Deschooling Society, Unschooling Schools and Institutional Neurosis

Introduction

The morning is not complete without interaction with patients and doctors. I continue to share what I feel about medical education with younger specialists and doctors whenever the opportunity arises. My observations are rendered irrelevant as medical care has evolved to take new dimensions .The impact of technology is now seen in the forefront of diagnosis and care; little do we see reasoning and how clinical skills helps in arriving at a diagnosis. Although I want to hold onto the old adage of great clinicians like Osler and even the teachers I learnt from in medical school some 40 years ago, holistic care appears to be relegated to the back as the patient is compartmentalized into systems and organs. In medicine, variety is not the spice of life. If I am a patient I do not want to be ‘processed by different specialists and doctors ‘for me to get appropriate care. I don’t want the imaging department and the laboratory to dictate what my diagnosis is. But I can just lament as two generation have come in since I started practising medicine.

Ritualism and Social Oppression

The ritualistic ward round I see today is no longer relevant to me as I walk through the wards. I choose to go and see a patient who appears to require some counselling or clarification about her ailment. It is not uncommon for many patients to declare they do not know why a surgery is to be done though they have consented to it; a combination of fear, wanting to know more from a third person and inadequate understanding as a result of language are often the reasons.

I sense a commonness and personal alchemy when I read the commentary by James Drife, Emeritus Professor of Obstetrics and Gynecology at Leeds lamenting  and reminiscing the 40 years he had been with the National Health Service in the UK , quoting Alan Bennett ‘s play (1968), ‘our generation was sick and tired of hearing our elders reminiscing’.  But he goes on to say that much has changed in caring for the sick, for the better or worse is debatable. Certainly it has become costly to fall sick as medical insurance companies and managed care are now part of modern medical care.

Talking of ward rounds, what do we see today, the consultant does a wiz round, and if he is not available, patient care slowly shifts to the second rank of young specialists and medical officers who are at various stages of training? At times it is comical to view the scene when two to three specialists walking through the ward from bed 1- bed 48 rather predictably with another 3 trainee doctors and perhaps 5-6 interns.  No indication of personalization or prioritization can occur with such a large troupe! Additions in the bed head ticket like ‘patient not in bed’ (because she has gone to the toilet)   throws the responsibility of care on the patient!  An authoritative prescriptive command as to what is to be done for the patient after being told about the case, a wry comment and the procession moves to the next bed, a clear sign of paternalism and ‘I am in charge’ attitude.  A path of least resistance is taken as the junior most doctors quickly scribbles on the patient’s notes, whatever he/she gathers from the encounter, without comment or clarification. The entry could be ‘change antibiotic, get MRI done, and trace the urine results. He rushes to the next bed just in time, as the procession would have moved on not waiting for him to complete the task of entering the wise words uttered; ready to scribble again! I am reminded of Omar Khayyam’s ‘…the moving finger writes and having writ moves on…’

What has happened to professionalism and patient care today? It worries me a great deal. How do we teach empathy and social interaction? What has the medical curriculum done in developing the professional today. Something is missing here, old I may be, but there is gap, a missing link. Something has happened to society and what appears apparent.  Is it the education system?

Institutional Neurosis

Many a time, I drop in later in the morning after the routine ward rounds are over as the resident and house officers are left to complete the tasks of the day, clerking new cases, performing discharge summaries, getting appointments from radiotherapy etc. Last Wednesday, two days after the Hari Raya break , the ward was literally empty. One medical officer was at the nurse’s counter with four house officers. I thought I could share my wisdom and hence came around attempting to evoke some enthusiasm in in each of them. The severe disappointment was a lack of appropriate response to almost all the questions I asked although they had all just recovered from a consultant’s ward round. Doctors today work hard but they could make it more productive and efficient if we got rid of redundancy of reviews, progressive approaches and continuity in care. Ritualism does not give rise to quality care. When a senior doctor is assertive and does not provide for deep discussion, we lose out in exploratory learning. We are task oriented and we get jobs done and fail to give complete care.  

Working in an institution for a period of time promotes ‘ordering’, following routines and fulfilling the work plan prescribed to complete the task. What I am amazed is the lack of breath and depth in knowledge of doctors today. Education in schools has done something ‘terrible; that after completing 5 years of medical education, they lose out on enthusiasm and the goings on outside the field. I am generalizing here but few doctors in their junior years , whom I have asked know  current affairs, the plight of the oppressed in other countries, what countries are in Africa, the ancient civilizations, who invented the television and what the Annual Budget released by the Prime Minister in Parliament means to the consumer.  Good citizenry is required of these young professionals to pave the path to freedom of thought, to be innovative and have great imagination to work to develop a utopian world.

When I was a student in the Psychiatric ward, Dr Teoh J I talked to us about ‘institutional neurosis’, where long staying patients go into a state of apathy, are submissive and lose interest in the surroundings. Enforced loneliness and loss of cognition contribute to a particular attitude and appearance they take.  An exploratory article on the subject is written by Russell Barton (1966). Sometimes, I wonder, does this only occur to psychiatric patients only!

Deschooling Society and Unschooling schools

I mentioned that these bright kids who entered medical school with such enthusiasm and vigour go through five years of doctrinated learning and evaluations, assessments, examinations and information that appears to nullify that initial ‘oomph’ at the end of the curriculum. Quite a few students give a sigh of relief when they get the final professional examination results, ‘No more reading and examinations anymore’.  

Education was a sign of development and has been in vogue since the 17-18^th century.  Today compulsory education is in force in most countries of the world. Responsible governments ensured that premises were available for children to be educated in which eventually grew into schools and institutes. Today schooling is big business and private education is very expensive but much sort after.

However, how do schools prepare for the future is the question. At least 12 years of formal education is in place excluding the few years spent in pre-school. The first and best teacher is mum, but with the promotion of pre-schools, the responsibility of learning has shifted to teachers and formal education. Are we in the right direction? That may be a point for discussion in a different forum.

In 1964 John Caldwell Holt was vocal when he wrote ‘How children fail’ and commented on the ‘pressure adults exert on children’ because of schooling.  Later, in 1967 he wrote another treatise on ‘How children learn’.

Schools have faults which need to be addressed today. Ivan Illich has written and discussed ‘Deschooling society’ to get out of the ritualism and the oppressive effects schooling has on learning. He has discussed about the ineffectiveness of institutional education and that self directed education should be promoted; new educational funnels need to be created. Current computer mediated education is making resources available at any time and at any place. Whoever wants to learn can access knowledge. Although the school is now said to be the ‘new world religion’ and is the fastest growth market we should be concerned about social polarization in multicultural regions, social degradation as a uniform curriculum is prescribed in a ‘one fits all’ approach. Institutionalizing values have their setbacks as new cultures and behaviour develops. Education philosophers are concerned about being socially powerless and getting into a state of psychological impotence.

When I was in secondary school I was taught about the Norman invasion of England. My history teacher spent hours emphasizing the impact the feudal system had on society where the peasants were exploited by the landlord. That system pulverised the very individuality of the peasant. Should we now be concerned about the new dimension schools have in directing the young mind in meeting set curriculum? We all went though a similar system. The good side was that we socialized to a good extent, we had teachers as role models and education gave us the breath to appreciate life. But I still can’t understand the relevance of learning additional mathematics and giving me a test on geography when I wanted to become a doctor. I firmly believe that we do not need the matriculation or Form Six classes to go to university. I am sure many would agree with me that they would have done their professional education just as well without the Intermediate classes!

Unschooling schools permits natural learning and intentional learning. Home schooling was for the elite in Victorian times but has now come to stay. Most times the parent becomes the mentor in home schooling. The concept of Unschooling as in home schooling is different from deschooling society which is advocating anti-institutional school.

Ritualization and following the words of contemporary theologians would not permit imagination and innovation. The ‘helpless’ student needs to take a broader perspective of education and not be bent in achieving grades and attain mastery of definable skills and behaviour. Although personal growth is not a measurable entity, one can evaluate the final school product and determine how effective he is as a professional, citizen and contributor to society’s needs.

Of course several factors impact on the concepts and the way forward would be difficult to conceptualize till basic needs of society is met i.e food and shelter, protection from harm and a safe environment . Education is fundamental to progress of a nation but there is a need to determine if the process of education is producing the intended products.

Conclusion

I have tried to look at the product of one profession I am familiar with and desire that the education curriculum, whether it is primary, secondary or tertiary be re-looked.  I am of the opinion that society needs to have a dynamic curriculum so as not lend to intellectual schizophrenia.  We do not want to produce professional s and citizens who lack motivation and show severe signs of working within restricted horizons. It is clear that increasing passivity would lead to lack of productivity and cooperation. In fact it may lead to destruction of culture and progress. Institutional learning is not the only means of education. The desired outcomes need to dictate how education should be accessed and leant.

Sivalingam Nalliah

31 Aug 2012

The Root of Empathy

Introduction

Working with medical students permits me to reflect on my own days where I looked for a friend and counsellor in my formative years in medical school. That is the time where the metamorphosis occurs from adolescence to adulthood. The kind and learned Moses Christie Karunairatnam, our Biochemistry lecturer, struck me as a scholar who wanted to share his wisdom and kindlness, truly living to the Tamil interpretation of his name ( Karunai- kindness!). I could approach Dr Tan who was our Physiology lecturer who was easy going and not confronting. The founder Dean held himself above all others and was revered as the icon of medical education. He had to be the Dean and nothing else, befitting all the attributes of a head teacher you would have read in Tom Brown Schooldays.

To be a professional taking care of the sick and maimed, one needs role models and have an innate feeling for the less fortunate. Empathy is one attribute that needs to be exhibited, something I recognised in many of my teachers, whether in medical school or in primary and secondary schooldays. Now, we do research in empathy, although I had falsely accepted that empathy comes with those who take up the profession of doctoring. It pains me to see how rapidly the scenario has changed and less time is spent to express this trait in our daily duties.

Empathy and Compassion

Language is a beauty in that one can express thoughts and what we want to communicate in words. We often ponder if there is a difference  between compassion and empathy. Well, there is a difference. The word ‘compassion’ is derived from Latin to mean ‘to bear with or to suffer with’. Empathy is slightly different and is taken as a component of ‘compassion’ to mean ‘enter into or maintain a relationship to caring’.

In the Hindu faith Ahimsa is widely used to refer to ‘God quality within a person’. Ahimsa was advocated by the great Mahatma Gandhi in his non-violent movement for Independence of India. Compassion is central to Buddhism where the Buddha professed ‘absolute compassion of all creation (Karuna’). The Judeo-Christian sect also maintains compassion as a manifestation of God’s love and mercy.

Clearly empathy is the recognition of others suffering ; how one perceives the wants, needs, sufferings, feeling and emotions by putting oneself in the other’s shoes. There is a deep connection that goes beyond sympathy and intense resonance is experienced in understanding the emotional changes in the other person.  K.R Eister, in his treatise, ‘The Psychiatrist and the Dying’ moves to advice the caregivers ‘to give themselves selflessly to the dying as a free gift of love’.

Ernest Hemingway quotes’ ‘when people talk, listen completely. Most people never listen’. This is a call for giving a ear to the needy and sick.  Aristotle, the Greek philosopher once said, ‘to perceive is to suffer’. The novelist J.Scott Fitzgerald quotes, ‘when you feel like criticizing anyone, just remember that all the people in this world hadn’t had the advantage that you’d had ‘.

The Revered Gautama Buddha upheld the need to empathise by this famous quote,

‘Resolve to be tender with the young, compassionate with the aged, sympathetic with striving, and tolerant with the weak and wrong. Sometime in your life, you will have been all of this’.

Mahatma Gandhi, the most tolerant human I have read about, in his Godly statements commented, when Hindu and Muslim religions divided India  into two countries  during the struggle for Independence, “I call him religious he who understands the suffering of others”.

Medical Student’s Feedback

When my mentees or protégés  go away from the medical school curriculum to do their electives, they need to do a rotation in a field that is different from the normal curriculum. I often persuade them not to get stuck with a large hospital getting impressed with more application of technology but go out into society so as to appreciate the needs of the community. Quite a few students  have been advised  to change their initial proposals to areas I thought would benefit them more as far as empathy is concerned. On the otherhand , I did not have to counsel a few, as I could see this innate trait inherent in some of them; that  feeling they want to serve and share. I was particularly impressed by one shy female student who  often expressed the lack of confidence she had with her spoken  English Language. She wanted some experience in rural health close to her hometown in Sarawak. I guided her how she could maximise her experience by working with the allied health staff. But I also persuaded her to read some books written by doctors expressing humanism to improve her English Language. I requested her to give me a  report on the works of the writers she had read. What I got was an amazing reflective report on the works of Albert Schweitzer, the Nobel Peace Prize winner who worked relentlessly looking after the sick in a small hospital in West Africa, Anton, the Russian novelist who had been a doctor expressing the emotive trauma he had suffered through his stories about mental institutions and poverty and the author of the Sherlock Holmes series (Arthur Conan Doyle) , himself a retired ophthalmologist.

Another student elected to work with children who had hearing impairment and she was compassionate in her report elucidating the details of educating these ‘challenged ‘ children and the dedication and commitment of the teachers who clearly were limited by both expertise and facilities. The same student went  on to do an attachment in a distant village in Nepal where a small 30 bedded hospital with a visiting doctor (weekly) nursed and cared for leprosy patients and those with neurological damage due to spinal injury. Again the student was more than compassionate in her longing to serve the disadvantaged and how lack of funds and medical expertise did not stifle the existence of the hospital. She was passionate in her expressions of caring despite language being a barrier to communication.

Is empathy a trait or can it be taught?

Western culture has been taunted as nurturing the stereotypical belief that women are more emotional than men and this being related to masculinity and feminity. The fallacy is that women are able to express and communicate their emotions to others better compared to men. The masculine male is expected to supress and control his emotions leading to the often quoted statement, ‘boys don’t cry’. Did we not see the emotions expressed by Andy Murray when he lost the much needed Wimbledon Tennis championship to Roger Federer this year?  When Murray won the Olympic Gold medal, beating Federer convincingly in front of the British crowd, did we not empathise with him, let aside Murray expressing his emotions openly. Boys do cry!

Although research into empathy shows that female doctors appear to be more empathetic than male doctors, this is not a universal phenomena. Empathy appears to be a trait although we do feel it can be taught as we grow and understand human relations.

The empathy culture

For successful communication the Japanese have ‘omoiyari’ as a core value which refers to harmonious relations. It is intuitive and is a kind of indirect communicative style inculcated in the culture. The closest translation of ‘omoiyari’ is empathy. It is an understanding of unexpressed feeling, desires and thoughts. It is meaningfully expressed as kind and caring and is incorporated into the educational curriculum apart from it being part and parcel of the Japanese culture.

A Japanese medical student of mine (the only one) has been in communication with me over the last 2 years as  my mentee and I see in him all the attributes of empathy. He expresses this humanistic aspect in whatever communication he has with me, sharing his feelings along the way. Recently he lost his grandmother to illness but the poignant expression of empathy, the guilt of not being able to be with her the last few days, the satisfaction of having spent a couple of days a week before her passing is testimony of the ‘omoiyari’ feelings.

In the USA social and emotional learning has been revitalised through programs like ‘Root of Sympathy’. The Institute of Learning and Brain Sciences in Washington, Seattle has initiated the ‘Seeds of Empathy Program’ for the 5 year olds and ‘Root of Sympathy’ for the 9 year olds. The NoVo Foundation is a promoter of societal transformation to encourage social and emotional learning.

Empathy, though may be a trait, needs to be taught as the world has become compartmentalized by job descriptions and skills containment. The supervisor wants the products to come with zero defect and mechanization and computerization that goes with current job descriptions, neither permits nor desires one  to evaluate the feelings of employees and staff. Key performance indices count for  bonus and not empathy. Socialization skills are reduced to completion of work measured by indicators and timelines. The term ‘societal control’ is offensive as it affects empathy. Today industry and organizations continue to program the human to perform and produce leaving the soft skills to lie by the side leading to stress, conflict and destruction of human value and morality. The threatening elements of mother earth’s environment can be traced back to a lack of empathy. Human aggression at work and play and a lack of regard for authority and societal norms clearly points to a lack of moral instruction and empathy for others.

Can Empathy be learned?

The common situation observed when aggression sets in, is that one gets upset and loses himself ; at this stageb one can say that empathy is sacrificed. As empathy is central to humanity one needs to explore if empathy can be learned. Experiments on animals show that empathy is not only seen in humans alone but also in animals.

In one experiment ,monkeys who are rewarded with food if they completed an electric circuit were induced to press the bar twice to get double the reward (food). But in the process of getting more food another cohort of monkeys nearby were made to suffer pain should the experimental group of monkeys pressed twice to get double the food. On seeing their fellow monkeys suffering pain, the experimental monkeys refused to press the bar even once, preferring to starve! Similar experiments have also been done on mice. Several observations by naturalists point to this phenomenon among the animal kingdom. With such innate behaviour can we imaging how cruel people are when they kill and maim in the various conflicts involving humans throughout the world?

Animals can’t be very different from humans as they too reproduce and mind their young. They protect and feed and show their feelings too difficult for humans to understand.

Recently an article appeared in Science (2010; 328:633-636) declaring  the frog to closely resemble the human as far as human genome are concerned- the  frog is a ‘kissing cousin’. This then reminds me  the fables I read that  of the forg turning into a prince on being 'kissed '. Now I wonder if it was a fable! The amphibian’s genome ( Xenopus tropicalis) resembles that of humans.  Apparently 80% of the human genes associated with diseases is found in this species. Hence, exhibit some empathy when you feel like destroying a frog in the garden the next you spot one,  consider kissing it!

If psychological learning theories are true to understanding the human mind then Behaviourism, Cognitivist and Metacognitivism should impact on how we can learn humanism and empathy. Parents as role models have a huge impact on the growing child. They could influnece the young in empathy and compassion. The environment has an enormous impact on how emotional intelligence is nurtured. I would opine that empathy can be taught and behavioural conditioning would contribute to successful adoption of empathetic approaches.

John Hurt gave a real –to- life performance in the movie,  ‘The Doctor’. This arrogant surgeon became an empathetic person after he fell victim to cancer and learned about humanism from a fellow young girl who eventually succumbed to blood cancer. I encouraged one medical student to see that movie and she wrote a moving commentary of the finer aspects of compassion and empathy.

Is Empathy in our Genes?

We talked about human traits that navigate us through emotions and empathy. Are there genes we have that controls empathy and stress. One hormone called ‘oxytocin’ which is so vital in parturition and breast feeding is now thought to be beyond it being a ‘love hormone’. It now looks like kindness, love, caring and feeling for others is genetically ‘wired’. Oxytocin has a great influence on social and emotional processing.

Serena Rodrigues Saturn and colleagues in California (Nature) reported that character traits like openness, caring and trusting is linked to genetic variations. The oxytocin receptor incorporates a docking mechanism in operating as a hormone and neurotransmitter. If the person has a ‘2G’ variant gene of the oxytocin receptor the person exhibited better social skills and higher self –esteem compared to those with a ‘AA or AG’ allele. The latter group, in their experiments were less capable of handling stress and difficult situations .

Conclusions

Compassion and empathy are human traits which signify the ability to feel for others. Although there appears to be evidence that this trait is genetically linked, rearing of the young through role modelling and exposing them to a humanistic environment would promote this social characteristic. Culture and religiosity have an impact on exhibiting empathetic behaviour. In a just world empathy goes beyond the environment of the person to ensure sustainability of the race, environment and all living things.

Sivalingam Nalliah

18 Aug 2012