Are we teaching medicine upside down?

In many ways, the way we teach medicine is inside out and upside down! We meet our first patients tucked up under white sheets wearing their pyjamas. We quickly become experts in pathology and diseases, and we start to define our patients by the disease they have – the man with the chest problems in bed 7, the woman with delirium.

But who are our patients, what kind of lives do they lead, where do they live, who is in their family, what has brought them, now today, to this ward with this illness?

The reality is that health and healthcare start in the community we live in and are closely related to who we are and our choices in life. Patients don’t start off life as patients, but people each living a unique life and having a unique set of environmental and social factors which influence the disease pattern they present with. Our training teaches us to use clinical guidelines which categorise our patients into groups and sub-groups, often with little room to individualise care.

In truth is it possible to treat a patient without first fully understanding the person who, simply because they are accessing medical care, is now labelled as a patient?

Where does health start?

Where does health start?  Certainly not in the hospital or the doctor’s office. We know, of course, that health is significantly influenced by our genetic makeup. But epigenetics teaches us that our environment has a direct influence at a cellular level. I often muse over the fact that my health was influenced not only by my childhood environment and the health of my mother in her particular environment when she was pregnant, but back to the formation of the ovum that became me, way back when my mother herself was a foetus in my grandmother’s womb at the end of WW1. We know from experience across the world and from a historical perspective that changes in the social and environmental determinants of health will have a greater influence on mortality and longevity than any hospital intervention. Yet the way we teach and fund medicine does not reflect this.

We take our public health for granted

A few years ago I visited the museum in Haworth in England, now a beautiful little town set in the glorious Yorkshire dales, but once a dark mill town where the Bronte sisters were brought up. Then there was gross overcrowding. The water supply, contaminated by seepage from an overpopulated cemetery, untreated sewage and animal carcasses, seeped into the lower levels of basements where several families lived in overcrowded conditions. Infectious diseases were rife, infant mortality was high and few people lived over forty years. It was not hospitals or medicines that changed that. Today these public health issues are still relevant, but in first world countries we take them for granted until there is a natural disaster like a flood or cyclone. In third world countries the absence of such public health measures are reflected in disease morbidity and mortality profiles. In PNG where I worked as a young Paediatrician, my 100 bed ward was full of patients with infectious diseases – diseases best prevented by environmental changes and immunisation. In our neighbouring Pacific Island countries, we now see the diseases of more affluent countries becoming more prevalent, life style choices becoming increasingly important.

Our choices and the way we live affect our health

From the time of our conception, our mother’s lifestyle and later our own choices influence our health outcomes so that the most important decision maker when it comes to our health is ourselves.  An early memory from my student elective in West Africa was of the doctor almost crying in frustration when a mother of twins brought in her emaciated and dehydrated babies that she was bottle feeding because she saw that as the modern way. Lack of access to clean boiled water caused the death of those twins.

Later when I was working in PNG, a law had been passed which discouraged bottle feeding by making the purchase of bottles and formula illegal. A nurse I worked with told me how unfortunate it was that white women were unable to breast feed – she had never seen this done publically. So as the town paediatrician, it became important to me to demonstrate that this was indeed possible and when Maria, my daughter’s number 2 mother, took her to the market, when asked what this tubby baby was fed on she proudly answered “Susu bilong mama, tasol.” Only breast milk!

Putting the emphasis in medical training where it needs to be

There is no doubt that exponential advances in medicine have led to the depth and breadth of medical knowledge being daunting for any student, graduate or undergraduate and make it very difficult for educators to prioritise which areas should be covered in an undergraduate curriculum. Consequently, in medical training public health is often seen as relatively unimportant, when in reality it should be foundational to medicine. Too often in medicine we put our whole focus on treatment of established, often end stage, disease.

If ever we are to have an impact on the population’s health and on the health budget we have to focus on the epidemiology of disease and how to make changes at a so called grass roots level. Our students need to be aware that they will make more impact on the community’s health by ensuring there is running water, access to a healthy diet and functioning toilets than practising end-stage medicine. The WHO has found that health care systems where an emphasis is put on primary health care have better outcomes than those that do not – fewer people are admitted to hospital and mortality and morbidity are lower.

Individualising health care

Patients are people first before they ever become unwell. If we are to develop an understanding of their needs, of their beliefs, of barriers to adhering to recommended treatments, we first need to paint ourselves a comprehensive picture of who they are. Making this connection helps to foster a different level of doctor/patient relationship, to support shared decision making and to work together on an individualised management plan which better suits our patients’ needs.

If we are ever to effectively address the burgeoning epidemic of chronic disease, we have to see health and therefore Medicine not as starting when our patients are admitted, but far earlier than that. In the community we need to address all those social and environmental aspects which determine health outcomes. At an individual level we need to encourage self-care. Our training of medical students needs to be reviewed so that early on they have a global view of what health truly is.

The elderly man in bed 7 was once one of 8 children brought up in a mining community near Newcastle. His father died in a mining accident when our patient was 10 and he had to leave school to go to work and support the family and the family lived in relative poverty. As a young man he supported his wife and 5 children by working down the pit. He was conscripted into the Vietnam war and has a medal for bravery in action. He is not well off because he lost his savings in the economic downturn. He supports the 3 children of his younger daughter who died from a drug overdose. His wife has Rheumatoid arthritis and is now in a wheelchair and he cares for her full time. He has a passion for pigeons and is a lay preacher in the local Lutheran church… He is so much more than simply the man with chest problems in bed 7, a gruff old man with a sheet up to his chin.