A behavioural approach to medical education

This article is written to honour Professor Herbert A. Aponso (Emeritus Professor of Paediatrics, University of Peradeniya) on his 83rd birthday of which fell on March 25 this year. Professor Aponso, the well-known paediatrician is one of the pioneer medical academics who always felt the need for a merger of behavioural sciences and medicine. He often mentioned that he was fostering the development of social paediatrics at Peradeniya. In his lectures he always emphasised the social aspects of paediatrics. He viewed social facts and behaviour as an essential aspect in understanding illness in people. Taking an example of tuberculosis, he once mentioned that believing tuberculosis is caused by mycobacterium tuberculosis is similar to saying that the Great London Fire was due to a matchstick.
Professor Aponso rejected biological theories that explained the differences in human behaviour on the basis of innate biological characteristics. He was critical of the ‘ivory tower approach’ to medical education, and restricting the medical education only to the ‘medical’ sciences. Very few medical academics share these progressive ideas about medical education in Sri Lanka, even now. During his tenure as the Professor of Paediatrics at Peradeniya, Professor Aponso initiated several important links and collaborative efforts between medical research and behavioural research. One of his major accomplishments was the setting up of a multi disciplinary research centre called the Centre for Intersectoral Community Health Studies (CICHS) together with members of other faculties in the University and scientists outside, through which many fruitful research programmes were carried out.
In this essay honouring Professor Aponso, I would like to further elaborate the position held by Professor Aponso, and bring forth the advantages and positive developments in an effort of social science infiltration into medicine.
Doctors being practitioners working with people, often in situations of crises require skills to deal with crisis situations of patients. They should be able to manage uncertainty, unpredictability, inconsistency and impossibility that they face in their everyday practice with dexterity and agility. They should display expertise in evaluating undifferentiated and complex problems. The doctors need communication skills in all such occasions to understand patients’ body language, breaking bad news in a good way and enable patients make informed choices. They should understand how patients think, what their values are, expectations and concerns. The doctors should demonstrate familiarity with consultation techniques pertaining to their profession.
Doctors as managers and employers of hospitals and private clinics, need managerial skills, organisational management skills, change management skills and knowledge of risk assessment techniques. They should understand general practice (GP) in their various forms and settings, structure of Practice Finance including the business and managerial aspects of their practice. They also need personal management skills, and effective time and workload management skills.
Doctors, especially those general practitioners, should understand the range of career opportunities available to them, including research, education, evaluation and assessment. They should be able to identify patients’ unmet needs and doctors’ educational needs, and make use of them effectively for career development. Doctors should be able to effectively and constructively respond to patients’ criticisms and complaints without jeopardizing patients’ dignity.
Becoming a medical doctor is not an end to the learning process. Demonstrating an ability to learn from experience using reflection and critical analysis of incidents should be inculcated by doctors.
Doctors should know patients’ treatment seeking behaviours, their cultural variations; individual and family psycho-dynamics and their interaction with health and illness; socio cultural, demographic and epidemiological issues pertaining to special groups, and the health needs of such groups of people, and the way in which these factors modify people’s use of the health care services.
They should understand the effects on health of adverse environmental factors such as flooding, drought, and socio cultural factors such as poverty, unemployment, inadequate housing, occupational diseases, malnutrition and environmental pollution etc. Doctors should develop cultural competency to address and understand illness behaviour in respect of age, gender, religion, culture, ethnicity and sexual orientation of the patients. The empathetic understanding of the complementary and alternative medical practitioners and their therapies that the patients use is an important aspect of their cultural competency. In addition, the doctors should adhere to the ethical principles of the profession, respecting patients’ confidentiality and interests of the public.
The above-mentioned aspects are as vital as the biology, chemistry, anatomy or physiology for the doctors who practice medicine. However, they are seldom taught in the medical schools in Sri Lanka. Medical education in Sri Lanka is largely the forte of medical doctors. Its structure and content is decided by medical doctors who are academics in the respective university departments. Therefore, no wonder why the medical education system in Sri Lanka is highly ‘medicalized’.
The significance of behavioural and ecological aspects for understanding illness has been emphasised at the very beginning of the development of medicine as a discipline, by Hippocrates. He not only emphasised the significance of behavioural and ecological factors for diagnosis of diseases, but also recommended that physicians should investigate such factors for comprehensive understanding of diverse nature of diseases.
"if one knows all these (behavioural and ecological) things well or at least the greater part of them, he (the physician) cannot miss knowing, when he comes into a strange city, either the diseases peculiar to the place, or the particular nature of common diseases so that he will not be in doubt as to the treatment of the diseases, or commit mistakes as is likely to be the case provided one had not previously considered these matters" (Hippocrates-On Air, Waters and Places)
The basic Hippocratic orientation has recognised the value of social environment for understanding diseases and treatment of them. Treatment of diseased people should take into account the whole person, which includes not only his physical body, but also his mental, spiritual and social aspects.
When medicine moved into the 21st Century the concentration on the whole person for understanding diseases and their spread has become much more important. Thus, the single cause approach of the ivory tower of medicine has been challenged. Now, everybody knows that social, cultural and psychological factors not only influence diseases but also they are important in deciding the form and intensity of the diseases. It has become clear that modern medicine must study the behavioural characteristics of people that it treats to make medical treatment effective. Modern health practitioners should know how patients manage their chronic disorders, seek money to pay for the consultations of doctors, how they control their symptoms, adjust their life styles to suit the disorders or diseases, their attempts to be in normal relationships with others, coping with stigma, social isolation and so on in order to better understand the patients and their diseases.
Since physicians and allied health personnel in Sri Lanka are not exposed to behavioural sciences, they do not know much about the personal lives and behavioural aspects of the patients. This situation is much worse when it comes to chronic diseases which affect families and patients alike, and lead to many difficulties and behavioural adjustments.
The poor understanding of the behavioural aspects of the patients among the physician and health personnel is largely due to the selection process of students for medical education in Sri Lanka and the structure of the syllabi. Since recently those who do well in GCE OL examination with good passes in mathematics and sciences which are treated as core subjects could get access to do science education at the GCE AL examination. When they get into the AL class, these students are completely denied any exposure to so-called ‘arts’ ‘humanities’ or ‘social science’ subjects. Before this new selection process was introduced, the identification of ‘science stream’ students was done at year six examination and the students who were selected for science stream after year six were not exposed to even the basics of language education. Those who do biological sciences at the AL examination when they enter the medical faculties of the universities, are taught with courses pertaining to the ‘medical syllabuses’ in the medical faculties. In this process, from AL examination upwards, none of these medical students is exposed to any social sciences or humanities, which makes the situation worse. Those physicians who undergo this highly medicalized training would intellectually dissect their patients into physical parts and concentrate upon treating only the pathological part of the patient.
This way using this fragmented approach, the doctors who undergo this medical training in our country would deal with parts of persons and not with the whole person. Thus the doctors have become ‘mechanics’ who work on the human body. They have separated out diseases from the individual experiencing them. Diseased people are seen as ‘patients’ and not as ‘persons’. While recognising the contribution of biological explanations towards understanding patient behaviour, we must acknowledge that such theories are not adequate or sufficient for a comprehensive understanding of diseases and ‘patients’. Fuller explanation of patient behaviour requires an examination of norms, values and status, and social structures and organisations of patients, their families and communities and the overarching culture.
Dr. Howard Rasmussen, founding director of the Institute of Molecular Medicine and Genetics at MCG, who died April 20, 2005 in North Carolina, mentioned in 1975, "Medicine is now (in 1975 in the US) faced with two distinct alternatives. It can either redefine disease or restrict its treatment to specifically medical conditions, or it can accept a broad concept of disease and change medical education programs to deal effectively with the wider spectrum of illness" (illness as opposed to disease). For a good description of how the Americans have looked at this problem, as far back as in 1972, read the three-volume study - Study for Teaching Behavioural Sciences in Schools of Medicine-by C.R Fletcher et al.
The revision of medical curricula to incorporate behavioural components occurred in the US as early as the 1970s. Reviewing how behavioural sciences have taken a stride in medical schools in the US, in 1976 Murray Waxler stated in a journal article that the medical education programmes in the US that he reviewed, described "in detail the enormous amount of effort that has been expended in trying to effect a major change in medical education and thinking. It would be necessary to have been a participant in medical education prior to 1960 to appreciate how drastically the scene has changed for the behavioral sciences. Anthropologists, psychologists, and sociologists are increasingly familiar figures in the lecture halls and seminar rooms, on ward walks, at grand rounds, on admissions committees, etc. in medical schools"
Many charge that medical schools in our country have deteriorated into ‘trade or business schools’. Whatever the merits of the charge, an intimidating, denigrating meaning is intended in it. After all, no one wants his profession to be designated as a trade or business, and teachers of the medical profession wouldn’t like the idea that they were training tradesmen or ‘Mudalalis’. These charges should be viewed in the light of how doctors treat patients, respect their dignity and deal with them within the bounds of medical ethics. Understanding human behaviour is important in treating patients. Perhaps, the time has passed when physicians can be so ‘casual’ in their suggestions, and requires a holistic approach to understand the patients and only then that doctors would be able to circumvent those charges and develop a fuller understanding of the patients and their diseases.
The objectives of behavioural infiltration in medical education in Sri Lanka would mean to
(a) Prepare medical students to cope with the changing socioeconomic situation of the country and communities, and in the medical system itself. (b) Sensitize students to the effects of healthcare delivery on the various segments of the population, viz. estates, rural, urban poor, and war-affected; and the many vulnerable populations such as the children, pregnant mothers, elderly etc.
(c) Provide facts, information, concepts, models and methodologies and tools to medical students who may become physician-administrators and (d) Change attitudes so that the students who become physicians will be better informed citizens who would look at ‘patients’ as ‘persons’.
The new understanding and infiltration of behavioural sciences into medical schools in the USA and Europe has created a new network amongst sociologists, anthropologists (and other behavioural scientists) and medical professionals which has brought many new dimensions to research and teaching in the medical schools in those countries. Anthropologists and sociologists now hold many joint positions between their departments and health and medical institutions. Medical schools, nursing schools, public health schools have created number of positions for anthropologists and sociologists in those schools. In addition, the behavioural scientists teach courses on medical anthropology, medical sociology, medical geography, social epidemiology, social psychiatry, public health, preventive medicine, family medicine etc in the medical schools and nursing and pharmacy programmes.
The results of this infiltration of behavioural sciences into the medical and allied medical professions have many positive developments in the US and Europe. One of the major change in the US education policy is that any student who does well in his/her BS (first degree), whether he has majored in languages, or chemistry, could enter medical school if s/he gets through the particular examination (MCAT) that selects students on a competitive basis for medical schools. Before they enter medical schools, they are required to complete certain number of courses (credit hours) on humanities and social sciences at the first-degree level. Many textbooks on behavioural sciences are now introduced into the medical syllabi in all the medical schools including the Harvard medical school.
It is high time the Sri Lankan universities learnt from successful medical programmes in other countries and develop the education system to incorporate behavioural sciences in to the syllabi, do away with the ‘ivory tower approach’ and be open to progressive thinking. The schools of medicine should train their students to be ‘whole professionals’ and not ‘part professionals’; they should be trained to look at ‘patients’ as ‘persons’. Such a change will bring in much-desired outlook to the medical profession in Sri Lanka.