From the Editor
What’s the best way of training future doctors?
Medical education has changed much over the years – schools across the country embraced the McMaster model, then cooled to it; efforts have been made to revisit core curriculum topics and add in more timely ones.
In the first selection, the University of Pennsylvania’s Dr. Stanley Goldfarb – a former associate dean of curriculum at the Perelman School of Medicine – bemoans the state of medical education. Controversially, he argues in The Wall Street Journal: “Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.”
Is he right? We discuss the essay and responses to the essay.
In the next selection, we look at a new British Journal of Psychiatry paper. Drawing on a large dataset, the University College London’s Jessica Deighton and her co-authors study the rate of psychiatric problems among youths. “Findings reported here indicate the scale of mental health problems in children across many schools in England is much higher than previous estimates…”
And in the third selection, Dr. Linda Gask, a British psychiatrist, considers autobiographies written by physicians. “These stories can, in turn, inspire, impress, inform, engage, and even shock through the sharing of personal conflict and confessions…”
Selection 1: “Take Two Aspirin and Call Me by My Pronouns”
The Wall Street Journal, 12 September 2019
The American College of Physicians says its mission is to promote the ‘quality and effectiveness of health care,’ but it’s stepped out of its lane recently with sweeping statements on gun control. And that isn’t the only recent foray into politics by medical professionals. During my term as associate dean of curriculum at the University of Pennsylvania’s medical school, I was chastised by a faculty member for not including a program on climate change in the course of study. As the Journal reported last month, such programs are spreading across medical schools nationwide.
Why have medical schools become a target for inculcating social policy when the stated purpose of medical education since Hippocrates has been to develop individuals who know how to cure patients?
So begins an essay by Dr. Goldfarb.
The former associate dean argues that “a new wave of educational specialists is increasingly influencing medical education” and that “they emphasize ‘social justice’ that relates to health care only tangentially.” While he acknowledges that health disparities should be eliminated, he notes: “teaching these issues is coming at the expense of rigorous training in medical science.” He writes: “Theories of learning with virtually no experimental basis for their impact on society and professions now prevail. Students are taught in the tradition of educational theorist Étienne Wenger, who emphasized ‘communal learning’ rather than individual mastery of crucial information.”
The author concludes:
Meanwhile, oncologists, cardiologists, surgeons and other medical specialists are in short supply. The specialists who are produced must master more crucial material even though less and less of their medical-school education is devoted to basic scientific knowledge. If this country needs more gun control and climate change activists, medical schools are not the right place to produce them.
This is a well-written essay (if somewhat light in citations). But is it a persuasive essay?
Certainly it has sparked debate. Dr. Jeffrey Flier, a former Harvard Medical School dean who oversaw a curriculum redesign tweeted: “The Goldfarb op ed is an exaggerated and misleading portrayal of medical education today. As a result, the kernel of truth regarding ‘woke medicine’ and politicization of the educational process will be lost in the process.”
Writing in the Philadelphia Inquirer, University of Pennsylvania’s Carolyn C. Cannuscio, Zachary F. Meisel, and Rachel Feuerstein-Simon note the importance of recognizing the failings of American health care and public health.“Dr. Goldfarb laments that medical education today emphasizes social justice, which he asserts ‘relates to health care only tangentially.’ Tell that to a mother in Flint.” Their piece is also well-written.
Do you have thoughts on this debate? Letters to the Editor are welcome.
Selection 2: “Prevalence of mental health problems in schools: poverty and other risk factors among 28 000 adolescents in England”
Jessica Deighton, Suzet Tanya Lereya, Polly Casey, Praveetha Patalay, Neil Humphrey and Miranda Wolpert
The British Journal of Psychiatry, September 2019
Recognition of the scale of mental health problems in children and young people and the implications that childhood mental health has for mental disorder in adulthood have led to increasing emphasis on prevention and early intervention. There has been a particular focus on schools as a universal access point for mental health support from research and policy alike. A recent green paper from the British government and a set of proposals arising out of it highlights the role of schools in supporting the mental health of children and young people and proposes the introduction of mental health leads in every school, alongside mental health support teams working with schools to offer individual and/or group-based support, as well as making referrals to more specialist services.
Such proposals drew heavily on prevalence data collected over a decade ago suggesting that one in ten young people experience mental health problems. However, one very recent report published after submission of the current paper reports slightly higher rates of one in eight and further studies indicate there may be higher rates in some populations (for example adolescent girls), with a range of groups showing increased odds of experiencing such difficulties (such as children from more deprived backgrounds and those with additional learning needs). The current study draws on a recent, large-scale survey of a community-based sample of adolescents to explore prevalence of mental health problems in schools and characteristics that increase the odds of children and young people experiencing them.
Here’s what they did:
- “Children… in participating schools completed surveys online in a usual school lesson. Survey data were collected using a secure online system as part of a teacher-facilitated session during a usual school day.”
- Children did a Strengths and Difficulties Questionnaire (SDQ), “a 25-item measure comprising four problem scales (emotional symptoms, conduct problems, peer-relationship problems, hyperactivity/inattention problems) and a prosocial behaviour scale.”
Here’s what they found:
- “The full sample for the current analyses was 28 160 out of a possible 30 866 adolescents…”
- “Across the 97 schools, 18.4% scored above the abnormal threshold for emotional symptoms, 18.5% for conduct problems, 25.3% for inattention/hyperactivity and 7.3% for peer-relationship problems; 42.5% scored above threshold for any one of the first three problem scales (emotional symptoms, conduct problems or inattention/hyperactivity).”
They write: “Findings reported here indicate the scale of mental health problems in children across many schools in England is much higher than previous estimates, with around two in five young people scoring above ‘abnormal’ thresholds for three of the four problem areas measured (emotional problems, conduct problems and hyperactivity).”
There is much debate as to whether or not psychiatric problems are rising in the adolescent population. This paper is a nice addition to the literature, in part because of the size of the database.
But caution is in order: the study drew from a dataset that didn’t focus on psychiatric disorders, but psychiatric problems.
Selection 3: “I remember, I remember: the therapeutic power of the medical memoir”
The Lancet Psychiatry, June 2019
According to the acclaimed memoirist Mary Karr, ‘Memoir is like therapy, the difference being that in therapy you pay them’. So why are doctors increasingly writing memoirs? Is there any therapeutic benefit in writing or indeed reading them?
What many medical memoirs have in common, it seems to me (writing as yet another medical memoirist), is how the writer tries to make some coherent sense of the transformative process of medical training on the person. From this develops awareness of the continued struggle to manage the impact of the profession of medicine on one’s own humanity, and it is almost certainly these stories that resonate most powerfully with the reader. This conflict between professional detachment and personal involvement is reflected in the key themes of medical memoirists. A doctor has intimate access to the mind and body of another person but, as a medical student, one can feel like an intrusive observer of another’s distress. Students really begin to learn their skills when they move beyond the laboratory to the bedside, yet they are practising these skills within the substrate of real people’s lives. They have to learn how to balance the need to be emotionally detached doctors capable of making the right judgment in a high-pressure environment, with being empathic and compassionate clinicians able to engage with their patients – perhaps the most fundamental split at the heart of contemporary medicine.
So begin a short paper in The Lancet Psychiatry by Dr. Linda Gask.
She goes on to write:
Medical memoirists use the medium of life-story writing to share publicly the tales of their lives. These stories can, in turn, inspire, impress, inform, engage, and even shock through the sharing of personal conflict and confessions, and finally provide an emotionally satisfying closure through the protagonist’s achievement of a sense of redemption. Perhaps medical memoirs play a part not only in redeeming and healing the writer, helping them to make sense of their experiences, but also in enabling the profession to collectively reflect on matters of identity and maintain its sense of coherence and resilience in difficult times – not only personally, but also professionally, therapeutic.
As medical memoirs grow more popular, Dr. Gask offers nice insights to the genre.
For the record, her memoir has been featured in a past Reading.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.