Hilary Thomas On teaching the art of doctoring

Published: 12/08/2004, Volume II4, No. 5918 Page 21

As career structures go, medicine has its limitations. Take a bright bunch of teenagers who thrive on competition and start out optimistic and idealistic. Enable them to keep swimming upstream until their early 30s. Then stop. Cut them off in their prime.

No obvious place to go for the 30 years.

No wonder doctors are reputed to be unhappy. The lucky ones will knuckle down to develop their service. They may find research fulfilling, get some reward from teaching or find management, medical politics, even travel, fills a gap. But they remain recognisably in the same job.

Many medical schools continue to leave their graduates ill-equipped to respond to the protean demands of 21st century medicine. In a recent survey of consultants, asked whether they felt adequately trained for their job, 96 per cent felt this was true for clinical skills, 50 per cent in communication skills, 45 per cent in management and a meagre 5 per cent felt trained in team leadership skills.How did we get it so wrong, when medicine is now quintessentially about working in multidisciplinary teams?

A health system which can flex in response to technological advance, economic fluctuations and societal expectations will serve public health more effectively. A well-prepared medical workforce will accommodate, even foster, these changes - and the individual should remain fulfilled. So what of medical education - not just the five years at medical school, but the accumulated experience of decades? How do we introduce change as a modus operandi, especially when, like most professions, medicine predominantly attracts the risk-averse?

Much of medical education is structured around a model that is decades, if not centuries, old.

It may be trite to describe medicine as both an art and a science, but looking at medical education from this perspective is illuminating. Doctors are essentially pragmatic so the science - didactic, Cartesian and reductionist - is easier to teach and populates the curriculum readily.

The art, which is based on narrative and intuition and often unpredictable, demands communication skills, empathy, teamworking, leadership skills and an understanding of the importance of relationships. Small wonder it has had to fight for air.

Yet looking back two decades I do not remember the nerves of the brachial plexus or the fine detail of Krebs cycle but I will not forget being taught how to break bad news and resolve conflict, or those role models whose humility and self-awareness enabled me to recognise the power of the team.Most of that was learnt after qualifying.

The real challenge for medical education will be to cultivate change agency and entrepreneurship alongside an awareness of personal development needs. This could place doctors in the vanguard of innovation and service development. If it fails, doctors will continue to feel frustrated and marginalised and the service will change more slowly, in spite and not because of them.

Professor Hilary Thomas is medical director of the Royal Surrey County Hospital trust.