The Doctor, the Patient, and the System: Reflections on Education for Clinical Careers

THE DOCTOR, THE PATIENT, AND THE SYSTEM: REFLECTIONS ON EDUCATION FOR CUNICAL CAREERS JEREMIAHA. BARONDESS* The form ofmedical éducation is not static; its shaping is a continuing dynamic process, subject to pressures both from within the educational system itself and increasingly in recent years from outside it as well, especially from the social and cultural contexts in which physicians work. The manner in which the educational system in medicine evolves should be primarily concept based, that is, rooted in examination ofthe needs of patients, the desired characteristics of the care system, the requirements of the educational and research enterprises, and the nature of what the doctor does. The alternative to concept-based educational change is change which is primarily constraint based, that is, chiefly reflecting extrinsic forces and agendas, often with heavy economic overtones, and oriented to an important degree around the solution ofaggregate problems rather than around educational needs or the clinical requirements of the individual sick. Pressuresfor Change in Medical Education The outstanding conceptual change in medical education in the modern era derived from the Flexner Report of 1910, which in effect dissolved the proprietary trade school mode and emphasized the need for a proper intellectual base in medicine. The format and emphases of our present educational system represent in large measure the continued development of the changes put in place by Flexner's study, but it has become increasingly clear that the needs of the modern clinician mandate some modification ofthe educational priorities that have evolved as corollaries. A second powerful and closely related force forchange, made possible This paper is based on the Meyerowitz Memorial Lecture, University ofRochester Medical Center, Rochester, New York, October 15, 1980.»Department of Medicine, New York Hospital-Cornell Medical Center, 449 East Sixtyeighth Street, New York, New York 10021.© 1983 by The University of Chicago. All rights reserved. 0031-5982/83/2602-0334$01.00 Perspectives in Biology and Medicine, 26, 2 · Winter 1983 \ 261 largely by the emergence of university medicine and an enlightened public policy ofresearch support, has been a revolutionary development of medical science and technology, especially in the past 30-35 years. A number of important, clinically related derivatives of this expansion of biomedical research should be noted, in addition to its remarkable yield of new information. Three are particularly critical in terms of their educational implications. First, the rapid development ofbiomedical science and technology has changed radically the nature of medical practice , tying it closely and irrevocably to the research and educational enterprise; in effect, clinical medicine has acquired a genuine science base for the first time. Clinicians are therefore required to be conversant with a rapidly evolving biological science as it applies to medicine, and a sharper and more pressing threat ofobsolescence ofthe knowledge base acquired in medical school and postdoctoral training must be confronted by each physician. The fact that medical practice has become much more closely related to continuously emerging research developments can only become more pressing in the future, as bioscience continues to change our understanding ofdisease and the responsibilities ofthe clinician . A second derivative of the new science base has been a shift of clinical perceptions in the direction of a more phénoménologie view of sick people. This has raised, as a clinical issue of importance, die distinction between disease and illness, that is, between biologic phenomena in disarray and ailing humans in disarray. This distinction was considerably less crucial before physicians had substantial insights into the nature and mechanisms of disease. In that era management ofillness, that is, ofthe disabilities, discomforts, life disruptions, fears, and formulations of the patient and his family, was the prime output and orientation of clinicians , for in fact there was little they could do to interfere with disease mechanisms at any reasonably fundamental level. Physicians are able now, however, to address disease much more effectively, and education and training in medicine have come chiefly to reflect and reinforce a clinical care paradigm which is increasingly disease oriented. The relevant issue which must be addressed is how to keep the illness-related functions of the doctor from being pushed aside, how to create a new synthesis that allows proper emphasis on both sets of...