The physicians of tomorrow will have to know more about economics, empathy, and their own limitations. - or else they won't survive medical practice in the next ...
Can physicians cope with recession medicine? EVELYNE MICHAELS
The physicians of tomorrow will have to know more about economics, empathy, and their own limitations - or else they won't survive medical practice in the next decade. That was the message as the Association of Canadian Medical Colleges and its counterpart Association of Canadian Teaching Hospitals held their annual meetings in Toronto recently. The theme that emanated from 3 days of panel discussions and workshops was clear: Canadian hospitals are in a state of extremis due to financial cutbacks. And while the institutions themselves are adapting, albeit painfully, doctors themselves are not coping well with some of the pressures of recession medicine. Physicians are ill-equipped to deal with today's economic complexities, the conference was told. Medical schools will have to respond to this deficiency and start teaching courses in financial management along with basic anatomy. The Canadian Medical Association itself recently recommended that more administrative content be included in undergraduate and postgraduate curriculum, and that solid management courses should be available to practising doctors. Joe Chouinard, the CMA's coordinator for medical education, says the medical schools are obliged to get involved: "They claim to have a social contract to educate according to social needs", he says. "If there has been waste and mismanagement in our hospitals.., physicians may have contributed as much to that as administrators." Dr. William Easton, past president of the Canadian Association of Evelyne Michacis, a freelance writer living in Toronto, is a CMAJ regular contributor.
Medical educators are beginning to realize that medicine is not 1 job but 100 jobs, many of which have little to do with surgical technique or bedside manner. Internes and Residents, told the conference that he sees other serious gaps in current medical training where, he says, "the hurdle concept prevails". "Knowing is more important than learning, winning is more important than enjoying, survival is more important than personal and intellectual growth", says Dr. Easton. "There tends to be a sameness about the
bright, highly motivated, obsessivecompulsive overachievers selected on the basis of grade-point average alone. Certainly medical schools have an obligation to choose the best and the brightest and then ground them in the basics of medical knowledge. But Dr. Easton expresses fear that "the underlying tone of the process is wrong.., somehow anti-human, anti-academic and certainly antiteamwork". Medical educators are beginning to realize that medicine is not 1 job but 100 jobs, and by the next century it may well be a 1000 jobs, many of which have little to do with surgical technique or bedside manner. There will be medical computer experts, medical administrators, medical public relations consultants, even medical politicians. Therefore. Dr. Easton believes, medical schools must open their doors to individuals of more varied backgrounds, interests and abilities - not only to the students who have a flair for basic science. Perhaps the best way to evaluate the job being done by the medical schools is to look at the final product: today's physician. Dr. Frank Kriger, president of the Canadian Federation of Medical Students, says the results of such an examination are both reassuring and alarming. "In the areas of technical prowess and application", he says, "Canadian medical students and doctors are second to none. But in the area of physician-patient interaction, physician awareness of such issues as sexuality, preventive and community medicine and counselling skills, the physician is badly lacking." Is it possible - or fair - to expect a doctor to know everything about the human body and psyche,
Kutcher: mythological self-image often backfires. its illnesses and treatment, pharmacology, the social and economic forces that impinge on his or her work, medical law and ethics, with a bit of English literature or art history thrown in to produce a wellrounded human being? Obviously such expectations cause enormous pressures, and apparently doctors today are not coping too well. The statistics are well known, at least among sociologists. Studies in Canada and the United States have shown that there is a higher incidence of mental illness, suicide, alcohol and drug abuse, marital breakdown and physical illness among physicians as a whole. In one group of medical residents about 80% showed significant signs of depression. Dr. Easton believes that medical schools have an essential role to play in at least alerting students of these potential problems. "There is good reason to believe that many of the behavioural patterns that predispose to later physician impairment are established during the years of undergraduate medical education", he says. "Instruction in self-awareness, stress management and methods of coping with social and emotional hazards of medical life should be included in every undergraduate medical curriculum." Dr. Stan Kutcher of the Canadian Association of Internes and Residents agrees that going to medical school today can be harmful to your health. He says young men and
women enter medical training with certain basic attitudes: self-sacrifice, perseverance, self-denial, altruism and the wish to be in control qualities that, if properly developed, are vital to the practice of good medicine. But because of intense competition and staggering workloads (some residents can work as many as 100 hours a week), changes in attitude begin to occur. "The trainees become less altruistic, more cynical, less able to empathize", says Dr. Kutcher. "Excessive work leads to the negation of personal needs, the use of intellectualization in dealing with problems, denial of personal weakness. We see people die or in the process of dying every day. We soon learn that in order to relieve pain, sometimes we have to inflict it." Physicians and physicians-to-be are also overburdened by a "perfectionistic and mythological selfimage", says Dr. Kutcher, which often backfires on them. They are quickly disillusioned and unable to seek help for themselves when they need it. This situation, which the medical establishment may deny or choose to ignore, can and must be changed - but only by restructuring attitudes, he says, not "tinkering with curriculum But changes in curriculum are one of the few tools medical educators can use in their attempt to produce better and healthier physicians. A number of medical schools across Canada have already introduced or are proposing courses in economics, management, and the humanities. For example, this year the University of Toronto Medical School is teaching first-year compulsory undergraduate courses in the medical humanities - philosophy, history, religious studies, law, and English literature, including lectures on Shakespeare's Hamlet. Dr. Richard Tiberius, an architect of the new humanities curriculum, says the program is justified "especially if one considers the role of the physician in the larger society and in making decisions which involve the patient's values, perception of self and of life". Similar innovations are being considered at the University of Ottawa, but observers of medical education
Rosser: someone has to give up something. trends agree that change comes slowly. Some believe this caution is necessary to avoid too much tampering with basically adequate and effective curriculum. Dr. Walter Rosser, chairman of the core curriculum committee at the University of Ottawa medical school, says there are no revolutions in his field, only slow gains: "Change itself implies that someone has to give up something", he says. "Twenty-five years ago there just wasn't as much medical knowledge as there is today, so it was easier to define the curriculum content." But the enormous proliferation of medical information has meant educators must now perform a sort of "curriculum triage" - often under pressure from various interest and specialty groups that want their own areas included in course content and protected from any course cuts. Dr. William Easton believes that medical schools will change with the times because they have no choice: the pressures from those they train and their patients will make refinements to traditional medical education compulsory. "It is no longer prudent or even possible to embark on a medical career without some working knowledge of the social and political forces which impact on us all", he says. "This kind of knowledge would do much to alleviate the anger, frustration and disenchantment that lies in wait for the uniformed practitioner." .
CAN MED ASSOC I. VOL. 128. JANUARY 1. 1983
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CAN MED ASSOC J, VOL. 128, JANUARY 1, 1983
CAN MED ASSOC J, VOL. 128, JANUARY 1, 1983
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