What is missing in our clinical education?

Pervana Kaur – University of Karol Marnkowski, Poland, Second Year Medical Student

  • Runner up student essay competition

Clinical education has a standardized homogenous route that in a stepwise manner churns out naive medical students into knowledgeable practitioners. But not every individual undertakes this uniform steplike pathway with such ease and I believe that the current clinical education system is not always accommodating to individuality.

In terms of individuality in this circumstance I am referring to an individual’s specific experience and susceptibility to burnout during the transition between being a student to practicing as a doctor. In medical practice, the idea of ‘burnout’ and ‘psychological stress’ although known are not actively taught about and prevented within education. (Kumar, 2016) Yet statistically in 2020, there was a burnout rate of 43% among healthcare workers, but the clinical curriculum fails to teach the preventive measures to students so that burnout out isn’t such a common occurrence for when they enter the workforce. (De Hert, 2020) The disparity of understanding the need for preventive measures of coping with the high demands of being a physician, I believe stems from the ethos continuously held in medicine which is ‘failure to fail’. (Elton, 2018)

Burnout is not specific to clinical practice; it can occur in all types of profession but as Thomas Holmes and Richard Rahe identified some individuals are at a higher risk of developing psychological health problems based on challenging life events which can commonly occur in clinical practice. (Mind Tools content team, 2009) Maslach and Jackson describe burnout as a three dimensional construct of emotional exhaustion,depersonalization and reduced personal accomplishment, which creates a greater risk of making poor judgements and compromises patient care. As students in clinical education we are taught the importance of patient care and yet dismiss the integral part that a physician’s self care plays in this. (Maslach and Leiter, 2016)

Prevention is consistently emphasized in healthcare in all senses, the media is infiltrated with healthy living image posters for stopping smoking, reducing alcohol intake and encouraging exercise as it is considered the most effective method of improving the health of the population but preventing burnout is not considered in the same sense. (Elton, 2018)

Modifying the curriculum for students to be better prepared for burnout and preventing stress related risk factors including integrating coping methods that allow students to become better adapted to the work environment is needed. Integrating methods of burnout prevention strategies early in a students clinical journey will not only build resilience but also normalize awareness of burnout and will mean that doctors can easily recognise symptoms and know ways in which they can resolve them. Although stress prevention may seem such a simple concept, adding it to a career and education scheme that is driven by the ethos of ‘failure to fail’ can prove challenging. Adapting the curricula to continuously reinforce burnout prevention, is needed and is necessary in substantially improving future patient care. (Kumar, 2016)

The current medical system not only consistently misses the person centered approach in reference to ourselves as the future clinicians it also does not always focus on the patient. This is because universally clinical education has been largely based on a reductionistic biomedical model that teaches students facts regarding diseases and abnormalities of the body but glosses over the importance of teaching the experiences and behavior of an illness. (Branch, Jr, 2001) This statement however does not negate the fact that the biomedical model is necessary, as students it is necessary to understand that through studies and empirical evidence, disease has cause and treatments but this should be balanced with the biopsychological model proposed by Engel that more clearly reflects clinical reality. (Borrell-Carrio, 2004)

The biomedical model is a long-standing approach to medicine supported by Hippocrates in the approach to the physical etiologies behind diseases but criticism lies in its failure to distinguish the difference between disease and illness. Often students, especially in pre-clinical years, reduce a problem observed in a patient to its disease’s pathomechanism and biomolecular background and are ineffective in understanding the experience of the illness.(Sadigh, 2008) I believe the quote by Cassell effectively explains this as ‘One cannot expect doctors to attend to sick persons as persons if they cannot describe them’. An illness is not just the physical change that occurs within an individual but it is the multitude of feelings, behaviors, and perceptions that make it so subjective.(ÁRNASON and HJÖRLEIFSSON, 2016)

But how can we mitigate the reductionist approach used in medical schools worldwide, one of the biggest things I believe that can be explored is developing case based learning in all parts of preclinical studies, the well known phrase of ‘putting a face to a name’ is a great example of how medicine is best taught through the lens of the individual who burdens the disease. This is not just viable in classroom settings but in the textbooks and medical literature which are used as sources of learning, each topic should be presented in relation to the clinical setting that it could be seen in. My own personal example of how effective this was during my first year of medicine, I was tasked to create a presentation on the biochemical process of Lesch Nyhan Syndrome. Having no previous knowledge of this disease, I reviewed the mechanism of the disease through medical textbooks and internet articles but it was only through a documentary that explained how this syndrome affected a 7 month year old baby and the effects that it had on his family where I was able to fully contextualize this syndrome. To date, this has been one of the most fascinating aspects of medicine which I have learnt about, because I am able to relate this individual’s experience to a complex biochemical pathway.

Person centered approaches to clinical curriculum are seen in today’s modern medicine with the development of osteopathic curricula which emphasizes the role of holism in medicine. Although principles are similar to the Hippocratic Oath, the Osteopathic oath’s main principle entails that the ‘body is a unit, the person is a unit of body, mind and spirit’, they have the intention to include all aspects of the patient, not just the symptoms. This approach will be useful to integrate into many more medical curricula worldwide rather than the select few, they produce students who are able to approach clinical scenarios more easily and regard cases as integrated pathways to reach a successful decision. (Advocatetanmoy, 2022)

In conclusion, clinical education is largely missing the centralization of the person in their approach especially in pre-clinical years. Medical education should never be as clear cut as learning symptoms and facts and students should be offered a chance to learn how medicine, socioeconomic status, thoughts and feelings can all combine together. Holistic medicine not only cares for patients as an entirety but also supports the student in their clinical pathway and so therefore in my opinion is a superior learning technique in medicine. (Rajendran, 2021)


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