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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 December 8; 335(7631): 1186.
PMCID: PMC2128634
Ethics Man

A perforated education

Daniel K Sokol, lecturer in Medical Ethics and Law, St George’s, University of London

Surely every medical student worth their stethoscope should be familiar with the bare bones of the profession’s history?

If asked to name famous doctors in medicine’s long and tempestuous history, what would you say? Hippocrates, Galen, Avicenna, Maimonides, Vesalius, Harvey, Lister, Osler, Cushing, Salk?

When I recently put this question to a class of third year medical students, I was disheartened to hear their first answer: Harold Shipman, the British general practitioner who murdered more than 200 patients and hanged himself in prison in 2003. The next most popular answer was Gregory House, a brilliant though mischievous, cynical, and quite fictional character of the popular American television series House.

A few days ago, I attended a surgical conference in London. A distinguished professor of surgery, who qualified in the first half of the 20th century, showed a chest x ray to the audience. “We used to see a lot of this in the 1940s, when I was a house surgeon,” he reminisced. With an austere nod of the head, he asked an unsuspecting junior doctor for a diagnosis.

Junior doc: “I guess it could be…”

Surgeon: “Don’t guess, boy!”

Junior doc (startled): “Is it a diaphragmatic hernia?”

Surgeon: “I discard you like a perforated condom.”

As I heard “Harold Shipman” and “House” leave the lips of those medical students, the surgeon’s colourful dismissal seemed apposite. How I wished consultants would use Osler’s method of asking students on ward rounds for some historical background:

A case of exophthalmic goitre comes in—the question at once is put, “Who was Graves? Who was Parry? Who was Basedow?” Of course the student does not know; he is told to bring, on another day, the original article, and he is given five or 10 minutes in which to read a brief historical note.

It is perhaps unrealistic to expect students to know more than the basics of the profession’s history, but surely every medical student worth their stethoscope should be familiar with the bare bones of the subject. Aside from history’s intrinsic interest, it can foster a sense of perspective and continuity, and a spirit of reflective inquiry. Physician-historians have written about how knowledge of medical history has improved their clinical practice, from preventing hubris to aiding diagnosis. Even a single session would benefit the student, and in answer to the obvious rejoinder “If history creeps into the curriculum, what goes out?” I suggest medical ethics, whose lessons can easily be incorporated into a history lecture. Medical history is replete with ethical issues. In fact, it is through studying the history of medicine that I became interested in medical ethics.

So I spent the next 30 minutes of the class discussing key moments in medical history: the transition from a supernatural to a rational model of disease, Galen’s humoral theory, vaccination, antisepsis, the germ theory of disease, and so on.

For the last part of the hour, we dissected William Osler’s essay Teacher and Student, in which Osler reflects on the characteristics of a good medical student and doctor. He writes of the art of detachment, the virtue of method, the quality of thoroughness, and the grace of humility. I asked the students about the importance of these qualities. We discussed the meaning of humility and the benefits of the virtue: the ability to identify and learn from our mistakes, to learn from others, to gauge our abilities, and make more balanced judgments about others. And inevitably, when the time came to discuss witnessed instances—or notable absences—of humility, the students invoked the cold hearted surgeon as the antithesis of humility. Where, in our hospitals, is the sensitive surgeon of T S Eliot’s East Coker?

The wounded surgeon plies the steel

That questions the distempered part;

Beneath the bleeding hands we feel

The sharp compassion of the healer’s art

Resolving the enigma of the fever chart.

Jotted down on a post-it note, a quote from the surgeon Richard Selzer dangles precariously on my computer: “The surgeon must remain anesthetized to the philosophical, the literary, even the human implications of his work, in order to be able to carry it out dispassionately, at the proper remove from the white heat of the event.”

How, if at all, can we reconcile these two extracts? I’ll ask the students next time.

After the class ends, I bump into one of the students on the underground. “How did you find the class?” I ask, aware that any positive answer would be borne out of politeness. “It was thought provoking, but the guy next to me didn’t see how it could help in exams.”

I discard you like . . .

Call me naive, but is there not something amiss about contemporary medical education when frequent examinations stifle the intellectual meanderings so essential for an expanded mind? In 1954, a 12 year old boy in the United States wrote to Mr Justice Frankfurter, an eminent Supreme Court judge, requesting advice for a career in law. The judge recommended that the boy read widely for “no one can be a truly competent lawyer unless he is a cultivated man.” Is that, I wonder, also true of medicine?

Is there not something amiss about contemporary medical education when frequent examinations stifle the intellectual meanderings so essential for an expanded mind?

Articles from The BMJ are provided here courtesy of BMJ Publishing Group