Amy Paterson queries the absence of politics in the medical curriculum, and argues for its introduction.
Recently, my medical friends and I sat quietly sipping our drinks as the lawyers, sociologists, and economists in our friend group carried on an eloquent and detailed conversation which spanned the cracks in neoliberalism, the changing world order due to the war in Ukraine, and Clarence Thomas’s argument against substantive due process. Our silence wasn’t a symptom of a lack of interest or awareness, we later mused; we all consider ourselves to be engaged global citizens: we read the news, are actively involved in the broader communities outside our local hospital settings, and care deeply about issues that impact our world. But despite this, we didn’t feel as equipped as our peers to engage in nuanced political debate. It didn’t feel like “our business”.
I have found myself in these sorts of conversations often over the last year, as I take time out of the long clinical hours I am accustomed to as a South African doctor to pursue a research degree in the melting pot of cultures and professional backgrounds that is UK graduate education. This time-out has offered me an opportunity to reflect on how my non-medical and medical colleagues engage differently in these more complex, political-leaning discussions. How did this idea that politics is not our business (as healthcare personnel) originate?
Politics is medicine at scale
Rudolf Virchow, the renowned 19th century German physician, believed, “Medicine is a social science, and politics nothing but medicine at a larger scale.” The idea that the teaching and practising of medicine ought to be apolitical is then arguably a new one. While Virchow believed that an intimate understanding of the problems of society was core to practising medicine; today the governing sentiment is that people are more interested in how a doctor might suture the wounds rather than stop the gunshots. As a result, while our law and business peers are encouraged through their training to gain a broader understanding of the world, many medical institutes subtly (even if unintentionally) dissuade us from this form of engagement, encouraging us to focus on our pathology and immunology textbooks and leave such matters to others.
What happens when … we don’t know how to begin understanding the injustices of what we are witnessing, never mind addressing them?
But what happens when whole populations are ill, and the only medicine for them is policy change, and we haven’t the first clue how to go about advocating for such treatment? Or when a virus shuts the world down and the powers that be offer ventilators to some nations and hand sanitiser to others, and we don’t know how to make sense of the injustice? What do we do with the pervasive feeling of helplessness when patients lose autonomy over their bodies, but we have had it subtly built into our professional belief systems that the treatment we offer is not our decision to weigh in on?
While many of Virchow’s ideas on biology and sociology may be outdated, one thing seems to hold true, politics remains medicine on a larger scale; or, to invert his statement: medicine is just politics on a smaller scale. In fact, research has shown that the type of healthcare we tend to consider the responsibility of doctors, nurses, hospitals, and pharmacies accounts for at most 25% of all health outcomes, the vast majority depending, instead, on what are today termed the social determinants of health. This brings me back to the question of whether we, as healthcare providers, critically engage with the world around us that impacts the health of our patients more than our medicines ever could.
As the river flows
A recent qualitative study involving interviews with health educationalists and medical students highlighted some of the barriers to building critical thinking into existing medical curricula. These include linear-thinking dogmatism, curriculum overload, student anxiety and stress, and ineffective evaluation systems, to name but a few. However, alongside these barriers sit solutions. These include opening traditional education systems to review and criticism, increasing the attention paid to the hidden curriculum, formal recognition of critical thinking as an essential dimension in the medical educational process, and increasing participatory learning throughout medical school.
This is an artificial divide that supposes those who prefer to focus on the science of medicine won’t have to deal with the politics of the practice
Some may argue that this is a matter of each to their own, and the upstream determinants of health should be left to the public health specialists while surgeons, cardiologists, oncologists and the like are left in apolitical peace to focus on their medical textbooks. But this is an artificial divide that supposes those who prefer to focus on the science of medicine won’t have to deal with the politics of the practice, navigate research power dynamics, or advocate for their patients when required. It is akin to arguing that because someone is destined to become a liver specialist, they shouldn’t have to attend lectures about the kidneys at medical school. The two are inextricably linked. By becoming territorial about the upstream and downstream river analogy commonly used in public health, we lose the natural understanding of the river metaphor all together. That is, the natural response of someone living downstream who finds their water poisoned is not to simply trust that someone upstream will do something about it, but that they themselves will begin to look upstream and work alongside upstream residents to resolve the issue. The health of the river is the equal responsibility of all who live along it.
Exceptions to the rule
Others may argue that they know of doctors who are politically engaged and powerful advocates. But these doctors are the exceptions rather than the rule; and the narrative is usually that through having politically engaged family members, through pursuits outside of the standard course of study, or through sheer determination to overcome a feeling of helplessness, rather than through training at medical school. These doctors (the likes of Professor Lydia Cairncross, Dr Seye Abimbola, and Dr Ulrick Sidney) do, however, serve as examples of how health professionals can become a greater force for health equity.
Health educationalists may contend that most medical school syllabi today teach students about the social determinants of health. But these are mostly taught in the same way that the symptoms of tuberculosis are taught: as list recital rather than critical thinking. Similarly, while our tools for thinking analytically about differential diagnoses are carefully sharpened, our tendency and ability to think critically about broader issues are left in a field of neglect, and thereby systematically, albeit unintentionally, blunted.
There are some promising exceptions to this rule, such as Duke University’s patient first curriculum which aims to engage students with the social context and drivers of health from the first year of medical school, and the inclusion of systems-based practice as one of the US Accreditation Council for Graduate Medical Education core competencies. These examples are promising signs of a future filled with more critically engaged clinicians.
I am not suggesting that institutions should aspire to make all medical students world-class political analysts or debaters, but simply that all medical schools should, at the very least, be obliged to teach and encourage some form of engagement with the politics of health in the form of seminars and tutorials. In many senses politics is inseparable from our trade, and in teaching the practice of medicine, our educators owe it to us to inform us of the powers that govern it and how to interact with them constructively.
- This post was awarded a runner-up in the LSE HE Essays in Education Blog Challenge in June 2022 in the open category.
This post is opinion-based and does not reflect the views of the London School of Economics and Political Science or any of its constituent departments and divisions.