1010 6.
Space, place, and time
are
paramount.
The predicament is usually related to this place and this time; it changes as these boundaries change. What obtains at the beginning of the consultation might be better, or worse, by the end of it.
of predicaments is discernment. Discernment is knowing a Schubert quartet when you hear
7. The
diagnosis
Picasso when you see one. It is about picking the fake one, from the genuine, the trivial from the profound. or a
-
8.
Knowledge ing.
of
predicaments
grows with understand-
9. Predicaments contain scope for social and
political
remedy. Many of the sources of human distress manifestly come from difficulties which are beyond medical remedy. But physicians can orient themselves and their students towards a form of medical practice which is widely accessible and capable of responding across the wide range of sickness, and be prepared to influence social policies which are conducive to sickness. CONCLUSION
Three components of sickness are separated to draw attention to the difference between things, processes, and situations. Most sicknesses will have something of each component in them. It will reduce therapeutic frustration and error if these components are recognised at diagnosis. They require different types of manipulation. Bioscience is concerned with what I call diseases and touches upon some illnesses. Disease models do not adequately explain either susceptibility or the particular expression of a disease within an individual. The tactics of bioscience seem seductively applicable to all sickness. Bioscience is attractive to doctors because it speaks to their painfully acquired rational expertise, to the scientist in their make-up, and validates their specialisation. But, for the public, bioscience’s general omnipotence amplifies its particular failures. Also it overemphasises the practitioner and undervalues the negotiator in the physician. If the person is not relevant to the equation of sickness, then the doctor is entirely responsible when things go wrong. The loss of public confidence in medicine, the criticism, the lawsuits, the deprivation of resources, suggest that the public seeks alleviation of sicknesses which, however intangible, are not lightly to be dismissed. The conceptual status of illness does not allow the same degree of bioscientific insight as applies to disease, though developments in behavioural sciences are hopeful. The language of predicaments is even more in its infancy but the ethogenic approach5 has its possibilities. Predicaments will have to be studied seriously if we are to understand differential susceptibility to illness behaviour and disease. This is because, no matter how much we learn about mechanisms within the body, the interface between the individual and the environment is personal and determined by attitudes and experience. It is desirable that medical students should be as systematically acquainted with predicaments (that is, know something about people and about the world) as they are with disease and illness. Most students know this at the start of their medical courses. Human Development Research Park Hospital for Children,
Headington, Oxford
Unit,
DAVID C. TAYLOR
Round the World United States FURTHER ALARM ABOUT EDUCATIONAL STANDARDS
SCORES in the scholastic aptitude test, taken by collegebound high-school seniors, have fallen again, and this is taken as more evidence that the schools are not doing a satisfactory job. The news of these lower scores is especially disappointing in the light of all the attempts to improve education in the high schools. The past few years have not been happy ones for schoolteachers or those who administer schools. Indeed some of the strikes by teachers that had been endured since the theoretical opening of the schools in September were settled only last month, and some are continuing. A few weeks ago over 48 000 teachers in 14 States, having no contracts, were on strike, and the usual reason for lack of contracts is the taxpayers’ revolt against increased school taxes, which cautions the school boards against the sought-after pay increases. School budgets have been voted down by the taxpayers in increasing numbers in the past few years. A vicious circle has arisen. The public is reluctant to increase support until there is clear evidence that the schools are doing a better job, and the falling standards are taken as evidence that the schools are not so
doing.
It has been announced that high-school students have just suffered the sharpest decline in mathematical ability yet noted
and that their problem-solving ability has slumped most seriously ; the cause of this decline is hotly disputed, but it can safely be said that no one body will accept fault. Coming at a time when ever more stringent tests of school leavers are being called for, the decline is very disconcerting to educationalists. Meanwhile, since they work with such unpromising material, it is no wonder that many liberal arts colleges are in deep financial trouble and contribute to the educational turmoil by competing hotly for the available students. This, coupled with the academic flabbiness which leads to "grade inflation", which fails to distinguish between excellence and mediocrity, and awards only As and Bs, has contributed to lowered achievement. Since those who do not master their subjects are
tempted exam
to
was not altogether surprising to hear that nursing registration had been sold on a wide
cheat, it
papers for
open market. Thus, thousands of nurses who took the test will have to sit the exam again, At the lower strata of education the Ford Foundation has now reported that things are getting worse. Present efforts to
abolish illiteracy seem totally inadequate, despite loud advocacy, costly programmes, and claims for success. The fact is that these programmes just do not reach large numbers of illiterate people who are never entering the orbit of the rapidly growing adult educational programmes. As is so often the case those who should benefit the most do not take advantage of social welfare schemes, while the better educated, the alert, the wealthier, take every advantage open to them. It is widely believed that the nation’s educational systems need drastic change. Perhaps a mechanism for this reform has been provided, for the old familiar Department of Health Education and Welfare has been broken up by the establishment of a separated Department of Education. So with the E of HEW excised, the department is now H and H-health and human resources.
1. Kendell RF. The role of diagnosis m psychiatry. Oxford: Blackwell, 1975. 2. Wooley S, Blackwell B, Winget C. Psychosom Med 1978; 50: 379. 3. World Health Organisation. International pilot study of schizophrenia, Geneva: W.H.O. Publications, 1973. 4. Szasz TS. The myth of mental illness. St. Albans: Paladin Books, 1972. 5. Harre R. The ethogemc approach: theory and practice. In: Berkowitz L, ed. Advances in experiment-social psychology. New York: Academic Press, 1977.
Space, place, and time
are
paramount.
The predicament is usually related to this place and this time; it changes as these boundaries change. What obtains at the beginning of the consultation might be better, or worse, by the end of it.
of predicaments is discernment. Discernment is knowing a Schubert quartet when you hear
7. The
diagnosis
Picasso when you see one. It is about picking the fake one, from the genuine, the trivial from the profound. or a
-
8.
Knowledge ing.
of
predicaments
grows with understand-
9. Predicaments contain scope for social and
political
remedy. Many of the sources of human distress manifestly come from difficulties which are beyond medical remedy. But physicians can orient themselves and their students towards a form of medical practice which is widely accessible and capable of responding across the wide range of sickness, and be prepared to influence social policies which are conducive to sickness. CONCLUSION
Three components of sickness are separated to draw attention to the difference between things, processes, and situations. Most sicknesses will have something of each component in them. It will reduce therapeutic frustration and error if these components are recognised at diagnosis. They require different types of manipulation. Bioscience is concerned with what I call diseases and touches upon some illnesses. Disease models do not adequately explain either susceptibility or the particular expression of a disease within an individual. The tactics of bioscience seem seductively applicable to all sickness. Bioscience is attractive to doctors because it speaks to their painfully acquired rational expertise, to the scientist in their make-up, and validates their specialisation. But, for the public, bioscience’s general omnipotence amplifies its particular failures. Also it overemphasises the practitioner and undervalues the negotiator in the physician. If the person is not relevant to the equation of sickness, then the doctor is entirely responsible when things go wrong. The loss of public confidence in medicine, the criticism, the lawsuits, the deprivation of resources, suggest that the public seeks alleviation of sicknesses which, however intangible, are not lightly to be dismissed. The conceptual status of illness does not allow the same degree of bioscientific insight as applies to disease, though developments in behavioural sciences are hopeful. The language of predicaments is even more in its infancy but the ethogenic approach5 has its possibilities. Predicaments will have to be studied seriously if we are to understand differential susceptibility to illness behaviour and disease. This is because, no matter how much we learn about mechanisms within the body, the interface between the individual and the environment is personal and determined by attitudes and experience. It is desirable that medical students should be as systematically acquainted with predicaments (that is, know something about people and about the world) as they are with disease and illness. Most students know this at the start of their medical courses. Human Development Research Park Hospital for Children,
Headington, Oxford
Unit,
DAVID C. TAYLOR
Round the World United States FURTHER ALARM ABOUT EDUCATIONAL STANDARDS
SCORES in the scholastic aptitude test, taken by collegebound high-school seniors, have fallen again, and this is taken as more evidence that the schools are not doing a satisfactory job. The news of these lower scores is especially disappointing in the light of all the attempts to improve education in the high schools. The past few years have not been happy ones for schoolteachers or those who administer schools. Indeed some of the strikes by teachers that had been endured since the theoretical opening of the schools in September were settled only last month, and some are continuing. A few weeks ago over 48 000 teachers in 14 States, having no contracts, were on strike, and the usual reason for lack of contracts is the taxpayers’ revolt against increased school taxes, which cautions the school boards against the sought-after pay increases. School budgets have been voted down by the taxpayers in increasing numbers in the past few years. A vicious circle has arisen. The public is reluctant to increase support until there is clear evidence that the schools are doing a better job, and the falling standards are taken as evidence that the schools are not so
doing.
It has been announced that high-school students have just suffered the sharpest decline in mathematical ability yet noted
and that their problem-solving ability has slumped most seriously ; the cause of this decline is hotly disputed, but it can safely be said that no one body will accept fault. Coming at a time when ever more stringent tests of school leavers are being called for, the decline is very disconcerting to educationalists. Meanwhile, since they work with such unpromising material, it is no wonder that many liberal arts colleges are in deep financial trouble and contribute to the educational turmoil by competing hotly for the available students. This, coupled with the academic flabbiness which leads to "grade inflation", which fails to distinguish between excellence and mediocrity, and awards only As and Bs, has contributed to lowered achievement. Since those who do not master their subjects are
tempted exam
to
was not altogether surprising to hear that nursing registration had been sold on a wide
cheat, it
papers for
open market. Thus, thousands of nurses who took the test will have to sit the exam again, At the lower strata of education the Ford Foundation has now reported that things are getting worse. Present efforts to
abolish illiteracy seem totally inadequate, despite loud advocacy, costly programmes, and claims for success. The fact is that these programmes just do not reach large numbers of illiterate people who are never entering the orbit of the rapidly growing adult educational programmes. As is so often the case those who should benefit the most do not take advantage of social welfare schemes, while the better educated, the alert, the wealthier, take every advantage open to them. It is widely believed that the nation’s educational systems need drastic change. Perhaps a mechanism for this reform has been provided, for the old familiar Department of Health Education and Welfare has been broken up by the establishment of a separated Department of Education. So with the E of HEW excised, the department is now H and H-health and human resources.
1. Kendell RF. The role of diagnosis m psychiatry. Oxford: Blackwell, 1975. 2. Wooley S, Blackwell B, Winget C. Psychosom Med 1978; 50: 379. 3. World Health Organisation. International pilot study of schizophrenia, Geneva: W.H.O. Publications, 1973. 4. Szasz TS. The myth of mental illness. St. Albans: Paladin Books, 1972. 5. Harre R. The ethogemc approach: theory and practice. In: Berkowitz L, ed. Advances in experiment-social psychology. New York: Academic Press, 1977.
