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The goals of medicine do not stop at the edge of the body

Over the last 100 years, the world, people, and our society have changed beyond measure. So have diseases, and we are now almost 75 years into the first ever age where cure of disease, successful organ transplants and near complete recovery from trauma has been possible. Despite all of this change, however, medical school curricula have hardly changed in a hundred years. Medical students are educated in more or less the same fashion as they were when I attended medical school more than 60 years ago. This is despite almost every medical school attempting to revise their curricula more regularly than locusts swarm, but with far less impact.

Medical science has advanced exponentially, as has technology, but, as vitally important as those are, they are only tools that working doctors use in caring for patients. We live in an age and society where science is a social force; where many believe that in medicine itself it is science and technology that makes diagnoses and treats patients. This is not true. Physicians using science and technology treat patients and are the diagnosticians. Physicians, however, use much more than their technical knowledge. Medicine is a field of relationships: the relationship between patients and doctors; relationships with other doctors and with the many other professionals involved in the care of patients; relationships with patients’ families; and with institutions such as hospitals, hospices, laboratories, and radiology units. Excellence in maintaining, growing, and utilizing these relationships is crucial to patient care. If this were not the case, and it was doctors’ knowledge of sci-tech that mattered most, then young, recently-trained physicians would be the most skilled doctors of all.

‘William Osler at a Patient’s Bedside. Johns Hopkins Hospital, circa 1903’ Reproduced by permission of the Osler Library of the History of Medicine, McGill University.

In clinical medicine—the care of sick patients in offices and clinics—it is widely known that physicians become better as they gain experience. This was true in times past and it is, if anything, more the case now. The basic tools in the care of patients are old fashioned—finding out the patient’s narrative and examining the patient.

Sadly, physicians trained in recent years are deficient in these skills. Furthermore, almost every hospital, medical school and other medical institution claims to be person-centered, but the medicine practiced there remains centered on disease. We believe that this is a result of holding on to a 200-year-old understanding of human illness: that if someone is sick they must have a disease. According to this longstanding concept, the job of the doctor with a sick patient is to find the disease. Since diseases are found in the body the doctor’s primary concern is with the sick person’s body.

To counter this, a different definition of illness is required when treating patients, one which reflects the fact that people consider themselves sick when they cannot accomplish their goals and purposes. Sick people’s functions can be impaired in a plethora of different ways, rendering them unable to accomplish their personal goals as they could when they were well. Since the patient’s goals and purposes are specific to them, an approach to medical care based on restoring or improving function becomes irrevocably patient-centered, and knowledge about diseases is relegated to a supporting, albeit important, role. It is now the role of the doctor to focus on this patient-centered approach in their daily practice by becoming not only as knowledgeable as they can about their particular patient, but as knowledge as possible about people in general.

The next step in medical training is for this to be translated into medical pedagogy. A medical curriculum is needed where knowledge about people is central: knowledge about normal personhood, about anatomy, physiology, function, and functioning —not only physical function but how persons function in their lives and in society. The educational blueprint must then advance to abnormal structure and function, and to how illness is experienced, recognized, and diagnosed. The environment of the medical school must place a premium on relationships: doctor to patient; doctor to learner; learner to patient. Such a curriculum has been laid out. Elements of it have been developed and delivered. It is about time it became ubiquitous.

Featured image credit: Strong Women by Samantha Sophia. Public Domain via Unsplash

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