What gets us into trouble is not what we don't know, it's what we know for sure that just ain't so. - -Mark Twain
If he were alive today, Mark Twain could have addressed the above remarks to the culture of academic biomedicine. The biomedical worldview has too often dismissed other important perspectives on life in the quest for lifesaving discovery. However, recent changes in the objectives of medical education are forcing educators who emphasize the biomedical worldview to consider, if not incorporate, other worldviews in their curricula. All medical schools now expect medical students to demonstrate competency in social, behavioral, and ethical dimensions of medicine such as communication and awareness of gender and cultural bias.1,2 Despite these expectations, many medical schools struggle to fully implement curricula devoted to these domains. Meanwhile, the hidden curriculum further undermines these beleaguered aspects of professional development and propagates a biased view of what is really important in medical training.3
Educational objectives as well as the culture of academic medicine carry implicit and explicit assumptions about what is important in life, including assumptions about health and the practice of medicine. This philosophy of life constitutes a worldview from which biomedicine is practiced. As a first step in addressing the discrepancy between the attention paid to social, behavioral, and ethical elements of medicine (hereafter, the humanistic competencies) in contrast to the so-called hard sciences, it is important to describe the positive and negative philosophical assumptions of the biomedical worldview that dominates medical culture. Here we briefly examine the concept of a worldview, discuss the implications of worldviews for medical education, and briefly outline two ways that the concept can be practically interwoven into the structure of preclinical medical education. This exposure can promote appreciation of nonbiomedical life perspectives and enhance physicians' self-awareness and the altruistic aspects of their professional development.
What is a Worldview?
Worldview means a philosophy of life that answers all the most fundamental questions of human existence.4 Derived from the German term weltanschauung (meaning view of the world), worldview is a way of naming the life perspective on which one approaches problems, looks for solutions, and thinks about life options.
Do worldviews similarly affect the practice of medicine? In the early 20th century, Sigmund Freud discussed the importance of weltanschauung at length. According to Freud, worldviews are inescapable features of human existence. In Freud's understanding, there were two predominant worldviews from which most life perspectives were shaped, the scientific worldview and the spiritual worldview. He argued that one is a believer either in a spiritual worldview, which ascribes human existence to a transcendent being, or in a materialistic (scientific) worldview, which ascribes human existence to chance. Both worldviews use assumptions about human existence that require faith.4 Freud believed in a materialistic worldview (i.e., the belief that the material world is the sum total of reality) and worked throughout his career to convince others that a spiritual worldview found in religion is childish. This approach also had significant influence on his clinical work as a psychotherapist. Because he saw spiritual worldviews as a neurotic projection, his work with patients sought to rid them of these pathological neuroses.4
Growing awareness of diversity suggests there are more than two basic worldviews, even within individuals. One prominent contemporary example of someone with a blended worldview is Francis Collins, MD, PhD, director of the National Human Genome Research Institute, whose firm commitment to a scientific intellectual perspective is informed and enhanced by his deeply held religious beliefs.5 Individuals may combine elements of different philosophical and spiritual traditions to craft their own life perspectives. Although most of medicine does not deal so directly with assumptions about human existence, nevertheless one can see from the example of Freud that explicit beliefs and implicit assumptions about human existence in one's profession and can shape the conduct of professional work.
Arguably, the biomedical worldview as the dominant professional cultural perspective of clinical medicine holds its own philosophy of life that sees cure as a goal, disease as bad, mortality as a failure (or something to be avoided at all costs), and outlines a moral imperative to intervene to treat or ameliorate the suffering associated with disease whenever possible. When one combines these assumptions with the intense cultural immersion that occurs in medical training, it is easy to see how the biomedical worldview is the dominant perspective from which physicians and physicians in training draw meaning and purpose.6
The Implications of Worldviews for Medical Education
The implications of worldviews touch many aspects of medical training and practice. According to Burger,7
It makes a difference whether an observer stresses the perspective of evolution, religious belief, social behavior, forms of communication, the measurable physiological, anatomical or biochemical characteristics, or other aspects. Furthermore, the uniqueness of the world of the individual, subjectively experienced, is not well accommodated in the biomedical worldview of care.
If students do not reflect both on the assumptions they bring to their training and also on the assumptions of the biomedical worldview, they may not gain sufficient insight into the biases that influence their professional development. Without such reflection, students risk getting into trouble-as Mark Twain warned-by steadfastly adhering to only one worldview without acknowledging that there are others, or by being unable to reconcile various worldviews when they intersect (or collide), as they often do in medicine.8
In the biomedical worldview, facts are external, material, objective realities that can be measured. This perspective regarding facts represents the legacy of Descartes, a philosopher who posited that the nonmaterial mind and the material body were separate. Because we accept that the material body is largely separate from the mind, we in modern medicine use our intellect to manipulate the body to improve its function. We consider the human body to be the primary object of our interventions, and improvement is measured with objectively quantifiable instruments.9 This mind-body duality has facilitated significant practical advances in medical technology in the last 150 years by allowing scientists and physicians to manipulate the physical world and thereby intervene in disease processes. However, despite growing psychoneuroimmunologic research demonstrating the limitations of a strong mind-body duality10 and attempts by George Engel11 and others to expand the biomedical model of health, biomedical assumptions largely persist.
Similarly, the epistemology (or theory of knowledge) and epistemological assumptions within biomedicine are fairly circumscribed. Drawing on biomedical assumptions about facts, the biomedical view of knowledge chooses certain preferred methods to gain knowledge. In this framework, mechanistic knowledge about molecular and cellular physiology are considered the soundest sources of knowledge. The results of highly controlled human experiments, such as randomized controlled trials, are also considered sound sources of objective knowledge, whereas the social and behavior sciences are euphemistically referred to as softer sciences (i.e., more subjective) and thus are considered less reliable sources of knowledge. Because of these assumptions about knowledge built into the biomedical worldview, any attempt to incorporate humanistic competencies into medical education understandably means fighting an uphill battle against the cultural mindset of biomedicine. Calling attention to these worldview assumptions in the course of medical training may ameliorate the limiting dimensions of the biomedical worldview.
The biomedical worldview has positive and negative dimensions. On the positive side, assumptions about facts and knowledge allow the trained clinician to think consistently and reliably with the tools of molecular biology, pharmacology, pathophysiology, and clinical epidemiology. These are indispensable tools in clinical medicine. However, the biomedical worldview fosters a vocabulary of problem solving that may inappropriately frame problems in a manner that leads to a doctor-centered approach to decision making and health care delivery that does not optimally meet patient needs. Furthermore, in the clinical training setting, a doctor-centered perspective can lead to disrespectful, degrading, or dehumanizing attitudes and behaviors. The related and well-documented adverse aspects of the hidden curriculum raise concerns about how trainees are initiated into the cultural perspective of biomedicine.
The assumptions underlying the biomedical worldview also have implications for curricular priority setting in medical education. In the biomedical worldview, the objective of medical education is to provide physicians with a firm basis to act diagnostically and therapeutically on the basis of the most recently acknowledged scientific results and to promote further research in all medical fields.9 Thus, it is common (although not universal) in the preclinical years for curricula to be designed featuring the objective/hard science course materials in the most ideal time slots, relegating the so-called subjective/soft science content to obscure and less ideal time slots, for instance, after grueling anatomy dissections or over lunch hours. In so doing, the culture of medical education propagates the hard-science worldview dominant at least since the reforms of Flexner and other leaders of medicine at the start of the 20th century. The power of this worldview in academic medicine often leaves deans scratching their heads about ways to better incorporate the mandated social, behavioral, and ethical competencies into precious curricular time!
Worldviews in Medical Education: A Modest Proposal
Our primary objective is not to judge which specific aspects of the biomedical worldview are positive or negative in medical education. Rather, we join the growing number of educators concerned for the fate of the humanistic competencies by calling for greater attention to the strengths and weaknesses of the biomedical worldview in medical education. Medical training could be enriched by expanding the professional worldview beyond the narrow scientific focus of the biomedical worldview. Many changes are needed in the culture of academic medicine if we as medical educators are to counteract the limited nature of the biomedical worldview and hold forth the positive, altruistic values of medicine as a profession. Here, we introduce two modest suggestions for the structure of undergraduate medical education that may call attention to the existence and importance of worldviews in the midst of the current culture of medical education. Because these suggestions can be adapted to meet educational objectives set forth both by the Liaison Committee on Medical Education1 and the Institute of Medicine,2 they are practical starting points for meeting existing medical education mandates.
A course: Foundations of Healing
Traditional structures of medical education focus on the basic biological sciences as the foundation on which biomedical training is based. We propose that before teaching the scientific foundations of medicine, medical schools begin with an introductory course describing the importance of worldviews for life as a physician and highlighting the intensive cultural experience of medical training. Such a course would stress the philosophy of science underlying the biomedical worldview, the epistemologies of other less conventional worldviews, and the humanistic orientation needed to become an effective healer. This course might be called Foundations of Healing.
The objectives of such a course would be threefold. First, it would introduce students to historic, altruistic, and virtuous elements of medicine as a way of laying a foundation for more specific learning topics in ethics, professionalism, and cultural competency. Second, it would include a basic introduction to biomedical assumptions about facts, knowledge, and reasoning as well as an introduction to other worldviews (e.g., biopsychosocial perspectives, alternative medical systems, etc.). Third, students would be introduced to the limitations of the biomedical worldview for life as a healer, with emphasis on its implications for personal and professional development.9 This anticipatory approach may help to inoculate students against the erosive influences of the hidden curriculum.12
Furthermore, such an introduction to key worldviews could foster students' reflections and awareness about their own professional biases that may eventually allow them to craft a more open and humble healing presence as they proceed through their training. The concept of the healing presence is grounded in the experience and phenomenological elements of practice and resonates with elements of care theory in nursing,13 and the relationship-centered care14 and self-care15-16 movements in medicine.
Others have proposed introducing specific life perspectives into the medical curriculum. For instance, Kligler et al17 describe how principles of integrative medicine can foster a greater awareness of complementary and alternative medicine and whole-person healing in medical school curricula. Such an approach would certainly help achieve much of the humanistic realignment of medical education that we and others are seeking.14-16 A Foundations of Healing course will provide an overarching philosophical context for examining the full range of worldviews (i.e., biomedical, biopsychosocial, psychoneuroimmunologic, spiritual, integrative, etc.) and the relationships between them. Such a course, we suspect, may more readily sustain appreciation of diverse worldviews in the midst of intense biomedical training.
Some may wonder about the wisdom of introducing students to the adverse aspects of the biomedical worldview at the beginning of their first year of medical school. Early in the first year it is too late to change fundamental character problems, yet too early for students to understand the practical realities of clinical medicine. There is also a legitimate concern that such a Foundations of Healing course may do little to mitigate the adverse effects of the biomedical worldview and the hidden curriculum in later clinical education. Nevertheless, we propose beginning medical school with such an introduction in the spirit of professional openness and transparency, while students' altruism is high and their receptiveness to the range of worldviews may not yet have waned. In our experience, students are burned out by the middle of their first year in medical school. That is why instilling in students a deep appreciation for the altruistic aspects of the profession (including the wonder of science, the opportunity for leadership, and the ability for practical service) and for the breadth and depth of a range of worldviews should begin as early as possible and be sustained throughout their training. As with other aspects of medical education reform, these structural changes should be evaluated empirically.
Horizontal strands
Trying to sustain awareness of worldviews can be quite difficult, given the inadequate attention to the humanistic competencies in medical school curricula. Because students are so quickly immersed within the biomedical worldview during their basic science years, they rarely emerge to encounter perspectives of patients and society whose worldviews may differ from that of biomedicine. To maintain the awareness of other relevant worldviews after the Foundations of Healing course described above, we propose humanistic horizontal strands. These would be structural elements of a longitudinal curriculum that intentionally interweave patient vignettes and case discussions intobasic science lectures to highlight the worldview perspectives and life experiences of patients (who, in many cases, may view life outside of a strictly biomedical perspective). Ideally, students would engage with those perspectives and experiences and appreciate differences between patient worldviews and the biomedical worldview in which they are being immersed. A curricular expert in social, behavioral, and ethical dimensions of medicine would serve as a liaison to basic science lecturers to facilitate development and incorporation of horizontal strands into didactic material. This longitudinal attention to multiple worldviews would simultaneously allow social, behavioral, and ethical objectives to be revisited within cultural correlation moments embedded in preclinical lectures, while accepting the existing time constraints of traditional preclinical curricula.
From Competence to Consciousness … and Back Again
We have proposed that current difficulties in achieving objectives in social, behavioral, and ethical domains in medical education exist in part because of the dominance and biases of the biomedical worldview itself. As educators look toward training the next generation in these critical dimensions of medicine, they should establish longitudinal curricular elements that encourage students to recognize their own worldviews and those of their professional culture, while simultaneously building their skill-based competencies in these domains. Such a four-year curriculum with an ongoing dynamic interplay between competency-building and consciousness-raising elements will give us a better chance of training the next generation of doctors in the human dimensions of medicine.
Acknowledgments
The authors would like to thank Charlie Wiener, MD, Pat Thomas, MD, Eric Bass, MD, and Jean Ogborn, MD, whose leadership and innovation on the Johns Hopkins Curriculum Reform Committee and professionalism curriculum galvanized the authors' interest.
Dr. Tilburt received fellowship support from the Greenwall Foundation and the National Heart Lung and Blood Institute during part of this project.
Disclaimer
The views presented are those of the authors and do not represent the positions or policies of the National Institutes of Health or the Department of Health and Human Services.
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