Springer, 2013. 111 pp.
“The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine—or, to put it more bluntly, they are too “scientific” and do not know how to take care of patients.”
Francis W. Peabody, The Care of the Patient. 1925
“A strong case is made that the present content, organisation, and delivery of health professionals’ education have failed to serve the needs and interests of patients and populations. What this Commission argues for is nothing less than a remoralisation of health professionals’ education. ”
Richard Horton, A New Epoch for Health Professionals’ Education. The Lancet 2010
Concerns about the moral development of medical students and young doctors have been around for far longer than medical ethics has been part of the undergraduate medical curriculum, and they remain, fundamentally unresolved. Nathan Emmerich reveals in the third chapter of his ‘Interdisciplinary and Social Theoretical Perspective’ on Medical Ethics Education, that there was a brief period in the 1960s when medical ethics was “an inherently political, and not simply ethical, project as it sought to effect change to the moral structure(s) of the profession.” (p.52) As it became embedded in the medical curriculum it gave up its political nature. Emmerich himself concludes, “medico-ethico-political questions … are not a matter of any great concern for every day medical practice. Therefore neither are they a concern for basic medical education,” (p.52).
Some of us involved in medical ethics education would strongly disagree, but this is not a book about what medical ethics education ought to be, but instead it serves as an overview of the theoretical perspectives one might use to study what medical ethics education is. Chapters three and four are less theory-laden, instead, summarising the recent history of medical ethics education in the UK. In spite of the concerns raised above, a modern medical ethics education does not aim to provide solutions to the problems of doctors who care too little or are out of touch with the people they serve. Even its early pastoral concerns in the 1960s have made way for a modern medical ethics, “marked by a specific way of thinking: a process of abstraction, which is broadly reliant on principles, cases and casuistic reasoning,” (p. 45).
Not long ago, a medical ethics reliant on etiquette and paternalism was assumed because a doctor was ethical by virtue of the being the kind of ‘gentlemen’ that doctors were, and medical ethics was not a subject that could be studied as, “One acquired it in the course of learning to become a good doctor,” (p. 44).
A lot has changed. For one thing, British medical schools are no longer filled from a stock of English gentlemen. By 2003 the proportion of female medical students in the UK peaked at 61%. Last year I taught a group of six, first year students from Barts and the London School of Medicine School of Medicine and only one, a woman, was white and British. The others, or their parents, had come from Jamaica, Afghanistan, Iran, India and Korea. Two were Muslim, one was evangelical Christian, one Hindu, one Catholic and one atheist. Four were women and none had medical parents. The moral dispositions students bring to medical school are more varied – especially in regard to gender and religion – than they once were were, and can, in theory at least, lead to tensions when they are exposed to a patriarchal hidden curriculum and a secular medical ethics education (pp. 2, 69). One way to resolve, or at least explore these tensions, is through reflection and reflective practice, described by Emmerich as “not only the medium of medical education, but also, to a large degree, its message,” (p.92). In my experience of teaching narrative medicine and reflective practice to this group of students and others, the range of ability and willingness to engage in reflective practice is far more marked than their ethnic and religious diversity. Furthermore, it has taken me a long time to develop the skills to teach and properly supervise reflective practice, and students report that the approach from other teachers varies considerably.
Emmerich is interested in not only these, but other factors that contribute to the moral development of medical students and “seek[s] to preserve sociological insights into the moral and medical socialisation of medical students whilst developing a theoretically complimentary perspective that can accommodate more formal education practices,” (p8). He uses the term enculturation, ‘to provide a way to overcome the disconnect between our understanding of the process through which the formal and informal curriculum contributes to the professional reproduction of medical students whilst leaving intact the potential for their content to be in conflict’ (p.28). Enculturation was one of a number of terms in this book that were new to me as a GP (family doctor), albeit one with interests in medical education and medical ethics. There is no glossary which would be especially useful, as an interdisciplinary textbook, almost by definition will present readers with unfamiliar words and concepts. If I am right in understanding enculturation to be refer to they way medical students get used to a particular way of ‘doing’ medical ethics, then it is true of how they get used to ‘doing’ medicine, or surgery as well. Emmerich explains that enculturated medical ethics, “In practice, in theory and in pedagogical delivery are a socio-culturally situated phenomenon” (p.87) He discusses the theories that one might use to study this, but he does not state where this phenomenon is situated, for example among the changing demographics of medical students, the globalisation of health and disease, the rise of healthcare consumerism and the increasing business orientation of medical education, the NHS and a great deal of healthcare around the world.
Some historical context to ground the theory is welcome in the fourth chapter when Emmerich discusses the influence of a Professor of General Practice, W.G. Irwin and his interest in the relationship between communications skills and medical ethics. Irwin pioneered the use of videoing consultations between doctors and patients and watching them with small groups of doctors to help them understand communication skills and the psycho-dynamics of the doctor-patient relationship. This is now routine in General Practice training. It has always been clear to me as a GP, that providing holistic care to patients with whom I have developed relationships over time has a moral quality, distinct from that of the hospital specialist providing episodic, disease-oriented care. But even this is under-threat as healthcare becomes fragmented, more GPs work part-time and specialists become more specialised. As medical sociologist and anthropologist Arthur Frank writes, “Th[e] structured disruption of continuity of relational care is more than an organisation problem; it is a moral failure of health care, deforming who patients and clinicians can be to and for each other,” (Frank 2004).
Where I felt this book could do more is in applying theory to contemporary practice. Not only is the social culture of medical education varied and changing, but also medical ethics education in the UK is a divided field with the dominant emphasis on medical ethics as a conceptual tool-kit. Medical ethical educators like Miran Epstein at Barts and the London and Deborah Bowman at St Georges are placing greater emphasis on the medical ethics of power and relationships, but they are notable exceptions.
For those of us interested in aligning medical ethics education with the needs and interests of the patients this book is a useful guide to the theories and challenges ahead.
Jonathon Tomlinson is a GP at the Lawson Practice in London and a NIHR In Practice research fellow at the Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry. He has a MA in Human Values and Contemporary Global Ethics and a Post-Graduate certificate in teachers in primary care. He has been teaching medical students in clinical skills, medical ethics and medicine in society since 2003 and writes a blog about the relationships between doctors, patients and society at http://abetternhs.wordpress.com/