Despite its relatively high health care spending rate, when compared with other developed countries, the United States ranks close to the bottom on nine health measures, including diabetes, obesity, and heart disease. The United States’ relatively poor record on these health measures is not due to the quality of the health care provided but, instead, is due to factors that restrict access to care, primarily income inequality and poor social mobility.1
That medical students should engage with pressing social issues like inequality (i.e., the unfair distribution of capital) and inequity (i.e., not providing a level playing field) in areas such as gender, sexual orientation, race and ethnicity, domestic violence, sexual abuse, and child abuse is accepted, as these social issues can present as health problems. How medical students should study these issues, however, is another matter, one that is discussed with extreme sensitivity, eloquence, and insight by Drs. Kumagai, Jackson, and Razack2 in their article “Cutting close to the bone: Student trauma, free speech, and institutional responsibility in medical education,” which appears in this issue of Academic Medicine.
Kumagai and colleagues question the practice adopted by some universities of using trigger warnings or statements indicating that the material covered in a class may be upsetting. Proponents of this practice argue that if sensitive issues, such as rape, are to be discussed, students should know in advance, as victims of rape might be retraumatized when they revisit the experience during the class. Kumagai and colleagues, however, suggest that trigger warnings do not distinguish between psychological trauma and discomfort. No medical educator wishes to cause trauma for a student, but exposure to discomfort, including conflict and ambiguity, is crucial to learning to be a doctor. Exposure to the discomfiting sights, sounds, and smells of pain and suffering is inevitable in clinical learning. In addition, medical students must learn that these symptoms often can be products of social injustice. They must gain insight into the relationship between power and privilege and health and illness, and reflect on the fact that, as doctors, they will occupy a privileged social position. Such consciousness raising must be an integral part of the medical school curriculum, beyond the tired principles-based ethics lessons that many schools already provide. Until the early 17th century, consciousness referred to moral conscience, but educators must expand this definition to what Paulo Freire3 called a “critical consciousness” or a “reading of the world.” Raising students’ critical consciousness will allow them to sensitively gauge the positions of others and to engage in dialogue to address issues such as inequality and inequity so that previously silent and silenced voices can be heard.
Education to foster this critical consciousness in medical students must be carefully designed. Just as medical interventions can have unintended consequences (“iatrogenesis”), misjudged or mismanaged educational interventions also can cause harm (“educational iatrogenesis”). A blogger who goes by the name “Ailsa”4 used the term educational iatrogenesis in 2008 to describe the unintended consequences of pedagogy as “damage to thinking, to learning, to connecting, to knowledge production.” Inequalities and inequities do not just affect patients “out there,” they also impact students in the classroom and clinic. In addition, microaggressions, or subtle put-downs, irritants, gestures, “unintentional slights,” and so forth, may stack up for stigmatized minority or marginalized students, who then must deal with the resulting stress.2 For example, women medical students (now just under 50% of students in the United States) may experience discrimination, including sexual harassment, especially in surgical contexts, that their male peers do not.
In working with students, faculty must develop extreme sensitivity to such issues. They must be good facilitators rather than just good teachers; they must treat the emotional currents in the classroom as important ingredients of learning. Sensitive regulation is also required. Drawing on Herbert Marcuse’s notion of repressive tolerance, Kumagai and colleagues note that free speech does not mean that all speech must be tolerated. The key question is: What voices are silenced by the privileged? Caring democracies are about deliberation and consideration, not everyone sounding off; and medical and surgical cultures, traditionally hierarchical, certainly cry out to be democratized in this way.
Developing a Considered Political Voice
Kumagai and colleagues propose “enhancing democratic dialogues” within a “courageous and inclusive curriculum” as a solution to the conundrum of how to create a critically reflexive medical education system. While nonhierarchical clinical teams and patient-centered practices are needed in our contemporary health care system, they work against the individualism and competition that traditionally have characterized the medical school experience and subsequent clinical practice of many doctors.
Faculty must learn how to create safe spaces for debates that shape students’ sensitive clinical practice. Building these spaces requires paying close attention to how students develop, exercise, and adapt their values—it is not teaching communication skills but, rather, nourishing students’ ethical capabilities through the articulation and fair redistribution of social capital (knowledge based, emotional, and ethical–aesthetic). Medical students must also learn tolerance and appreciation and gain insight into privilege (especially their own emergent privilege) and other power structures, while also learning how to resist the forces nurturing silence. By resisting these forces, students can encourage voices of protest, rather than foster injustice and insult. This resistance should not just be encouraged but actively taught to students. But are current faculty members up to this job when medical culture has traditionally drawn a line between health care and politics?
In politics—the study of power structures—the maldistribution of poor health as a consequence of social inequality is tied to hierarchy, privilege, and the exercise of sovereign power. We must recognize that health gains are often a consequence of brave acts of resistance against the status quo by doctors and politicians at the top levels. I believe, for example, that the Patient Protection and Affordable Care Act is one such act of resistance.
Given the importance of the relationship between social inequalities and poor health, is medical culture ripe for politicizing, for moving beyond the niceties of “politics with a small p” to “Party Politics” and considered ideological stances? Joseph Stiglitz5 argued that inequality is not just about economics but about politics too, where the wealthy hold the power to shape the markets through regulation and legislation. A key market today is health care, which simply cannot be left to market forces in which the already privileged have a head start over others. Regulation then is required, but it must not be co-opted either, by the already rich few who can perpetuate and increase inequality.
Doctors must be able to respond to the social causes of illness politically as well as clinically. This requires the politicizing of doctors, which historically has been anathema to the medical culture. In the United Kingdom, this issue has gained prominence recently. A series of strikes by junior doctors in England in the first half of 2016, culminating in a complete 48-hour strike supported by three-quarters of junior doctors and by the majority of the general public, suggests that the physician workforce has become politicized in a way that we have not seen before. (The term “junior doctor” covers all grades below the most senior level, so some junior doctors may have been in the workforce for over a decade.) These doctors on strike wanted to bring to others’ attention their worries about the creeping privatization and chronic underfunding of the National Health Service in the United Kingdom, and the way they chose to accomplish that goal was with a political action.
Creating a Reflexive Medical Curriculum
Inoculating medical students against educational iatrogenesis demands that medical school faculty be properly educated in pedagogy. While core faculty members may have to attend teacher education courses (now common in medical schools in the United Kingdom), and the more innovative medical schools may even provide teaching and learning courses for medical students, how the wider circle of clinical teachers learn these lessons in a culture that still relies heavily on the “see one, do one, teach one” apprenticeship model is still unclear. Facilitating students’ learning with expertise and sensitivity (rather than just teaching) adds another layer that moves well beyond what faculty can learn during basic teacher education courses. Instead, mentorship and supervision are also needed. In addition, faculty need expertise in psychotherapy—managing catharsis related to restimulated distress and emotional ability; working with the dynamics of transference and resistance; and adapting to “liquid” or “open” group process. Still, faculty members must know their limits and when it is necessary to refer students to more experienced counselors, psychotherapists, or psychiatrists.
Medical culture is notoriously hierarchical and authoritative. How can we counter this tradition and establish democratic pockets? First, where metaphors of the body as machine (e.g., How are your waterworks?) and violence and aggression (e.g., the war against cancer) shape the medical landscape, a new pedagogy of liberation must be implemented to generate and manage new metaphors to shape a more feminized, tender, and democratic culture. This shift requires careful, reflexive attention to language and performance in clinical and educational contexts. Next, individualism (“the heroic doctor”) must be replaced by the collectivism of patient-centered, interprofessional teamwork to create the environment within which political transformation to authentic democratic practices can occur.
While we can create safe learning spaces for facilitated dialogue around issues of social injustice—where ground rules for confidentiality and discussion are explicit—the hidden curriculum may counteract this carefully constructed but fragile safety net. In addition, microaggressions are more common in the daily lives of medical students than in the formal curriculum, as students gather in their various social and specialty groups. We must ask ourselves then how we can teach students to not close ranks within their specialties when incidents and accidents occur but to blow the whistle or resist in spite of the potential consequences. (At the time of writing this piece, junior doctors are the only health care group in the National Health Service who do not have automatic legal protection if they blow the whistle on poor care or dubious practices.) But, what reach does the formal curriculum have into the private lives of medical students as they develop their professional identities? And how does an agenda of political consciousness raising fit with the disheartening knowledge that cynicism, empathy decline, and emotional insulation still typically set in by the third year of medical school?
Kumagai and colleagues invoke Marcuse’s notion of repressive tolerance, reminding us that so-called free speech can be authoritarian and intolerant of difference and should be challenged in a democratic climate. Marcuse, who creatively fused the work of Karl Marx and Sigmund Freud, sadly is read little these days, but his insights are worth recalling here. He noted that we have replaced the moral order of art with that of technology.6 Contemporary medical education is fascinated by instrumental technologies, such as imaging techniques, which some have described in turn as the demise of the physical examination. However, the purpose of the bedside exam goes beyond diagnosing to cultivating human presence and touch as expressions of care—an art with a moral facet. To teach medical students this art, faculty should garner support from experts in drama, performance, and literature who already are familiar with the cultivation of critical consciousness. Here is the medical humanities’ place in the medical and surgical curriculum.
Critically reflexive politics, which medical students may find abrasive as they challenge their preconceptions, must be aesthetically tuned to be sensitive, gracious, formative, embracing, considered, and not crude and overbearing. Expert faculty facilitators must be thoughtful and caring citizens engaged in researching their own practices and values. Ethics, aesthetics, and politics then can come together in a reflexive medicine curriculum.