Body of knowledge

MEDICINE JOHN ROWAN WILSON

For some years now there has been concern in the medical profession about the supply and the nature of what is known as 'teaching material.' This doesn't, as the outsider might reasonably think, refer to blackboards or lan- tern slides, but to patients. It is an awkward but inescapable fact that medical students have

to learn their trade, not from books but on the bodies of sick people. to learn their trade, not from books but on the bodies of sick people.

In the old days of the voluntary hospitals this was not much of a problem. Being used for teaching purposes was one of the ways in which A patient was expected to repay the hos- pital for looking after him. Under the Health Service, this kind of direct obligation no longer

exists. The medical staff are now dependent on the goodwill of the patient and his under-

standing of the necessity for clinical teaching if medical education is to be effectively carried out.

Most patients are wonderfully cooperative, and accept the teaching round gladly as a

social duty; some even actually enjoy it.

American doctors, who have the greatest diffi- culty organising clinical teaching under their predominantly private system, are extremely envious of this aspect of British medical edu- cation. However, there are other difficulties involved in maintaining the standard of in- struction which has been taken for granted in the past. There is general agreement that

clinical teaching is no longer so easy to carry out, or so well related to the practical needs of the student, as it was ten years ago.

This is largely because of changing patterns in medicine and in the nature of hospital

treatment. The gulf has widened between the type of case which is now admitted to a teach- ing hospital and that which a young doctor may expect to encounter in general practice.

At one time, for example, one might expect to see a patient with lobar pneumonia in a teaching hospital, but antibiotics have ended that—these cases are now managed effectively at home. Old people, who form one of the most difficult and important problems in general medicine, tend to be directed away from the teaching centres. The result is that the student is in danger of qualifying with an impressive knowledge of the techniques of kidney transplantation but with only the sketchiest ideas of how to cope with acute bronchitis.

Steps have been taken to try to correct these deficiencies, by allying the teaching hospitals with district general hospitals- and by the intro- duction • of compulsory internship before quali- fication. In the new medical schools at Southampton and Nottingham, special pro- vision is being made to see that students receive a good proportion of their teaching outside research institutions. The University of Edin- burgh has a special department dealing- with general practice which gives instruction on the problems which are specific to the GP. But there is still a long way to go before the average student's training period bears an ade- quate relationship to the life he is likely to lead afterwards.

It is, for instance, now recognised that a very large proportion of the conditions pre- senting in practice have a psychiatric basis. Yet a recent report by the College of General Practitioners has shown that most GPs think that the psychiatric instruction they had as students was an inadequate preparation for their future careers.

Psychiatric teaching certainly presents special difficulties, since the presence of students both at the taking of the patient's history and the giving of psychotherapy is likely to cause em- barrassment and damage the atmosphere of confidence between doctor and patient. How- ever, techniques have been developed to get over this, such as the use of closed-circuit tele- vision, or one-way mirrors which (with the permission of the patient) enable students to observe from another room. The fact is that there are ways available to plug most of the gaps in medical education, if we have the will and imagination to apply them.

But in the end, whatever modifications are made, the success of clinical teaching must depend on the standard of conduct of the teacher and students, and their constant respect for the sensitivities of the patient. On the basis of many years' experience in teaching hospitals, I would say that on the whole patients are treated with great consideration. But there are exceptions. This is rarely due to callousness —far more often to a lack of imagination which fails to understand how carefully patients listen to what is said during a teach- ing round, and how easy it is for them to misunderstand.

Very often it is not what the doctor says but what he omits to say which causes anxiety. I was talking the other day to a woman who had suffered from a weakness of one leg since childhood. She had been diagnosed as suffer- ing from a rare condition, muscular dystrophy. When she went back to the teaching hospital for a check-up, the surgeon demonstrated the leg to the students and told them the original diagnosis was mistaken—the paralysis had been caused by polio. It was clear, of course, to the students that this misdiagnosis was largely of academic interest and did not affect treat- ment. But it was not clear to the patient, who went home worrying silently that if the right diagnosis had been made something extra might have been done. After reassuring her, I said, 'I suppose he didn't realise you were listening.' She said, 'He should have known perfectly well I would be.' And, of course, she was right.