J. Jerry Rodos, DO, DSc, RN
Midwestern University and Chicago College of Osteopathic Medicine
Presenting the Second Charles E. Odegaard Lecture:
Sixth National Conference on Primary Health Care Access
Hyatt Regency Beaver Creek
April 8, 1995
William H. Burnett (Department of Family Medicine, University of California, Irvine): I am pleased to introduce Doctor Charles Odegaard to introduce the Second Charles E. Odegaard Lecturer. Dr. Odegaard was in the Western part of China at that time of the first lecture in the series, and so was not able to be in Maui to introduce Dr. Emery Wilson, the first Odegaard Lecturer. So it was with profound pleasure that we have him with us to introduce the second lecture in the series.
Dr. Charles Odegaard is the only living member of the Millis Commission – the Commission that brought together so many of the changes in postgraduate medical education in the 1960’s and which has had profound effects in other parts of medical education. Dr. Odegaard has been a former president of and is now an an emeritus professor at the University of Washington. I know we’ll continue to hear more about Dr. Odegaard’s accomplishments over time. At this point I would like to present Dr. Odegaard to introduce Dr. Rodos, the Second Odegaard lecturer.
Introduction of the Odegaard Lecture by Charles E. Odegaard, Ph.D., President Emeritus, University of Washington
Charles E. Odegaard, PhD : Well, ladies and gentlemen it’s a great pleasure for me to have this opportunity to introduce an Odegaard lecturer here in Beaver Creek. I’m particularly pleased to be here at this moment to introduce Dr. Rodos to this audience. Dr. Rodos began his voyage in an interesting way. As a young man, after becoming a registered nurse, he was assigned to watch after a group of Boy Scouts at a summer camp. At the camp an osteopathic physician appeared on the scene who liked his work and talked Dr. Rodos into the idea of becoming a physician. He has obviously served a very great career. It’s a great privilege to me to introduce him for this lecture.
Dr. Rodos had a rich experience in more than one medical school, was a founder of the New England College of Osteopathic Medicine and the Dean of the Chicago College of Osteopathic Medicine. He serves as advisor to the Director of the National Health Service Corps and has been a member of the Corps’ National Advisory Council. I think with his very rich background he’s the ideal person to present this lecture. So it’s with great personal pleasure that I call upon him as the Odegaard speaker.
J. Jerry Rodos, DO, RN (Consultant to NHSC Director, Former Dean, Chicago College of Osteopathic Medicine, Chicago): Thank you Dr. Odegaard. First let me deal with several disclaimers. I don’t know anybody from Utah, except Dr. Marian Bishop (FN-1). She didn’t teach me how to do grant reviews. They kept me on for lots of years. I never learned, and they finally threw me out (laughter). Second, I’m no longer an RN because I could no longer continue to qualify with the continuing education units that they required. It’s been 17 years since they threw me out.
What I’m going to talk about today is focused on education. It was with great difficulty that I didn’t throw the entire talk out after the last several sessions and redo it, as I sometimes want to do, but Dr. Odegaard and the review committee would have been disturbed if I did that.
When we talk about an education, which we’ve done for the last several days, please understand it also applies to what we as a profession have done, or maybe I should say, not done.
There is purpose in establishing a named lectureship. In my view, the creation of such a vehicle is to call attention to someone whose life and work is an inspiration, or who serves as a role model, or whose influence is geometric. Such a person is Dr. Charles Odegaard. It is to our credit that we honor him in life because he truly is all of those things that I have indicated. He has been a dean, a university president, he served at the Josiah Macy, Jr. Foundation as a director of the Minorities in Medicine Program, and he has served as a consultant to the Kaiser Foundation. He has received honorary degrees from numerous universities and colleges in recognition of his achievements.
He was educated at Dartmouth and Harvard, receiving his Ph.D. in 1937. Over the years his counsel has been utilized by the U. S. National Commission of UNESCO and the National Endowment of the Humanities. He chaired the American Council of Education. He served on the Citizen’s Committee on Graduate Medical Education of the American Medical Association, known as the Millis Commission. He has served on the National Commission on Health Manpower and is currently a member of the Institute of Medicine of the National Academies of Science.
As a member of the Millis Commission, Dr. Odegaard and his colleagues introduced the term primary care to the United States, a term which saw its introduction in British literature in 1937 in Lancet. The Millis Commission gave it rebirth and definition. He was president of the University of Washington at the time the WAMI Consortium came into being. It was his support and his reputation for academic accomplishments that helped the WAMI proposal achieve the credibility which assured universal support. In 1986, the Kaiser Foundation published his book “Dear Doctors: A Personal Letter to Physicians”. And in 1992 he presented to this group the second Gayle Stephens Peer Reviewed Lecture. It is an honor for me to present the second Charles Odegaard lecture and an even greater honor to have Dr. Odegaard present and to introduce the lecture.
Before I launch into a review of twentieth century medical education, I’d like to offer you a short parable.
Imagine that the year is 2200. The story might have been uncovered in an archological dig in the Tomb of King Campbell, once king of Quasi-Experimentation. [I didn’t know there were any citizens still alive. (Laughter)] One year during the king’s reign, he climbed to the top of the highest mountain in his land, as often as he did, to observe his people. When he looked out upon the land, he was not happy with what he saw. He noted in one corner of his kingdom there were many physicians who were not caring for patients as he wanted them to do. And in another corner of his kingdom, there were many of his people who were not able to access the care. This troubled him greatly. So he went into The Temple of Medical Education of his land.
“Tell me what to do”, he said to the wise men of Academic Medicine. “The physicians of the kingdom are not caring for my people as they should”. “Your physicians do not know enough,” said the wise men of Academic Medicine. “Our medical school will give them the vast amounts of knowledge about diseases and their cures, which we have recently discovered through scientific research”.
The king was very grateful for this advice and returned to his kingdom and arranged for his students to spend more time listening to the wise men at the medical school before they graduated. After a period of years, the King went to the top of his high mountain again. And there he looked out over his land expecting to be pleased with what he saw. But he was gravely disappointed. The way the physicians were caring for the people had not changed. He searched his mind about what to do next. And the name of an obscure prophet came into his consciousness. Call the Prophet “Pedagogy”.
Now Prophet Pedagogy lived at the bottom of Buffalo Hill in a far off place. [Some of you will remember it.] Desperate, the king went to Prophet Pedagogy and he said to him: “The physicians of my kingdom do not care for my people. They do not improve the health of my people – in fact, sometimes my people cannot get care. They only seem to care for diseases in people. I asked for help from the wise men at the Medical School Temple. They taught my physicians more knowledge, but their work does not change. Can you help me? ”
“Yes,” said Prophet Pedagogy, “I can help you. Go back to your Kingdom and do these things: Concentrate not on the knowledge that the physicians may need, but on their attitudes and their beliefs. Be sure to define these attitudes and beliefs in precise behavioral terms and carefully measure and evaluate and document how much of each of these traits your medical school graduates possess. For above all, you must cherish the holy scientific method without fail.”
The king went back to his wise men. The wise men of the Temple of Academic Medicine were reluctant to follow the advice of the prophet. Things like attitudes, values and believes seemed extraordinarily vague – even soft, some said. But when the wise men discovered that the Prophet Pedagogy was of the same religion – the religion of the holy scientific method – they followed his advice. They even came up with a name. “If cognitive is everything we teach,” they said, “then everything else hereafter will be called ‘non-cognitive'”. Pleased with themselves, they even specified defined variables, and created instruments to measure the non-cognitive, as only the followers of the religion of holy scientific method could do.
A decade passed. The king climbed once more to the zenith of the highest mountain. He was old now. The journey was difficult. Yet, he was spurred on by his expectations that when he reached the top he would look at the glorious fruits of his labor. But the king looked over his sick kingdom and he could scarcely believe what he saw. Temples had been constructed everywhere. There was the Temple of the Affective Domain. There was the Temple of Criterion Reference and there was the Temple of Quantitative Measures. Even more astounding running from one temple to another, were people he had not seen before. Some were physicians turned pedagogists. Some were pedagogists turned medical pedagogists. They all carried a black bag of schools, one from each Temple: the Temple of the Affective Domain, the Temple of Criterion Reference and the Temple of Quantitative Measures.
They wore the mantle of arrogance once worn only by the wise men of the Temple of Academic Medicine that the King had consulted so many years before. But most discouraging of all, while some physicians seemed to have changed as a result of the educational programs, most seemed to be practicing their art just as he had observed the first time he climbed the mountain. Completely spent, the king trudged down the mountain never to be seen again.
Now all parables have moral messages. This has several, but I should like at the moment to develop one central message, which is that academic medicine as entrusted by society has a responsibility to undertake several important social missions towards improving the health of the public, including education, patient care and research. This trust is given implicit authority by generous public funding and by considerable autonomy, and in general, by the respected position that academic medicine been allowed to occupy.
Medical academia can take pride in its successes, manifested by a premier scientific establishment, development in the use of sophisticated medical technologies and drugs, and recent dramatic decline in death rates from some specific diseases. Academic medicine, however, has been relatively unresponsive to a number of vexing public problems, including skyrocketing expenditures for medical care, substandard indices of population health, an uneven quality of care, unfavorable geographic and specialty distribution in the matrix of physicians, and widespread disability from long-term, chronic care problems and psychiatric disorders.
There are many reasons why academic medicine has chosen to define its task narrowly, including the intractability of some of these social problems and the attractiveness of the biomedical model. The central issue is how well academic medicine will fulfill this responsibility to the public in the future.
To the degree that academic medicine continues with its narrow definition of mission, it violates its implicit social contract and further jeopardizes its primary source of support. And in this way, Dr. Odegaard left us a very subtle, quiet message yesterday. He reminded us that, in fact, we have been well-supported. We have been autonomous. What we have not done is to regulate ourselves – either as medical educational institutions or as medical services institutions. So those of us who are at this stage of our lives have passed the baton, if you will, to the younger generation, we, in fact, have not created a past upon which you should solely build the prologue of the future.
We have, in fact, not defined our tasks, not met our contract with society. And it was interesting for me to hear in the last hour that we look to the government to regulate ourselves when we have been given for the last seventy years the opportunity to regulate ourselves.
There is an alternative. In recognition of its public trust, academic medicine can choose to expand its current activities to being more responsible and more responsive to the health concerns to the general population. And I’m going to focus narrowly on medical education.
One could take a broader perspective, but the focus of the Odegaard lecture is medical education. And so I propose to examine factors in Twentieth Century medical education which may be responsible for some of the most persistent and significant failures in our contract with society. Three fundamental factors and their influence on the education of physicians are offered with a hypothesis, followed by suggestions of addressing those factors and their consequences.
It is the hypothesis that until three fundamental factors are addressed, the basic failures of twentieth century medicine will exist despite all symptomatic treatment. Indeed, as has been pointed out in a number of critiques, the same failures have already persisted for over half a century, having been described in a study published in 1932, by W.C. Rappleye. (Those of you who have not read that study, I suggest that you find a copy. It is in the Journal of Medical Education and is the final report of the Commission on Medical Education of 1932.)
Unfortunately, the factors (as far as I have been able to determine) have either been unrecognized or they have been accepted as “givens”, intrinsic to medicine and as immutable as the law of physics. The fact is, however, that they are only time-honored concepts and practices that have remained unquestioned. The following are my perceptions of each and the ways that they contribute to basic and persistent deficits in the education of physicians, deficits which grow even larger in the face of advancing knowledge and technology, and, to use Derek Bok’s phrase “the metamorphosis of health care system and its attendant policy problems”.
Factor one: the structural framework of the curriculum.
In his critique, Derek Bok, President of Harvard University, stated that “the Flexnerian form of medical education has remained essentially unchanged for 70 years”. Well, it is now 80 years and I believe that the fixity and archaism of curriculum structure are directly traceable to factor one. It seems self evident that a primary consideration in designing an educational program should be the subject of the curriculum. Presumably, the central subject of the medical curriculum is man, his frailties, and what to do about them.
Unfortunately, the form and, to a large degree, the content of the typical medical curriculum is determined more by the contrived nature of the institution than by the inherent nature of man and the nature and origin of his illnesses. It seems preposterous that the education of physicians should be so much shaped by institutional departments serving disciplines that have evolved around research strategies, technologies, components of the body or disease categories in serving administrative purposes, and shaped so little by the way physicians should practice or by the objects of their practice.
Because there is no “whole-patient” department, medical education suffers because of the “missing person syndrome”. Manifested by the symptoms addressed by both the GPEP report and that by President Bok and a number of other reports, man must become the concern of every department and the unified theme of the curriculum as a whole.
Factor two: The Reification of Disease.
The language used in talking about disease eloquently bespeaks the unspoken premises and concepts that we have about disease. One speaks of them as though they were sort of autonomous entities, predatory in nature, always waiting the opportunity to attack. For example, we speak of the natural history of this or that disease as though it was a free living organism and argue whether this or that combination of signs or symptoms represents a “real entity”. One speaks of wars against disease. One speaks of fighting disease and an increasing resistance to disease as though it was indeed an adversary, threatening from without. One hears and reads various versions of the pious platitude that the physician must treat the patient as well as the disease, as though it were possible to treat the disease except through the patient.
But, however we think and talk about diseases, the fact is that nobody has ever seen a disease. All that is evident are persons who are sick in various forms in more or less patterned ways. The unfortunate consequence of the focus on disease, their natural history, causes and cures, is inevitably a de-emphasis of the person who is said to have the disease. Persons who share the same or similar patterns are filed into the same category. Are implicitly victims of the same causes and candidates for the same cures. Their differences as human beings become irrelevant, or, at best, of secondary interest.
The concept of disease as entities contributes to the continued survival of another archaic concept. Despite the verbal disavows, and the allusions to the multi-factorial models, much of the teaching and research in medicine seems predicated on the notion that every disease is traceable to a cause and there is or will be a cure for each once the cause is identified.
Neglected are the human factors that permit the causes to become causes and the cures to be cures. That is, the participation of the patient in the pathogenesis and in the recovery. Overlooked are the inherent healing mechanisms and the fact that it is the patient who gets well and not the doctor nor the medicine that makes him well. The cure comes, if it comes at all, from within.
One of the most unfortunate consequences of preoccupation with diseases as the main business of medicine, is that it blinds us, as physicians, to our responsibility in the maintenance and enhancement of health. People are seen as being in one or the other of only two possible states. They are either sick or they are well, and only those who are sick with presumably nameable diseases are eligible for medical attention.
Failing to see and to be taught that illness and health are not distinct unrelated phenomena, but part of an unbroken continuum extending from high-level health through lower levels of vigor, to minor departures from health through various degrees of illness, to life-threatening and terminal illness. We, the medical profession, have virtually abdicated responsibility for the promotion of health as the most comprehensive and effective form of preventive medicine – perhaps our highest responsibility.
Factor three: The Parts explain the Whole or the Whole is the Sum of the Parts.
Another underlying and unquestioned theme guiding medical education in this century, and a prevailing theme in biomedical research is the best way – indeed the only way – to understand man and his frailties is to take him apart and to reduce him to his irreducible components. When we have identified each part and shown how it operates, and shown how it may go wrong, then you may understand man, how he goes wrong and how to set him right again.
Thus, we seek to find out and teach how a warped molecule may produce a warped mind; how the altered permeability of a membrane, and inhibition of an enzyme, the change in a transmitter or receptor at a neuro-effector junction may lead to the impairment of this or that organ or function and thus to the illness of the person. And knowing this, what to do to that part to cure the disease and restore the health of the person.
This – the so-called reductionist approach which dominates medical research – has, of course, been enormously productive and the source of many of our greatest medical advances. It is at the heart of the scientific method of modern medicine education. There is no denying its importance, or its essentiality to continued medical or scientific progress, or that the quality of the parts and of their operation profoundly influences the health, well-being or clinical course of the individual.
This, however, is only a part of the picture. What is missing is the recognition that the person provides the context. The environment in which the parts operate, and how the person lives, thinks and behaves, influences how the parts operate. This is the basis for the importance of “lifestyle” as the major health determining and disease preventing factor.
To draw a simple analogy: if one wishes to understand water, it is undeniably important to know that is composed of hydrogen and oxygen in a certain relationship. However, even the minute study of hydrogen and oxygen and of their bonds would not have yielded the properties of water – the three states, boiling and freezing points, the surface tension and viscosity, or the fact that the specific gravity of the solid state is less than that of the liquid state. In fact, if one wishes to understand water, one must study water. As Alexander Pope said: “The proper study of mankind is man.” The proper study of human health and disease is also man. He is the missing person.
The effects of the three factors – the missing person, the reification of disease and reductionism – have kept the structure and methods of medical education fixed for many decades and its content neglectful of discipline and perspectives vital to medical practice. This is not to deny that there are other contributory factors, such as those identified in the many critiques that I have mentioned. Critiques of medical education, critiques of medical delivery, the continued emphasis on memorization and on lectures (passive learning), rather than on principles and concepts, problem-solving and self-directed learning which formulates active learning. It appears unlikely that these will yield to correction until it least factor one above is engaged.
I had planned to bring this morning what most of you have seen is a little PDR pocket size source for a major text that weigh 7.6 ounces. And despite its readability, its relative inexpensiveness and its containing what most of us would agree are the major medical texts of our time, my institution (certainly not yours!) continues to make the students memorize drugs by classes, hundreds at a time, as if there were some purposeful meaning to this exercise. To still remember which protozoa have five flagella on one side and two on the other side. As if they couldn’t flip open a little Harrison Book and discover it.
For some time, I thought about creating a fourth factor. Several physicians at the twilight of their career made the mistake of returning to be medical students. It’s interesting that the two of the most outspoken were pediatricians who were quick to draw to our attention that, in their opinion, the atmosphere, environment, and the manner in which many of us treat medical students would meet the clinical definition of child abuse. (Laughter)
I would like us to take those observations seriously. While this atmosphere evolved slowly after the Flexnerian era, it intensified in the post-Second World War decades. Though many researchers have looked at this issue, it is not easy to evaluate the impact of this environment on young physician, his attitudes or his values, his original sense of service or sacrifice, or his core motivations.
We have studied the attainments of graduates who have gone through some new pathways that we have developed to try to change the old curriculum. However, what we have measured have not been these factors of attitudes and values and motivations.
What we measured were performance on boards, acceptance into residencies, evaluations by faculty – measures which of themselves may be unimportant. I believe we have not looked at the significant factor that these new designs may have in fact have significantly left unaltered, which is in fact the motivation by which most students apply – what they envision themselves doing in the care of the general public.
So, I offer these three factors, with perhaps the fourth, as the major contributors to the problems in medical education that have been so well identified, perhaps with some different views, in various reports. Reviewing these reports is therefore unnecessary and beyond the purpose of this discourse with you, which is to offer, perhaps, some causative factors and a hypothesis to be explored and tested.
According to these critiques, what is needed and what is not sufficiently in progress is a reduced emphasis on the amassing of mere scientific information and greater emphasis on concepts, principles, and especially, on the acquisition of knowledge, skills, attitudes, values and personal attributes.
These attributes enable physicians to want to deal effectively with people, their diversities, idiosyncrasies and frailties as well as their complaints and disease:
First, to view each disease as a product of constellations of multiple factors in an individual’s life rather than merely (to use Bok’s phrase) “a scientific phenomenon consisting of deviations from a biomedical norm, and resulting from a determining cause or set of causes that are somatic or biochemical”.
Second, to communicate well and to listen sensitively and discerningly.
Third, to be aware of and sensitive to the psychological, socioeconomic and ethno-cultural influences on health and disease.
Fourth, to deal with the emerging ethical dilemmas of medical practice. We have heard several times during the past few days about the fact that the managed cost programs are not happy with graduates of our schools because we have not trained them to do what it is that they need to do. I have a concern that we seem so eager, in fact, to produce physicians to do what it is they want them to do. Because it is an ethical dilemma when decisions about health care are made in the board room and not in the examining room.
Fifth, to emphasize the promotion of health and the prevention of illness, no less than the treatment.
Sixth, to motivate patients to adopt more healthful lifestyles.
Seventh, to be aware of the influence of their own behavior as distinct from their advice and treatment on the clinical outcome.
Eighth, to use their behavior therapeutically.
Quite obviously, abilities such as these have much of their basis in the humanities. While transcending science and technology, they incorporate science and technology into the form in which they can be most effectively applied and practiced.
Perhaps it should be said at once that we will never create a medical superman, who will be proof against all frailties, who can take full responsibility for all aspects of his patients’ lives, and who can understand all the forces that impact and inform all the individuals who come to him for help. Indeed, trying too hard to be perfect can lead to illness in the physician himself – another disturbing trend. We must acknowledge that the physician, no matter how well prepared, will have limitations. But this is another way of saying that medicine is an art. In fact, in some views, the highest of the art forms.
I propose, therefore, that man, his frailties, and the sources of his vulnerability become the underlying theme of the medical curriculum. It is no longer sufficient for us to lament that our students come to us well primed in the sciences but quite innocent in the humanities and their relevance to the practice of medicine. (Ironically, it is to be noted, as I have noted before you many times, that despite our lamentations, grade point average and MCAT scores continue to be the dominant selection process.)
It is proposed that medical schools assume the responsibility for instruction in the humanities and that it be done in a clinical context – that the Department of Humanities, if one is created, become a clinical department. What a wonderful way, by the way, to teach history taking, to teach a whole other group of activities as some of us have had the opportunity to do in our medical curriculums.
To set the tone for the rest of the curriculum, it would seem relevant to begin with the study of intact man and human life before he is taken apart and his component parts scattered among the disciplines for minute study. This would establish human organisms and human lives and human values as the context in which the components function and in which the components collectively make possible. Is it not ironic from this viewpoint that a profession dedicated to the enhancement to the quality of life should begin training with the inert pickled remains of life and that the training should be regarded as well begun when those remnants have been reduced to disposable rubble?
Most of our knowledge about man’s component parts and processes at levels extending from molecule to the organ system has come from the study of lower animals and mammals in particular. At these levels, human organisms differ hardly at all from other mammals. Nevertheless, man is a totally different organism, living a totally different life, in man-made and man-transformed environments, with hand-me-down biological machinery that evolved under circumstances vastly different from those of human life.
Wherein are the differences, and how do they influence the working of the machinery? Conversely, how does the machinery contribute to the unique features of human life, with what new problems? What demands unique to homo sapiens are placed into the bodily components? That is, how differently are they used and abused in human life that they may contribute to human vulnerability?
Questions such as these will provide a suitable matrix in which to shape the study of life structure and process and their breakdown and aberration.
No less relevant in the unique features to the human species and human life and perhaps more crucial to understanding human diseases and their origins, is the diversity of mankind – the infinite variety of ways to be human and of being normal. Not only do we begin life with diverse endowments, but in what ways and to what extent does our curriculum vitae thereafter determine how well the inherited machinery works? What parts are likely to become impaired and in what ways?
That is, how do these differences determine the individual physiological path that each person follows: the level of health, vulnerability in general, and susceptibilities in particular, the length and quality of our lives, and the causes of our deaths? How does one’s culture, beliefs, and expectations about health, disease, medicine and doctors influence one’s level of health, susceptibility to illness and response to medical treatment, ethnic group, socioeconomic circumstances, societal role?
These are among the kinds of questions that should be in the students’ minds as they pursue the study of medicine.
Questions in the preceding sections illustrate the kinds of biologic, biographical, behavioral, environmental, ethno-cultural, and socioeconomic issues and factors in health and disease that need to be explored, along with the somatic and biochemical causes of deviation from biomedical norms.
I have no illusions that medical curricula will be reconstructed around the human core. I do believe, however, that early introduction of students to the humanistic aspects of medicine will help them to put the scientific aspects in proper perspectives and that the new kinds of questions that they ask will, over a period of time, help their teachers do the same.
It seems likely that interdisciplinary teaching – already in place in many medical schools – will emerge as the best way to implement the human-centered curriculum. Such change seems to be required, not only by the complexity of the subject – men and women, their frailties and what to do about them – but also by the student’s needs to acquire the knowledge and skills in the form in which they would be utilized and practiced. After all, caring for a patient, the physician does not call the role of the disciplines, saying “First I will examine the anatomy, then the biochemistry, then the physiology, etc.”
By the time post-graduate training is complete, the physician has forgotten the diciplinary departments from which this or that bit of knowledge was drawn and incorporated into his own expanding and deepening reservoir. Certainly, the partition of basic knowledge into the scientific disciplines is much less relevant to practice than to research and, after all, the overall majority of us are being trained for practice.
It is probable that at least the early stages in the humanization of the medical curriculum may be accomplished without basic reorganization of the medical school. It may even be desirable for the immediate future to retain departmentalization according to research discipline and clinical specialty. It seems likely, however, that the development of interdisciplinary man-centered programs should in time cause some blurring of interdepartmental barriers.
Almost certainly, the evolving curriculum itself will suggest the appropriate organizational adaptations from time to time. And in this context, institutional structure does not seem to be a fundamental issue as long as it does not intrude on curricular design and as long as that design is based on the given nature of man rather than the artificial nature of the institution.
In conclusion, it may be of some value to question how the human-centered curriculum will affect the teaching of the medical sciences. It will no longer be enough, for example, for the physiology department to deliver the best possible course in physiology. Instead, it becomes necessary to ask “What is the best role for physiologists in the education of physicians for the twenty-first century”?
Perhaps the basic science department, more than the clinical department, will find the greatest difficulty in dealing with the enormous diversity of largely uncontrolled human variables that influence the biologic process. The physiologist, whom I have been picking on for my example, is being asked to cross the large gap between the realm of the scientist, whose quest is for universal laws, and the realm of the clinician, who, with each patient, deals always with the absolutely unique, that is still in accord with those universal laws.
It is undeniably important for the doctor to know in great scientific detail about the heart, the adrenals, the stomach, etc. But is equally important for teacher and student to keep in mind that these are abstractions – even Platonic ideals that really do not exist in nature but only in the minds of men and women.
For there are only hearts, adrenals, stomachs, etc., all observing universal laws, yet each differing in some way from all others, according to the person whose body it functions and has functioned, and according to the life that that person has lived and the environments of that life.
Understanding these differences is what prepares the student to understand why some hearts or other organs become impaired in different ways at different ages, while others go on functioning for a century or more. What is required, then, in designing the humanistic medical curriculum is the multidisciplinary reconcilement of the unique and the universal.
Several years ago when I was still in New England, I found in marble, an inscription in the wall of an old state hospital, in Tewkesbury, Massachusetts (for some of you who know New England). It inscribed a quote from its superintendent who was there for some years by the name of Bradford. It did not even distinguish him with a first name or any years, but I love the quote and I would like to share it with you as I close:
“The doctor should be broadly human. He must deal with the vagaries of age and the fancies of youth, the sports of boys, and the appetites of men. In his profession he tests the aviator, he rations the soldier, estimates the endurance of the laborer and cares for the worried mother and relieves the desperate financier.
His thought must reach to the ideals of the clergyman and interpret the flesh-prompted dreams of the man of the world. And in his service, neither the precision of science nor the efficiency of business methods will suffice. For above all else the practitioner must preserve and exercise the kindly indulgence of a considerate friend. In what academy can these lessons be taught”?
Burnett: We have some time for comments. The moderator for this session is to be the distinguished chair of family medicine at the University of California, San Francisco, a member of the Coastal Research Group Executive Board, which helps bring you this conference, Dr. Jack Rodnick.
Rodnick: I think we are all touched by a very wise address. What we want to do is to have a chance in the next ten or fifteen minutes to discuss some of the aspects of general medical education as well as some specific comments or questions of Dr. Rodos.
I, myself would like to make you a couple of comments at least. As I reflect upon the medical school where I teach, I think many people share the same values that you do. But we have found it particularly difficult over the years to find the right kinds of courses that the students really appreciate and that have captured the students’ minds.
Yet they say, if the course doesn’t have a test, if the students are not going to be graded on it, if it does not cover information which will be asked on the board exams, then it doesn’t really integrate into the rest of the curriculum. What are some of the specific ways that you have encouraged this humanistic aspect of medicine? Have you approached it through separate courses or do you try to integrate into every course?
Rodos: A consultant, of course, is somebody who is at least 500 miles away from home and has a briefcase and slides. For me to tell you that it is easy to change an established curriculum in an established medical school, would have to be the best after breakfast joke you have heard in a long time.
You know, we get a degree of arteriosclerosis and degenerative arthritis, so the time in a medical school curriculum which each discipline demands, far exceeds the number of hours available. Change in an old school is difficult.
In a new school, let me tell you, it is fun. I have had that opportunity in my career for a number of years, to develop a curriculum around a Department of Humanities as a clinical department, given the responsibility to teach history taking. The idea is not unique to me. A number of articles in the medical literature tell how to do that and describe its impact on students.
The second, is some of which you have already discussed, that the curriculum in effect determines what the student needs to do, and that is what you are asking. The answer has two parts. One part is the exposure to the entire panorama of human experience. In New England when I had the opportunity to start with year one, and beginning with year one, students were out with the community.
They were with physicians in the community, with public nurses in the community, with ambulance runs. The focus was not on medicine, but on seeing why these services were used by what people and how. And what services were used? Who came to the emergency room every second night the one month you were there? Who was on the ambulance calls night after night after night? And the role of faculty at that school was to translate those experiences into some principles and issues, not about how to take a blood pressure.
When you move into a position with the charge, presumably, to change a school?s curriculum, the positive involvement of the faculty is critical. When you take on that charge at an established institution, it really is tough, and I cannot tell you that I succeeded at all in my second assignment (at Chicago College of Osteopathic Medicine) with the same aplomb that I did in my first (the New England College of Osteopathic Medicine).
In fact, if I had to grade myself, it would be a C-. Because you need to change the way the faculty does things and faculty do not like to change. You and I might prefer to lecture because we are comfortable lecturing. We may not like to do small groups, because we have never done small groups. We do not like interactive sessions because we have never been part of any. The idea of retooling the faculty is very frightening to most of them. You need to do it in a way that is not threatening.
But you raised the issue of the students. That is a major issue. Students come to us having been prepared to say what we expect them to say. My friend, a psychology professor, used to say that if we required students to learn to play the Tchaikovsky Second Concerto before they graduated, they would all learn it, because that is what we expected them to do. We tell them that we want them to say this or do that and they do it.
And they worry about board examinations because we create the image of their needing to pass them. Yet the boards are really a bogus thing. Let me ask you a question. In this room are hundreds of years of academic experience. Has any of you ever had a student who eventually did not pass the boards? Look around the room. I bet that we cannot conjure up five among us. I have one. Marian probably has one.
Some of the rest of you may know one. Do you know how many students we have touched over the years? I say to the students in orientation, “I want you to look around, ten percent of the faculty are dumber than you are”. (Laughter) “Please keep that in mind. They passed their boards, got residencies, and got certified. Ten percent at the minimum are dumber than you are. Your job is to find out which ten percent. (laughter) When you have the list, please come see me. If you win, I’ll take you to dinner”.
Now, I’m half joking, but only half joking. Who creates this myth? Who establishes it? We do. Who creates the need in our institutions for memorizing where the five flagella are in protozoa? Okay, it’s a task, it’s a challenge. And the reason I chose to address it in this lecture is because I believe it affects how we practice. I believe it affects how we take responsibility for the professions and for the delivery of health care. I believe that it is, in fact, the essential part of our contract with society. I need to expand on one part of the lecture, which I don?t believe I did well.
We have been left unregulated as a profession for many decades. We have not guarded that responsibility well – I am criticizing me just as well as calling it to your attention – not just in education, but in service. How are we doing so well with less hospitalization now than before? Because we didn’t make any efforts to find out what needed to be done. Why are we now doing health manpower studies?
Why is it that we don’t know what it costs to educate a student or to educate a resident? Is there anyone else that you would allow to have run through so much public money in this period of time without any accountability or understanding? That is something to think about. What poor Congressman Rostenkowski did is peanuts, compared to what we’ve done. He gave away some chairs and ashtrays and hired his son-in-law.
Rodnick: I would appreciate it if people would comment, or you might want to share some of the ways that you have worked with students or residents in helping to teach some of these values.
Mary Ellen Bradshaw, Washington, D.C.: I thank you for an extremely inspiring lecture. I think you have spoken to the soul and conscience of the medical profession, which some of us have always considered a vocation. And I think we have lost that over the years.
There are two points that I wanted to make. It has come to my attention that in many of our medical schools, our students do not take the traditional Hippocratic oath, or other similar oath, which is essentially a commitment to the basic principles of the medical profession. I think we need to restore that in our institutions.
My other thought is that we might make some difference if we changed the requirements for premedical studies for students who are entering our medical schools. Instead of a heavily science-weighted curriculum, we should stress far more the humanities and the understanding of mankind. And that should be the focus of the MCATs. People will study whatever it is takes to get into medical school. Thank you.
Rodos: The most critical department in the medical schools is the Committee on Admissions. But many of you have served on the admissions committee. Yet, even though we all agree that the humanities are important, what is the first thing we look at in a medical school application? The MCAT scores! Now there is a reason for that, and the reason is growing, but our behavior has not changed. There are some advantages to being old, otherwise it is highly overrated. For those of you who are not there, let me tell you that in advance. (laughter)
One of them is that you can remember how this started. Clinical schools used to take risks. Medical schools stopped taking risks during the days of the early capitation grants. Some of you will remember that the capitation grants included bonuses for reduction in the failure rates, which used to run in this country as high as eight to ten percent a year.
When the government gave bonuses for you to reduce your attrition rate, there was no reason for taking a chance. In fact, there was a financial penalty for taking a chance. The student who came to you with a major in the humanities or medieval history was a risk and the risk had value – money value. If the student failed, we didn?t get his capitation payment anymore.
We don’t get evaluated for our residual rate any more. There still is an economic incentive for keeping attrition low. An empty position in a medical school results, in fact, in a loss of tuition. So I don’t want to minimize that. But I want you to know the historical reasons for why we changed our approach to admissions. And most interesting, once the capitation payments were eliminated, we continued to behave the same way as when they existed.
We still look at MCATs. The secretaries of my institution are still the ones who decide that if the MCATs aren’t right at the set number, swish – the application is rejected. We have a terrible dilemma. We have lots of people who want to be physicians. You get three, six, eight, nine applications per position, so you are making up reasons to turn down students. And everyone of you who have to sit on admissions committee have done this.
Lorena Chicoye, MD, Medical College of Wisconsin: I presently sit on the admissions committee where we just got 7500 applications for 200 positions and so, you are right. As soon as they don’t meet that bottom criteria for MCATs, they are rejected. To mitigate this, we even made up a little formula for our students where we don’t count the first year of their undergraduate work because we knew that they had partied that year, and we count the third and fourth year higher. It really is bizarre!
However, I want to comment on two points. First of all, I have been involved in a “fight to the finish” with other members of our admissions committee – in particular with the basic science people. Myself and another physician had argued that physics was really a rather useless requirement for medical school.
The basic scientists jumped up and down and screamed and hollered that you must have physics to be an orthopedic surgeon. But I guess that they had forgotten that the physician who was fighting with me was an orthopedic surgeon from the community, who basically told them that that was a bunch of crap and that they didn’t know what it was like to be an orthopedic surgeon.
This brings me to the point that we need to be a part of the basic science curriculum in a contributory manner and in a very forceful manner. What basic scientists are teaching, they fail to understand, is not necessarily what we need to know. Our fight was to put communication into the curriculum prior to them coming into medical school and then find a way to kind of weasel it in through the medical school curriculum. That was number one.
Number two is that I got jumped on rather heavily by the basic science people for using a Michael Jackson video tape that did for a study with my psych class. And honest to God, I had three basic science professors come in and scream at me, how dare I use this Michael Jackson television tape for exhibiting potential psychiatric problems (laughter). And they were really very angry and upset about the fact that I was doing this. So I think we really need to infiltrate more of those first and second basic science years.
David N. Sundwall, Washington, D.C.: One quick comment, Jerry. Thanks for that lecture, it was terrific and reminds me that one of the more memorable lectures that I have heard at these meetings is the one that you gave in Williamsburg in 1992 on what it is really like in trying to run a school. I just want to put in a word for all of those good teachers that I had over the years that were humane and sensitive and were terrific role models for me.
I know it is tempting to demonize academics and some of those awful scientists, but you know some of the best teachers I have had were specialists. One comes to mind, I would just like to kind of immortalize, Ted Badger in Boston, who was an internist who was a pulmonary specialist who taught me how to be what you call a considerate friend.
For balance, I want us all to comb through our memory and remember that in our institutions that there are terrific people in every specialty. A lot of them are family doctors, but I have a feeling that people bring to medical school their values. I am not sure we can teach humanism as we can embellish or complement those who have had it all along and there are some people who no matter how much negative experience they have in school, they maintain it and it comes across in how they take care of patients.
Rodos: A couple of comments. That is why admissions committees are so important. That is why clinicians should dominate admissions committees. And you need to look at, if you want to produce generalists, that the GPA has to be 3.5 to 3.7. Because if you get higher than that you tend to produce focused specialists. The data are out there, we don’t need to reinvent it.
Thomas C. Brown, Ph.D., Pacific Hospital, Long Beach: I am sort of reminded real quickly of the elementary school system where kids in the kindergarten come in very enthusiastic about education, wanting to learn and very open-minded. And by the first grade, you know something like 75 percent of them have been turned off to learning. I often see, I think that, the Gray studies out of Utah shows that happens in medical education and I wondered if we need to look at those kinds of things.
Rodos: I think we need to look at all of them.
Rodnick: Dr. Odegaard, Dr. Rodos, thank you very, very much.
(FN 1) Throughout the conference, various speakers had made reference to to times they had lived, worked or visited the neighboring state of Utah. F. Marian Bishop, Ph.D., MSPH, the Emeritus Chair of Family and Preventive Medicine at the University of Utah was a colleague of Dr. Rodos’ on the National Health Service Corps National Advisory Council.
Last Updated (31 March 2006 12:39)
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