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On stepping twice into the same river: The wet feet ofDr. FellRivkah MathewsPublished online: 18 May 2009.

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On Stepping Twice into the SameRiver: The Wet Feet of Dr. Fell

Rivkah Mathews

In the middle of the nineteen seventies a slogan began appearing on motorvehicles in Victoria: 'the AMA makes me sick'. Discontent with medicalservices and medical practitioners reached high proportions. The Vic-torian president of the Australian Medical Association deplored what hesaid was unfair publicity: 'respect for the profession at large is not what itused to be.'

An investigation into patient complaints initiated by the AMA itselfrevealed ample reason for the growing mistrust of doctors. That doctors'rooms were overcrowded, their hours inconvenient, that they keptpatients waiting, were common complaints. Doctors did not listen prop-erly, were hard to understand, shrugged off problems as being trivial ('hebelittled me').1

Media reports repeatedly confirmed patient discontent: many doc-tors were seen as unhelpful and inaccessible.

The wife of a brain damage victim said, 'It took me four days to seehis doctor for ten minutes, during which he spoke in medicalterms I could not understand'... The mother of a child . . . hadnot been able to understand the doctor who attempted to explainher daughter's condition . . . He had scoffed at her when she triedto discuss different methods of treating her child. 'I was made tofeel stupid', she said.2

A specially commissioned article in the Medical Journal of Australia,'Anti-medical feeling', isolated two major complaints: patients saw doc-tors as authoritarian and non-caring. Challenged, doctors agreed readilythat patients should be full participants in the cure of their illness and thata holistic approach to medicine was desirable, but the writer took this aslip-service only. The deeper level of the complaints were not consideredand were not accompanied by change. 'Resentments linger on'.3

This I know, and know full well,I do not like thee, Dr. Fell.

How far was medical education responsible?In relatively early days the young colony of Victoria was blessed with

a flourishing Medical Society, its members having received their quali-

1. AMA Gazette, no 272, 1982, p. 33.2. Age, 22 June, 1981.3. Medical Journal of Australia, vol 2, no 3, 1979, p. 130.

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fications in British or European medical schools. Discovery of gold hadbrought the opportunists, and doctors had become perturbed about whatthey saw as an intolerable evil which

in the form of scarcely disguised quackery, parades itself beforethe public, penetrates the dwellings of the humble and illiterate,trifles with disease, and even abets the stratagems of death, whilstprofiting by heartless extortion.4

Legislative enactment to protect legally qualified practitioners was of pfessional and public importance, doctors argued.

Antipodean as may be, they felt no compulsion to cultural cringe.Setting up the Australian Medical Journal, doctors spoke of its great objectsand expressed the hope that it might be a vehicle of information speciallyvaluable 'both from its novelty and its local character'. Its first editorialspoke of the need for the medical profession to possess an organ of its ownwhich would 'embody its views and represent science and truth honestlyand fairly'. The Journal announced its intention of publishing the collec-tion of extracts from the latest European publishers, works containingrecords of all that was new and interesting in medical science. Notes onevery subject pertinent to medical science were to be collected and it wasintended that the 'peculiarities of disease in this country' be communi-cated to others:

we truly believe that medical science is not unfittingly or dishon-ourably represented in Australia . . . talented and highly giftedminds will be found to represent us fairly and satisfactorily in thescientific arena of the world.5

The scientific arena was stimulating: in the air was Darwin's challenge toestablished authority, soon to be followed by the great Claude Bernard'sseminal work on the transformation of medicine from empirical practiceto legitimate science. The ensuing decade produced Virchov, Koch,Pasteur, and Lister, consolidating the era of scientific medicine.

But while local doctors felt themselves capable of offering medicaleducation, no privately funded group or institution had the resources so todo. In 1856 the Victorian government's decision to set up a Universitylaunched the first medical course, where instruction was, said RedmondBarry, to be 'of the most liberal kind'. The 'gentlemen' studying for themedical profession should not only render themselves proficient in theparticular department to which they had directed their efforts, but shouldbe thoroughly acquainted with such other branches of literature as wouldgive an assurance that the mind, instead of being confined to one par-ticular kind of instruction, had received a liberal and expansive training.6

In a social milieu where the stumpjump plough counted for more thanliterature, the attributes of the liberal mind set out by Newman — free-

4. Australian Medical Journal, vol xi, January 1886, p. 51.5. Ibid., p. 48.6. Ibid., vol viii, July 1863, p. 230.

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dom, equitableness, calmness, moderation and wisdom — were of par-ticular value.

The genie of the medical school was Anthony Colling Brownlesswho, as Vice Chancellor, had pressed for the early opening of a school ofmedicine. Brownless was influenced by the more practical orientation ofthe Scottish system of medical education and was determined to develop aschool which combined an emphasis on the importance of clinical medi-cine with a commitment to the new scientific method.

The first professor of the medical school, George Halford, fully metBrownless' requirement that the man selected should be eminent for hislearning and a fluent and able orator, a man who would be an 'ornament'to the University and give 'tone and character' to the medical school.Halford's brilliant opening address — 'it was impossible to forget, to becallous to the fact', he said, 'that we were about to commence, for the firsttime in the southern hemisphere . . . a complete course of lectures onAnatomy, Physiology, and Pathology' raisea one criticism only:

I desire, above all things, to see a certain acquaintance with naturalphilosophy shown by the candidate for our medical and surgicaldegrees... so much as might interest a youth and teach him toreflect upon what he sees... he would be certain hereafter toapply his knowledge in the readiest and best manner to his prac-tice.7

Halford's interest in science was not a narrow one, nor did he intend hisgraduates to be scientists only: 'there might, very properly, I think, be asecond test, suited to his capacities as a man'.

The inaugural address of the first lecturer in the theory and practiceof medicine, James Robertson, applauded the requirement of the newlyformed General Medical Council of Britain that all medical students giveevidence of a degree in arts before being permitted to graduate.

Nothing can contribute so much to the advancement of Medicineas the accession of students to its ranks, whose minds have beenpreviously not only well disciplined and developed by a liberaleducation but at the same time stored with scientific facts . . . Theprimary object of all education, the improvement of the mind, iskept steadily in view . . . Students are encouraged to think andreflect, to examine and judge for themselves. This training of themind is especially necessary to students in Medicine.8

The undergraduate curriculum included the basic sciences — gen-eral and comparative anatomy, physiology, pathology, chemistry; theclinical subjects were taken in the teaching hospitals, and Halford's desireto strengthen the scientific content of medical studies was fulfilled in1873, when in the medical course natural philosophy was accepted as analternative to Greek and Latin, and two years later replaced them. It is a

7. Ibid., p. 231.8. Ibid., vol x, April, 1865, p. 99.

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tribute to its founders that the Melbourne faculty has continued along theBrownless/Halford path, scientific, liberal, adding subjects and Chairsaccording to necessities of relevance, contemporaneity and social respon-sibility.

Restriction on numbers entering the Melbourne medical schoolbegan in 1946 and by the end of the fifties the Murray commission intotertiary education recommended the establishment of another universityand another medical school. If the second half of the nineteenth centurysaw the dawn of scientific medicine, in the second half of the twentiethHiroshima signalled the blazing triumph of homo faber. Nowhere werethe possibilities of an alliance between science and technology morebreathtaking than in medicine. Dr. Christian Barnard's first heart trans-plant (by the grace of electronics observed not only by students but thewhole world) moved the image of the technocrat-surgeon closer to thegods. Pygmalion's Galatea had nothing on the twentieth century spareparts man.

R.R. Andrew, first Dean of the Monash medical school, while pay-ing due tribute to the achievements of technology in medicine, was in thatgreat tradition which preceded the division into C.P. Snow's two cultures.Committed to the liberal view, Andrew intended that the medical curri-culum should provide the setting in which students could learn funda-mental principles, establish habits of reasoned and critical judgement anddevelop a capacity to use these principles and judgements wisely.

Andrew was conscious of new directions in medical education: medi-cine was developing in what he described as two great encircling move-ments, the behavioural sciences and molecular biology. The behaviouralsciences needed disciplined research, using the raw material of a dynamiccommunity, and the growing involvement of the biological sciences inthe molecular level of the basic sciences needed an inter-disciplinaryapproach. The practice of medicine he saw as changing towards co-operation; the doctor, although the focus perhaps of health care anddeployment in the community, was to become a member of a team.

How, then, was scientific medicine within the liberal framework tobe taught? How was the mind to be trained? How were habits of reasonedand critical judgement to be developed?

The liberal commitment was not intended as a commitment toabstract theorising. Halford's speech was intensely practical, if florid, inhis sketch of the field of study and in his advice to students. Robertsonwished his students to acquire that practical knowledge which could onlybe gained by close observation and careful examination at the bedside inhospital wards. Edward Barker, in his inaugural lecture for the surgicalcourse, recommended that his students not spend too much time readingbooks. 'Seeing and examining will be more useful to you than reading'.For his part, Richard Tracy, one of the founders of the Women's Hospitaland the first lecturer in obstetrics and the diseases of women and childrentold his students:

You must study medicine very differently from the way you have

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studied more exact sciences. No amount of book or purely theor-etical knowledge will do; you must become learned in the dailypractical details of hospital, medical and surgical practice.9

Melbourne's belief in a judicious combination of theory and practiceremained in place and was validated in 1910 by the seminal study ofmedical education conducted in the U.S.A. by Abraham Flexner. Learn-ing by doing was the first step in basing medicine on science, said Flexner,distinguishing three stages in medical education — the dogmatic, inwhich 'facts had no chance if pitted against the word of a master', theempirical, which lacked the techniques to judge between phenomena, toorganise facts or to check on observation, and the scientific, 'the severelycritical handling of experience'. Scientific medicine was concerned toexpel superstition, speculation and uncritical empiricism, and to base bothknowledge and practice on observation, experiment, induction. Sciencewas a matter of observation, inference, verification, generalisation. Medi-cine should not be seen as an art, for, if so, practitioners would be encour-aged to proceed with a clear conscience on superficial or empirical lines. Ifon the other hand the doctor stayed firmly with the view that medicinewas a science, this would help him clarify his conceptions and proceedmore systematically in the accumulation of data, the framing of hypoth-eses and the verfication of results.10

By the time Monash was established, this approach to education forscientific medicine had been further elaborated by the General MedicalCouncil of Great Britain and enshrined in the influential U.K. Todd •Report. (Brave new world as the Commonwealth of Australia might be,Australian medical standards were still being monitored by the GMG andthe Todd conclusions were of particular significance.) The essential objectof undergraduate education, Todd repeated, was to educate the student inthe medical sciences and in their application to human diseases. Themethods of science were to be applied in education, using techniques ofobservation and measurement which would yield data the reliability andvalidity of which could be systematically appraised. There was to bestrong emphasis on the methods by which data were obtained in psychol-ogy and sociology, demonstrating that human behaviour and social insti-tutions could be investigated by the established methods of science.

The World Health Organisation supported increased emphasis on'man himself in medical courses, urging the inclusion of psychology andsociology among the basic sciences. Psychology should be based onviewing the individual as a behaving organism in the context of family,work and society.

Its emphasis should be on the behaviour of the organism as adatum of biology, susceptible of eventual analysis by naturalscience methods that have been used elsewhere with success.11

9. Ibid., p. 114.10. Abraham Flexner, Medical Education: A Comparative Study, New York, 1925, p. 4 -5 .11. W H O , The Undergraduate Teaching of the Basic Medical Sciences, Copenhagen, 1968, p. 6.

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If the methods of science were to be applied to education in all areasof the medical curriculum, then it was necessary for educators to find amodel which would conform to the criteria of scientific method. (Thateducation had no other content or purpose apart from teaching theknowledge, skills and attitudes appropriate to medicine appeared to betaken for granted.) Extrapolating these to education meant seeing theconduct of education as something capable of accurate and objectiveobservation and measurement, committed to neutrality so that reliabilityand validity could be maintained.

The already established traditions at Melbourne and the directiontaken at Monash were congruent with this orientation. The content ofmedical education was seen as knowledge of facts and principles relatingto the structure and function of the human body, its disease processes andmechanisms, and understanding of the principles in the analysis of humanbehaviour and social functioning. The capacities and skills to be acquiredin applying this scientific knowledge in the analysis and solution ofproblems were summarised. At the completion of each component of thecourse, students should be better able to read published works critically, toidentify errors in reasoning, to use learning resources efficiently, to usejudgement in selecting information and concepts, developing balancedappreciation and reasoned argument, to analyse problems effectively andformulate solutions, and to recognise the importance of scientific methodin assessing the nature of problems and in formulating solutions tothem.12

As was to be expected, both faculties stressed the need for doctors todisplay compassion, empathy, sensitivity, to establish effective communi-cation with patients arid good relationships with colleagues. Educationwas understood as the utilisation of knowledge, the process by whichknowledge was acquired and applied. The model selected, thus empha-sising the development of cognitive skills, may be seen as what has beencalled a technology of the mind: the intellect, carefully sharpened, canably encounter any content, using its skills as tools in mastery of any areaof knowledge. Thomas Huxley, that truly liberal scientist would havebeen at home:

That man, I think, has had a liberal education who has been sotrained in youth that his body is the ready servant of his will anddoes with ease and pleasure all the work that, as a mechanism, it iscapable of; whose intellect is a clear, cold, logic engine, with all itsparts of equal strength and in smooth working order; ready, like asteam engine, to be turned to any kind of work, and spin thegossamers as well as forge the anchors of the mind.13

Developing the clear cold logic engine was assisted by acceptance of aneed to define objectives in ways by which outcomes could be observedand measured according to the rules of scientific method. Expressing12. These principles are a summary of material published in the medical faculty handbooks of both Univetsities and in G.G.

Schofield's article, 'Educational Objectives for the Faculty', Final year Magazine 1976, p. 13.13. Quoted in S.J. Curtis, M.E.A. Boultwood, A Short History of Educational Ideas, London, 1966, p. 448.

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all course and subject aims as clear direction to designated learnings andbehaviours was seen as an essential prerequisite of all educationalpractice.

This was straightforward enough in studies based on factualknowledge or motor skills; it was more difficult in non-technical areasand here the approach was clarified by the Royal Australian College ofGeneral Practitioners.

Used to train G.P. educators of new graduates entering family prac-tice, the RACGP postgraduate training manual, Focus on Learning, insistedthat it was as important to define behaviourally objectives in the affectivedomain as it was in the cognitive or psychomotor. It was imperative to usethe precise language of scientific method. Imprecise phrases — 'to know','to realise', 'to be aware of were to be replaced by more specific terms —'to write', 'to compare', 'to elicit response from' etc. Rather than statingthat doctors should be compassionate or concerned or able to solve pro-blems, doctors were to be asked 'to demonstrate (my emphasis) empathy,concern and compassion for patients', 'to demonstrate interpretive andproblem solving skills'.14 The assumption was clear: once observable andcapable of assessment, objectives were congenial to science.

For the hundred and thirty years since the establishment of our firstmedical school educators, faithful to the liberal intellectual vision, havebeen consistent in the commitment to develop the mental faculties of theirstudents. Following the rules of scientific method, scientific medicine hasthus been safeguarded from the shifting winds of subjectivity and partis-anship. Medical education has rested firmly on a harmonious balance ofthe scientific, the liberal-humane, the vocational and the sociallyresponsible.

Who could ask for more?An ungrateful public, apparently.The nineteen seventies saw not only student and community revolt

against what they claimed was a dehumanised medical course but anextraordinary turning to alternative, 'fringe' medicine, a burgeoning ofself help groups, the launching of a massively profitable health foodindustry and the phenomenal rise to best sellerdom of books on diet,exercise and/or meditation. Ivan Illich's notion of medical nemesis —that twentieth century doctors do more harm than good — gave an in-tellectual framework to public disenchantment: medicine, said RichardTaylor, was out of control.

Medical educators responded valiantly to the disaffection. Commit-ted as they had always been to the vision of a caring and sensitive doctor,they interpreted the difficulty as one of communication breakdown,stressing even more urgently the necessity of developing ever morerefined skills in this area. But the problem was not one of inadequatetechniques; it was the content of the communication which was wanting.Rapport and mutual respect, the basis for effective communicationbetween doctor and patient, have nothing to do with skill. The essence of

14. W.E. Fabb et. al., Focus on Learning in Family Practice, Melbourne 1967, p. 27.

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communication is that it is a social act, its meaning determined in theencounter.

Old woman, old woman, can you lend me a farthing?I'm sorry, kind sir, I'm very hard of hearing.

Old woman, old woman, shall I love you dearly?Thank you, kind sir, I hear you very clearly.

The humanisation of the non-caring doctors was interpreted bymany as redressing the imbalance between the affective and cognitive,between compassion and science, by including humane studies in curri-cula; an American educator argued that students could grow by partici-pating vicariously in a wide range of human experience not personally orimmediately available to them. True enough.

But how he appropriates such experience, how he develops theskills of maturity which he potentially can learn from history orliterature, are rarely part of the teaching. We believe such skillsnot only can, but should be taught, as the clinical humanistic skillsof the art of medicine . . .15

The humanistic skills were listed — awareness, perceptiveness, empathy,discrimination.judgement, tolerance, even-mindedness, dedication, com-mitment, self, awareness.

The Achilles heel of the process model was showing. These areskills??? Maturity is a matter of skill, to be demonstrated, measured, veri-fied according to the methods of science??? God help his patients and Godhelp Dr. Fell. Huxley's clear cold logic engine, trained in the techniquesof problem solving, could not bear the load in that crucial area wheredoctors faced patients as human beings rather than cases on which toapply their expertise and express the power bestowed by knowledge: 'hebelittled me . . . '

Was it time for Dr. Fell to find another river to step in, to hang hisclothes on a mulberry bush and not go near the polluted waters? Shouldhe, as the radical critics argued, jettison the liberal ideology, which servedonly to disguise the real nature of an unjust, uncaring and alienatingsociety, using medicine to perpetuate domination by apowerful elite? Didthe froth and bubble of liberalism serve as diversion from the dangerousquicksands in which doctors submerged patients by depriving them ofautonomy and accentuating their social powerlessness?

Yet who would want to dispose of the free, open and equitable mindprojected by Newman? Who would dispute that pursuit of sweetness andlight was not a legitimate aim of education? Who would want to support ahumanisation that undervalued science and rejected its struggle fortruth?

The doctors' dilemma was a real one which honing skills ever moresharply could not effect. Clues to its resolution lay in another sphere:

15. E.A. Vastayan, 'Among other things, art', in Geri Berg, (ed.), The Visual Arts and Medical Education, Carbondale,1983.

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educators needed a sense of history. Liberal/humane scientific medicinehad been seriously compromised by the alleged neutrality, objectivityprecision, consistency displayed by brilliantly trained doctors at the doorsof the gas chamber. Medical educators would never more escape theshadow of Auschwitz.

It cannot be argued that such matters are the concern of the doctor ascitizen, not as doctor, the Hippocratic Oath — to do no harm — and itsmodern equivalent, the Declaration of Geneva — by which doctorsundertake to serve humanity by the laws of humanity — are essentiallyto do with ethics, ideology and, in the end, politics. Indeed, as a socialpractice among human beings, medicine has always been a matter of pol-itics, for the humanity to be done no harm, to be served by the laws ofhumanity, has always been unequally dealt with.

From earliest records it may be seen that medicine for the privilegedand powerful has differed from medicine for the poor and powerless. TheHammurabi code of Mesopotamia included several laws pertaining tomedicine. If a doctor treated a freeman for a severe wound and cured him,he received ten shekels of silver, if the son of a plebeian five, and if a slave,the owner paid two shekels. It is unclear which category the doctor wouldhave preferred to treat, for monetary recompense for success was accom-panied by punishment for failure.

If a doctor has treated a man with a metal knife for a severe wound,and has caused the man to die, or has opened a man's tumour witha metal knife and destroyed the man's eye, his hands shall be cutoff. If a doctor has treated the slave of a plebeian with a metal knifefor a severe wound and caused him to die, he shall render slave forslave.16

In Greek times Hippocrates desired physicians to work for the ben-efit of the sick, but the community of the sick was by no means homo-geneous. Plato spoke of two kinds of physicians; the freeborn attended thefreeborn, slaves attended slaves — treatment differed radically.

The rigid stratification of feudal society meant that physicians, bynow trained in the medieval universities, ministered only to the higherranks of society, while the masses continued to rely on folk healers. In theeighteenth century only the very wealthy could be assured of the servicesof a qualified doctor, forcing the general public into the hands of moun-tebanks and quacks and the ubiquitous wise women.

The triumph of science in the nineteenth century allowed attentionto public measures which raised the level of health of all members ofscientifically-oriented western societies. Nevertheless difference in pro-vision of medical services persisted. The rich had access to well trainedphysicians, the poor to their own devices or the medical equivalent of thecarpet-bagger. In our own time health is seen as a universal right, but oneis reminded here of Anatole France's wry observation that both the rich

16. Albert S. Lyons. R. Joseph Petrucell, Medicine: An Illustrated History, South Melbourne, 1979, p. 67.

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and the poor have the right to sleep under bridges. The link betweencapacity to pay and access to doctors and health services is self-evident.

Injustice does not render the liberal mind obsolete. The issue here ishow the liberal mind, shaped within an unjust tradition and discrimina-tory practice, is to surmount its own socialisation. Pericles neither thoughthimself authoritarian nor felt himself uncaring in his vision of health asthat state of moral, mental and physical well-being which enabled man toface any crisis with the utmost facility and grace. For his slaves, of course,health was something different: Pericles' democracy had little to do withliberty, equality, fraternity.

Other pressures distorted Newman's pure vision, the difficulties fora liberal education being compounded by the location of doctors in ahierarchy, distancing them from patients. Social division in the history ofmedicine had its co-relative in the status of its practitioners.

If barbers and apothecaries were once held in contempt, by the timeof Melbourne's establishment surgeons and physicians had achieved socialeminence. In colonial life they were men trained for positions of respon-sibility, said a Dr. E.E. Mackay at the time, and they brought with themcertain ethical and social ideals which 'set a standard of conduct' in ascattered community. Many doctors held high positions in society — onebeing Mayor of Melbourne, another the first Speaker of the LegislativeAssembly, and, perhaps bringing even more cachet to the profession, twowere amongst the founders of the Melbourne Club and one of the VictoriaRacing Club.17 Their self-image was high; doctors saw themselves as

gentlemen whose education, abilities, acquirements and positionshould elevate them far above the meaner attributes of falliblehumanity.18

In spite of the democratic aspirations in the Victorian public educa-tion context, a hundred and forty years on doctors continued to occupy amuch higher place in the social hierarchy than the community they wereto serve. As students within a class biased university they were privilegedamong the privileged: in proportion far greater than their peers in theeducation faculties, a 1980 study showed medical students as coming fromthe highest social status parental backgrounds in income, occupation andeducation.19 ,

It would be pointless to pretend that, even in the country where Jackwas supposed to be as good as his master, such entrenched differentiationwas without effect. The AMA's own review of patient perception of doc-tors indicated that education could not neglect the influence of status.'I was made to feel stupid . . . '

Both medical faculties in Victoria have shared the hope that trainingin scientific method, emphasising problem solving skills and projectingparticular behaviours would create wide ranging and flexible and respon-

17. K.S. Inglis, Hospital & Community: A History of the Royal Melbourne Hospital, Melbourne, 1958, p. 29.18. Australian Medical Journal, vol i, January, 1856, p. 52.19. Education Research and Development Committee, Students in Australian Higher Education: A Study of their Social Com-

position since the Abolition of Fees, D.S. Anderson el. al., Canberra, 1980.

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sible minds. Yet science itself has moved on from Bernard's, Flexner's,even Todd's times. Here, too, education has something to learn fromhistory.

Thomas Kuhn's dismissal of the concept of science as an intellectualactivity free of ambiguities, Bridgman's repudiation of the 'ballyhoo'about scientific method, Feyerabend's mischievous but apt comment thatin science anything goes, the Medawars' contention that scientific methodis the potentiation of common sense, the implications of the theory thatthe study of matter itself is observer dependent lead to an understandingthat what you see depends on when and where you see it. It is no longerreasonable to ostracise a Harvey for his belief that blood circulates throughthe body. 'I not only fear that I may suffer from the ill-wind of a few, butdread lest all men turn against me.'

Science, as every schoolgirl knows, ain't what it used to be. Likebeauty, it has moved into the eye of the beholder: we observe and verifythat which our time and place permit us. A failure to come to grips withthe implications of changing notions of science leaves medical educationfirmly in the stifling embrace of scientism, the belief that the truly 'objec-tive' methods assumed to be used in the physical sciences offer a paradigmfor all other disciplines.

Yet Dr. Fell sees clearly enough the sermon in the stones lining thestream which carries him along. The aim of education for the practice ofmedicine, says the RACGP, is

. . . to promote the growth of wisdom — the intangible product ofknowledge, reflection, experience and understanding which per-mits the separation of truth from error, the significant from thetrivial and the greater from the lesser good.20

Wisdom, the intangible, judging what is good, have little to do withmeasurement, demonstration verification. Solomon knew that wisdomlay in reflection on the everyday experience of inconsistent, irrational,contradictory human beings. Proper use of the intellect transfers patientsfrom their role as data of biology, as objects of applied science, to teachersof what the eminent G.W. Pickering saw as an old fashioned but potentremedy for the disorders of medical education — common sense.

Medical education is suffering from historical myopia, preventing aclear view of its meaning in contemporary terms. Rather than looking tothe manipulatory techniques of an information society to overcome com-munication barriers between doctor and patient, medical education shouldtake account of history. Dragging to the surface ugly features in thephysiognomy of medicine might help doctors overcome covert assump-tions generated by socialisation within a class divided tradition. Further,history can reassure us that the chaste virtues of scientific method are notsubverted by seeing science in medicine as related to politics and ethics. Itis not paradoxical to understand scientific medicine as a human project,

20. RACGP, Training Handbook, Melbourne, 1974, p. 6.

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The Wet Feet of Dr. Fell

thus value laden and partisan. You act according to your philosophy.Doctors treat ailments according to theirs.

A concept of medical education as something different from a pol-itically influenced social activity burdened by particular historical tra-dition cannot help doctors shake off the shackles of medicine's ambiguouspast.

However important the sciences are to medicine, however mindblowing the possibilities of technology, medicine itself is neither sciencenor technology but a social relationship informed by science. 'Exposure tothe problems of human beings in the community is part of the orientationof the student to his scientific training and his future life's work' said theKarmel Report into medical education.21 Wrong. Exposure to the pro-blems of science is part of the orientation of the student to human beingsin the community. When doctors are trained to diagnose and resolveproblems in science first and then turn their gaze to their community, it islittle wonder they are are unable to focus accurately.

It was Virchov himself— and whose scientific credentials are moreimpeccable — who judged

the neglect of the history of medicine has produced that deso-lating circulatory movement in medical science which, almostwithout any metabolic changes, again and again produces thesame material.22

Breaking out of desolation means discarding notions of education as aprocess only, of itself sterile and void. Education for scientific medicine isnot the virginal handmaiden of science. Prime expression of a society,education carries conflicting aims, ideas, values and mores among whicheducators must choose, whether deliberately or, under the guise of neu-trality, by default. The purpose of all instruction, says Dewey, is moral:after Hiroshima and Auschwitz, learning to do no harm means learningabout the politics of medicine, learning how to frame the laws of human-ity in order to serve humanity.

Halford, we recall, was concerned with the doctor's capacity 'as aman'. Flexner wanted his doctors to work positively for moral as much asphysical well being: 'it goes without saying that this type of doctor is firstof all an educated man'. 'What matters most in education', said the GMC,'is not the knowledge imparted to a man, but what the man becomes in thecourse of acquiring knowledge'.

And there's the rub: what, in our time, is to be an educated man, aneducated woman, an educated doctor? One of the big questions, implicitwhen civilisation began and to be pursued until its end, perhaps perilouslynear.

In exploring.what matters most medical education does not need tothrow overboard its devoted commitment to science, its eager liaison withtechnology. Once the sciences fall into place as one way, perhaps the key21. Committee on Medical Schools, Expansion of Medical Education: Report of the Committee on Medical Schools to the Australian

Universities Commission, Canberra, 1973, p. 126.22. Quoted in Erwin H. Ackerknecht, Rudolph Virchov: Doctor, Statesman, Anthropologist, Madison, 1953, p. 146.

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Rivkah Mathews

way, for medical knowledge to serve humanity, other modes of knowingenter the field of medical education. The process model finds its appro-priate location, compassion is released from the straightjacket of behav-iourism and the liberal minded, scientifically knowledgeable doctors arefree to grapple with the problems of their responsibility to their demo-cratic community.

It is time for Dr. Fell to change horses in mid stream.

MeridianThe La Trobe University English ReviewARTICLES/COMMENT/REVIEWS/PHOTOGRAPHS/ILLUSTRATIONS ^

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Enquiries: The Subscription Department,La Trobe University Bookshop,La Trobe University, Bundoora, Victoria, 3083.

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