he said "cascade into general use without assessment of their effectiveness. We order groups of tests simultaneously rather than in relation to a logical sequence of decisions in diagnosis." Evans noted one large, randomized, controlled, clinical trial that showed that a battery of multiphasic screening tests done on admission failed to shorten hospital stay or improve clinical diagnosis and in fact was associated with a 25% increase in second opinion consultations, a 78% increase in total tests done and a 5% increase in total hospital costs. This and supporting evidence is convincing argument to end "shotgun diagnosis and multiple choice medicine and. . return to critical judgement in the process of diagnosis." Having expressed the urgency for medical schools to get into this type of evaluation, Evans admitted that most, because of their teaching traditions, just weren't equipped to do the job. Too many had ingrained departmental priorities and hierarchies. One thing they need is to bring in clinical epidemiologists, who can combine extensive knowledge of human biology and the natural history and variations of disease with epidemiologic and statistical skills to allow productive evaluation. Once aboard, clinical epidemiologists should be made an integral part of the crew - "they should not be isolated as a new and separate subspecialty. They should interact with all the clinical programs." In effect, says Evans, medical education should encourage the physician to look beyond individual patients to the health status of a defined population, and this means getting into environmental and occupational hazards, social pathology and lifestyle characteristics. It means identifying what needs
certain groups have, and actually searching out those individuals with preventable conditions and treatable disorders. There is evidence that Evans' expanded view of the role of medical schools has support. In 1974 the Association of American Medical Colleges surveyed 88 deans about what changes they considered would have the most profound effect on their institutions. Their predictions included: * Establishment of a national system of control of specialty distribution of physicians. * Greater public accountability for improved medical centre management. * Much higher priority for continuing medical education. * An assumption by the academic medical centre of responsibility for most graduate medical education. They also foresaw the academic medical centre becoming the hub of tertiary care in a regional network of health services. And, not to be neglected, there was a clear signal from the surveyed deans that they wanted a much tighter link between the medical profession, public health and preventive medicine. Obviously such changes would have impact on the roles and expectations of medical students. And that might necessitate striking a more equitable balance between the science and the art of medicine. Return to classics Dr. Lewis Thomas, president of the Memorial Sloan Kettering Medical Center in New York, told the conference he felt there was a means to restore that balance, a means rooted in some classical approaches to education. Medical schools have erred greatly, said Thomas, in becoming ob-
sessed with science to the exclusion of the humanities. Most students now perceive their future in med icine as depending on their getting straight As and having a superman's grasp of science. They take for granted that they are at war with each other and that any means of achieving the desired grades is justified. This attitude leads to some ugly behaviour, said Thomas. it results in sabotaged experiments of colleagues, textbooks vanishing from the library and pages torn out of selected monographs and journals. Because of this obsession with sciences, some of the best courses in the humanities and foreign languages are dismissed. And there goes the foundation of a good education. But not all of this should be blamed on the students, said Thomas. Despite the rhetoric of deans and schools' representatives, students still have a fair perception of what is expected of them. They know that if they are not in the top 10 of academic achievement, their applications have slight chance of being acted upon. Thomas told the educators that the demise of Greek and Latin from American university life was a great "disaster". Classical Greek, he said, should be restored to the curriculum. There is no better way to test the development of the student's mind and to test his "tenacity', resolve, his capacity to understand the human being and his affection for the human condition." In effect, anyone who could master Homer's language and the torment of his poetry will have passed a "shrewd test" of the qualities of mind and character needed to become a physician. Thomas emphasized this is not to denigrate the role of science in medical learning, but just to even up the equation a bit.
The future of US medicine It has become obvious to American physicians that if they want to look into their own futures, they
should ask a Canadian about his recent past. Dr. L.H. le Riche, registrar of the
1554 CMA JOURNAL/JUNE 23, 1979/VOL. 120
College of Physicians and Surgeons of Alberta, told the medical education congress that the recent past is
bitter memory indeed, one that has made many Canadian physicians uneasy. "The medical profession finds itself floundering in a morass of government laws, rules, regulations and computers. The spectre of government is ever present in the doctor's office. No longer is accountability to the patient sufficient, but medicine must satisfy that impersonal third party, the state." Le Riche set out not to garner interprofessional sympathy, but to point out the landmines that complicate the terrain when government rearranges the geography. Physicians getting into a national health insurance relationship with government had better not become sensitive about being called names. Any fault ever found is interpreted as the physician's doing, he said. "Politicians continue to imply that state medicine flows from our prescription pads. They say we are too expensive and order too many expensive modalities of investigation and treatment.., therefore the state must intervene." For example, despite the massive social acceptance of the pill and greater permissiveness, it is physicians who are blamed for the great increase (to 55 000 in Canada last year) in abortions. Physicians are also blamed for the enormous costs of maintaining a growing elderly population, just as they are for the growing trends in drug abuse, said le Riche. "Is just living in our two countries such a hazard that no less than one quarter of the population is at any one time taking pills?" Agonizing confrontations Le Riche noted that the intrusion
and expansion of national health insurance has forced agonizing confrontations for Canadian physicians. One is that between money and a physician's ethics - "there is no doubt that the overall philosophy towards billing and money has undergone a radical change." The national health insurance program, being a government monopoly,
Physicians are blamed for population's drug dependence
certain groups have, and actually searching out those individuals with preventable conditions and treatable disorders. There is evidence that Evans' expanded view of the role of medical schools has support. In 1974 the Association of American Medical Colleges surveyed 88 deans about what changes they considered would have the most profound effect on their institutions. Their predictions included: * Establishment of a national system of control of specialty distribution of physicians. * Greater public accountability for improved medical centre management. * Much higher priority for continuing medical education. * An assumption by the academic medical centre of responsibility for most graduate medical education. They also foresaw the academic medical centre becoming the hub of tertiary care in a regional network of health services. And, not to be neglected, there was a clear signal from the surveyed deans that they wanted a much tighter link between the medical profession, public health and preventive medicine. Obviously such changes would have impact on the roles and expectations of medical students. And that might necessitate striking a more equitable balance between the science and the art of medicine. Return to classics Dr. Lewis Thomas, president of the Memorial Sloan Kettering Medical Center in New York, told the conference he felt there was a means to restore that balance, a means rooted in some classical approaches to education. Medical schools have erred greatly, said Thomas, in becoming ob-
sessed with science to the exclusion of the humanities. Most students now perceive their future in med icine as depending on their getting straight As and having a superman's grasp of science. They take for granted that they are at war with each other and that any means of achieving the desired grades is justified. This attitude leads to some ugly behaviour, said Thomas. it results in sabotaged experiments of colleagues, textbooks vanishing from the library and pages torn out of selected monographs and journals. Because of this obsession with sciences, some of the best courses in the humanities and foreign languages are dismissed. And there goes the foundation of a good education. But not all of this should be blamed on the students, said Thomas. Despite the rhetoric of deans and schools' representatives, students still have a fair perception of what is expected of them. They know that if they are not in the top 10 of academic achievement, their applications have slight chance of being acted upon. Thomas told the educators that the demise of Greek and Latin from American university life was a great "disaster". Classical Greek, he said, should be restored to the curriculum. There is no better way to test the development of the student's mind and to test his "tenacity', resolve, his capacity to understand the human being and his affection for the human condition." In effect, anyone who could master Homer's language and the torment of his poetry will have passed a "shrewd test" of the qualities of mind and character needed to become a physician. Thomas emphasized this is not to denigrate the role of science in medical learning, but just to even up the equation a bit.
The future of US medicine It has become obvious to American physicians that if they want to look into their own futures, they
should ask a Canadian about his recent past. Dr. L.H. le Riche, registrar of the
1554 CMA JOURNAL/JUNE 23, 1979/VOL. 120
College of Physicians and Surgeons of Alberta, told the medical education congress that the recent past is
bitter memory indeed, one that has made many Canadian physicians uneasy. "The medical profession finds itself floundering in a morass of government laws, rules, regulations and computers. The spectre of government is ever present in the doctor's office. No longer is accountability to the patient sufficient, but medicine must satisfy that impersonal third party, the state." Le Riche set out not to garner interprofessional sympathy, but to point out the landmines that complicate the terrain when government rearranges the geography. Physicians getting into a national health insurance relationship with government had better not become sensitive about being called names. Any fault ever found is interpreted as the physician's doing, he said. "Politicians continue to imply that state medicine flows from our prescription pads. They say we are too expensive and order too many expensive modalities of investigation and treatment.., therefore the state must intervene." For example, despite the massive social acceptance of the pill and greater permissiveness, it is physicians who are blamed for the great increase (to 55 000 in Canada last year) in abortions. Physicians are also blamed for the enormous costs of maintaining a growing elderly population, just as they are for the growing trends in drug abuse, said le Riche. "Is just living in our two countries such a hazard that no less than one quarter of the population is at any one time taking pills?" Agonizing confrontations Le Riche noted that the intrusion
and expansion of national health insurance has forced agonizing confrontations for Canadian physicians. One is that between money and a physician's ethics - "there is no doubt that the overall philosophy towards billing and money has undergone a radical change." The national health insurance program, being a government monopoly,
Physicians are blamed for population's drug dependence
