1925, "Scientific medicine in America — young, vigorous and positivistic — is today sadly deficient in cultural and philosophic background."16 He undoubtedly would be disappointed to see the extent to which this critique still holds true. . . .

The moral dimension of medical education requires that students and residents acquire a crucial set of professional values and qualities, at the heart of which is the willingness to put the needs of the patient first. . . .However, the values of the profession are becoming increasingly difficult for learners to discern; the conclusions they draw, as they witness the struggle of underinsured working people to obtain health care, marked differences in the use of expensive technologies in different health care environments, and their physician-teachers in complicated relationships with companies that make health care products, should concern us. . . .

It has long been observed that assessment drives learning. If we care whether medical students and residents become skillful practitioners and sensitive and compassionate healers, as well as knowledgeable technicians, our approaches to the evaluation of learners must reach beyond knowledge to rigorously assess procedural skills, judgment, and commitment to patients. . . ."

I have many ideas of my own about this. However, it has to begin with the admissions process. Today, medical schools admit largely on the basis of strong academic performance in the sciences, and high scores on standardized tests of scientific knowledge and reasoning ability. Many medical students have almost no background in the humanities or social sciences. Most disturbing, they do not all share the fundamental values essential to compassionate healing, nor the capacity for empathy essential to understanding the lifeworlds of patients who typically come from very different social and cultural backgrounds. It is very difficult, if not impossible, to fix these deficiencies in the educational process. People who do not belong in the profession should not be admitted to medical school in the first place. Let's figure out how to start there.

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