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 17-18th 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
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