A Critic’s View of Medical Education

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Charlton Chapman
Title: “A Critic’s View of Medical Education”
VTR: 9/22/82

I’m Richard Heffner, your host on THE OPEN MIND. On our last program I indicated that no program provokes as much response to our discussions here as one that deals with medical matters. That’s true when we talk about recent advances in medical knowledge about certain illnesses, and about their treatment. But it is particularly true when we deal here on the OPEN MIND with the structure of American medicine, with the nature of its practitioners, with medical ethics, with the concept of informed consent. That’s when you in the audience indicate your strong feelings about doctors and their profession. And those feelings are strong indeed. That’s why I’ve invited as my guest today a medical doctor profoundly concerned with medical education and medical ethics, with developing good doctors. Dr. Charlton B. Chapman, former Dean of the Dartmouth Medical School, is now Chairman of the Department of the History of Medicine at the Albert Einstein College of Medicine.

Dr. Chapman, thank you for joining me today here on THE OPEN MIND. And I, you know, I should begin by noting that what you’ve characterized as your most recent, but not your last, critical comment about what you call “education for medicine” is entitled: What is a Good Doctor? So I think I ought to ask you that question, and ask too whether medical schools today are generally helping us develop good doctors.

CHAPMAN: Well, it’s a difficult question. Yes, I think they are, although I think the medical schools and medical education in general are very seriously faulty. We can get all kids of definitions of a good doctor. Of course the patient oftentimes will say a good doctor is one who is willing to listen. Well, that’s very important, but that’s not a sufficient definition. I would say the first requirement is for a doctor to know his technical business. After that, he should have a very deep understanding of his ethical and legal obligations to the patient. And of course his ability to listen, compassion and so on, these are all very important attributes, but some of them are very hard, of course, to teach formally in a medical school.

HEFFNER: Why do you say, “Hard to teach formally?”

CHAPMAN: Well, what would a course in human compassion be? It would be very hard to do. I say that these things which the layman holds very important – and I do, too, by the way, there’s no question they’re terribly important – but they’re best taught by a role model. And unfortunately I think we have fewer role models of this type in American medical education today than we did when I was a student.

HEFFNER: Well, you say, “What would a course inhuman compassion teach?” Let me ask you whether that means that good doctors, in terms of the definition in which you include compassion, are born rather than made?

CHAPMAN: They are, probably. It has to do, I think, with what happened so them from a very early age. Many students come to us, come to medical school with these characteristics very well developed. Some come with them only latent, and they do respond to examples of role models and so on. Some of them you can never do anything with along these lines.

HEFFNER: Well, I don’t want to pull the teeth of criticism. You have been critical of medical education.

CHAPMAN: Yes, yes.

HEFFNER: Now, therefore, let’s for a moment focus on that aspect of your thinking about…

CHAPMAN: Right.

HEFFNER: …what goes on in medical schools.

CHAPMAN: Well, may I start off by saying American medical education – and as you say, I have been very critical of it, and still am – is not all bad. If we judge the product in terms of practicing physicians, competent practicing physicians, I think American medical education compares favorably with education anywhere in the world. I wouldn’t say that it’s better. I would say though that it’s more demanding of the student and also more expensive. I think it’s more demanding than it should be, and more expensive than it should be.

HEFFNER: Why do you say, “More demanding”? Or how would you characterize it then?

CHAPMAN: Well, let me focus first of all now on what happens at the premedical and preclinical phases of medical education. Premedical, of course, is at the arts and sciences level, while the student is attempting to discharge the premedical requirements like the science requirements, biology, chemistry, physics, organic chemistry and so on. And in addition, to get a liberal education. It’s not easy to do. That phase, then the preclinical phase is usually the first two years in medical school when the young student is coming up against anatomy and biochemistry, physiology and so forth. The last two years, of course, are clinical. But I want to focus on the premedical and the preclinical phases. And I say that they are inordinately demanding. I think it has to do with the design of introductory courses in the sciences, both at the arts and sciences level and in the medical school. They are still designed as they were roughly when they were first put together, in the last century mainly. They focus inordinately on method and fussy detail, and not very much on basic concepts and the whole conceptualization process, which is what I think a student really needs. Actually, the way they are structured now, they drive students away from those areas, science areas. And the result is we have students coming into medicine who are basically antiscientific. This is very unfortunate. Science does have something to do with medicine.

HEFFNER: But you say, “Inordinately demanding”. As a consumer?

CHAPMAN: Yeah.

HEFFNER: …as a consumer of medicine yourself, don’t you want a doctor or physician who has had inordinate demands made upon him to train him?

CHAPMAN: Well, yes, I want him well-trained, but what I was trying to put across a moment ago, you can have a paradoxical effect if you focus on fussy detail and memory work. You favor what a nineteenth century authority, Thomas Huxley, said was, you focus it in favor of the crammers and the grinders. Now those terms sound very contemporary. He used them 100 years ago in reference to medical education. And I think they’re still applicable.

HEFFNER: Dr. Chapman, what do you do without a crammer and a grinder as your own medical man? Should he scratch his head and theoretically conceptualize what might possibly be wrong with you but not have the cramming and the grinding behind him?

CHAPMAN: Well, truth is that the cramming and the grinding doesn’t really give him much of the material or many of the tools that he will use when he is looking after you clinically. Most of those will be acquired in his clinical training. This is just a long-winded way of saying that the scientific underpinning, the training in the basic sciences and so forth, isn’t very well correlated with the clinical training. The two do have something to do with each other, but they’re not as intimately related as it was once hoped they would be.

HEFFNER: Then as a former dean of a medical school, and as a person who teaches medical history, your conviction, your act of faith is that less emphasis on the hard science and the premedical school period?

CHAPMAN: Well, and preclinical. I have looked at them both as a unit in a sense. I’m not really saying less science; I’m saying better science. I want to change those introductory courses so that the student really spends his introductory time in learning the basic concepts. I think, for example, one could construct a course at the college level that we might call “The Basic Concepts of Medical Science”. That would be chemistry, physics, biology. Take one year, or maybe a year and a half, and if it were properly done, I think it would then be quite adequate preparation for entry into medical school.

HEFFNER: Could one say with some justification perhaps that since that hasn’t been done, and seemingly it hasn’t been done…

CHAPMAN: No.

HEFFNER: …that it really can’t be done?

CHAPMAN: Well, it can be done. But you now approach what I consider to be the basic defect of higher education in the United States today. It’s not just medical schools, but medical schools and arts and sciences divisions are really built on the premise that the department is the important structural unit. And it’s independent, all-powerful. And in effect, in medical schools, I once referred to them as independent, fiercely independent baroners. They’ll have nothing to do with each other. So that they plan curriculum as they think it ought to be without regard to what goes on in other departments. This is despite the fact that if you take those three I mentioned, biology, chemistry, physics, when these were first put together as so-called disciplines in the nineteenth century they were one thing; now the content is almost entirely different. And there’s tremendous overlap, which means that departments planning their courses independently will be very repetitive among other things. But they place an inordinate, and I think a somewhat destructive demand on the student.

HEFFNER: In the process of selecting those few…

CHAPMAN: Yes.

HEFFNER: …comparatively few who will be admitted to medical school, do you feel that the medical schools are reflecting the criticisms that you offer of medical education in their selection?

CHAPMAN: A little. I think things are beginning to change. To the present time though, admissions committees in medical schools have focuses very, very heavily on grade point averages, academic achievement judged by grades, particularly in the sciences. It’s now quite apparent that grade point averages at the college level and even in medical school don’t have much to do with any kind of judgment with regard to clinical competence in years later, after they get out of medical school. A difficult matter this one.

HEFFNER: You k now, I read that in one of your articles. And I thought to myself, if that is the case – and I’m sure you wouldn’t have written it if it weren’t the case –

CHAPMAN: No.

HEFFNER: …then why in the world haven’t we changed, radically changed the process by which we admit young people to medical school, and I daresay perhaps to law school too?

CHAPMAN: Well, yeah, I think the two are comparable in some sense. I would say that one of the paradoxes of the whole thing is that there’s a lot of discontent about this whole education for medicine process in faculties over the country. And yet it proves to be extraordinarily difficult to change it, for reasons that I mentioned a minute ago. But admissions qualities, or admissions practices, I’d say admissions committees in medical schools work longer hours and harder than any other committee in the school. And yet much of it is just spinning of wheels. They are really looking for evidences of differences, superiority, this candidate better than that candidate on the basis of grades, and then on down the list there come certain other qualities which are very difficult to judge.

HEFFNER: And you say there is not a positive correlation.

CHAPMAN: Right.

HEFFNER: …in terms of researches between mastery of those presumed skills, meaning informational…

CHAPMAN: Yes.

HEFFNER: …adaptations early on and being a good clinician later on. How about the other way around? What have you discovered as to the background, as to the grades, as to the accumulation of information at the college level in those tough science courses on the part of those people who do become good clinicians? Do you go back and find that the good clinicians are those who had more liberal arts in their background, didn’t do so well in their strong sciences? What do you find?

CHAPMAN: Well, I don’t think it’s been examined as methodically as it should be. It seems to me that what you would probably find – and this again is an impression, it’s not something which I can document – but the, what you might call the inquisitive, the conceptualizing type of approach to scientific matters is the important thing. And some students have that. They may still make very low grades in chemistry, physics, and all the rest of them, because they are not really patient with regard just to the acquisition of facts.

HEFFNER: And if they make those low grades, we really don’t too frequently let them into medical school?

CHAPMAN: We frequently will exclude them. Now, I have great sympathy for admissions committees, because I’ve served on them for many years. I began in this business of medical education 35 years ago. It’s really been practically all of my professional life. And I’ve been on admissions committees maybe half that time. And I don’t know the answers to these questions. What we were really asked to do is to judge some quality in the student who is applying that will tell us what he will be like 20 years down the road, that he will be conscientious, he will be able, and he will be an effective practitioner. Very difficult.

HEFFNER: So difficult, I gather, that many people, not just in medical schools’ admissions procedures but in other professional schools too then just go by the numbers.

CHAPMAN: Pretty much. I think…I know there is more experimentation, more willingness to experiment, for example, in medical schools. I know some schools that are setting up small numbers of students that they have admitted even though their grade point averages were kind of middling, mediocre even. But they’re taking them on the basis of distribution of interests and so on. We’ll get some answers, I think, as these things really run their course. I can say though, in terms of my own experience, this is a little anecdotal, but as dean I was given the privilege of admitting students, a few each year, around the admissions committee, didn’t have to go through the admissions committee.

HEFFNER: How did it work out?

CHAPMAN: And I never missed. These were students who – I agree that I would not choose anybody who had low grades, because he might not be able to cope with the regular medical school portion – but deliberately, people who were in the middle ground gradewise, but who had taken a year off, gone in the Peace Corps, something like this. They didn’t look very good on the record as far as grades were concerned. But they did will in medical school.

HEFFNER: You of course realize that that was true of many of us some years ago before going by the numbers became so important.

CHAPMAN: Yes.

HEFFNER: I used to be in a position where I could call, in law school, call a dean of admissions and say, “This is a good student. I know he didn’t do that well on his exams, and I know he didn’t do that well in his courses, but I know that this is a good student”. And as your experiences was, I never really made terribly good mistakes. They were good people, they worked out well in law school, and they worked out well afterwards, too. So we’re talking about numbers and the curse of numbers. You’re concerned with medical ethics. What do you think can be done by way of teaching medical ethics in the medical school? Is it possible beyond the example that you talked about before?

CHAPMAN: Oh yes. I think what’s been happening in the last ten years in medical education in this regard is very interesting. It may be peaking out now. I don’t know. It may be diminishing a little. But I think most medical schools now have some kind of training in, oh, law or philosophy or medical ethics or professional ethics or whatever it’s called. We approach it at Einstein. We do have a philosopher in residence there who participates in clinical enterprises. And she approaches questions right at the bedside that have ethical dimensions. Does it very well. That kind of teaching is, I think, going on in most medical schools. This is in addition to the role model. I think it takes both. I don’t think you can…Without the role model it’s very, very difficult to fill that deficit by lectures or seminars. Very difficult.

HEFFNER: I would guess that as you look at young people coming into medicine today you feel that they have a greater burden ethically than ever before…The kinds of questions that can be put to doctors now in terms of life and death.

CHAPMAN: Well, I think that’s true. And I would say also that they are much more aware of these things, even before they enter medical school.

HEFFNER: Did you say “aware of” or “wary of”?

CHAPMAN: Aware. Aware of. They’re talking about ethics when they come in, and even before they enter medical school. They are interested in these things. And this is, I think, a plus. But it’s a change in the climate. For example, I think, well, when I came into medical school no one was talking about the right to die with dignity. And yet, since then (I graduated in ’41) there has been an enormous change, not only in the general public attitudes, but actually in the case law, the common-law precedents. It’s still in the process, of course, but things are being done now like turning off life-support measures and so forth under certain circumstances that would not have been done them, wouldn’t even had been considered.

HEFFNER: Dr. Chapman, what would you teach a medical student about those matters?

CHAPMAN: Well, I have a rather simpleminded principle that I go on in terms of ethics. And I start with it. And the idea is that if you don’t start right you’re not likely to wind up right. But that principle is simply that the physician is bound by his status, professional status, and his, well, his whole demeanor to put the interest, welfare, legitimate rights of the patient above all other considerations within the professional relationship. Now that’s quite a mouthful, and of course the philosophers consider it to be an oversimplification. Well, it serves my purposes very well, because it means then that you stand off and you look at your own decisions with regard top the patient. Now, are those the right decisions? Are they really in his interest? You are likely then to inquire a good deal further than you would have done if you had merely proceeded along the authoritative position that, as I once said, is something like the millstone around the neck with the patient.

HEFFNER: What do you mean “authoritative position”?

CHAPMAN: Well, the authoritative tradition really goes back to the Hippocratic caucus, and the doctor knows best. That the doctor will in all cases do the best thing for the patient but he doesn’t need to take into account what the patient may want. That the doctor knows best and therefore can be expected to do the best thing. Well, this is simply not the case. It has a very subtle effect on the reasoning of the physician. Actually, I don’t know many doctors today who, on the pompous mold, “I know all about it and I’m not going to tell you anything; this is what we’re going to do, and that’s that. I don’t know any doctors who proceed this way now. I did. I remember some back in the earlier years. Most doctors, I think, try to look at it much more broadly than was once the case.

HEFFNER: Do the malpractice laws lead to that? Is it a function of fear to some extent?

CHAPMAN: I think to a very limited extent. That gets us into another area. Of course, I’d like to say that the law is at one end of the spectrum and ethical considerations are at the other end. Now this again is an oversimplification. The thing that interests me is the changing between law and ethics. Ethics do get translated into law, as you well know. And this has happened. For example, well, you mentioned informed consent. This is one prime example of ethical concepts that were basically read into the law. Paul Cardoza, I think is the one who is generally thought to have done that. But in that decision, 1912, I think, he sounded as if he were just reading straight out of John Stuart Mill.

HEFFNER: But you know, the question, and you’re talking about Mill, and you talk not about his emphasis on individuals but upon individuals ultimately being free to serve the larger interests of society.

CHAPMAN: Yes, yes.

HEFFNER: What about social interests? You say there is the physician, and he consults his own training, his own needs, his own point of view…

CHAPMAN: Yes.

HEFFNER: …and there is the patient. Isn’t there a consideration too, of society…

CHAPMAN: Oh, frequently. But as I say, it’s my conviction that the physician has to start with the patient. That’s where his primary obligation lies if he’s in practice. Now, of course, if he is not in practice, he may be functioning as a medical-legal physician of some kind, that’s a different matter. But if he is looking after patients, in the very first instance he has to put that patient’s needs, interests, welfare, legitimate rights above all other considerations. Then he must consider the social implications, if any. Now, there are frequently quite a few, of course.

HEFFNER: I was going to ask you about that, to what degree you find conflicts between the interests of society and the well-being of the patient?

CHAPMAN: Well, the one that comes to mind immediately is, if you have a patient who – well, let’s take the most extreme example I can think of – that might benefit from a cardiac transplant. Now the costs of those procedures is beyond the means of any but the most wealthy patients. Most of them that have been done have been done in some measure, and maybe totally, at public expense. Well, you can argue the question, it becomes a very broad social question, how justified are we to commit $150,000 of what amounts to public funds to that one patient when that same amount of money might be applied to, oh, infant care, welfare, and so forth that would then affect many more people?

HEFFNER: That’s a question.

CHAPMAN: Yes.

HEFFNER: What’s your answer?

CHAPMAN: I don’t have any easy answer, simply because, in general, it’s not the physician who really makes the decision. It will be made some other way. I would come into it though. And where I have been confronted with such things I have, in general, I think, really tended toward the broader decision. For example…But I haven’t done it with cardiac transplant. I was a cardiologist years ago and got out of it just as this was coming in. And I disapproved of it, and I still have serious doubt.

HEFFNER: Disapproved of what?

CHAPMAN: Cardiac transplants. It was too expensive. And I thought that it was introduced prematurely. In fact, the whole history of cardiac transplants, you may remember the first weeks and moths after Christian Barnard did the first one, there was this mad scramble to get credit, to get in. And I think this was a disgrace. Nowadays, surgeons who are still doing them are conducting themselves much more responsibly. But to get back to your question, when I have had to make the decision, as for example, like the renal dialysis and all, I have, I would say, more often than not tended not to do it unless it clearly had a long-range beneficial effect. I have not considered it fair nor justified to use public funds when all you were doing was gaining of six moths or a year for a patient.

HEFFNER: Long-range beneficial effect for the patient?

CHAPMAN: For the patient.

HEFFNER: And when you say, “Unless you’re doing something more than gaining six moths or a year for the patient?”

CHAPMAN: Yes.

HEFFNER: Dr. Chapman, if you ever find yourself on the receiving end – because I assume that I may be on the receiving end – would you want the same considerations?

CHAPMAN: Well, I like to say yes, but of course you well know that neither one of us will say how we will feel when we are on that receiving end. I don‘t know whether you’ve ever been in the situation where fatality, your own fatality, might be an end result. I have. And I have said it’s impossible to predict how you would feel under those circumstances. But it seems to me that if one has lived a reasonable life and at an advance age winds up with hopeless arteriosclerosis or brain damage, even though you can be compos in between episodes of dementia, that I can’t see that I would want to continue under those circumstances.

HEFFNER: We’re not now talking about a person who is really comatose. We’re now talking about a person who…

CHAPMAN: No, no, no, no, no. They‘re just senile, prematurely…Well, not prematurely, but senile.

HEFFNER: Well, I’m thinking of the fact that, on a governmental level, there seems to be a continuing push now toward providing medical help, assistance with the proviso that these major steps are not taken if we’re only dealing with a year or six months or more.

CHAPMAN: Yes.

HEFFNER: I find that very difficult to accept. And I find it strange that…

CHAPMAN: You mean you think that these things should be applied even if the outlook is only six months or so?

HEFFNER: To say only six months or a year, I guess, as a historian I’m well enough aware of what has happened in the lives of…

CHAPMAN: Yeah, yeah.

HEFFNER: …individuals in six moths or a year. Now, your students are going to have to make these decisions.

CHAPMAN: Yes. And of course I think one has to talk finally in terms of probabilities. For example, you speak of a patient, say, who’s got bilateral renal failure, plus a lot of other damage, brain damage, cardiovascular damage, or an elderly patient for example, what are the chances, what is the probability that some magic wand is going to be discovered within six months that will restore him to something like normal? Zero. Zero.

HEFFNER: I don’t think the question so much is what will restore him, but what can be done in six months, what six months of life…

CHAPMAN: Oh, I see.

HEFFNER: …or a year of life means.

CHAPMAN: Well, I would certainly be prepared, indeed have taken into account what the patient and his family had to say about that. I think, here again I get back to my basic principles.

HEFFNER: It must be a fascinating thing now – and we’re ending the program – to deal with these ethical problems within the context of teaching young to-be doctors.

CHAPMAN: Well, it’s interesting, I must say, although many of them of course are not answerable with precision, as you know. And I know I haven’t answered your questions with any degree of precision. I wish I could, but I think we have to keep on trying.

HEFFNER: Dr. Chapman, thank you so much for joining me today here on THE OPEN MIND.

CHAPMAN: Thank you very much. A pleasure.

HEFFNER: And thanks, too, to you in the audience. I hope that you will join us here again on THE OPEN MIND. And meanwhile, as an old friend used to say, “Good night, and good luck”.