Medical generalists: connecting the map and the territory

A modest psychologist once said that an acquaintance with the details
of fact is always reckoned, along with their reduction to system, as an
indispensable mark of mental greatness (James, 1918). Unfortunately,
reducing the dynamic facts of living systems to system requires the class
of mental greatness granted to none – many minds modelling are needed
(J.N. Warfield, 2003).

Education needs to foster generalists - those who recognise that the
art of dialogue and critical thinking are irreplacable. Without adequate
training in the art of collaborative and individual thinking, the 'system'
can come to dominate individuals. Only when the relevant dynamic facts of
the system are internalized can the system be mastered. As the system of
biomedical knowledge expands toward higher levels of complexity and
organization, mental processing demands increase. With the public belief
that an 'ideal' state of knowledge is accessible, expectations placed on
the individual practitioner increase. A medical doctor is also asked to
leave plenty of room for compassion. As the focus of care shifts from
acute to chronic, and as the populations ages, the necessity for wisdom is
also attached.

But the mind is a limited workspace. During their general education
all students need time to understand how the mind works. Without first
mastering the art of dialogue and critical thinking, a system of ideals
can crush the esteem of the best adapted, strongest individuals. As David
Bohm notes, 'you could say that our ordinary thought in society is
incoherent – it is going in all sorts of directions, with thoughts
conflicting and canceling each other out. But if people were to think
together in a coherent way, it would have tremendous power'.

With dialogue and critical thinking, the force of the system can be
optimized. But optimized never implies perfect.

Siu (1957) reminds us of the good-life-reasoning of Confucius:

The ancients, who wished to preserve the clear and good character of
the world, first set about to regulate their national life. In order to
regulate their national life, they cultivated their family life. In order
to cultivate their family life, they rectified their personal life. In
order to rectify their personal life, they elevated their heart. In order
to elevate their heart, they made their will sincere. In order to make
their will sincere, they enlightened their mind. In order to enlighten
their mind, they conducted research. Their research being conducted,
their mind was enlightened. Their mind enlightened, their will was made
sincere. Their will being sincere, their heart was elevated. Their heart
being elevated, their personal life was rectified. Their personal life
being rectified, their family life was cultivated. Their family life
being cultivated, their national life was regulated. Their national life
being regulated, the good and clear character of the world was preserved
and peace and tranquillity reigned thereafter. (p. 136).

Thinking about how best to optimize human action- the gestalt of
motivation, emotion, cognition, and behaviour, embodied and embedded -
involves thinking about human nature. An ideal space needs to be provided
for concentration and contemplation. Quality thinking takes time to
develos -- it requires a system that provides the appropriate scaffolding.

A collection of attitudes are thought to undergird a quality thinking
process. The critical attitude is a functional cognitive and affective
state defined by the Delpi report (Facione, 1990) as follows: possessing
the cognitive skills of interpretation, analysis, evaluation, inference,
explanation and self-regulation, along with the affective dispositions of
being purposeful and self-regulatory, habitually inquisitive, well-
informed, trustful of reason, open-minded, honest in facing personal
biases, and willing to reconsider one’s position. A grand selection of
virtues: the consensus view in the Delphi report is that it’s very likely
that none possess all.
Operating in potential coherence with the critical attitude is the
constructive attitude, which maps onto acts of synthesis that seek to
bring the products of critical thinking, the facts, into a system of
relations suitable for reasoned problem-solving and decision-making.
Naturally, the merger of critical and constructive attitudes is one of the
more difficult challenges the thinker has to face. As noted in the Delphi
report:

Not every useful cognitive process should be thought of as critical
thinking (CT). Not every valuable thinking skill is CT skill. CT is one
among a family of closely related forms of higher-order thinking, along
with, for example, problem-solving, decision making, and creative
thinking. (p. 5)

The merger of the critical and constructive attitudes, and their
consistent application in supportive educational contexts, is fundamental
to systems thinking.

Doctors who are offered training in the art of quality systems
thinking -- grounded in a strategy of problem-based, dialogue-based
learning -- will be better inoculated against the stress of rapid change
in the system. A new cohort of doctors trained in this way will put a
leash on the system and bring it to heal. Only psychologists who are
highly trained in the art of systems thinking can offer this training.
Unfortunately, they are few and far between. But they will emerge.

Quality medical doctors will embrace quality systems thinking
psychologists. Together their compassion will produce something new in
culture for the next generation.

Facione (1990). Critical Thinking: A Statement of Expert Consensus
for Purposes of Educational Assessment and Instruction. The California
Academic Press.

James, W. (1918). The principles of psychology. New York: H. Holt and
Company.

Siu, R. G. H. (1957). The Tao of science : an essay on Western
knowledge and Eastern wisdom. Cambridge, Mass.: M.I.T. Press.

Warfield, J. N. (2003). A Proposal for Systems Science. Systems
Research and Behavioral Science, 20, 507 - 520.

Warfield, J. N. (2004). Linguistic Adjustments: Precursors to
Understanding Complexity. Systems Research and Behavioral Science, 21, 123
- 145.

Competing interests:
None declared

Medical eduation especially in India is rapidly changing, there is
less emphasis on general practice with most graduates nowadays opting for
specialist training. As Dr Hegde points out, only a very small fraction of
illnesses need specialist care and treatment. I think we should change
this system and more emphasis should be laid on general practice.

Competing interests:
None declared

I agree - the Gatekeeper metaphor is outdated. But be aware that
practice-based commissioning may herald the return of a really
'conflicted' cheque-book version of gate-keeping !

At present, we GPs are frequently bypassed, either direct to A&E, or
out-of-hours ..

Though we may stand at the gate, we often have no hope of admitting
or referring patients to Secondary-care services which are FULL UP, hence
we are frequently dumped on, and bear the brunt of patient frustrations.

Occasionally I think of myself as DOORWAY to health, but too often I
feel like a DOORMAT.

Competing interests:
Doorway or Doormat?