Intended for healthcare professionals

Rapid response to:

Editorial

Campaign to revitalise academic medicine kicks off

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7440.597 (Published 11 March 2004) Cite this as: BMJ 2004;328:597

Rapid Response:

THOUGHTS FOR ACADEMIC MEDICINE REVISIONISTS TO CONSIDER

• There is more than adequate evidence to expand medicine’s worldview
beyond the useful but unduly narrow biomedical model to include social,
environmental, familial, occupational and emotional factors on health
disease and to substantially expand its educational venues beyond the
hospital to include physicians’ offices, patients’ homes, nursing homes,
rehabilitation facilities, and hospices.

• The notion of single “causes” for the majority of diseases should
be abandoned and the concept of predisposing, precipitating, and
perpetuating factors adopted by recognizing that most illnesses require
clusters or sequence of several elements to evoke biological or behavioral
changes, e.g. genes, diet, and sedentary life-style for diabetes; strong
coffee, aging, and “stress” for atrial fibrillation; relative poverty,
depression, and the tubercle bacillus for tuberculosis; climatological
change, “stress/depression” and a virus for the common cold etc.

• Everybody needs a compassionate Personal, Generalist Physician (or
Nurse Practitioner or even Aide) who listens to the patient, uses
efficacious and cost-effective interventions, refers judiciously, works in
a group practice, and is sensitive and knowledgeable about the
demographic, cultural, social, biological, and other environments
surrounding the practice and its geopolitical jurisdiction.

• Students should be required to prepare a paper describing briefly
the clinical features, incidence/prevalence, and costs of individual and
population-based therapeutic and preventiveinterventions for the ten
commonest problems in their own jurisdictions, in their country, and in
three developing countries.

• Referrals to specialists and super-specialists should be made by
generalists with substantially decreased differential physician re-
imbursement for self-referred patients they treat.

• At graduation all physicians should be thoroughly knowledgeable
about the clinical, biomedical, behavioral, and population perspectives in
medicine and healthcare – their current concepts, methods, contributions
and limitations.

• Courses in anatomy, molecular biology, biochemistry, and immunology
should be shortened and their principles incorporated into longer courses
that focus on knowledge and skills in recognizing and counseling
individuals and populations about genetic, familial, and occupational
influences on susceptibility to illness and disease and on the rationales
for pharmacological, procedural, and behavioral interventions with
emphasis on their relative efficacy and costs.

• For each patient assigned, the student should turn in a report of
the charges for the admission and a statement of the costs of the
treatments prescribed on discharge for the next year or fraction thereof.

• A short (1-3 months) course should be given by a safety engineer
from the aviation industry explaining how “near misses’, errors, and
catastrophes are reported and managed.

• All medical curricula should include a substantial required
lecture/reading/study/essay course on both the history of the scientific
method and the history of medicine.

• All medical curricula should include a substantial required
lecture/reading/study/essay course based on the humanities that bear on
pain, suffering, deprivation, medical interactions, and living with
disability, and that includes works by physicians and nurses.

• All medical students should be required to spend at least two three
-month electives working as a generalist in a deprived area or in a
developing country – one each in urban and rural settings.

• Specialization should not start until after graduation and the
numbers of residents in an institution should be limited to those who can
be effectively mentored and supervised; the wisdom of the practice of
letting the residents/house staff “run the place” and “learn by doing”
should be reconsidered.

• The Health Information System should be based on patients’
presenting symptoms, complaints, problems, or questions using the
International Classification of Primary Care which can then be mapped to
the International Classification of Diseases as required in order that
episodes of care and the natural history of illness can be investigated
and monitored.

• The first year should include a substantial (6-12 months) exercise
where two patients, one with a chronic illness and another with an acute
disease, are presented and discussed or alternatively each student is
assigned such patients with the charge to write a paper using medical
journal standards that discusses how the illness was first labeled, what
the diagnostic criteria are, how it is coded, how many such patients there
are in the relevant city, county, state, and nation and how this
information is known by the health departments, what interventions are
used and the evidence for their efficacy, the costs of treatment those
afflicted individually and collectively in the relevant the jurisdiction,
who pays, and finally what is beingdone to limit the spread,
deterioration, and prevention of the condition and who is responsible for
each of these, etc.

• Starting in first year and continuing throughout the curriculum,
each student should be assigned one patient with a chronic
disease/disability who is followed regularly at home, and elsewhere if
indicated, and for whom a brief monthly status report is prepared.

• Curiosity should be stimulated by having each student submit a
brief annual essay discussing some facet of a disease, patient care,
intervention, health policy etc. for which no adequate explanation,
justification, or resolution could be found.

• Every student should be present for at least 3-5 encounters when
“good” news and 3-5 when “bad” news is given to the patient and/or
relatives.

• “Common” diseases are very common” and “Rare” diseases are very
rare.

• For the vast majority of diseases “caring” (more than the “placebo”
effect”) is at least half of the “cure”.

Kerr L. White M.D., klw2j@virginia.edu

Competing interests:
None declared

Competing interests: No competing interests

12 April 2004
Kerr White
Retired (Former Deputy Director for Health Sciences, the Rockefeller Foundation)
250 Pantops Mountain Rd, #5328, Charlottesville, Virginia, USA, 22911