140 Doctor : And you were alone too. Patient : He said I should be cheerful and look on the bright side. Doctor: Easy to say (A gentle kick. The physician separates himself a little from the son’s attitude and from any expectation that he too will have the same attitude.) There were a lot of times when you just wanted to forget. Patient: The medicines didn’t help at all. Doctor: Some of the people blamed you too. (A stronger kick. 7%, doctor is not among the blamers. Also, he does not take upon himself the defence of his profession.) Patient: The worst was when I bled. And I passed out. Doctor.- Then the drinking really began. You were scared to death. (Note that the doctor does not ask about drinking. He simply makes a statement about the drinking. The patient can confirm it, correct it, or pass it by altogether. He has not driven her into a lie.) Patient: I didn’t want to. I knew it was wrong. Doctor: (The temptation now is to moralise or command. It will be much easier to influence the patient by staying by her side.) No, then it got harder to resist. ’

AIMING AT THE TRUTH

Statements aimed at the projections have two salient features. First, they refer to someone else, neither the patient nor the doctor (in our example, to the son or

Medical Education

IF I WERE A DEAN ..

DAVID BROOKS* "How is it that little children are so intelligent and men so stupid? It must be education that does it".-Alexandre Dumas, fils, quoted in L. Treich’s L’Esprit d’AZexandre Dumas.

It had been a typical day; no rare pathological prohad been observed but we had seen many examples of the complex interrelationship in patients between their pathophysiological disorders, psychological and behaviour processes, and social environment. The medical student’s reaction had been guarded; after all it was his first day in the practice. cesses

"What have you been telling yourself about general practice ?" he was asked. "I worked hard for my A levels to get into medical school and I am working hard now, therefore I expect something better than this" he replied. "Most of your patients have trivial organic illness or simply want a shoulder to cry on".

Considering that nearly half our graduates enter general practice, attitudes such as this can hardly be described as appropriate. Are we at risk of producing a generation of doctors unable to meet the medical needs of the community which does consist largely of ordinary people with ordinary problems? Figures from the Universities Central Council on Admissions in 1976 show that well over half the medical-school entrants had A level grades of A, B, B, (or A, A, C) or higher and that these very able students are taken from a group that studies science at university.’ Are we producing very com*General practitioner, 133 Manchester Old chester M24 4DZ. 1.

Report

of the Universities Central Council on

Road, Middleton, Man-

Admissions, 1976.

"some of the people".) We divert attention from the immediate relationship, making it less intense. Essentially, counter-projective statements point, out there, and because projection tends to follow attention, the uncomfortable ideas fall less heavily on the relationship. In this way strangers can talk comfortably while watching a disaster or a parade. Secondly, the grammatical tool is a statement, not a question, exclamation, or the urgings that make up the associative method. Doctors get so used to asking questions that they forget how other people talk. We emerge from medical school and our hospital with a formidable battery of questions. There is almost nothing we are not prepared to ask. Of course questions have great value, but there are other tools as well. Listen on the bus or subway: ordinary conversation is built largely on statements. One statement leads to another; one corrects, erases, confirms another. Mutual impressions are created without anyone being put too much on the spot. We need to use these new tools as efficiently as the stethoscope and ophthalmoscope. They are not very difficult tools and their edge is often surprisingly keen.

petent medical scientists who may prove to be excellent at pathophysiological research but not very interested in caring for the sick? As Simpsoni pointed out in 1972, we do not show very many signs of knowing where we are going in medical education-a state in which we run a fairly high risk of arriving somewhere we should not be. Surely it is just as important that doctors can use knowledge and skills to make sound judgments, that they are sincere and stable, that they have an ability to communicate with ordinary people, and that they are sensitive enough to be more concerned about the problems that patients bring to them than about the diseases that they might be suffering from. There is evidence that many doctors cannot talk to patients’ and it has been argued that our selection criteria are too limited and that we must give more consideration to desirable personal qualities.4 However, no assessment procedure for personal qualities has the required predictive validity, and if such a procedure were available it would probably be impractical in view of the numbers of school leavers involved. In any case, do we really want to select certain personality traits in aspiring medical students? It has proved possible to define the qualities required of a general practitioner by producing a job description for teaching and learning. The newly qualified medical graduate has no comparable job description, and by definition he may branch off in any direction into many different careers requiring many different attributes, some involving purely scientific skills and some requiring both scientific and behavioural skills. The problem as outlined above does exist but it is not the result of faulty selection. There is no evidence that personal qualities that might be regarded as desirable in a doctor are any less evident in students with high A-level grades than they are in a populationwho never took A levels 2. Snnpson, M. A. Medical Education—a Critical Approach. London, 1972. 3. Byrne, P. S., Long, B. E. L. Doctors Talking to Patients. H.M. Stationery ’Office’, 1976. 4. Gilmour, A. Lancet, 1977, ii, 985. 5. The Future General Practitioner: Learning and Teaching. London, 1972.

141 at all. Students who have strived for and obtained high A-level grades have, at least, demonstrated a high degree of learning ability, and past performance is the most reliable guide we have to future performance. What they learn in our medical schools is another story. High A-level grades may imply high I.Q. or intensive application. Will graduates become disenchanted with the routine of most medical work when exceptional A-level grades equate with exceptional I.Q.? They might-and this is the real problem for the deans. If our graduates are unable to serve the medical needs of the community the fault lies in their undergraduate and postgraduate training rather than their selection, with what they learn rather than how well they learn. We have yet to define an undergraduate curriculum in terms of learning objectives which express in behavioural terms what we expect our basic doctor to be able to do.6.7 If doctors cannot talk to patients, perhaps this has something to do with the fact that most medical schools show little evidence that they regard this as a particularly important learning objective. Helfer and Levin8 observed senior medical students in a paediatric clinic in 1967; they demonstrated that the students tended to adopt a rigid and stereotyped approach which could push a parent into giving incorrect information. One suspects that many junior students have an innate ability to talk to patients and that medical schools may be destroying ability, producing senior students who learn to talk at patients rather than with them.

The selection of high-ability students produces other How will the inner-city comprehensives cope with medical-school requirements and will even more students come from the independent schools? What about the country’s need for physicists, industrial chemists, and other scientists as medical schools increasingly tap the pool of high-ability students? These problems are largely the responsibility of central government rather than the deans, although the deans could help by being less insistent on science A levels. Will my children obtain medical school places? Probably not, but then the Todd Report pointed out that 23-1% of the children of medically qualified parents had to repeat some part of the course compared with 18.5% of the children of other parents.

In

England

Back home from the U.S.A., my head is full of disconnected rhythm. Walk. Let Yourself Go to Pizza Hut. Don’t walk. Have a Good Day. Think! You’re Welcome. Curiously, among all the strange encounters, the clearest is the trim young mother in the London Tube. (This was on the way back from Heathrow. If it had not been for the airport strike, I should not have been Underground at all). So proud, she was, of her six-months baby in his new push-chair. The smile never left her face. Talked to him all the time. With utter lack of embarrassment, in adult language. "You’ve never been to Earls Court before, have you? You always wanted to go to Earls Court, didn’t you? I expect you’ll tell your Daddy you’ve been to Earls Court, won’t you?" So it went on for half an hour. It evidently went on all the time. Highly educative, I am sure. He will be an early developer. A lesson to us all. But stop: what happens when a sibling arrives? How will this child feel then, if she switches her whole-time attentions ? You could have a problem there. Reactions of the passengers. Marked sex distinction. All the women smiling too, glorying in her glory, unable to look at anything but the baby. All the men staring steadfastly ahead, faces pink with repressed masculine shame. Makes you Think!Does Daddy get a look-in? Disconnection is the stuff of life. Walk, Let Yourself Go. You gotta let yourself go this way anyhow. There’s a strike on, didn’t you know? It looks like you won’t make your main-line connection. You could have done without Earls- Court on this trip, couldn’t you? You won’t Have a Good Day. You’re getting your Welcome back home, all right.

problems.

If I were a dean my attitude would be one of vigilant conservatism with regard to selection, prudent experiment with regard to the undergraduate curriculum and the postgraduate training programmes, and liberal encouragement towards the introduction of careers-counselling networks for graduates; objective assessment should be available at this stage. If variety is the spice of life it is the essence of medicine. I thank my partners Dr A. D. Clift and Dr

J.

A. Maudar for valu-

able comment. 6.Lancet,1977,i,985. 7.Wyn Pugh, E., Lloyd, G.J., McIntyre, N.Br. med. J.1975, iii, 688. 8.Heifer, R., Levin, S.J.med. Educ. 1967, 42, 867. 9.Report of the Royal Commission on Medical Education 1965-68. H.M. Sta-

tionery Office, 1968.

Now

*

*

*

My colleague’s daughter made several unsuccessful expeditions to the shops and supermarkets in search of a well-known brand of fibrous breakfast food. Obeying the injunctions of the medical journals about the benefits of fibre, the elderly locals must have emptied the shelves and the pantechnicons, with replacements not due for a week. Her father suggested an emergency call to the tobacco giants: "They must be wondering what to do with their New Smoking Material." *

*

*

CORONARY

At first, unease, As if the real things Have no substance. And then Pain

Erupting Like a flame Seated in the mediastinal pit, Which blazes up

Scorching, numbing The molten centre of the world. Now, Stillness Eyes closed, and a whisper, "Is someone coming?" "Yes darling, keep still" And there they are,

Strong men, Blue-uniformed, Competent. "Hold this and breathe"

Oh! dousing ease. Arms lifting,

Wheeling, Cold air darkness. Then a rushing

Rocketing, swinging, Wheeling. Swing doors On the bed As he is. Hands gentle

Unbuttoning And in the chest The furnace glows White-hot. And at last Memory recedes In the blessed Nepenthe Of Heroin. ’

If I were a dean

140 Doctor : And you were alone too. Patient : He said I should be cheerful and look on the bright side. Doctor: Easy to say (A gentle kick. The physi...
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