Section7: Introducing new subjects and communication in medicine

Abstract

One of our initial difficulties was that we were talking about communication, and at first became so aware of how we were communicating, that it became difficult to communicate. However, we agreed to consider the papers and materials prepared by the members of the group with regard to three main themes: (i) education for scientific and critical thinking; (ii) two aspects of clinical communication, doctor-patient communication (teaching and evaluating interview techniques) and communication with regard to problems which are eventually disturbing to the student and doctor, such as human sexuality and death, dying and terminal care; and (iii) communication between health professionals, in speaking to each other and writing for each other. We will summarize some of our conclusions and recommendations. (a) We are talking about new types of subjects rather than new subjects, arising from a concern with the problems and deficiencies of health care, rather than from specialist or discipline pressure groups; they aim to offer new skills and attitudes based on analyses of health care problems. They are function-oriented rather than traditional disciplineoriented. Just as most of our countries have suffered in recent years from financial and economic inflation, so there is a real problem of curriculum inflation, which is one of the forces leading to ‘innovations’ which may not be needed, useful, or even new. New subjects and disciplines, developing within the health professions, demand time in the curriculum to establish the importance of the discipline and its teachers and proponents, so the number of topics in the curriculum increases steadily. Already established subjects often seek more time, to increase and protect their importance and power within the medical school system. As high prestige professional positions are generally associated with multiple educational qualifications and long years of training -so groups of health professionals seeking higher prestige may attempt to get it by insisting on longer periods of training, and more qualifications, even if these are not directly relevant or contributory to their actual health care practice. Finally, as educational qualifications are used too often as the controlling gateway through which people can move up to positions of greater privilege in society, inflation occurs, reducing the value of the qualification itself. In a developing country, for example, where few people gain an education, you can get quite an important position and quite a well-paying job with just a junior school-leaving certificate. That certificate becomes the selective gateway determining access to promotion. But when very many people have that certificate, its value drops, like the pound or the lira. Now you may sweep the streets if you possess that certificate. But if you want a higher or more senior job, you need a higher certificate. When too many people have this, then a University degree is necessary-and so on. Medicine has provided some especially awesome examples of this process. (b) The examination controls the system. A new subject demands its share of the examinations, lest the students will have to neglect it in order to prepare for the other exams. But the examination method must becongruent with the innovation. Don’t, as so many schools have done, integrate the teaching and then give separate, disintegrated examinations. Don’t teach to achieve critical and independent thinking unless your exam identifies, evaluates and rewards such thinking. Don’t teach communication skills unless your evaluation will identify, evaluate and reward such skills. Don’t ask the student to write an essay about how to talk to a dying child; don’t give him a multiple choice question about how to give an injection. If you want a student to be able to critically review a bad medical research