Almost three years ago exactly, I published an essay here on Synapsis titled “In Defense of Humoralism.” In it—to briefly summarize—I highlighted how common ways in which patients understand the etiology of their illnesses and formulate folk treatments can often be understood as humoralistic. Consequently, physicians dismiss these ideas as superstition, as they do not run congruent with our biomedical models for disease. I argued that rather than dismissing these ideas out of hand, physicians ought to engage with these other ways of knowing as a means to better understand the lifeworld of their patients.
Three years later, I want to return to that idea from a slightly different perspective. Today, I want to explore why medical trainees and clinicians often have such a difficult time engaging with the illness scripts and folk logics that many of our patients (and indeed, often we ourselves) use to make sense of their distress every day.
While a multifactorial issue, I believe that the structure of contemporary medical education encourages trainees and clinicians to be rigidly committed to the biomedical paradigm, to the exclusion of other ways of knowing. This has been detrimental.
As a whole, medical education in the twentieth century was devoted to training people of science. Of natural science. This is one of the key bequests of the Flexner Report of 1910. At the behest of the Carnegie Foundation, Abraham Flexner, a schoolteacher from Louisville, Kentucky, undertook the herculean effort of assessing medical schools in the United States and Canada. During the nineteenth century, American physicians were late to adopt standard “scientific methods” relative to European counterparts. Unlicensed healers and unaccredited medical schools represented a major impediment to the centralizing, modernizing, and scientizing aspirations of American allopathic physicians or MDs, as discussed in Paul Starr’s seminal The Social Transformation of American Medicine (1985). By identifying schools worthy of praise and those of scorn, Flexner articulated a vision as to how medical schools could reorient medicine along scientific lines in the new century.
While many pages could be written grappling with Flexner’s legacy, there were, I think, two particularly significant effects. The first was the standardization of medical education along German lines—namely two preclinical years focused on the teaching of basic scientific (chemistry, biology, etc.) content, followed by two clinical years in which students served as clerks in teaching wards in a hospital. That is, the Flexner Report advanced the idea that basic science was the bedrock for clinical science. The second major legacy of Flexner was the massive contraction in the number of medical schools, with disproportionate impact on schools training Black physicians with racist rationale. This lack of access has persisted into the twenty-first century, as Black and Brown students remain underrepresented in medicine over a hundred years later.
We should understand these two effects as inextricably linked. If we privilege the basic sciences as the most important, most objective and context-neutral way to know the world, we are more likely to sustain a structural unjust system that fails to see just how important social context is, even in—or perhaps especially in—scientific and medical ways of knowing. Not only does outsize emphasis on basic scientific epistemologies lead us to have fundamental mis- and dys-understandings of patients, but it also makes it more difficult to recognize the social inequities inherent in our system of practice, and more difficult for trainees to develop the toolbox necessary to make concrete change in that system. Being a physician—tackling medicalized racism, misinformation and mistrust, social and structural determinants of health, engaging with our patients’ diverse lived experiences—requires more than organic chemistry, after all.
In recent years, physicians have begun to recognize the limits of clinging to that basic sciences worldview, particularly as burnout and dropout have plagued the medical workforce. Scholars have thought about how best to “teach empathy” to students, and as a part of that process, many have begun to expose students to medical ethics and the social determinants of health. Despite this, the central dogma of medical education, if you will, persists: medicine is a natural science.
For that reason, we must radically reimagine the foundations of medical education. If we are to begin to address the deep structural issues that plague medicine as a social practice in 2023, that means first recognizing that the social sciences—as philosophy and as practice—afford real benefits to trainees on their own terms. Scholars have already written exquisitely on this. What we need now is a Flexnerian-magnitude paradigm shift to ensure that medical education empowers trainees to tackle the problems of this century, rather than relitigating the professional conflicts of two hundred years ago.
Medicine is a social science. Rudolph Virchow observed that 150 years ago. It’s about time that we train physicians that way.
Header image: The Flexner Report, 1910, Wikimedia Commons (https://commons.wikimedia.org/wiki/File:Carnegie_Flexner_Report.djvu)