Friday, July 8, 2016

Fixing the Basic flaw in Medical Education and Health Care


There is a basic flaw in the commonly held concept of Medicine that lies at the root of all the maladies prevailing in the field of medical education and health care. Successful practice of Medicine consists of about 2/3rd body medicine and 1/3rd mind-body and mind-body-spirit medicine. But only the 2/3rd component of body medicine is generally recognized as Medicine. The remaining 1/3rd is considered, if at all, under alternative medicine. While body medicine is based on structure and is therefore objective and easily teachable, mind-body medicine and mind-body-spirit medicine are more subjective and picked up by doctors after years of practical experience.

Medical colleges with their present curriculum can teach only the 2/3rd component; the rest of 1/3rd is mostly self learnt by students and doctors through observation of peers and teachers who teach by setting an example. If we consider this fact it becomes obvious that too much importance is being given to activities based on something that is incomplete by itself: body medicine-based examinations, specialisations, CME points, renewal of license and so on. It is appropriate to learn and update oneself about diseases of the body and their management but all such learning should be tempered by the fact that it pertains only to the 2/3rd component of Medicine. To be successfully utilized, this knowledge needs to be combined with the remaining 1/3rd component that is learnt through subjective experience. That is to say medical knowledge to be complete needs to be combined with a positive and empathetic approach towards the patient. Such a wholesome approach towards the patient not only treats the patient better but helps create better doctor-patient (or patient's attendants) relationship, avoids potential conflict and indirectly helps healing.
 
The incomplete and ignorant notion of Medicine that is widely prevalent not only complicates management by making its application mechanical but also results in Medicine being taught in a mechanical manner based on a curriculum that is built mainly on body medicine. The doctors thus produced, unless they are exposed to wholesome teachers, tend to behave more like machines lacking in empathy. Inappropriate glorification of body medicine encourages unnecessary investigations, escalates cost and allows third parties to take control. Instead of a wholesome approach towards patients, approaches catering to various disparate interests have come to determine medical education and health care delivery. Modern hospitals tend to become more like workshops, patients seen more as study materials and the disease burden as well as students aspiring to become doctors - fields to be harvested. Correction of the basic flaw should start with widespread recognition of the incomplete nature of grossly teachable and evaluable medicine. The Regulatory authorities should try to add completeness to medical education by emphasising the neglected 1/3rd component of Medicine and make the wholesome medical teacher the fulcrum of all learning.
At the entry point, entrance exams to UG/PG courses should in addition to testing proficiency in the required subjects, also test the candidates’ ability to feel for and render help to those in need of it. How this can be done is a matter that needs help from educationists. Mere logic based tests in the concerned subjects as at present will only worsen the malady and chaos. Being more subtle and subjective, the 1/3rd component is easily side-lined. Corrective measures need wisdom and vision. Just as diseases like obesity, diabetes mellitus and dyslipidemia need basic life style modification to be meaningfully treated, the maladies in the field of medical education and health care require basic conceptual modification. Healing by doctors should, as a rule, imply healing of the mind, body and the spirit and not merely the body.



Empathy, Research and the Medical Teacher


           In recent times, it is recognized that the quality of empathy is crucial for the successful delivery of health care.1 Empathy is a natural quality present in every medical student that needs to be fostered along with academics. It is known that students in the final year no longer feel as empathetic as they were when they joined the first year of medical course.2,3 The cause for the decline in empathy lies in the structure of modern medicine that is based on the laws of physical sciences requiring the use of predominantly logical thinking and action. Since subjectivity has to be excluded to learn objectively there is little room for development of subjective feeling leading to a neglect of intuition and empathy. Because of the tendency for decline of empathy during the course of medical education, several methods have been suggested to improve empathy among students and physicians. 4

Adding to the factors contributing to decline of empathy is the lack of understanding of the three psychological aspects of being a doctor: (1) Doctor treating the patient (Medical Practitioner), (2) Doctor updating himself to treat better (Continuing Medical Education) and (3) Doctor analyzing data and understanding new aspects of diseases and their treatment (Research).

The first aspect of treating the patient is the basic urge that drives the student to take up the career of medical profession. This interest in treating patients is what the society first expects from the medical profession. The purpose of medical education is to train doctors who can treat patients having different diseases with competence and compassion. The first task of the regulatory authorities should expectedly be to ensure that the medical colleges are equipped with appropriately qualified manpower (as well as infrastructure) to carry out this task.

The second aspect of being a doctor is the urge to keep abreast with new developments in the medical field so that he/she is able to improve the care given to the patients. This is a desirable trait and every doctor naturally has this to a greater or lesser extent. However for a qualified doctor who is already equipped with compassion and basic competence, the need to update oneself with medical knowledge is arguably best left to his/her own judgment.

The third aspect is the urge to learn from the information available while treating patients to understand unknown aspects of diseases and devise new treatment. Many doctors do this either by observation of patients over years or by methodically collecting data in designed studies, analyzing them and publishing their findings in journals.

The first aspect of being a competent and compassionate doctor does not depend on the second aspect of being updated with latest knowledge and even less on the third aspect of having interest in research and publication. Individual doctors who may be good in research may be found lacking in the ability to adequately care for the patient and vice versa, since different skills are required for these two functions.

When the regulatory bodies for medical education and practice do not understand the above three psychological aspects of being a doctor, it spells trouble. Though familiarity with research is needed, making publication of research papers compulsory for deciding the standing of a medical teacher seeks to whitewash all medical teachers into one category of having the capacity to do research whether or not they have the core capability of providing adequate patient care. In reality there is heterogeneity of medical teachers; some are good in patient care, some in doing research. Medical students learn different sets of skills from different teachers.

Given the central importance of empathy in patient care, the regulatory bodies have to ensure that under-graduate medical students are trained to treat patients with knowledge as well as empathy and the medical teachers set an example in this respect for students to learn from. While the medical teacher needs to be updated on the latest medical knowledge, the ability to do medical research is not a must for imparting basic medical education. Post-graduate medical education needs teachers who are capable of managing all types of cases while imbibing new medical knowledge with the added ability to impart their knowledge to post-graduate students. An ability to do research is only an added skill that may be taught to the students. Any doctor is welcome to take up research in a full-fledged manner if he/she is so inclined but that should be the individual’s choice.

Making publication of research papers mandatory for medical teachers is basically unsound. It can only ‘force feed’ research into those who are not inclined to it and spawn low quality and questionable research publications. It will shift the focus away from the need to train competent and compassionate doctors, which is of core importance from the point of view of a good health care system. The number of years of teaching medical students should remain the criterion to decide on the standing of a medical teacher, and not the number of research papers published by them. A nuanced approach by the regulatory bodies in matters of health care, medical education and research would help to avoid loss of the quality of empathy among doctors and medical students and prevent deterioration of the health care services.

References:

1. Hojat M. Ten approaches for enhancing empathy in health and human services cultures. J.Health Hum Serv Adm. 2009 Spring:31(4):412-50
2. Chen D, Lew R, Hershman W, Orlander J. A cross-sectional measurement of medical student empathy. J Gen Intern Med. 2007 Oct;22(10):1434-8. Epub 2007 Jul 26. http://www.ncbi.nlm.nih.gov/pubmed/17653807
3. Chen DC, Kirshenbaum DS, Yan J, Kirshenbaum E, Aseltine RH  Characterizing changes in student empathy throughout medical school. Med Teach. 2012:34(4):305-11. http://www.ncbi.nlm.nih.gov/pubmed/22455699
4. Ziółkowska-Rudowicz E, Kładna A. Empathy-building of physicians (Parts I to IV). Part I--A review of applied methods Pol Merkur Lekarski. [Polish] 2010 Oct;29(172):277-81.

5. Medical Council of India: Minimum Qualifications for Teachers in Medical 
 
Institutions Regulations, 1998  
 
http://www.mciindia.org/Rules-and-Regulation/TEQ-REGULATIONS-06.08.12.pdf