Nicaragua (1984): In a hospital—or at least what was labelled as a hospital—a physician receives an elderly woman in a hypertensive crises. He administers the only anti-hypertensive medication available—Reserpine—a drug that is now rarely used because of its side effects. To his profound dismay the patient suffers a stroke and dies a few hours later. There are no morgues in such rural hospitals. There are no ‘funeral parlours’ in the villages. Families take their departed loved ones home for burial. In this instance, the family, owners of a pick-up truck, considers returning home with their mother in the back of the truck, laid out alongside bags of fertilizer. In a flash, they recognize it to be undignified: “Mom, after all, was still warm!” So, with the assistance and blessing of the physician they prop mother up in the cabin and off they drive! A dusty and dilapidated red Ford pick-up, with a cadaver sitting in the passenger seat, is seen making its way through vast expanses of sugar canes.
I was that physician in 1984. The events I describe above do not capture the dilemmas nor reflect the contexts in which the majority of medical practitioners work today, most assuredly not in resource-rich nations. However, all too familiar are such flashes of human dramas and plights, accompanied by an uncertainty, at times crippling, due to an inevitable lack of clear, tested, and validated scripts to guide the behaviours of patients, families, and doctors.
One of the obligations of medical schools is to graduate doctors who will be able to make humane and compassionate decisions—competently—within a framework of scientific knowledge. It is useful to dissect the claims expressed in this sentence.
With respect to “humanness and compassion:” whilst undeniably an enduring aspiration, medicine has not always been up to scratch and there are times in history when this core expectation has needed highlighting. This occurred, for example, in 1803 when Thomas Percival crafted a code—the first modern one—of medical ethics. A contemporary incarnation of guidelines for good ethical conduct has been the emphasis on professionalism.
Image credit: Image courtesy of the Osler Library of the History of Medicine, McGill University. Do not reproduce without permission.
With respect to science: scientific methodologies became prominent in the discourses of medicine as well as medical education following WWII. This has culminated, spectacularly, in the munificence of numerous medical research establishments and the influential evidence-based medicine (EBM) movement. EBM has been a driver of medicine’s institutional functions and structures for the past 30 years. Few would question the importance of evidence, science, and objectivity, even though many have argued that scientism needs to be tempered and humanism given greater pride of place in the medical act.
What about the word “competently” in the middle of that sentence: What does it mean? Is this qualifier all “to the good”? Clearly, no one would want an incompetent doctor. However, the issue has been confused recently by the arrival of the term “competency.” The relationship of competency and competencies to competence and competent is under scrutiny. Many opinion leaders, although thankfully not all, subscribe to a framework called “Competency-Based Medical Education” (CBME) believing that it will ensure safe and competent doctors.
CBME is founded on the premise that identification of the key tasks or steps of a specific professional role or activity will permit educators to assess and certify learners on their mastery of that unit of work. The activity can be referred to as a competency. Competency is etymologically linked to competence but should not be conflated with competence.
The CBME approach revolves around the notion that a competency must be specified in behaviourally measureable terms. Achieving this is possible for some important medical activities, particularly for procedural or manual tasks. But, it is impossible for many clinical decisions and acts. One cannot provide a template for curious, creative, and courageous professional responses. One cannot reliably measure empathy, resilience, or the tolerance of uncertainty. One cannot prepare a student for every contingency—to know that a clinical situation requires entering a patient’s room with a light and easy step and reassuring smile rather than a deliberate gait and a questioning facial expression. As my brief anecdote demonstrates, medicine is not a rote activity and doctors cannot be reduced to assemblages of competencies—the implication in CBME. It would be unfair to consider CBME as ignis fatuus. It will surely make a useful contribution but it holds a potential to distract and misdirect. Viable alternatives are needed to guide and, critically important, to inspire medical educators. One is available.
The preeminent physician of the 20th century was William Osler. Osler is widely regarded as the complete physician. It is not widely known that he described an approach to pedagogy; he called it “the natural method for teaching medicine.” The natural method was an apprenticeship grounded in patient care. For Osler, the patient was the most important and precious source of knowledge for physicians and physicians-to-be. I am confident that Osler would have understood the importance of the doctor acting as a facilitator and counsellor for that Nicaraguan family.
Osler’s natural method needs to be re-examined, repurposed, and reimagined in the light of current day challenges. It can continue to serve contemporary medical schools and is ideally suited to provide a conceptual anchor for an authentic physicianship, by which I am referring to the attributes of physicians needed to fulfil the roles of the healer and professional.