From the Editor
Should medical education “stay in its lane?”
Two weeks ago, we discussed an essay by the University of Pennsylvania’s Dr. Stanley Goldfarb who warns that: “Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness.”
This week, we feature two letters to the editor responding to this essay, both original content for the Reading of the Week, and both from physicians affiliated with the University of Toronto.
Drawing on the medical literature and her life experience, Dr. Juveria Zaheer wonders what makes a medical expert or a physician scientist. “Being a medical expert or a physician scientist isn’t just about learning about biology – it’s about committing to the creation of a society where every life is worth living.”
Looking at medicine and philosophy, Dr. Suze G. Berkhout questions the basic assumptions of Dr. Goldfarb’s argument. “Goldfarb misrepresents the place of values in shaping scientific and medical knowledge.”
Both letters are thoughtful and worth reading.
Letter to the Editor
Several years ago, I was a third-year psychiatry resident working along side a medical student in the CAMH emergency department. We were discussing a client’s traumatic history of marginalization and oppression and its impact on her experiences of accessing and engaging in mental health care. The medical student acknowledged the challenges and sighed, and said, “This is why I want to do internal medicine. If you come in with an MI (myocardial infarction), you get the same care. It doesn’t matter what colour you are or where you’re from.” He seemed reassured by this idea – that an individual physician could make a difference to an individual patient fairly and irrespective of pesky population-level social determinants of health. It was our responsibility to have the technical knowledge to care for patients, and everything else was secondary.
This view was shared in Dr. Stanley Goldfarb’s Wall Street Journal commentary, “Take Two Aspirin and Call Me by My Pronouns.” In it, he laments the infiltration of “progressive causes” into the medical curriculum, expressing concern that future physicians are receiving an education on topics “tangentially related” to the practice of medicine, at the expense of basic scientific knowledge. After all, who would want an oncologist, cardiologist or surgeon who hasn’t mastered the medical expert role? And wouldn’t a physician scientist focus on building “fundamental knowledge of disease processes?”
What makes a medical expert?
“The zeitgeist of sociology and social work have become the driving force in medical education. The goal of today’s educators is to produce legions of primary care physicians who engage in what is termed ‘population health.’”
Dr. Goldfarb argues that an infiltration of social scientists and focus on population health leads directly to poorly trained specialists who are unable to master the material in their field. It is an oncologist’s responsibility, however, to understand the significant disparities in cancer outcomes across population groups.1 Similarly, cardiologists must grapple with the extensive research that suggests that women and minority groups receive poorer quality of care following myocardial infarctions across multiple domains than men and whites.2 A thorough understanding of social determinants of health isn’t tangential to medical practice, it’s crucial to providing appropriate client care. Through changes in the medical school curriculum over the last ten years, medical students are aware of these issues, and can avoid assumptions like the well-meaning medical student I worked with long ago. A focus solely on the individual application of medicine, as advocated by Dr. Goldfarb, robs physician trainees of the critical context required to make change in inequitable systems, and robs patients of the acknowledgment of these inequalities and the opportunity for improvement.
What makes a physician scientist?
“Medical school should produce physician scientists, not physician social justice activists.”
JAMA’s twitter account had linked to Dr. Goldfarb’s pieces as well as Drs. Cannuscio, Meisel and Feuerstein-Simon’s rebuttal, with a poll asking, “Medical school should produce physician scientists, not physician social justice activists – Agree or Disagree?” Do medical schools have to choose between training physician scientists and physician social justice activists? Do these identities represent polar opposites on the spectrum of physician-hood? The work happening at the University of Toronto Department of Psychiatry indicates otherwise. Here are just a few examples of social justice driving high quality science.
Dr. Vicky Stergiopoulos, Clinician Scientist and Psychiatrist-in-Chief at the Centre for Addiction and Mental Health (CAMH), has a program of research that focuses on interventions to improve housing outcomes, service coordination and social inclusion for adults with serious mental illness.3 Dr. Simone Vigod, Scientist and Psychiatrist-in-Chief at Women’s College Hospital, is an international expert in perinatal mood disorders whose work raises awareness in gaps in access to specialized perinatal mental health care for vulnerable populations.4 Dr. Kenneth Fung, Psychiatrist and Clinical Director of the Asian Initiative in Mental health Program at the Toronto Western Hospital, works to understand the impact of culture on help seeking and aims to break down stigma and barriers in order to improve care.5 Dr. Paul Kurdyak, Director of Health Outcomes and Performance Evaluation at CAMH and Mental Health and Addictions Research Program lead at ICES, provides better understanding of determinants of and barriers to treatment for mental illness in Ontario, and advocates for all Ontarians to receive high quality mental health care, regardless of where they live.6 Dr. Alex Abramovich, Independent Scientist at the Institute for Mental Health Policy Research at CAMH, is committed to ending LGBTQ2S youth homelessness and is a leading advocate for trans-inclusive mental health research and care.7
What makes a physician advocate?
“As Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change…”
The Royal College of Physicians and Surgeons of Canada identifies “health advocate” role in their framework for improving patient care by enhancing physician training. Part of this role includes advocating for treating patients with respect and dignity, rather than making a throw-away joke about their pronouns. As an emergency department psychiatrist and scientist whose program of research focuses on suicide prevention, I know that suicide is a complex outcome with biological, psychological, social and psychological underpinnings. It is my – and our – discipline’s responsibility to understand the ways in which financial stress, inequality, trauma and oppression, cultural background, isolation and lack of access to care intersect to lead to this tragic outcome that affects individuals, families, and communities. Being a medical expert or a physician scientist isn’t just about learning about biology – it’s about committing to the creation of a society where every life is worth living.
I hope, that over time, the medical student I met ten years ago maintained his passion for providing the highest quality, evidence-based care to every person who comes through the hospital doors. I hope, too, that he considers how physicians can best help those who don’t make it through the doors, and understand that pointing out and addressing inequities in care or social determinants of health isn’t a personal indictment of an individual physician but rather a crucial step in ensuring the well being of all Canadians. And I hope he calls people by their preferred pronouns.
Juveria Zaheer, MD, MSc
University of Toronto
- What Are Cancer Disparities? National Cancer Institute. https://www.cancer.gov/about-cancer/understanding/disparities/what-are-cancer-disparities-infographic. Accessed September 30, 2019
- Romero T, Velez P, Glaser D, Romero CX. Do Gender and Race/Ethnicity Influence Acute Myocardial Infarction Quality of Care in a Hospital with a Large Hispanic Patient and Provider Representation? Cardiol Res Pract. 2013; 2013: 975393.
- Stergiopoulos V, Hwang SW, Gozdzik A, et al. Effect of Scattered-Site Housing Using Rent Supplements and Intensive Case Management on Housing Stability Among Homeless Adults With Mental Illness: A Randomized Trial. JAMA.2015; 313(9):905–915.
- Vigod S, Sultana A, Fung K, Hussain-Shamsy N, Dennis CL. A Population-Based Study of Postpartum Mental Health Service Use by Immigrant Women in Ontario, Canada. Can J Psychiatry. 2016 Nov; 61(11):705-713.
- Fung KP, Liu JJW, Sin R, Bender A, Shakya Y, Butt N, Wong JP. Exploring mental illness stigma among Asian men mobilized to become Community Mental Health Ambassadors in Toronto Canada. Ethn Health. 2019 July 24; 1-19. (Epub ahead of print)
- Kurdyak P, Stukel TA, Goldbloom D, Kopp A, Zagorski BM, Mulsant BH. Universal coverage without universal access: a study of psychiatrist supply and practice patterns in Ontario. Open Med. 2014 July 15; 8(3):e87-99.
- Abramovich A, Cleverley K. A Call to Action: The Urgent Need for Trans Inclusive Measures in Mental Health Research. Can J Psychiatry. 2018 Aug; 63(8): 532-537.
Letter to the Editor
Suze G. Berkhout
I was pleased to see that Reading of the Week has chosen to cover the debate sparked by Dr. Stanley Goldfarb’s piece, “Take Two Aspirins and Call Me by My Pronouns.” Your question, asking readers to consider whether the piece is actually persuasive (even if smoothly written), is astute. The rhetoric of medicine is, indeed, one of the central issues here. Dr. Goldfarb laments a shift in medical education that he believes is overly politicized. But in attempting to persuade his reader, Dr. Goldfarb relies on a tacit veneration of the fact/value distinction, and presumes that this distinction is unquestionably persuasive.
The notion that science is value neutral is not uncommon, and is tied to interlocking assumptions about scientific rationality and objectivity. This includes the assumption that rationality and objectivity in science are necessarily disconnected from motivations, ideologies, biases, and social goals.1
Motivations, goals, and ideologies have historically been seen as “contaminants” in the scientific process, antithetical to truth. Rejection of these so-called contaminants have shaped who we view as a scientist, and what they might study. For instance, many of the foundations of empiricism rest on the historic notion that a scientist could only be a gentleman (with specific gender, racial, ability, and class markers). This is intimately linked to concepts of truth and objectivity – only those who were deemed to be without material interests or “biological” impediments to rational capacity were considered able to give a reliable observational account.2,3,4 However, decades of work in the history and philosophy of science, in the sociology of scientific knowledge, and in feminist and critical race theory, have undermined the fact/value distinction within science and medicine. Values suffuse our production of facts at every level – social goals and values shape the entirety of the scientific process, from how research questions are conceptualized and studied, to how research is funded, to how it is published.1,5 What we take as fact is the stabilized end-point of a process of production – a process whereby values and social goals give shape to the steps that make it up.6
So Dr. Goldfarb’s attempt to persuade his reader that “woke” medicine is somehow too politicized, misses the mark – not only because of inaccuracies (housing, gun violence, and water are decidedly health issues) – but also because he fails to appreciate how the generation and application of scientific and medical knowledge is inevitably a social enterprise, embedded in relations of power. Dr. Goldfarb misrepresents the place of values in shaping scientific and medical knowledge. We need to be explicit about what these values are so that we can have informed discussions about how they impact our practices. And as some philosophers of science have noted, a pluralistic approach to the production of scientific knowledge, one that takes into consideration issues of equity and diversity, might actually make for a stronger form of objectivity.7 Ultimately, this would make for better medicine.
Suze G. Berkhout, MD, PhD
University of Toronto
- Solomon M. Social Empiricism. Cambridge: MIT Press; 2007.
- Shapin SA. Social History of Truth: Civility and Science in Seventeenth Century England. Chicago: University of Chicago Press; 1994.
- Latour B. Science in Action. Cambridge: Harvard University Press; 1987.
- Latour B. How to Talk About the Body? The Normative Dimension of Science Studies. Body and Soc. 2004; 10(2/3):205-229.
- Longino H. Science as Social Knowledge: Values and Objectivity in Science. Princeton: Princeton University Press; 1990.
- Latour B. Laboratory Life. Cambridge: Harvard University Press; 1979.
- Harding S. Strong Objectivity: A Response to the New Objectivity Question. Synth. 1995; 104(3):331-349.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.