February 14, 2013 | Posted By Wayne Shelton, PhD

Medical educators over the past six decades have designed educational objectives and curricula as though it was the educational process itself that determines students’ values and their behavior as professionals, without considering the influence of the structural environment on medical trainees. From the 1950’s on, as Samuel Bloom observed in 1988, there are examples, continuing to present day, of medical schools devising curricula with the goal “…to repair what were believed to be the dehumanizing effects of scientific specialization, but with the retention of the best of science.” To achieve these goals educators drew from the social sciences and humanities, and by the 1970s, from the growing interest in medical humanism and specifically from the field of medical ethics, which now is mostly referred to as bioethics. Bloom claims these subjects, like science, have been split off from the context of how they impact medical practice and taught mostly as an intellectual activity, thus creating a dualism between theory and practice. The curriculum has been assumed on its own to be an instrument of behavioral change that follows from knowledge. The essential process of social organization is sadly lost from view and deemphasized. How can we account for this rift?

First we must appreciate the enormous influence of the complex, bureaucratic, scientific, corporate-like structure of modern medical schools in the contemporary industrial society, with strict criteria for entry and promotion. This system represents a powerful status quo setting that is often assumed to be a given, fixed practical reality. Thus, a key disconnect in medical education is that of ideology from social structure, where the former is covertly subordinated by the latter. This structural setting means medical education puts at risk its stated educational objectives, which may be undermined by the random influences of the structural setting in which medical students receive their clinical training. 

At the same time new initiatives, such as the Medical School Objectives Project (MSOP) over the past 15 years, meant to foster humanistic knowledge and skills in medical education deemed necessary for new physicians have created ever more competition for precious curriculum time. Given the intense pressure imposed on medical students to do well in the basic sciences during the first two years to insure a favorable class rank and be competitive for a desired residency slot, students may view additional non-science courses in the curriculum as interesting, but less important. Moreover, these additional courses, including ethics and humanities, may not be pass/fail only, which provides less incentive to take them as seriously as the science courses. The risk within the current paradigm of medical education is that medical students learn implicitly to treat courses or themes like medical ethics, cultural competency, narrative medicine, etc., as compartmentalized and split off from the clinical knowledge and skills they are actually learning from role models during their clinical training. Because of the way medical education is structured, students may not fully integrate humanistic components of their education in their practice. In fact, students’ actual experiences in clinical training may lead to learning outcomes that are contrary to the stated formal objectives of the curriculum. 

Granted it has been over 20 years since Bloom first made his analysis of medical education, his insights remain significant. The unintended influence of powerful structural factors within medical education continue to put humanities and ethics at risk of being marginalized. For constructive reform in medical education to occur medical educators must be as concerned with the effects of the structural setting in which medical training occurs as they are in designing over curricular objectives. For the latter will never be achievable until the former provides an accommodating learning environment. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

3 comments | Topics: Education , Health Care Policy , Philosophy , Social Science


Heddy-Dale Matthias, MD

Heddy-Dale Matthias, MD wrote on 02/25/13 4:52 PM

I agree wholeheartedly with Dr. Shelton. The only time in my training where bioethics was INTEGRATED with clinical care was during my critical care fellowship at Pittsburgh. It would have been impossible to manage patients without these important discussions. I now practice anesthesia full-time, and bioethical discussions are anathema! Discussions such as, "Do you think this patient should be getting surgery as he's dying?" never occur where I practice. (It might be conjured, but it is never spoken. "After all, that is the surgeon's decision," never-minding a similar phrase of defense uttered by low-level Nazis.) I find that questions of ethics, "utility," "futility," etc. are absent from most private practices of medicine, especially critical care, oncology, and surgery. I find that even such ethically "benign" discussions of efficacy and costs of testing "none of my business." This attitude leads to the complete absence of discussions about a patient's life, joys, hobbies, family in most clinical practices. An extra five minutes is all it takes. I honestly think I know more about my surgical patients than their surgeons, because I spend that tiny bit of time. Medical care cannot be practiced in a vacuum, and the "stuff" that fills the vacuum of each patient is his "narrative", his "story." Without it, we physicians are merely technological mechanics.
Richard R. Pesce,MD,MS, FCCP, FACP

Richard R. Pesce,MD,MS, FCCP, FACP wrote on 02/26/13 3:41 AM

Perhaps I was fortunate in my educational experience and training. Ethical consideration was frequently present during training. Although exposed to these ideas during medical school, most of these ideas were presented and discussed in undergrate school. The college I attended insisted all graduates have a background in philosophy and western civilization no matter the major. This influence carried through training. This is why I think undergraduate education needs to be examined very carefully. The attitude developed here will influence and carry through practice.

Albina wrote on 03/30/13 10:55 AM

1.I completely agree that there were a “large nmebur of indoctrinations during our school years” (like the examples quoted in your fifth paragraph) trying to inject biased views into the mindsets of the students. But that was then and now is now. If current textbooks still carry these biased views (or propagandas), smart students should be able to recognize them and protest (or leave that school and find another school, if this choice exists.). (Therefore I don’t object to the revised policy of the HK government that schools be allowed to make their choice to introduce the subject or not, provided that sufficient schools exist for those who want the subject and for those who don’t.)2.I completely agree that “A fair and unbiased decision may still not be possible since “fairness” and “biasness” are relative terms.” I believe what those National Education concern groups in Hong Kong want is that events happening in the past should be judged in a fair and unbiased manner during the class. Again, of course, this is not possible. So they want the events to be discussed openly and freely so that everyone can express opinions (and teachers should not give scores based on which side (pro or con) the student stands on). (This is my belief only, based on newspaper readings – I have not verified.)

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