Oration to the Congregation for the Conferment of Degrees by the University of Malta. Jesuits’ Church, Valletta, Malta. 30 November 2007
Humanity and Medical Education in a Changing World
Professor Joseph Cacciottolo MD, DSc
Head, Department of Medicine, Faculty of Medicine and Surgery
Thirty-two years ago this month, I was in this same Jesuit church, to have my MD degree conferred with the dignity that this solemn occasion deserves. I have since practiced medicine in several settings and in different roles. Much has changed over the years: our society has transformed radically, and the organization and delivery of health care is different. The rapid advances in medical science and in all branches of technology constantly force us to review our thinking and change our praxis.
What have not changed over the years, are patients’ needs. Patients’ faces often mirror their pains, and their secret fears. Although patterns of disease change over the years, patients’ faces, or their anxieties, have not changed at all.
It is essential to practice today’s medicine with an understanding of complex science, with the aid of sophisticated biotechnological apparatus and with due attention to statistical detail, however, one must not forget that the same statistics are composed of people, and that in reality there are faces behind numbers.
The scope of medical education in today’s world is to produce doctors that are relevant to the health care needs of individuals and of our increasingly multicultural communities. Medical teaching needs to be responsive to the whole of a person who is a patient, and the fact that medicine is a caring profession that uses science, should be the principle of all our teaching activities.
The concept of medical education is at times in dispute, and often, in many medical schools there is contest between medical scientists and clinical teachers. The primary interest of the medical scientist is research, and this must be encouraged and funded well. However this cannot be at the expense of teaching medical science in isolation from clinical subjects, and all barriers between what are traditionally termed ‘pre-clinical’ disciplines and ‘clinical’ studies should be removed. Such division serves no useful purpose and may actually blur the concept of patient-centered care. Educational strategies in this regard should be designed to involve students with patients at the very outset of their medical studies. This is now facilitated by our move to Mater Dei Hospital, and the close proximity of the University should lead us to a seamless course of medical studies.
Much of medical instruction in the past involved didactic, and often pedantic, approaches on the part of the teacher. It also assumed a reciprocal unquestioning acceptance of facts on the part of the student. The teaching of medicine should however only minimally be concerned with imparting facts. The internet ensures us continuous access to facts, and in any case, facts can rapidly change in the face of more compelling evidence.
Our principal concern should be the teaching of the application of knowledge. The overall purpose of medical education, in consonance with its University setting, is to teach method and encourage habits of mind.
The possession of knowledge and skill in its application, are very desirable, however they are not enough to produce a humane doctor. It would be wrong to train a doctor that is proficient in treating diseases, yet is unable to comprehend or appreciate human predicaments and social milieux. The practice of medicine is essentially about care and compassion, and patients will only care about how much their doctor knows, after they know how much their doctor cares.
Medical education curricula at all levels need to emphasize the human element of medicine and foster its practice not only as a profession, but also as a vocation. To practice medicine is also to serve, and doctors are in a unique position to be of service to the dispossessed and to the most disadvantaged members of our community. The weak, the disabled and the poor, deserve more of our attention and certainly equal respect. Irrespective of our status or office, what defines us is how we treat others, and indeed, our measure is what we give, not what we have.
The objectives of medical education change over time, in order to respond to new challenges. Some traditional objectives are now less relevant to today’s society. Conversely, new objectives have emerged, foremost amongst them the need to counteract the increasing dehumanization of medicine and to redress the decline in empathy.
There are several factors related to the growing dehumanization of medical care, also euphemistically called ‘clinical detachment’ and ‘non-personal involvement’. There is a danger that the patient is perceived exclusively in scientific terms and therefore not treated as an ill person but in terms of deranged organs or deviations from the normal in laboratory tests.
The trend to super-specialisation in medicine is an irreversible positive progression and as a consequence, a team approach, with the involvement of several specialists frequently becomes necessary. This may result in poor coordination, while the relative anonymity may dilute responsibility and reduce meaningful contact with both patient and family.
In tandem with super-specialisation, there is the frequent introduction of increasingly sophisticated diagnostic procedures, and these themselves, together with unavoidable economic considerations, may add to the distance between patient and doctor.
One cannot ignore the rising incidence of medico-legal litigation and the prevalence of defensive medicine in our community. These issues are of critical importance as they are already reshaping the practice of medicine. In this regard, it is difficult to determine whether these trends are the cause, or the effect, of decreasing personal involvement between doctor and patient: probably it is a blend of both. It is therefore crucial to address these factors at all stages of medical education.
One of the chief reasons for taking up medical studies is the desire to heal, or at least to comfort people in need. Medical schooling, then stresses the importance of strict objectivity, clarity of evidence, and clinical neutrality. It is therefore not surprising that medical educators in many Universities are concerned by the negative effect that clinical training itself may have on empathy.
Empathy, in a medical context, may be described as an understanding of the patient’s perspective and emotions, together with the ability to communicate this awareness to the patient. It does not imply pity or feeling sorry for patients, as that would be unacceptably condescending. At its most basic, empathy is about kind words of understanding, sincere encouragement, and a reassuring hand.
Decline in empathy among the medical profession has several documented causes, among them the rigorous system of medical training, which too often is rigid in its horizons. As Sir William Osler, Regius Professor of Medicine at Oxford, put it, over 100 years ago: the system which is designed to eliminate the incompetent, often succeeds in stifling the inventiveness and imagination of the competent. To this one could now add such unintentional outcomes as numbing of feeling, and blunting of empathy.
One cannot teach empathy and the precepts of humanity as theoretical concepts, or in isolation. Training in interpersonal communication skills and mentored interaction with patients sharpen the capacity to understand verbal and non-verbal cues from patients, and has been shown to enhance empathy.
Another proven and practical way to reinforce the humanity of medicine is to include appreciation of the humanities as part of a doctor’s professional development. This would dovetail with our University’s novel project, Degree Plus, aiming to enrich and widen educational experiences beyond course curricula. Familiarity with literature, philosophy, art, music, theology and politics compliments medical studies in so far as they help the doctor appreciate each patient’s individuality, thoughts and feelings, in the context of social fabrics.
This holistic concept of medical care is certainly not a new one, and Moses Maimonides, the twelfth-century Jewish sage, physician and theologian, wrote that the physician should not treat the disease, but the patient who is suffering from it. The dictum by this great humanist is probably even more valid in this day and age and serves us as a steadfast anchor in this rapidly changing world.
In conclusion, I wish to specifically address all graduands in this congregation. I heartily congratulate you, for you have proved your academic worth, and it is with pride, that our University celebrates your well-deserved success. This event is another important landmark in your quest for knowledge and I wish you many more landmarks on this never-ending journey.
I exhort you to go forward without fear, in all your endeavours. Your only real obstacles are inflexibility of mind and resistance to change. The real leaders amongst you will be men and women of vision, who continually seek innovation and instigate change. I wish upon you the boldness to go forward with confidence, sustained success in your careers and much joy in your journey through life.