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versión impresa ISSN 1575-1813
Educ. méd. vol.11 no.4 dic. 2008
A patient called Dr. MacKee
Un paciente llamado Dr. MacKee
Director General de la Fundació Josep Laporte. Profesor Asociado de la Universitat Autònoma de Barcelona.
‘Because today I’m sick. Tomorrow or 30 years from now on, you’ll be sick’
Dr. MacKee to his first physician
The film The Doctor, directed by Randa Haines, shows how a physician, Dr. MacKee (played by William Hurt), experiences within his own hospital the same inadequate treatment he used to give his patients. Dr. MacKee is a prominent heart surgeon who is rather inconsiderate towards his patients until he suffers a throat cancer and discovers the importance of feelings and communication between physicians and their patients. Dr. MacKee learns from his disease what he didn’t learn at medical school or in his years as a physician: all doctors end up being patients. And therefore, the way you deal with your patients shows your house officers how you want to be treated when you become the patient. This is why the first thing Dr. MacKee does after going back to work is to have all his house officers stay in hospital for 72 hours as patients. ‘That way you can learn what they never explained to me,’ MacKee says to them.
The story of Dr. MacKee highlights some of the contradictions in the teaching of medicine today, the most important of which is perhaps the fact that patients have no say when it comes to defining the contents of the curricula in medical schools. In a society in which, in most cases, 85% of the cost of medical studies is funded by taxpayers’ money and most graduates are going to practise in the public health system, it seems logical to take into account citizens’ opinions about what their physicians should be like and which of their needs are the most pressing. To a certain extent those needs have been voiced in different qualitative studies conducted in recent years by different authors, including those carried out within the context of the Universidad de Pacientes.  Thus, both the Declaración de Barcelona de las Asociaciones de Pacientes y Usuarios and the Agenda Política del Foro Español de Pacientes deal with the model of physician desired by patients in Spain. In fact, point 5 of the ‘Decalogue’ calls for the following as a fundamental right: ‘specific instruction and training in communication skills for professionals’ and point 17 of the Agenda Política says that ‘medical schools should design curricula that are geared more towards meeting the needs of today’s patients and society by including subjects on ethics, health care policy, professionalism and physician-patient communication, as well as incorporating the patient’s perspective into teaching in the classroom.’ 
There does not appear to be a general feeling of distrust towards the medical profession in Spain, where trust in physicians and public health institutions is very high, in fact quite a lot higher than that expressed with respect to other professions and institutions belonging to sectors outside the area of health care.  In any case, we might think that, as Dr. MacKee so well expresses in the film, this trust really stems from vulnerability, fear and worry. Patients are in no position to adopt an attitude of distrust towards their physician or the institutions that are going to treat them. The relationship of power between physician and patient is therefore asymmetrical, the former having an enormous capacity to decide on what is going to happen to the latter. And the physician is the one who must adopt an attitude that reduces this asymmetry. Putting oneself in the patient’s shoes is the first great step towards making the relationship less asymmetrical, but this is something that goes beyond experience and knowledge. And therein lies the full power of the message conveyed by the film The Doctor and by its lead character.
The case of Dr. MacKee is an example taken to the extreme but, as he himself recognises in the film, we can begin to prevent similar situations if we look at things from the patient's perspective right from the beginning of our medical studies. It is difficult to question the fact that most students starting their first year at medical school do so out of a vocation they feel to care for and to be of help to patients. The fact that a degree in medicine takes more years of study than other courses, requires specialisation after graduating, calls for full-time dedication, has a very high minimum admission GPA and is not associated with high salaries all allows us to suppose that somebody wishing to study medicine is driven primarily by a vocational calling.
Now, vocation is a feeling that changes as time goes by, so that while studying medicine or, above all, when it comes to interacting with health care institutions in matters concerning diagnoses and the treatment of diseases, one may often get the feeling that that call to aid the sick is heightened or displaced. This mobilisation of vocational interests is influenced by a number of circumstances. Furthermore, medical studies deal with diseases and specialities in a vertical manner, without including transversal elements or the study of transversal aspects in the first cycle of the degree course, when students have still not come into contact with patients or health institutions. Moreover, this vertical structure has an influence on students, who begin to think about the ‘speciality’ they would like to take up instead of ‘the patients’ that they would like to treat.
As studies in medicine and surgery progress, the focus shifts from the ‘subject’ towards the ‘object’, which means that initially doctors treat illnesses rather than people. This becomes clear in the hospital when we speak of the ‘pancreatic cancer’ in room 227 or the ‘terminal’ in ward 6, rather than referring to the actual patient. As Dr. MacKee reminds one of his house officers, ‘terminals are for buses’ and ‘my patients have got names and surnames’. On the other hand, many students carry out their training at university hospitals, where the model of professional success seems to be far more concerned with research than with the quality of the health care or with teaching.
The situation of vocational shift described here becomes even more obvious when the exams that students must pass are, in most cases, based on diseases and force them to traverse a deterministic landscape that only usually admits five possible answers: a, b, c, d and e. Strangely enough, medical practice is by nature probabilistic, which means that the exam system used seriously perverts the training process because it forces the future physicians to think differently to the way pathological phenomena are actually produced. The exam system employed conditions the way learning takes place as well as the way physicians act in the presence of their patients, since a panoramic view of the patient in his or her context is replaced by analytical parameters and the findings of diagnostic imaging tests. This deterministic, reductionistic and algorithmic view of disease, and hence of the patient we have before us, can lead to biases and medical errors. The best way to prevent such issues from appearing is to understand how doctors think and to educate them to think in a critical and far-reaching manner . The sum of the details may confuse reality.
University education is essential for defining the model of professionals we want to have. And another aspect to be taken into account in the current model is the need to incorporate into the degree course a model of teaching based on clinical problem-solving and on teamwork. Using classes to impart knowledge that the student can read in a textbook is neither appropriate nor enlightening. In fact, classes should be spent on outlining situations and cases that students are going to find in their day-to-day clinical practice and the lecturer’s role will therefore be to guide students towards critical inquiry and the search for answers. This model of training requires both individual work, in which the tutors play a crucial role, and group work, because in the real world professionals work as a team and the contribution made by the whole is usually greater than the sum of the individual efforts. This last fact is important because both medical studies and the professional practice of medicine in Spain are very individualistic and competitive. As a patient, we prefer to have several people thinking about our case rather than having to rely on just one single opinion.
Finally, reproducing clinical situations typically found in a physician’s daily practice should include the presence of patients themselves as teachers. Fortunately, more and more patients are willing and able to contribute with their experience in hospital, and combining this with the experience of physicians is the best way to approach excellence in therapy. In fact, in Spain patients also hold their own medical conferences.  Thus, patients help to provide a view of the most important training needs of Spanish doctors in transversal areas (i.e. clinical ethics, physician-patient communication, literature, professionalism, patient safety, mourning, quality of health care, health care policies, and so on). At the same time, in the absence of solutions to such needs, these professionals are also a long way from being capable of satisfying the real needs of their future patients. To do so, we need a ‘patient-based medical education’, and achieving this involves having the courage to want to innovate and progress and so meet the needs of those that fund the greater part of public education. The problem of convenience and complacency in medical education is that they turn training into a rigid, bureaucratic and less significant activity. As a result and under these conditions, it becomes difficult to promote excellence. Moreover, a democratic society should be able to contemplate and implement a number of different alternative curricula, so that members of teaching staff and students are free to choose the ones that are best suited to satisfy patients’ needs. In a democracy, having a single curriculum only makes sense as something resulting from insecurity, fear and misunderstood authority. If society and patients are changing, physicians and their training should do so too. There should be no need to suffer a serious disease like Dr. MacKee in order to understand this, although that film should be shown in all medical schools.
Dedicated to the late Dr. Helios Pardell for his commitment to improving medical education in Spain.
1. Jovell AJ, Navarro-Rubio MD. Escuchando la voz del paciente. Gac San 2008; (Suppl 1): S192-7. [ Links ]