262 ATTITUDE CHANGE IN MEDICAL STUDENTS SOMEWHERE in their list of educational objectives,
medical schools dutifully list the achievement of suitable professional attitudes. Apart from the notinsuperable difficulties inherent in defining " suitable " attitudes, there are some important questions which have not yet been adequately answered: Do medical students’ attitudes change while they are at medical school ? Can specific teaching programmes change students’ attitudes reliably or usefully ? Two reviewers have lately examined the evidence on these points.1,2 There have been a few longitudinal studies, focusing principally on psychosocial attitudes. The classic, work is that of Eron,3which suggested that medical students increase in cynicism and decrease in humanitarianism (at least as measured by attitude scales); Christie and Merton4 as well as Gordon and Mensh5 have supported these findings. Some have argued6 that the cynicism is an adaptive and understandable reaction to the medical-school environment, and that it is related to the training process rather than to medicine as a career. Indeed, Reinhardt and Gray have shown that, four years after graduation, physicians in specialties with " high interaction " with patients do tend " low-interaction " to be less cynical than colleagues in specialties who had similar cynicism scores on graduation. Certainly there is no evidence that medical education increases humanitarianism or benevolence in students,. or enhances any other attitudes we might deem desirable. At the very best, it may not grossly interfere with these attitudes in students who arrive at medical school already strongly imbued with them. Of investigations on the influence of teaching on attitudes, most have examined the effects of most
special comprehensive-medical-care programmes, at Cornell 8,9 and Colorado,10 which emphasise prevention of disease and rehabilitation and deal with the full range of illness from structural pathology to emotional and family problems. A positive attitude to the treatment of patients with psychosocial problems, and more favourable attitudes to other members of the health-care team,sometimes emerged, but they faded quite soon after the students returned to the usual. curriculum. Teaching on family medicine or psychiatry seemed not to change students’ preferences for treating physical illness, once such preferences were established. General psychological research on attitude development and change supports these findings. So long as the student’s own group and the faculty share and reinforce particular attitudes, educational attempts to encourage other attitudes are unlikely to have more than evanescent effects. So what is a medical school 1. 2.
Rezler, A. G. J. med. Educ. 1974, 49, 1023. Simpson, M. A. Medical Education: A Critical Approach. London,
3. 4.
Eron, L. D. J. med. Educ. 1958, 33, 25. Christie, R., Merton, R. K. ibid. p. 125. Gordon, L. V., Mensh, I. N. J. educ. Psychol. 1962, 53, 48. Becker, H. S., Geer B. Am. soc. Rev. 1958, 23, 50. Reinhardt, A. M., Gray, R. M. A. J. med. Educ. 1972, 47, 112. Merton, R., Reader, C. G., Kendall, P. L. The Student Physician. Cambridge, Mass., 1957. Reader, G. G., Goss, M. E. W. Comprehensive Medical Care and Teaching. Ithaca, N.Y., 1967. Hammond, K. R., Kern, F. Teaching Comprehensive Medical Care. Cambridge, Mass., 1959.
1972.
5. 6. 7. 8.
9. 10.
If we regard certain attitudes as important good health care, we must probably concentrate on selecting students who already possess such attitudes before admission, rather than expect the curricuto
do ?
for
lum to achieve some form of attitudinal transubstantiation. Selection based principally on intellectual qualifications is known to be unsatisfactory in many ways. Perhaps formal attitude assessment should play a leading part in the selection process.
AN ESPERANTO OF LIVER DISEASE
THE International Association for the Study of the Liver has cooperated with the World Health Organisation in a noble undertaking to prepare a modern
nomenclature, diagnostic criteria, and diagnostic methodology for diseases of the liver and biliary tract. Co-sponsored by the John E. Fogarty International Center for Advanced Study in the Health Sciences (Bethesda), the finished product1 will be available during the summer of 1975, and the proceedings of the Acapulco meeting will have a condensed version. The 15 chapters on nomenclature and diagnostic criteria cover hepatitis, fibrosis and cirrhosis, cholestasis and diseases of the biliary tract, focal lesions, vascular lesions, metabolic disorders and fatty liver, and tumours of the liver and biliary tract. 5 chapters on diagnostic methodology discuss clinical evaluation, functional evaluation (of the hepatocyte, biliary passages, hepatic vascular bed, and hepatic mesenchymal cells including immunocytes), morphological evaluation, and microbiological and toxicological procedures in establishing diagnosis. Each disorder is tackled along a set pattern, which includes a definition followed by clinical, functional, morphological, and aetiological criteria. Confusing and obsolete terminology is included under a heading rejected ". Liver-function tests are set out according to their ability to evaluate, in turn, the hepatocyte, biliary passages, hepatic vascular bed, and hepatic ,
"
cells. Clinical pathologists will be interested to note that tests have been categorised as level 1, which can and should be available at any medical facility; level 2, which are available in special hospitals; and level 3, which are available in centres which specialise in diseases of the liver. The terms and standards are those recommended by a commission of international clinical chemists, who are likewise trying to reduce confusion by standardising biochemical units internationally.
mesenchymal
This international manual of liver diseases provides worldwide gold-standard on definitions of a confusing variety of liver and biliary-tract disorders. It will also help the World Health Organisation to redefine its International Nomenclature of Disease, and the International Association for Study of the Liver intends to maintain it as a continuing manual of international standards-a necessary and praiseworthy undertaking. This esperanto of liver disease should enhance understanding of hepatology across the world. a
1.
Fogarty International Proceedings No. Printing Office (in the press).
22.
U.S. Government
medical schools dutifully list the achievement of suitable professional attitudes. Apart from the notinsuperable difficulties inherent in defining " suitable " attitudes, there are some important questions which have not yet been adequately answered: Do medical students’ attitudes change while they are at medical school ? Can specific teaching programmes change students’ attitudes reliably or usefully ? Two reviewers have lately examined the evidence on these points.1,2 There have been a few longitudinal studies, focusing principally on psychosocial attitudes. The classic, work is that of Eron,3which suggested that medical students increase in cynicism and decrease in humanitarianism (at least as measured by attitude scales); Christie and Merton4 as well as Gordon and Mensh5 have supported these findings. Some have argued6 that the cynicism is an adaptive and understandable reaction to the medical-school environment, and that it is related to the training process rather than to medicine as a career. Indeed, Reinhardt and Gray have shown that, four years after graduation, physicians in specialties with " high interaction " with patients do tend " low-interaction " to be less cynical than colleagues in specialties who had similar cynicism scores on graduation. Certainly there is no evidence that medical education increases humanitarianism or benevolence in students,. or enhances any other attitudes we might deem desirable. At the very best, it may not grossly interfere with these attitudes in students who arrive at medical school already strongly imbued with them. Of investigations on the influence of teaching on attitudes, most have examined the effects of most
special comprehensive-medical-care programmes, at Cornell 8,9 and Colorado,10 which emphasise prevention of disease and rehabilitation and deal with the full range of illness from structural pathology to emotional and family problems. A positive attitude to the treatment of patients with psychosocial problems, and more favourable attitudes to other members of the health-care team,sometimes emerged, but they faded quite soon after the students returned to the usual. curriculum. Teaching on family medicine or psychiatry seemed not to change students’ preferences for treating physical illness, once such preferences were established. General psychological research on attitude development and change supports these findings. So long as the student’s own group and the faculty share and reinforce particular attitudes, educational attempts to encourage other attitudes are unlikely to have more than evanescent effects. So what is a medical school 1. 2.
Rezler, A. G. J. med. Educ. 1974, 49, 1023. Simpson, M. A. Medical Education: A Critical Approach. London,
3. 4.
Eron, L. D. J. med. Educ. 1958, 33, 25. Christie, R., Merton, R. K. ibid. p. 125. Gordon, L. V., Mensh, I. N. J. educ. Psychol. 1962, 53, 48. Becker, H. S., Geer B. Am. soc. Rev. 1958, 23, 50. Reinhardt, A. M., Gray, R. M. A. J. med. Educ. 1972, 47, 112. Merton, R., Reader, C. G., Kendall, P. L. The Student Physician. Cambridge, Mass., 1957. Reader, G. G., Goss, M. E. W. Comprehensive Medical Care and Teaching. Ithaca, N.Y., 1967. Hammond, K. R., Kern, F. Teaching Comprehensive Medical Care. Cambridge, Mass., 1959.
1972.
5. 6. 7. 8.
9. 10.
If we regard certain attitudes as important good health care, we must probably concentrate on selecting students who already possess such attitudes before admission, rather than expect the curricuto
do ?
for
lum to achieve some form of attitudinal transubstantiation. Selection based principally on intellectual qualifications is known to be unsatisfactory in many ways. Perhaps formal attitude assessment should play a leading part in the selection process.
AN ESPERANTO OF LIVER DISEASE
THE International Association for the Study of the Liver has cooperated with the World Health Organisation in a noble undertaking to prepare a modern
nomenclature, diagnostic criteria, and diagnostic methodology for diseases of the liver and biliary tract. Co-sponsored by the John E. Fogarty International Center for Advanced Study in the Health Sciences (Bethesda), the finished product1 will be available during the summer of 1975, and the proceedings of the Acapulco meeting will have a condensed version. The 15 chapters on nomenclature and diagnostic criteria cover hepatitis, fibrosis and cirrhosis, cholestasis and diseases of the biliary tract, focal lesions, vascular lesions, metabolic disorders and fatty liver, and tumours of the liver and biliary tract. 5 chapters on diagnostic methodology discuss clinical evaluation, functional evaluation (of the hepatocyte, biliary passages, hepatic vascular bed, and hepatic mesenchymal cells including immunocytes), morphological evaluation, and microbiological and toxicological procedures in establishing diagnosis. Each disorder is tackled along a set pattern, which includes a definition followed by clinical, functional, morphological, and aetiological criteria. Confusing and obsolete terminology is included under a heading rejected ". Liver-function tests are set out according to their ability to evaluate, in turn, the hepatocyte, biliary passages, hepatic vascular bed, and hepatic ,
"
cells. Clinical pathologists will be interested to note that tests have been categorised as level 1, which can and should be available at any medical facility; level 2, which are available in special hospitals; and level 3, which are available in centres which specialise in diseases of the liver. The terms and standards are those recommended by a commission of international clinical chemists, who are likewise trying to reduce confusion by standardising biochemical units internationally.
mesenchymal
This international manual of liver diseases provides worldwide gold-standard on definitions of a confusing variety of liver and biliary-tract disorders. It will also help the World Health Organisation to redefine its International Nomenclature of Disease, and the International Association for Study of the Liver intends to maintain it as a continuing manual of international standards-a necessary and praiseworthy undertaking. This esperanto of liver disease should enhance understanding of hepatology across the world. a
1.
Fogarty International Proceedings No. Printing Office (in the press).
22.
U.S. Government
