Doctors, science and society
Article first published online: 21 DEC 2012
© Blackwell Publishing Ltd 2013
Volume 47, Issue 1, pages 7–9, January 2013
How to Cite
Swanwick, T. (2013), Doctors, science and society. Medical Education, 47: 7–9. doi: 10.1111/medu.12051
- Issue published online: 21 DEC 2012
- Article first published online: 21 DEC 2012
Of a pair of papers published in this edition of Medical Education,1,2 one argues for and the other notes the curricular predominance of biomedical science and its failure to realise the Flexnerian ideal of the ‘good doctor’.3 Both papers emphasise the need for an awareness of the prevailing discourses around medical education and both conclude that biomedical science should be conceptualised as just one form of knowledge in medical education, albeit an important one.1,2 Taking a philosophical stance, Martin asks: ‘…if we are going to take responsibility for the education of persons who are to become doctors, what do we owe these persons?’1
Biomedical science should be conceptualised as just one form of knowledge in medical education, albeit an important one
The heart of the matter, though, must refer to what we ‘owe’ society. What is the point of a doctor? Why are doctors necessary? What is expected of a doctor, let alone a ‘good’ one? These questions were, of course, addressed by Flexner,3 but they require continuous rehearsal and reconsideration as medical education adapts to the evolving needs of the human animal within a given socio-economic context. Indeed, it is precisely in response to this challenge that there has been in recent years an introspective flurry of activity around the defining of the doctor’s role, which has manifested in holistic frameworks for medical education such as those outlined in CanMEDS4 and Tomorrow’s Doctors,5 which foreground those elements of the curriculum that transcend the purely scientific. Two curricular trends in particular are worth highlighting: firstly, the humanisation of the curriculum through participatory practices that engage learners with people and the social world, and, secondly, the shift in focus from the doctor as an individual to the doctor ‘in context’, who represents one agent among many working within a team, organisation or system.
There has been in recent years an introspective flurry of activity around the defining of the doctor’s role
But however medical education is reframed, one likely development appears to be inevitable: the dominance of the doctor is no longer assured. A recent article published in the Economist stated: ‘Doctors look set to become much less central to health care.’6 The article concluded: ‘Resources are slowly being reallocated. Nurses and other health workers will put their training to better use. Devices will bolster care in ways previously unthinkable. Doctors meanwhile will devote their skill to the complex tasks worthy of their highly trained abilities. Doctors may lose some of their old standing. But patients will clearly win.’6
One likely development appears to be inevitable: the dominance of the doctor is no longer assured
So what are these ‘complex tasks’ worthy of the doctor’s ‘highly trained abilities’? What can doctors uniquely bring to health care systems that add societal value? Somewhat ironically, the route to resolving this issue may lie not in liberal education, a focus on the humanities or in broadening curriculum content, but in reconsidering the positions doctors occupy in relation to science and to society.
As Whitehead points out, Flexner argued first and foremost for science as an attitude of mind rather than an accumulation of facts, referring to ‘…the persistent effort of men to purify, extend, and organise their knowledge of the world in which they live’.3 The notion of the ‘scientist-doctor’ reflects a habit of enquiry, a curiosity about the world and a critical engagement with all its aspects. This indeed is the obligation to which patients hold us. They don’t expect doctors to know everything. Google will do that for them. They do, however, expect us to be able to navigate the scientific world, critically engage with it and above all communicate its concepts clearly and humanely. We are their guides, curators and translators. But the doctor’s role as intermediary extends beyond these functions.
The notion of the ‘scientist-doctor’ reflects a curiosity about the world and a critical engagement with all its aspects
In his recent bestseller What Technology Wants,7 the writer Kevin Kelly develops the construct of the ‘technium’. Whether or not you buy into Kelly’s ideas, they provide a useful metaphorical basis from which to start to explore the role of the doctor in relation to science and society. The technium, Kelly argues, is the sum of human achievements: it includes culture, science, law, software, hardware and so on; in other words, it represents the grand totality of things, methods and processes, or the ‘extended human’.7 Kelly’s underpinning thesis is that the technium develops a life of its own as one technological development inevitably leads to another, seemingly without allowing humans to influence the directions in which technology ‘wants’ to take us.7 The Western world’s epidemic of type 2 diabetes represents an example of an outcome of human technical achievements (resulting in the use of cars, TV, fast food outlets, etc.) over which we have little control.
The technium represents the grand totality of things, methods and processes, or the ‘extended human’
Perhaps one way to think about the scientist-doctor is as a ‘go-between’ or as someone who works at the interface between the patient and the technium. Thus the scientist-doctor brings the patient and biomedical science into apposition in an attempt to maximise health benefit, and acts as an intermediary between the human and the increasingly complex, and arguably autonomous, universe of technology. In this space, the scientist-doctor has a number of social responsibilities, all of which are aimed at bringing about improved health outcomes:
- 1facilitating public understanding that enables effective and productive engagement with biomedical science, its constructs, products and processes;
- 2applying intellectual scientific tools such as clinical reasoning, critical appraisal and risk assessment;
- 3bringing science and technology directly to bear on patients through the application of acquired skills, and
- 4aligning health care resources, teams and systems in a way that marshals scientific and technological resources to best serve patient needs.
The issue of import, then, does not concern how scientific (or not) we train our doctors to be, but, rather, how we can develop doctors who have a broader conception of what it means to work at the interface between science and society, and how we can equip them with the ability to do so in a beneficial way. This is where doctors and, by inference, medical education can add value.
Perhaps one way to think about the scientist-doctor is as a ‘go-between’ who works at the interface between the patient and the technium
To return to the two papers published in this issue of the journal,1,2 as both imply, thinking about thinking is clearly important, but the kind of thinking in which students and trainees need to engage concerns their roles as applied scientists and how one co-produces knowledge with others. Perhaps the issue to be resolved does not really concern a ‘yes/no’ decision on the impact of philosophy, but refers to where philosophy is to be found. Rather than problematising the predominance of science in the curriculum, it may be that medical education should become even more scientific but that we need to adopt a broader definition of what that means.
- 3Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching [Carnegie Foundation Bulletin No. 4]. New York, NY: Carnegie Foundation for the Advancement of Teaching 1910..
- 4The CanMEDS 2005 Physician Competency Framework. Better Standards. Better Physicians. Better Care, 2nd edn. Ottawa, ON: Royal College of Physicians and Surgeons of Canada 2010., ed.
- 5General Medical Council. Tomorrow’s Doctors. London: GMC 2009.
- 6The Economist [Editorial]. Squeezing out the doctor. The Economist2 June 2012. http://www.economist.com/node/21556227 . [Accessed 3 August 2012.]
- 7What Technology Wants. New York, NY: Penguin 2011..