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"Philosophy of medicine as a core discipline for learning the theory of medicine.” Jonathan Fuller — Transcript

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0:00um so welcome back everyone um
0:03i'm very glad to welcome uh jonathan
0:05fuller
0:07for the next talk so jonathan is
0:09assistant professor in the department of
0:11history and philosophy of science at the
0:12university of uh
0:13pittsburgh and he works in philosophy of
0:16science philosophy of medicine and in
0:17particular his interests
0:19in the metaphysics of diseases uh
0:22philosophy epidemiology and
0:23evidence-based
0:25medicine so his talk today is entitled
0:29philosophy of medicine as a core
0:30discipline for learning the theory of
0:32medicine
0:34so um over to you john
0:38okay thanks so much harriet and thanks
0:40alexander for this kind invitation i'm
0:42glad we were able to do this
0:44although i'm sure it's been said before
0:46all of us would probably much rather be
0:49there face to face um nonetheless i'm
0:52very excited to share some of my
0:53thoughts around
0:54the role of philosophy of medicine in
0:56medical education today and i guess if i
0:58was to describe
0:58this talk um it's a bit
1:02maybe five percent autobiographical so i
1:04have some experience in medical training
1:07um i did medical school at the
1:08university of toronto
1:10have some experience in med and
1:12philosophical teaching in medicine
1:14um in the canadian context um
1:17and a little bit philosophical as well
1:20maybe 50 philosophy 5 autobiography and
1:2445
1:24miscellaneous okay so
1:29i mean this is a question that's
1:30probably been asked many times before
1:32but what exactly could philosophy of
1:34medicine offer for medical trainees
1:36and this picture here is a picture that
1:38i took from my view in the back row in
1:39medical school i was one of the back
1:41benchers
1:42um at this particular lecture the a
1:45medical education researcher was telling
1:47us about
1:48um when and how to slow down and think
1:51more analytically
1:52in medical training based on her
1:54research she's a surgeon scientist
1:56at the wilson center for health
1:58professions education research at the
2:00university of toronto
2:01where i spent quite a bit of time while
2:03i was finishing my
2:05phd in philosophy so here are some some
2:08suggestions that i often hear and that
2:10others have often put forward for
2:12philosophy of medicine and what it might
2:13offer
2:14ethics critical thinking skills
2:18providing a liberal arts background to
2:19round out a scientific medical education
2:22and virtues of humanity empathy and
2:26related virtues in that family
2:29and i i guess the first thing i'll say
2:31is yes
2:33but that these kinds of of
2:37values these the things that i'm
2:38listening on this slide here are not
2:40so specific to philosophy of medicine as
2:43the discipline conceives of itself
2:45in fact philosophy of medicine is often
2:47defined to us to exclude bioethics which
2:49is principally
2:50the discipline that teaches ethics in
2:51medical school and
2:53that deals with ethical problems in
2:54medicine more generally
2:56and i think the medical humanities and
2:59social sciences
3:00in general can do things like teach us
3:02critical thinking skills how to
3:04recognize our assumptions
3:05bring them to the forefront and
3:07understand their
3:08where they come from um provide a
3:11liberal arts background
3:13um and if we want to go to to topic or
3:16to disciplines like
3:18literature narrative medicine and so on
3:20are equally
3:21well placed to instill virtues like
3:22humanity and empathy
3:24so i think that philosophy medicine
3:27shares there's some redundancy with
3:29what other medical humanities and other
3:31disciplines can offer
3:33to medical education nonetheless i think
3:36there are some
3:36unique advantages
3:40to teaching philosophy of medicine in
3:42medical training
3:43and my talk will be focused on just a
3:46specific
3:48role for philosophy of medicine in
3:49medical training and that is
3:51to develop and teach the theory of
3:54medicine
3:55so i don't want to devalue these
3:58important other functions
3:59philosophy of medicine or other
4:01disciplines in medical education
4:03i'm just going to focus on this
4:04particular
4:07this particular value of philosophy of
4:09medicine so
4:10on the left here is a slide from a talk
4:13i gave not a talk
4:14a lecture i gave at the university of
4:16toronto to first-year medical students
4:19um this is a talk i gave sporadically
4:21over time
4:23sporadically because whether or not a
4:25talk on epistemology which was what this
4:27lecture
4:28lecture was about was considered
4:31valuable
4:31to the medical students very much
4:32dependent on who was running the
4:34curriculum at the time
4:36so there really wasn't a lot very much
4:38consistency there
4:39in terms of whether or not students were
4:41getting epistemology which i taught
4:43probably three times overall over the
4:44years that i was at the university of
4:46toronto
4:47in contrast i was a lecturer at mcmaster
4:50university in
4:52ontario canada for five years in which
4:55i consistently taught epistemology in
4:57the curriculum
4:58um and my experience at mcmaster was
5:01very different from my experience at the
5:02university of toronto
5:03i could share some some more insights
5:06about that later on the q a if
5:08you'd like but um the first kind of
5:09lesson that this taught me was that
5:11um you know medical education is not
5:13just this panacea
5:15the challenges that one institution
5:16might be different in the challenges at
5:18another
5:19and in fact even the kinds of medical
5:21students that one encounters in the
5:22classroom can vary
5:24quite considerably within a same county
5:27province or state um so students at the
5:30university of toronto were
5:31not so receptive at times to learning
5:34epistemology
5:35students at mcmaster university were
5:36very enthusiastic about it
5:39there might be some reasons for that
5:40again we can talk about that a bit later
5:43okay so when i'm talking about ethereum
5:44medicine what exactly am i getting at
5:47so my thinking is that when someone
5:49learns
5:50to do engineering they of course
5:53learn to do this partly on the job so an
5:55engineer will
5:57undertake really a lifelong learning
6:00like any other scientist or professional
6:03in which they will pick up all sorts of
6:05habits
6:07tacit knowledges heuristics and ways of
6:10being a good engineer
6:12but of course when they're learning to
6:13be an engineer they're going to learn
6:14physical theory
6:15they're going to learn certain methods
6:17learn to use certain mathematical
6:19apparatus
6:20become versed in certain tools and learn
6:22the norms
6:23of the trade one would think that in
6:26medicine we should be doing the same
6:27thing
6:28so of course you know clinical thinking
6:30and clinical reasoning is often said to
6:32be something that we learn by doing
6:34i think that's very much the paradigm
6:36for teaching clinical thinking in
6:37medical schools at least in the context
6:39of which i'm most familiar the
6:41uh the atlantic triangle of canada the
6:43u.s and the united kingdom
6:45but i think i think it's it's a fairly
6:48general fact that a lot of medical
6:49training happens
6:50on the job where even medical trainees
6:53themselves
6:54will have clinical experiences
6:56supervised clinical experiences where
6:58they're learning to do medicine
6:59learning by actual doing and practice
7:03and i think that's fine and i think
7:04that's right however
7:06i think it's at least i think it was
7:09surprising at least to me
7:10that there wasn't so much explicit
7:13education in the theory of medicine
7:15where i trained at the university of
7:17toronto so in other words we didn't
7:19really learn
7:20how we were supposed to go about
7:21thinking except by
7:24imitating other clinical thinkers
7:28i never learned you know what what the
7:29goals of medicine were um what the whole
7:31enterprise was about what the general
7:33approach to
7:34um medicine was why we were diagnosing
7:38what was really prognosis about how was
7:40treatment linked to diagnosis
7:41fundamentally
7:42i mean we learned through very specific
7:44examples like how do we approach
7:46a patient with chest pain but i couldn't
7:49really just through my training alone
7:50step back and think about what exactly i
7:52was doing and understand it
7:53in any clear or thorough sense
7:57i didn't know what health i wasn't
7:58taught what health and disease were i
8:00mean
8:00in one slide in one lecture the lecturer
8:03distinguished between sickness illness
8:04and disease
8:06i never really was was taught to
8:07understand and work with these
8:08distinctions
8:09um i really didn't i wasn't really
8:11taught what the different schemes or
8:13modes of reasoning were in
8:15diagnosis in treatment um nor
8:18um what the value of explanation was in
8:20medicine and the list can kind of go on
8:23so the point is that although i spent a
8:25lot of time in the classroom
8:27sitting there in the back row learning
8:29about the theory
8:30of physiology and
8:33um clinical epidemiology i never really
8:36learned what i would consider to be the
8:38theory of medicine
8:39which i understand as the core
8:41metaphysical concepts
8:43epistemic norms and principles
8:46and ethical norms and goals of of
8:49medicine
8:50and to the extent that i did learn about
8:51these things i sort of picked them up
8:53through
8:54inference and so you know learning to to
8:57think clinically
8:58was achieved a little bit through small
9:00group learning by dealing with specific
9:02examples and cases and a little bit by
9:06learning to kind of imitate my
9:08colleagues and my
9:09supervisors and this this was this was
9:12challenging for me because
9:13um there wasn't a cultural context in my
9:16institution in which
9:17um clinical educators would verbalize
9:19what was going on in their head when
9:20they were
9:21thinking about a differential diagnosis
9:23and making a diagnosis and trying to
9:25come up with a management plan they
9:27wouldn't often talk aloud
9:29so i was forced to make inferences about
9:31what the what the cognitive patterns
9:33might be and what the reasoning
9:34strategies might be
9:35and what the what the meaning of the
9:37concepts they were working with
9:38actually was okay so this this to me
9:42um is is somewhat somewhat of a problem
9:45um and it's a problem in part because if
9:48we don't
9:49make explicit the concepts principles
9:52and norms with which we're working
9:54we risk a number of things so we risk i
9:56think them being learned
9:58incompletely or not at all and also it
10:01sort of closes off
10:03some important aspects of medicine you
10:06know both to its trainees and to
10:07outsiders
10:09um so you know it's very i think it's
10:11very difficult for people to understand
10:13what's going on in in diagnosis in part
10:16because diagnosis is mainly just learned
10:17through
10:18doing and that makes it very difficult
10:20to scrutinize
10:21and indeed to improve upon it by doing
10:23research on diagnostic reasoning
10:25and seeking to improve our methods of
10:27diagnosis
10:28okay now of course there is some
10:30research on these areas
10:32research that comes from fields like
10:34psychology computer science
10:36and other areas so there is a developing
10:38research foundation for these things
10:40but my point here is that it's often not
10:43brought
10:44into medical education or at least in my
10:46experience it certainly was not
10:49okay so here's a here's a nice quote
10:51from um jerome casserer
10:53and um richard koppelman from
10:572010 in their book on learning clinical
10:59reasoning in which they
11:00try to seek a much more explicit
11:02approach to teaching the theory of
11:03medicine
11:04and they say that rather than teaching
11:05clinical reasoning in medical school
11:07teachers of clinical medicine have
11:08substituted standardized histories and
11:10physicals
11:11book chapters that list the myriad
11:13causes of individual symptoms
11:14an apprentice system in which the expert
11:16or the student is expected to imitate
11:18others
11:18formal approaches to recording patients
11:20problems and lockstep
11:22algorithmic charts for blind guidance
11:26so they go as far to say that basically
11:28students are not learning
11:29clinical reasoning because they're not
11:31learning a general and flexible approach
11:33to doing that
11:34now the theory of medicine for me isn't
11:35just clinical reasoning i mean
11:37it has to do with such things as the
11:38goals of medicine
11:40and important concepts disease illness
11:42health and so on
11:44um but but clinical reasoning is a core
11:46part of what i can seem to be the theory
11:48of medicine
11:49okay my point is that it's certainly not
11:52being taught explicitly
11:53and therefore really who knows what
11:56people are picking up
11:58okay now of course ethics is taught
12:00quite explicitly
12:01um from the 1960s and onward bioethics
12:04developed as a discipline
12:06and is now integrated into medical
12:08schools all around the world
12:10um why why did that happen i mean in
12:12part i think it's because
12:14um ethical or moral dilemmas are
12:17sometimes more easily recognizable than
12:19metaphysical or epistemic ones sometimes
12:22epistemic and metaphysical problems can
12:24masquerade as ethical ones
12:26but it's also not to say that epistemic
12:29and metaphysical controversies have been
12:31completely absent from medicine and
12:33medical training
12:34a big development happened in the 1990s
12:37when the evidence-based medicine
12:38movement
12:39came around and said look we're doing it
12:41all wrong
12:42we're using the wrong kinds of evidence
12:44and we need to restructure the way we
12:45think about
12:46evidence evaluating evidence and
12:48applying evidence in patient care
12:51okay when it comes to philosophy
12:53medicine philosophers and medicine are
12:54working on
12:55many of these concepts principles um and
12:58the stuff of the theory of medicine and
13:01really there are too many great examples
13:02of philosophers and medicine doing this
13:04um to name any one or two
13:07um so i think actually we do have
13:09something to offer with respect to the
13:10theory of medicine
13:11so let's do it so okay so
13:15again sticking to my own experience this
13:17was um
13:18a the title slide from the one lecture i
13:21had
13:22the one explicit lecture i had in
13:24medical school on the theory of medicine
13:26and what it was we were supposed to do
13:28when we hit the wards
13:30so focusing on clinical reasoning in
13:32this case so we see here some concepts
13:34from psychology system one and system
13:36two thinking
13:37pattern recognition some ideas from
13:39philosophy
13:40perhaps i remember the lecturer talking
13:42about the hypothetical deductive methods
13:45and then in the realm of treatments but
13:47the goals of treatment what it meant to
13:48heal
13:49control and relieve um and this was
13:51quite welcome from my
13:53perspective but again this was this was
13:54kind of one talk um
13:56throughout medical school and you know
13:58always as a medical student
13:59i knew that if there was just one talk
14:02on a particular subject
14:03it wasn't going to be important um
14:06that's just this is one
14:07one cue that you pick up as a medical
14:10trainee
14:10the things that are are foundational to
14:13being a doctor are the things that are
14:14integrated into
14:16many aspects of medical training so we
14:18have this idea
14:19um in canada of a spiral curriculum you
14:22have to learn the same things over and
14:23over
14:24and it has to be done in an integrated
14:25fashion otherwise it's not going to
14:28actually structure the way people think
14:29people think okay
14:36okay so the next question naturally to
14:39ask is what discipline should provide
14:41the research base for this theory of
14:42medicine
14:44and i want to stress that i mean if
14:45we're teaching the theory of medicine
14:46that
14:47teaching has to be grounded in good
14:49research just like teaching pathology in
14:51medical school has to be
14:52up to date and grounded in the best best
14:55pathological science
14:56is out there and the teaching of
14:58clinical epidemiology has to reflect
15:00um you know the best methodological
15:02innovations around
15:04study design and evaluation so here are
15:07some some obvious candidates that others
15:08have suggested
15:11evidence-based medicine bioethics logic
15:13computer science
15:14psychology the health humanities
15:16humanities generally
15:17and medical education research and so
15:20first again
15:21i'll be very democratic and say yes i
15:23think that all these disciplines have
15:24something
15:25important to offer in developing and
15:27teaching the theory of medicine
15:30so evidence-based medicine for instance
15:32has
15:33made some great strides in understanding
15:35how we evaluate
15:36evidence in health care and synthesize
15:39evidence
15:40um it's provided a kind of
15:42epistemological framework for thinking
15:44about evidence
15:46but as philosopher miriam solomon
15:48pointed out this epistemology is
15:50incomplete
15:52and um very explicitly so so
15:55evidence-based medicine doesn't claim to
15:57teach people how to think through all
15:59the problems that a physician faces
16:01um instead they're just concerned with
16:04really evaluating and implementing
16:06evidence from clinical epidemiology in
16:08the clinic
16:10okay so this is a this is a contribution
16:13for evidence for evidence-based medicine
16:14but it's a circumscribed one
16:16bioethics of course is uh importance um
16:19the way the bioethics is normally taught
16:21is well maybe you'll get a lecture
16:24in my experience on different ethical
16:26theories
16:27and then and really you know in many
16:30contexts in which i'm
16:31familiar bioethical training is quite
16:33practically oriented you learn some
16:35principles and approaches to dealing
16:36with ethical dilemmas or controversies
16:39and and solve ethical problems which
16:42of course is important um but there's
16:45much more to the theory of medicine than
16:47just
16:47ethics and solving particular practical
16:49problems
16:51uh particular practical bioethical
16:54problems
16:55okay logic um i mean clearly clinicians
16:58reason logic is the
17:00discipline that studies one way to
17:03understand is the discipline that
17:04studies
17:05reasoning good reasoning um and so
17:08you know i think there's a role for
17:09logic to play in identifying
17:11informal and formal fallacies that
17:13people commit and
17:15teaching people the difference between
17:16different kinds of reasoning
17:18but of course logic study things very
17:20generally and what we need really in
17:21medicine
17:22are our local patterns and schemes for
17:24reasoning and local principles for
17:26for reasoning well computer science
17:30can simulate clinical reasoning and then
17:32we can learn a bit about clinical
17:33reasoning in that manner
17:35um of course the you know
17:39a lot of excitement in computer science
17:40now is around artificial intelligence
17:43and arguably the role of artificial
17:45intelligence at least the way that
17:46research in this field is going at the
17:48moment
17:48is to either supplement or supplant
17:50clinical reasoning
17:51rather than to shed light on it so
17:54coming up with
17:55computer programs that can essentially
17:56replace some of the work that physicians
17:58do
18:00but i'm focused here on teaching
18:01clinicians the theory of medicine how to
18:02how to
18:03how they themselves themselves should
18:05think at least before the computers take
18:07over
18:08um psychology of course studies what
18:10goes on between the ears
18:11the clinical cognition some applications
18:14of psychology in
18:16clinical education have been teaching
18:18the kinds of heuristics and biases and
18:20cognitive mistakes that people make
18:22often derived from studies outside of
18:24clinical medicine
18:26you know in psychology undergraduate
18:28students and things like that
18:30um this i think is is important because
18:32clinicians do make
18:33all sorts of cognitive errors um
18:37but when i talk about the theory of
18:38medicine i'm really talking about
18:39something a little bit different
18:41than the kinds of mental shortcuts that
18:44clinicians make and the kinds of
18:45mistakes that they make
18:47talking about the kinds of concepts and
18:49principles that they should be adhering
18:51to in their
18:51in their reasoning okay so the health
18:54humanities generally
18:56have lots to offer but um but again i
18:58think different disciplines have
18:59different
19:00emphases and different um different
19:03things to teach a clinician so narrative
19:05medicine and literature and medicine
19:07can teach people about stories of
19:09illness experience of illness
19:11and perhaps it's been argued to teach
19:12people uh to be better at taking a
19:15medical history
19:16and better observers and and appreciate
19:19ambiguity
19:20and um nonverbal cues and things like
19:23that
19:24um which is important but not exactly
19:26what i'm talking about
19:27um on the other hand uh disciplines like
19:30medical sociology and medical
19:33anthropology can teach people to uncover
19:36some current cultural assumptions um and
19:39scrutinize them
19:40hit medical history can also in in a
19:42similar way
19:43um expose um some of the peculiarities
19:46or some
19:47assumptions of practice through
19:48comparison with the past and all these
19:50things again are important but i'll show
19:52you
19:52show you in a slide or two um exactly
19:54what i think philosophy of medicine can
19:56offer
19:58and finally medical education research i
19:59think should be mentioned here
20:01in a way it's kind of an emerging
20:02research field one that i
20:04um i had a quite a bit of exposure to
20:07while i was
20:08doing my phd it's an interdisciplinary
20:10that area that involves psychologists
20:13sociologists anthropologists clinicians
20:16and other methodologists who study the
20:18medical curriculum
20:19and ways of teaching people to be better
20:20physicians
20:22it's it's in that way fairly open-minded
20:25um and at least in many many places in
20:28which medical education research is done
20:31quite welcoming of research in the
20:33humanities and
20:34social sciences and i think its primary
20:36role really is to serve as this
20:38important bridge
20:39between a discipline like philosophy of
20:41medicine and
20:42um and medical education itself so
20:45medical education research can
20:46help us understand how best to teach the
20:49theory of medicine
20:51although in and of itself it really
20:53can't tell us what the theory of
20:54medicine is it has to rely on
20:55disciplines like philosophy of medicine
20:57to do that okay so i've said the word
21:01philosophy
21:02the term philosophy of medicine many
21:03times and many of you will know what
21:05this is
21:05but i just want to give you a sense of
21:07what i think the philosophy of medicine
21:08is all about
21:10um so with some colleagues including
21:12alex broadbent we
21:14very recently launched a journal an
21:15academic journal in philosophy of
21:17medicine
21:18called philosophy of medicine an open
21:20access journal
21:21hosted the university of pittsburgh and
21:24one of the main starting points for this
21:26journal was to define the philosophy of
21:28medicine in a very inclusive way
21:31when we talk about the contemporary
21:33history of this field many people have
21:35said that it kind of really gets going
21:38and growing in the in the 2000s
21:42when people like alexander byrd and
21:44others started hosting
21:45regular conferences in philosophy of
21:47medicine
21:48and when philosophers of science started
21:51to more and more turn their attention to
21:53epistemic problems especially related to
21:55evidence-based medicine
21:57and since then there's been a growth of
21:58interest in fields
22:00now for that reason that a lot of the
22:03recent growth and interest was from
22:04philosophers of science
22:06philosophy medicine is sometimes defined
22:07as a sub-discipline of philosophy of
22:08science
22:10one that studies specifically just
22:12metaphysics and epistemology of medicine
22:14as opposed to other topics like ethics
22:16and politics
22:18now phenomenology is often included here
22:20as well
22:22and maybe some other some other areas
22:25but it's often defined
22:26in a somewhat narrow way now when we
22:29were
22:30found in this journal we wanted to make
22:31it clear that we think the scope of the
22:32meta of philosophy of medicine should be
22:34broad
22:35just as the scope of medicine is broad
22:37and so we conceive of medicine as
22:38basically being
22:39you know not just clinical medicine but
22:41other health professions and
22:43it's self-concerned with all of the
22:44concerns of medicine it's
22:46medicine so health disease and so on
22:50and also if you really want to widen it
22:52going beyond health care itself but
22:53other spheres that influence the health
22:55of
22:56individuals in the public um like public
22:58health
22:59um and and really you know if we want to
23:02talk about the social determinants of
23:03health
23:03we need to talk even much more broadly
23:05about that
23:07okay so i think that you know so defined
23:10this
23:10this really leaves quite a lot of room
23:12for integrating
23:13insights from disparate areas of
23:15philosophy
23:16uh into medical practice because while
23:19medicine is certainly scientific um
23:23i think that it's not i think i think
23:25that at least
23:26arguably it's not just an applied
23:30science of
23:30applied clinical epidemiology um
23:33pathology and other medical sciences
23:36okay so then now that we have some some
23:39sort of grips on
23:40the vast scope with which we can
23:42understand philosophy of medicine
23:44why should philosophy medicine serve as
23:45a core discipline if not the core
23:47discipline for developing and learning
23:49the theory of medicine and
23:52my first answer to this is okay so well
23:55you know physics is the science that
23:59at least in part helps to develop the
24:01theory of engineering
24:03through providing physical theory
24:06and when i told you already that i think
24:09the theory of medicine consists of
24:10metaphysical concepts
24:12epistemic principles patterns of
24:14reasoning
24:15ethical ethical norms and goals for
24:17medicine
24:18and these things metaphysical concepts
24:21epistemology and ethics are exactly the
24:22things that philosophers
24:24study so in a way i've i've set up my
24:27understanding of the theory of medicine
24:28so that philosophy is the discipline
24:29that studies the theory of medicine
24:31okay but i'm not i'm not doing this in
24:33an artificial way because i really think
24:34that
24:35um you know i'll show you in a moment
24:37there really are important and
24:38fundamental
24:39concepts principles and norms for
24:42reasoning that physicians just have to
24:43know
24:44um how to do and that philosophers of
24:45medicine um in fact
24:47currently study so my first answer was
24:49that philosophy of medicine is just a
24:51research discipline that works on the
24:53theory of medicine
24:55another answer might be that um given
24:58the fact that all these other fields
24:59psychology computer science and so on
25:01are also relevant to understanding the
25:03theory of medicine
25:05philosophy medicine can also play an
25:06important mediating role here
25:08because philosophers are quite
25:09generalists in their in their thinking
25:12um you know philosophy is on some
25:15understanding just
25:16you know the application of good
25:18principles of thinking
25:19including argument and other tools to
25:22general problems in
25:23in that we encounter as
25:26as people in fact wilfred sellers
25:29defined it as
25:30um being that the aim of philosophy is
25:33to understand how things in the broadest
25:34possible sense in the term hang together
25:35in the broadest possible sense of the
25:37term
25:38i think this is important because
25:39there's a risk that it will be
25:41it will become unclear how
25:43evidence-based medicine and what it has
25:45to say about
25:45clinical epidemiological evidence um
25:49jives with what flaw with what
25:51psychologists have to say
25:52about cognitive errors and biases in
25:54medicine how do these different
25:56things fit together and philosophy can
25:58tell
25:59can answer that question also i mean
26:03a virtue of philosophy is that it can be
26:04both descriptive and normative
26:07so not only should we describe the
26:09theory of medicine as it currently is
26:10but we should seek to improve it
26:12we should just as other basic
26:15foundations of medicine develop over
26:17time
26:17theory of medicine should improve and
26:19develop too
26:20and finally philosophy i think at its
26:22best prices clarity and understanding
26:24um which is exactly what i think we need
26:27to when i argue that we need to
26:28explicitly teach the theory of medicine
26:30this is exactly what i'm getting at
26:31rather than implicitly gleaning what the
26:34theory of medicine is all about we need
26:35to clearly
26:36articulate it and teach people what it's
26:38actually about
26:40okay so on this slide you know i'm
26:43juxtaposing wilfred sellers with
26:44hippocrates why am i
26:46why am i doing that um okay with some
26:49hesitation i want to point out that
26:52if you look at the history of medicine
26:54it's not the case that
26:55the theory of medicine has just been
26:58either absent or has
27:02not been explicitly formulated in a way
27:04that's influenced clinical practice
27:06so in the western tradition hippocrates
27:09and the hippocratics
27:10explicitly formulated a theory of
27:11medicine that is
27:13a set of concepts about what makes for
27:15health and disease
27:17and a rich understanding of disease
27:19based on
27:20their naturalistic understanding of the
27:23human body
27:24and then a set of treatment principles
27:25based on this as well which essentially
27:27saw
27:27therapy as reversing the problems um
27:31which which is
27:32in which the ways in which disease
27:33manifested in the body
27:35um in case you don't know this took the
27:37form of a very a very simple system
27:39um humoral physiology and then
27:42humoral thinking came to influence
27:44medicine for thousands of thousands of
27:45years
27:46um so i mean hippocrates was a natural
27:49philosopher
27:51he came at the tail end of the
27:52pre-socratic period of western
27:54philosophy
27:55in which he was doing lots of
27:57speculative thinking about
27:59disease and human physiology and then
28:01applying that
28:02that thinking to a theory of medicine
28:04how physicians should go about
28:05understanding and treating
28:07illness and of course
28:10um you know for thousands of years this
28:12was kind of kind of became codified in
28:14medicine and in many ways was difficult
28:15to shake off
28:17um so what i want to what i want to do
28:19by suggesting that we we ought to
28:21work on and better incorporate a theory
28:24of medicine to medical teaching
28:26um is to basically improve upon what
28:28hippocrates tried to do
28:30and we're well placed to do that because
28:31you know since the period of
28:33pre-socratic
28:34western philosophy many branches of
28:37philosophy have developed
28:38quite well and so we now have ethics
28:41epistemology
28:42logic and many other areas in their
28:44contemporary form so in other words
28:46philosophers and medicine have a lot
28:48more to offer
28:49in terms of a theory of medicine
28:50thankfully than hippocrates did
28:54what i'm suggesting is that we need to
28:54develop a new theory of medicine using
28:57the best philosophical research we have
29:00okay so finally what are some of the
29:02topics what are some of the what are
29:03some of the forms that this
29:04theory of medicine will take so
29:08here i'm i'm showing a number of topics
29:11by way of a kind of sample curriculum
29:12for theory of medicine
29:15something that i've been kind of
29:16thinking about in recent years and
29:18months
29:19since i finished my medical training and
29:23i won't go into all these topics in any
29:24detail i'll focus just on disease
29:26illness diagnosis and diagnostic
29:28reasoning
29:29but just to touch on some of these other
29:31core topics
29:33which each might maybe serve as a
29:34lecture in
29:36in medical school in addition to being
29:38incorporated into medical training
29:39beyond
29:40that um on the topic of what is medicine
29:42we have to understand
29:43what it is that physicians do the goals
29:45and scope of medicine which i think
29:46you've heard a little bit about
29:48from alex broadbent this morning um we
29:51need to understand what's the general
29:52approach of medicine i mean
29:54why and why is it diagnose prognosticate
29:57and treat this evolved in a very
29:59particular historical context and why is
30:01this the approach
30:02of clinical medicine i think we need to
30:04understand the difference between
30:05different medical traditions
30:07alternative and scientific medicine and
30:08so on in order to provide some context
30:11for medical training
30:13then i think we need to teach very more
30:15broad and general
30:16ideas about what it is to reason what
30:19evidences
30:20values are how these things come
30:21together and how one ought to
30:24do clinical decision making and then
30:26return to these various topics in
30:28teaching
30:29specific um functions of the clinician
30:32so diagnosis
30:33prognosis and therapy
30:36okay so in the realm of disease illness
30:38and diagnosis
30:39um so one should learn um what's
30:42commonly a distinction between disease
30:44and illness and philosophy of medicine
30:46and learn about the different ways of
30:47thinking about disease from a concept
30:49perspective
30:50um i think there should be some
30:51phenomenology of illness to get people
30:53to appreciate the ways in which
30:55people experience their suffering they
30:57have to also think about
30:58the relationship between disease and
31:00explanation um
31:02mechanisms play an important role in the
31:04basic sciences
31:06my second year education in medical
31:08school uh the course itself was called
31:10mechanisms management management and
31:11manifestations of disease
31:13but i was never told what a mechanism
31:15was or the really the relevance of
31:16mechanisms to clinical thinking
31:18um empathy of course is an important
31:20role the clinician but there's an
31:22important gap between
31:23um first person's experience of illness
31:25and what for instance
31:27biomedical scientific explanations can
31:29provide
31:30and then one one also has to think about
31:32what function diagnostic categories are
31:34playing
31:34and what role they serve in perhaps even
31:36labeling patients as having a certain
31:38pathology
31:40some of the topics that philosophers
31:41themselves think about
31:44and then once we have these kind of
31:44concepts we can then think about about
31:46what it means to do
31:48diagnostic diagnosis what it means to
31:49reason diagnostically
31:51um so what role does a differential
31:54diagnosis actually play in medicine
31:55there's a kind of
31:57there's a kind of i mean to me i think
32:00it's a kind of myth that
32:01the reasoning process of medicine
32:03proceeds where
32:05you start with a clinical presentation
32:06you formulate a differential diagnosis a
32:08list of
32:09potential diagnoses that might explain
32:12the clinical
32:12presentation then you narrow this down
32:14into a single diagnosis and you make a
32:16diagnosis
32:17and then move on from there to provide a
32:19diagnosis in a treatment plan
32:21i think this model is highly simplified
32:24and
32:24i think it'd be better to kind of probe
32:27and acknowledge
32:28some of the ways in which it's much more
32:29complicated than that in clinical
32:31practice
32:32by looking at the goal of diagnosis
32:35and then we should also talk about
32:36diagnostic evidence the forms that this
32:38takes
32:39kind of applying some of the principles
32:41that we might introduce
32:42earlier with respect to what evidence is
32:44and and
32:46what are some of the the kind of norms
32:47of um what make uh
32:49of how medicine might be better or worse
32:52or how different pieces of evidence
32:53should come together
32:54in order to warrant a hypothesis
32:57we should apply those general principles
32:59to diagnostic evidence
33:00and to think about particular diagnostic
33:02reasoning schemes and here are just
33:04really some that just come immediately
33:05to mind
33:07both from my experience reasoning
33:09clinically but also from what
33:11philosophers of medicine themselves have
33:12have studied so this isn't meant to be
33:15um
33:16a definite proposal about exact things
33:18that one should teach in the realm of
33:19disease
33:20illness and diagnostic reasoning but
33:22just some examples of the kinds of
33:23things that might be important for a
33:24medical student to learn
33:26um um in order to
33:29think more carefully and critically
33:30about what they're actually doing when
33:31they
33:32diagnose
33:35okay so and really i'm sort of glad i
33:38didn't spend so much time on the
33:40specifics of what topics
33:42i think one should teach within a theory
33:43of medicine because i think
33:45raphaela did a very good job of that um
33:48but i do want to spend a bit of time
33:50talking about how we might go about
33:51teaching the theory of medicine
33:53and here i'm just going to offer three
33:54basic principles or ideas
33:56um so consistent with what i said before
33:59i think
34:00in part this has to be done explicitly
34:02so here's a textbook called learning
34:04clinical reasoning that i think serves
34:05as a pretty good model
34:06for how we can approach this um
34:09published by jerome cassero who was the
34:12editor-in-chief of the new england
34:13journal of medicine and
34:16helped to create a series in the new
34:17england journal of articles
34:20around topics like disease diagnosis
34:23therapeutic reasoning and other aspects
34:25of clinical thinking
34:27okay so they put this together in a book
34:29and the approach of the book was that
34:31the first 20 was laying out explicitly
34:34some of the some of the
34:35core ideas around topics like diagnosis
34:38and management
34:39and then moving into cases quite quickly
34:42cases in which they explored
34:44a real clinical problem that one of
34:47their colleagues had
34:48um encountered and then had an expert
34:50clinician think out loud about some of
34:52the reasoning that they took
34:53in in dealing with it and then finally
34:55kind of analyzed
34:57that this script that they actually
34:59transcribed
35:00and to pull apart some general patterns
35:03and general general
35:04um ideas that it illustrated from the
35:06first half of the book
35:08so you know where this fit in the
35:10curriculum i think alongside
35:12places in which um things like history
35:14taking and other
35:15very general basic skills are taught um
35:19in order to in addition to learning how
35:21to
35:22you know structure a medical history and
35:24think about the kinds of
35:26questions one might ask you also have to
35:28think about the purpose of this um
35:31this entire process and how the pieces
35:34of
35:34um evidence that you generate might
35:36actually be relevant to
35:39the diagnosis that you're considering so
35:42i think you know
35:43explicitly early on in the curriculum is
35:44one important place
35:46where the theory of medicine should be
35:48taught but i think it also has to be
35:50case-based and at least in some parts
35:52discussion based
35:54so case-based reasoning is basically how
35:57how clinical medicine is taught
35:59in the north american context now
36:00there's a there's an emphasis on things
36:02like problem-based learning
36:04case-based learning in medical education
36:07as well
36:08as in medical practice and academic
36:10health science centers
36:12um things like morning report in
36:14hospitals where one would talk
36:15where where clinicians gather together
36:17and talk about a case um clinical
36:19pathological conferences where they talk
36:20about
36:21again a case and what might might have
36:23gone wrong
36:24and these again are important context in
36:26one which one should reinforce
36:28an understanding of the theory of
36:29medicine um so one should flesh it out
36:31through particular examples and not just
36:33in the abstract
36:35and then and finally i think this is a
36:36bit specific to um
36:38philosophy and humanities generally i
36:41mean the way that um philosophy
36:43is done and taught is through discussion
36:46um so we explore different
36:48positions their strengths and weaknesses
36:50and the arguments for and against each
36:52um and i think so therefore to some
36:55extent some
36:56learning of the theory of medicine
36:57should also follow this pattern um in
36:59which it's and probably in small group
37:00settings people
37:01um discuss controversial topics um
37:05through explicit reference to the
37:07epistemic
37:08metaphysical or ethical problems
37:10underlying them
37:14now i think this is i think this is also
37:16a way of fostering an important
37:19skill of the clinician which is to
37:21recognize disagreement
37:22understand disagreement and and
37:25really to find a way to go on in the
37:28face of disagreement
37:30so you know there isn't consensus on
37:32every philosophical problem
37:34and yet i think we do make progress in
37:35philosophy by fleshing out the different
37:37positions
37:37the space of possibilities their
37:39strengths and weaknesses and
37:41um and getting a sense of the overall
37:42picture the state of
37:44a particular problem or field and i
37:47think that
37:48to suggest that um there shouldn't be
37:51ambiguity
37:52or uncertainty in medicine is just both
37:53patently false and dangerous
37:55um so i think that we have to
37:56acknowledge that just like there there
37:58is
37:59genuine controversy around um pretty
38:02much any philosophical problem
38:04there should we should present this
38:06controversy as a way of
38:08in a way that teaches people to
38:11get on while recognizing that there
38:13isn't um
38:15closure on the particular problem
38:19okay so uh like any good philosopher now
38:24it's time for me to talk about
38:25objections uh here's
38:27here's just a a recent photo in which
38:30somebody was
38:31delivering an objection to a talk i gave
38:32on nothing related to what i'm talking
38:34about today
38:35okay so i'm gonna run through a few of
38:37these objections and some preliminary
38:39um preliminary thoughts that i have
38:42because the first
38:43i think and some of these have
38:44definitely been talked about already
38:45today so
38:46um first one might say there's just no
38:48evidence
38:49to suggest that explicitly teaching the
38:52theory of medicine will make for better
38:53physicians okay so the first thing i
38:56want to say to that is a bit
38:57tongue-in-cheek um
39:00and that's what it what what is it you
39:01mean by evidence um
39:04and if you can't at least come up with
39:05some sort of answer to that question
39:07what you're looking for then i think
39:08that that self kind of argues
39:10in favor of what i'm proposing here that
39:13we need to be teaching
39:14people better about evidence and how to
39:16use it in clinical medicine
39:17but to be a little bit less
39:19tongue-in-cheek um
39:22you know i think it's fair to say that
39:23we don't have the kind of evidence that
39:25we often find elsewhere in medicine for
39:27various aspects of the medical
39:28curriculum
39:29there's a movement evidence-based
39:30medical education that wants to rectify
39:32this through
39:33doing clinical trials on medical
39:35education and there's an entire field of
39:37medical education research in which they
39:39study the medical curriculum
39:41using tools from areas like psychology
39:44and clinical epidemiology
39:46i say this to suggest that it's i don't
39:48think it's um
39:50in principle impossible in fact to
39:52generate an evidence base
39:54in order to um to justify what we're
39:57doing but of course
39:59when we're proposing any new innovation
40:01in a curriculum it's always going to be
40:02the
40:03the case that there won't be direct
40:04empirical evidence before we try it out
40:06for the first time
40:07so that might suggest that we need to
40:09pilot the curriculum in
40:10in small small subsets of a cohort
40:14um or once you introduce it in a certain
40:16year compare what happens to the
40:17previous year
40:18and so on and these are the kinds of
40:19approaches that we take at the
40:21university
40:22or used to take at the university of
40:23toronto whenever we were introducing
40:25big curricular changes and so i think
40:27it's our responsibility to study what
40:29impact these things have
40:31but you know as was already pointed out
40:33we have to clearly define what the
40:34outcomes we're actually interested
40:36are and and of course it's not going to
40:39be possible to
40:41in a few years determine what long-term
40:44impact
40:44this might have on on the development of
40:48of medical expertise
40:50that being said you know i don't think
40:52it's a very good excuse
40:54to say that because it's hard to measure
40:56and hard to study that we shouldn't do
40:58it at all
40:59i just think that it's a challenge
41:00that's not specific really to
41:03or not so specific to philosophy of
41:05medicine and faces pretty much any
41:07aspect of the medical curriculum
41:09and there is a field medical education
41:10research that seeks to get around this
41:12problem so i think we need to
41:14rely on our colleagues in that area in
41:15order to help us understand how we can
41:17better study
41:18the ways in which we can teach the
41:20theory of medicine well
41:22okay the second kind of objection is
41:24that
41:26it's often said that expert clinical
41:28thinking is
41:29automatic rather than analytic more
41:32similar to perhaps
41:33cycling than solving a math problem
41:37okay so there is automatic clinical
41:40thinking
41:41for sure um paradigmatically in
41:43diagnosis
41:44um people have studied this think that
41:48a lot of experts rely on
41:51shortcuts pattern recognition and
41:54all these other things that you wouldn't
41:55necessarily learn from a book
41:58so learn how to how to be clinical
41:59experts not through explicitly
42:02you know reading out a set of principles
42:04and applying them
42:05but they kind of learn to do this over
42:08a long period of time after training
42:10themselves on many many cases
42:12they they generate illness scripts or
42:15exemplars
42:16and then they use these to guide
42:17diagnostic reasoning there's a body of
42:19research on this topic
42:21and i think it's important um but i
42:23think you know i don't want us to over
42:24exaggerate
42:26um the the importance of um
42:29of what sometimes called fast or
42:30intuitive thinking
42:32at the expense of analytic thinking
42:34because it is the case that
42:36there is a lot of slow analytic thinking
42:38in in clinical medicine as well
42:40um and this might take this might take
42:43place within dialogue with other
42:45colleagues
42:46with the patient themselves and even um
42:48within a patient a physician's internal
42:50monologue as well
42:52so i think it's just a myth that there
42:53is no analytic thinking in
42:56in clinical medicine so that's the first
42:58thing i want to say
42:59um the second thing i want to say is
43:01that um
43:06so just just kind of defaulting to what
43:08clinicians currently do
43:10um isn't going to be good enough um
43:12because of course we should be striving
43:14to be better than that
43:15so you know it might be the case that
43:18clinicians currently kind of learn
43:20how to um be efficient and effective in
43:23doing diagnosis
43:24through accumulating experience um
43:28but are they reasoning the best that
43:29they could is there something we could
43:31be doing to point out how they could be
43:33reasoning better
43:34and i think one one kind of rationale
43:37for teaching
43:38some of the principles and the concepts
43:39explicitly is that it serves as a
43:41scaffold
43:42on which this experience can be built i
43:44think there's an analogy here with how
43:46um how other kinds of theory are taught
43:49in the medical curriculum
43:51so we learned things like anatomy and
43:52physiology and pathology
43:54pharmacology these days not so much
43:59because our inferences just take the
44:01form of
44:02kind of direct inference from you know
44:05physiological theory and there is some
44:06of that
44:08but oftentimes it what it really serves
44:10as is a scaffold
44:11in which to build clinical knowledge
44:14around science symptoms
44:15how they hang together um what what
44:18combinations they present what are their
44:19causes
44:20and so on so that we can we can then
44:23reason about the more direct stuff of
44:25clinical medicine which
44:27is our patient presentations um
44:30the kinds of evidence that one typically
44:32uses when they're making treatment
44:33decisions which takes the form of
44:35empirical studies and so on i think in a
44:37similar vein
44:38theory of medicine can serve as a kind
44:40of scaffold for building a clinical
44:42knowledge base and acumen
44:45and the last thing what i want to say
44:46about this on this point this objection
44:48is that
44:48what i'm talking about is not it's not
44:50just clinical cognition and clinical
44:52reasoning
44:53i'm talking about important concepts and
44:55broader
44:56a broader framing for medicine as well
44:59that that's
44:59conscious of um the nature of disease
45:02the goals of medicine
45:04and so on okay
45:07a second point might be that a second
45:09objection is that philosophers can't
45:10seem to agree on anything one might
45:12worry
45:12um and is this really going to be
45:14helpful if we're just
45:16um if we're just you know presenting
45:19let's say
45:20a natural um concept of disease
45:23alongside a normative one
45:25and um debating their merits and
45:27demerits and then saying well at the end
45:29of the day
45:30there's just a debate to be had
45:33my first answer that is that i think
45:35actually yes there is some value to
45:36doing that
45:37um because that disagreement in
45:39philosophy is matched by disagreement
45:42in medicine um so clinicians don't
45:44always agree with one another
45:46they often have irreconcilable
45:48viewpoints and
45:49guess what i think sometimes there might
45:52be no fact that matter about who's right
45:53and who's wrong
45:54but we still have to kind of get by and
45:56learn to work with and appreciate that
45:58disagreement
46:00the second thing i want to say is that
46:02you know i think philosophy focuses on
46:03the points of disagreement because of
46:05course
46:06um that's part of the art of the trade i
46:08mean we're trying to defend positions
46:10flesh out their differences and kind of
46:13think about how one position might be
46:15superior to another that's at least some
46:17of what philosophers are doing
46:19um but that does that masks i think a
46:21lot of consensus and agreement among
46:23philosophers
46:24um so we tend to focus on things we
46:25disagree about at the expense of things
46:27that we actually
46:29share the the commitments that we share
46:31um so there might be
46:33more consensus in philosophy of medicine
46:35um
46:36than at first meets the eye and so of
46:38course we should be presenting not just
46:39the debate but also the consensus
46:43um and you know i think it's it's i
46:46think it's
46:47very important to to recognize that
46:50neither medicine nor philosophy medicine
46:51are settled
46:52and they'll never be settled um so we
46:55should constantly
46:56continue to develop philosophy medicine
46:57alongside
46:59the foundations of medicine and and what
47:01i'm suggesting is that
47:02it's okay if philosophy isn't settled
47:04because that's part of the nature of
47:06um of clinical medicine as well okay the
47:10next
47:11worry might be the theory just doesn't
47:12interest medical trainees
47:14so think about some of the comments that
47:15rafaela got on her evaluations
47:18and i've gotten comments like that in
47:19the past as well
47:21um and i think this is this is actually
47:23as raphael pointed out a quite a
47:25practical challenge because um it seems
47:29like in context in which she's familiar
47:31and ones in which i've taught as well
47:34a student input and student evaluations
47:36actually determine
47:37who gets to speak in the medical school
47:39so it actually it does have consequences
47:41whether or not
47:42students are interested in what you're
47:43saying
47:45okay so that's a problem and and in a
47:46way it's a bit unfair
47:48because you know i found embryology
47:51terribly boring
47:52but you know there was no there was no
47:55threat of embryology being
47:56um kicked out of the curriculum just
47:58because me and other people didn't find
48:00it terribly interesting
48:01but i think there is a real threat of
48:02philosophy of medicine being kicked out
48:04of the curriculum if medical students
48:05aren't
48:06interested okay so now i do think it's
48:09important for people to be engaged
48:10because if they if they don't if they're
48:12not interested in what you're teaching
48:13them then they're just gonna
48:14zone out um so that's why i think it is
48:17important to make this relevant
48:18and that's why i sort of structured the
48:20sample curriculum that i showed you
48:22around
48:23topics in clinical medicine disease
48:25diagnosis and therapy and so on
48:28so to show the relevance and you
48:30actually have to integrate it within
48:31a context in which people are learning
48:34um how to be doctors
48:36learning how to sort through actual
48:38clinical cases and problems
48:41um and indeed i mean we have to
48:45we have to find a way to get people
48:46engaged in the topic and that's a that's
48:47a real challenge
48:48um and i sort of have some hesitation of
48:51labeling
48:52um what i'm talking about theory of
48:53medicine because i worry that
48:55the term theory might lead people to
48:58leave people's eyes to roll back in
48:59their heads
49:01unless they are social scientists and
49:03humanities
49:04scholars who love theory um theory is
49:07not something that
49:08um oftentimes people in the other
49:10scientists talk about
49:12quite explicitly so i do worry about
49:14that terminology but um
49:16on the other hand um to get to my next
49:19point last objection on this slide
49:22i think especially realizing that what
49:24we're offering here is a theory of
49:25medicine
49:26and very much makes what i'm talking
49:28about um
49:30relevant to a medical humanities
49:32curriculum
49:33so i think one way in which to kind of
49:35get this
49:37into a curriculum is to suggest that
49:40this is a way of teaching the medical
49:41humanities
49:43a way of teaching things like a way of a
49:47way of
49:47inculcating into people um virtues like
49:50empathy by teaching them about the
49:52limitations of
49:53our scientific understanding the nature
49:54of illness and so on
49:56um so i think this is essentially a
49:58medical humanities curriculum i'm
49:59proposing it's just one
50:00specifically in the philosophy of
50:01medicine um
50:03so that's one place in which it could
50:05fit in which there are places in which
50:06there's an established medical
50:07humanities curriculum
50:09in the north american context social
50:11science schools have to have some
50:13training in social sciences and
50:14humanities now
50:15according to the accrediting body um so
50:18that creates an opportunity
50:20and and i think there are other places
50:21that it should it should go so it should
50:23go alongside teaching the basics
50:25as well as more advanced topics and you
50:28know
50:28while i appreciate the concern that
50:30medical curricular are always overloaded
50:32i mean if there's ever a free hour in a
50:34medical curriculum they're always going
50:36to fill it with something
50:37unless they're unless they're like um i
50:40think many
50:41wise institutions that are now
50:42recognizing that overloading people with
50:44too much
50:45time and facts um might not be the best
50:48way of
50:49um of teaching medicine in fact we have
50:51to pay attention to the
50:54the um the negative impacts that some of
50:56the way we teach
50:57medicine might be manifesting in medical
50:59trainees physician wellness
51:01um being the term of art there but you
51:03know i think it's a fair concern that
51:05physicians are are required to learn a
51:07lot
51:08um but what i'd say there is that um
51:12surely learning how to diagnose and
51:15treat a patient
51:16should be one of the school two of the
51:18core
51:19skills that physicians should learn
51:22during their training
51:24okay so the point is to make the case
51:27that what i'm offering here
51:28is directly relevant to the things that
51:30physicians have to do
51:32so you know on that argument
51:35we better get to it
51:38and i will end there awesome thank you
51:42so much john that was just
51:43a very very interesting talk um so
51:46um as usual if anyone has any questions
51:48they can use the
51:50hand racing function or drop me a line
51:53in the chat
51:54so we've got one from dineca
52:01i'm trying to unmute myself uh i'm muted
52:05yeah that works
52:06okay yes and the camera on isn't working
52:09i have um perhaps a slightly different
52:11question
52:12um because you mentioned
52:16that evaluation was very important
52:19i think it's also very important when
52:22american students pass their exams and
52:25exams are incredibly
52:27standardized in medical school very
52:29different from philosophy
52:31people have to do oskis and they have to
52:34hit
52:34certain questions and whatever so i was
52:38just wondering what are your ideas about
52:40assessment
52:43good yeah so that so yeah very important
52:46um
52:47and yeah that's my experience as well so
52:49increasingly oscis
52:51basically how people are evaluated
52:53throughout their medical training
52:54and these are very standardized exams
52:57that consist
52:58usually a clinical scenario sometimes
52:59involving a standardized patient
53:01an actor and physicians or
53:05physicians in training are supposed to
53:08go through a mock exercise of how they
53:10would solve that problem
53:11and they're evaluated on their
53:13diagnostic skills
53:15and therapeutic management plan or
53:17whatever that station
53:18is trying to examine so i think i think
53:21there's two ways that we need to
53:23evaluate medical students or medical
53:27trainees understanding the theory of
53:28medicine the first way
53:30is that i mean there are these
53:31standardized exams that one takes
53:33throughout medical school
53:34but there also are just kind of book
53:36exams that people have to
53:38take especially earlier on in their
53:40clinical training and throughout i mean
53:41i had
53:42to do a combination throughout my own
53:43medical training of you know
53:46oscars and multiple choice and short
53:49answer questions
53:50and so you know short answer questions
53:53and and
53:54to a lesser extent multiple choice
53:55perhaps are are a way to kind of test
53:57some of the ideas that we're talking
53:59about here
54:00short answer questions in particular or
54:01how i remember being examined on
54:04bioethics earlier on in my medical
54:06training um
54:08but then of course we still need to
54:09evaluate um
54:12evaluate whether or not students are
54:15learning the theory of medicine in these
54:16same kinds of formats
54:18that we're using to assess their other
54:21core skills so their ability to make a
54:24good management plan
54:25um and to counsel a patient well on a
54:28clinical problem
54:29okay so we do definitely need to do that
54:32this is a challenge that faces
54:34that face is not just philosophy of
54:35medicine though so it also faces
54:36bioethics
54:38and typically in what's what's done
54:41at the university of toronto where i
54:43trained um is that
54:45um people will you know the examiner
54:48will
54:49will often have a kind of checklist
54:50there and they'll be looking for
54:53um for things like um
54:57was the physician able to um
55:00to kind of hear the the patient's
55:03concerns
55:04were they able to formulate a management
55:07plan
55:08that explicitly incorporated the
55:10patient's preferences and values
55:12um and you know
55:15in a more kind of negative way were
55:17there any lapses of professionalism or
55:19ethical behavior
55:20so we do evaluate these things but we
55:22don't but of course in that context
55:23we're not evaluating
55:25um the individual's understanding of
55:27can't
55:28versus um utilitarianism and
55:31you know whether or not they chose the
55:33appropriate ethical system or indeed
55:35you know how they might have how they
55:37actually might have reasoned ethically
55:38towards
55:39the answer that they came to so in a
55:42sense what we're evaluating there
55:44is we're evaluating the effect of
55:45teaching people such things as
55:47professionalism and bioethics on how
55:48they go about
55:50treating a uh treating a patient and of
55:52course here
55:54the more explicit training that one gets
55:55earlier on in things like bioethics
55:58gets just mixed up with let's say
56:00they're training on the job
56:02that they had when they went about
56:03seeing patients so we're not just
56:04evaluating that
56:06um whether or not they picked up that
56:08those earlier concepts that they
56:09they were taught um when they sat in a
56:12bioethics lecture in
56:14in a small group um when they went
56:16through a case
56:17and um you know were able to to talk
56:20about
56:21um bio ethical dilemmas and how to
56:23resolve them
56:24um in a small group setting so uh
56:27we're testing that but we're also
56:29testing um you know
56:31their ability to to kind of integrate
56:33that with what they learned
56:35um through more practical experiences on
56:37the ward so the problem there is that
56:39um you know if that so if that
56:42individual let's say was to bomb that
56:44station was it was the problem in the
56:46earlier explicit uh education that they
56:49received in
56:49in their bioethics training or was it
56:51that that training wasn't reinforced
56:53through the kind of practical learning
56:55that one needs
56:56in order to kind of get it to stick and
56:58to integrate it properly into
57:00into clinical practice so it so when we
57:03get to these more
57:04more practical evaluations like an ascii
57:07oftentimes you're kind of
57:09what you're essentially assessing is how
57:11well the students picked up these
57:12these various different components of
57:13their clinical training and put it all
57:15together
57:16um so so i think you could actually in a
57:19way
57:20stick the stick this kind of assessment
57:22right into
57:23parts of a standardized exam in which
57:26the assessor was evaluating whether or
57:28not the
57:29the trainee came up with a good
57:32diagnostic plan whether or not they
57:34considered
57:35all of the relevant possibilities
57:37whether they reasoned well
57:39whether they came up with a
57:40well-justified plan and whether upon
57:42questioning they could actually
57:44you know verbalize their justification
57:45for what they did
57:47um so yeah i guess what i'm saying is i
57:50think there are places in which these
57:51things
57:52really already are assessed in a more
57:55uh standardized practical context like
57:57an osce
57:58um but of course this
58:01what students are demonstrating there is
58:03not just what they picked up when they
58:04were
58:04more explicitly learning something like
58:06bioethics they're just demonstrating at
58:08the end of the day
58:09how all these things came together um in
58:12in influencing how they approached a
58:14clinical problem like that
58:16okay thank you thanks okay so next we
58:20have alex
58:27sorry alex broadbent so i've unmuted
58:30um thanks john i wanted to ask about um
58:33well that had two things to say one is
58:35sort of just more of a comment
58:36when you're talking about imitating
58:38other clinical thinkers
58:39and all this stuff it just took me back
58:42to the sort of implicit
58:44you know or all sort of cunion idea
58:47about how science
58:48works in general uh and the sociologists
58:51of scientific knowledge who
58:53who say that this you know if you if you
58:55agree with them then then what you're
58:57describing is actually very much the
58:58norm across the sciences
59:00um the role of theory is uh
59:04in in science teaching more generally is
59:07um i know that medicine isn't a science
59:10but the role of
59:11theory and even in science teaching is
59:13is
59:14is highly suppressed uh you get
59:16historical anecdotes discovery
59:18stories and so forth which might not be
59:20particularly historically accurate but
59:22you know convey a kind of exemplar and
59:24then people are expected to this you
59:27know learn
59:27they learn to think like those
59:29scientists did
59:31and i was just struck by how similar
59:33that seems to be to the medical case and
59:35of course it's not it's no
59:36accident because in the you know part of
59:38that whole story is that science is kind
59:40of like a you know there's an
59:41apprenticeship model
59:42which is like the professions which is
59:44like law and light medicine and and i
59:45just wondered
59:46i suppose on the sort of critical end of
59:48that observation would be well
59:50um you know is it it perhaps there's a
59:54reason that things are that way
59:55are you sure it would necessarily help
59:57to be for it to be more explicit um
1:00:00um and i i i the other
1:00:03sort of thought i had was um
1:00:07uh is there a reason to think that
1:00:10the so the question sort of a sort of
1:00:14larger question is whether there's a
1:00:15good reason to think that
1:00:19that noise sorry oh
1:00:23sorry uh whether
1:00:27whether there's a there's a good reason
1:00:28to think that um teaching philosophy to
1:00:30medical students
1:00:31is is useful um
1:00:35but i'm worried that your answer to that
1:00:37which is yes it is because
1:00:38that they it teaches them it helps them
1:00:41to learn the theory of medicine
1:00:42it just pushes the question back to
1:00:44whether learning the theory of medicine
1:00:46is useful
1:00:47um so is is learning is that i mean
1:00:51i mean one of the things that interests
1:00:52me is that i think in the development of
1:00:53medicine as a discipline and the whole
1:00:55conceptual framework and so forth
1:00:57clearly there are significant
1:00:58theoretical concerns you pointed out
1:01:01that the
1:01:01the the philosophical milieu in which
1:01:04hippocrates was
1:01:05was working and all of that um
1:01:09but does that mean that your day-to-day
1:01:10doctor um
1:01:12uh actually needs that stuff so that's
1:01:14that's that's the second sort of
1:01:16sort of question and whether we call it
1:01:17philosophy or whether we call it the
1:01:18theory of medicine
1:01:20you know does that actually make a
1:01:22difference
1:01:25good yeah so i think i'm so on your
1:01:27first point
1:01:29um this is something that i worry about
1:01:30i mean um
1:01:33forever really the one of the main ways
1:01:36in which medicine has been taught in the
1:01:38western tradition
1:01:39we're an apprenticeship model and really
1:01:41it was only
1:01:43really only in the 1800s in the western
1:01:46context
1:01:49that that a kind of more standardized
1:01:52approach to medical education
1:01:54took hold at the universities um you
1:01:57know first in paris and then
1:01:59in some ways last in america um
1:02:02in which people were expected to learn
1:02:04theory first
1:02:06and then they were expected to go onto
1:02:09the wards
1:02:10and take part in this clinical
1:02:12apprenticeship but it was at that at
1:02:14that point it became principles before
1:02:15practice
1:02:16and there was people thought that now
1:02:18there was enough medical theory around
1:02:20that um you needed to actually devote
1:02:22some time in any medic
1:02:23any any medical school um worthy of
1:02:26calling itself
1:02:27a medical school to learning that theory
1:02:29before you hit the
1:02:30hit the wards so you know the thought
1:02:33the thought is that you know there's
1:02:35more to just um
1:02:37being a good doctor than learning how to
1:02:39um
1:02:40learning how to behave like your
1:02:42clinical mentors you have to learn
1:02:44some basic science understanding you
1:02:47have to
1:02:47learn some explicit knowledge in order
1:02:50to
1:02:50uh to be a good doctor so really i mean
1:02:53part of what i'm saying is already
1:02:54in a way recognized to some extent
1:02:57within
1:02:58our current models of medical education
1:02:59there is some some
1:03:01some material that one has to master
1:03:03before you
1:03:04you learn to before you're able to you
1:03:07know
1:03:08head into a clinic and start to
1:03:11learn by imitating and doing
1:03:15okay so why so why your second question
1:03:17was really why
1:03:18should we supplement learning about
1:03:22concepts and theory in physiology with
1:03:26learning concepts in theory and
1:03:27philosophy of medicine basically
1:03:30um and you so yeah you know so part of
1:03:32what part of what i'm saying is that
1:03:35there are there are parts of the theory
1:03:37of medicine that we just we still
1:03:38still have to still have to be worked
1:03:40out i mean there still are working on
1:03:41these areas and they're underdeveloped
1:03:44so thinking about the you know the goals
1:03:45and scope of medicine i think is
1:03:47is an area of um under development and
1:03:50philosophy of medicine
1:03:51and uh and so i think some of these
1:03:54areas we just need to
1:03:56continue to work on before before really
1:03:59we're even able to
1:04:00um offer anything um
1:04:04very clear to say to uh to a medical
1:04:05trainee as philosophers of medicine
1:04:08um so yeah that's the first thing i want
1:04:11to say
1:04:12but um on the other hand there is
1:04:16an ex an implicit theory of medicine
1:04:18that that clinicians already learned
1:04:19throughout their medical training
1:04:21they learn implicitly what it means to
1:04:24diagnose someone and what one should be
1:04:25doing when one is engaged in diagnosis
1:04:28and they learn implicitly though or
1:04:31intuitively the kinds of
1:04:33mental processes that one should
1:04:35undertake in doing diagnosis
1:04:38so part of what i'm suggesting here is
1:04:39that um
1:04:41is not that we should be um teaching the
1:04:44theory of medicine
1:04:45in places where it's not already taught
1:04:48i'm saying
1:04:49in part that we should be teaching the
1:04:51theory of medicine differently
1:04:52in those instances in which it currently
1:04:54is taught only implicitly
1:04:57okay so then really that pushes the
1:04:58argument onto why it would be useful to
1:05:01teach
1:05:02some of these things explicitly um
1:05:05and i mean there i think
1:05:10in the absence of you know empirical
1:05:11evidence i really just have to
1:05:13rely on analogies so um
1:05:17so imagine yeah so imagine
1:05:20trying to um
1:05:24to understand how to be a lawyer without
1:05:26learning important legal principles
1:05:29so this is not legal principles are not
1:05:31just you know particular cases in the
1:05:33decisions that were made
1:05:35they're also the kind of the very the
1:05:36very general fundamental and often kind
1:05:38of taken for granted
1:05:40um precepts and constraints
1:05:44found within a particular legal system
1:05:46that people have to learn as part of the
1:05:47theory of law
1:05:50what i'm saying is here is that there's
1:05:52something similar going on in medicine
1:05:53that there are just these
1:05:55this there's a general approach um
1:05:58and i i actually really like your kind
1:06:00of cunion analogy
1:06:01um to doing clinical medicine that
1:06:04evolved in a certain context
1:06:06um that consists of you know diagnosing
1:06:08prognosticating and treating someone
1:06:10um to some extent in that order and
1:06:13alongside that certain concepts of what
1:06:14a
1:06:15disease is um about um how
1:06:18how about how a diagnostic taxonomy is
1:06:21structured
1:06:22and um and to learn these
1:06:26and to understand these principles and
1:06:27concepts purely by
1:06:30trying to imitate and guess what's going
1:06:31on between someone else's ears
1:06:33i think is just a risky way of teaching
1:06:36um clinical thinking um so
1:06:40you know it's a it's a way of teaching
1:06:42what you have to kind of infer
1:06:45uh what the relevant concepts and
1:06:46principles are
1:06:49and so i think yeah so i think there's
1:06:52at least a risk there
1:06:53the risk we run that people are going to
1:06:55learn
1:06:56the foundations of medicine the theory
1:06:58of medicine in a way that's incomplete
1:07:00and they're going to be misled because
1:07:01they don't have a window into
1:07:04how other people are how their mentors
1:07:06are thinking
1:07:07and i guess the third thing i want to
1:07:08say is that what i'm suggesting here
1:07:11is of course experimental um
1:07:14and so um
1:07:18assuming that there is some rationale
1:07:20for trying this
1:07:21um i think we should give it a give it a
1:07:24try and then evaluate its impacts
1:07:26and at the end of the day i'm willing to
1:07:27stand corrected if it turns out that
1:07:30um that just like um trying to teach
1:07:33people to be better cyclists
1:07:34by telling them exactly how to move
1:07:37their toes
1:07:38and their hands might cause them to fall
1:07:39off their bike it's it's you know it's
1:07:42possible that
1:07:43um trying to teach clinicians to be
1:07:45better diagnostic reasoners by teaching
1:07:47them
1:07:47um more explicitly the concepts and the
1:07:50patterns of reasoning
1:07:51might you know lead them to fall off
1:07:53their chairs when they're trying to
1:07:55diagnose someone
1:07:56so i'm very much willing to stand
1:07:58corrected if it turns out that this is a
1:07:59bad idea
1:08:03great so um matt is next
1:08:06hi thank you for the talk um this might
1:08:08not resonate with you but when you were
1:08:10talking about
1:08:11um making it interesting and that that's
1:08:14how you get philosophy medicine into
1:08:15medical education
1:08:17uh it struck me that what interested me
1:08:18in philosophy of medicine
1:08:20was finding out that in my own uh
1:08:22clinical specialty the emperor had no
1:08:25clothes in a lot of ways that there were
1:08:26a lot of things that
1:08:28needed a lot of reflection and once
1:08:29reflected upon didn't make a lot of
1:08:31sense with respect to the diseases that
1:08:32i treat and what i call evidence for the
1:08:34treatments that i render
1:08:36um and so in terms of interesting
1:08:39contemporary medical students i wondered
1:08:40if contemporary controversies aren't
1:08:43the way to interest them and then i
1:08:45wondered if such reflections on
1:08:46contemporary controversies aren't kind
1:08:48of necessarily subversive like if you're
1:08:50if you're going to be very critical
1:08:52about the way diseases like chronic pain
1:08:54or mental health disorders or even
1:08:56osteoporosis are defined
1:08:58does that become subversive to the
1:09:00institution really quickly and i just
1:09:02wondered in your own teaching if you
1:09:03ever
1:09:04encountered friction between
1:09:06institutional goals and
1:09:07uh philosophical critical goals
1:09:11interesting yeah no i think so okay so
1:09:14first i completely agree i think a great
1:09:16way to motivate
1:09:17some of this is to point out tensions
1:09:19and controversies and conflicts
1:09:21um and that because then people kind of
1:09:24open their eyes and say
1:09:25okay so there's something unresolved
1:09:26here and um
1:09:29and then if you give them a way of
1:09:30understanding the controversy and maybe
1:09:31even a way out of it that's
1:09:33that's kind of quite helpful um i think
1:09:35in a way that's that's what motivates a
1:09:37lot of bioethical teaching too i mean
1:09:39people are faced with uh
1:09:40concrete problems and they have to know
1:09:42how to how to navigate the
1:09:44navigate those um and come to a kind of
1:09:47reasonable
1:09:48compromise or solution so so i first i
1:09:51just want to completely agree with that
1:09:52but um
1:09:53but your second question was your second
1:09:55part of the question was also very
1:09:56interesting so
1:09:58um yeah i mean i think some of this
1:10:01stuff can be subversive in that it's it
1:10:03can be critical so we could be
1:10:04questioning the way that
1:10:05um clinicians currently think um and
1:10:07scrutinizing the concepts that they
1:10:09actually use
1:10:10and maybe even the goals of what they're
1:10:12doing
1:10:13um if we were to say that perhaps people
1:10:15are too focused on
1:10:17um diagnosing and treating disease using
1:10:20technologies like drugs or surgeries and
1:10:23we should be more concerned with
1:10:24people's well-being
1:10:25their social context and um you know
1:10:29um to take an example from the
1:10:31university of toronto
1:10:32writing people a dis a prescription for
1:10:35um
1:10:36money rather than writing them a
1:10:38prescription for um
1:10:40drugs this is something that somebody
1:10:41suggested you know why are we
1:10:43why are we you know focused so much on
1:10:46um
1:10:47the medical problems that our patients
1:10:49are coming in with when we should real
1:10:50when really like our time is better
1:10:52is better spent advocating for
1:10:55um a society in which um
1:11:00that sets them up for that sets them up
1:11:02for better health and maybe that would
1:11:03be
1:11:04have more impact so i mean very
1:11:07controversial
1:11:07and bold statements like that of course
1:11:10challenge
1:11:11the system itself um and
1:11:15my own my own experience at the
1:11:16university of toronto when i was there
1:11:17we
1:11:19we introduced a curriculum
1:11:23that sought to teach people to be
1:11:25reflective about the culture of medicine
1:11:27and some of the problems in the culture
1:11:28of medicine
1:11:30this went under the heading of you know
1:11:34equity and inclusion
1:11:37rather than anti-oppression which was
1:11:41a suggestion that a colleague of mine
1:11:44wanted in order to make it a little bit
1:11:48more palatable to
1:11:50people in positions of power in the
1:11:51medical curriculum and maybe a little
1:11:54bit less jarring to people who would be
1:11:56attending those sessions
1:11:57but nonetheless i mean we were teaching
1:11:58people to kind of
1:12:00be a bit skeptical and critical about
1:12:01the culture of medicine and so it was
1:12:03it was in a certain sense subversive but
1:12:06um
1:12:10you know i think the way that that the
1:12:11act that we were actually able to sell
1:12:13that
1:12:14uh was by fitting ourselves into
1:12:17um an existing way of talking about
1:12:19what's important in medicine by saying
1:12:21that what we were teaching is
1:12:22is how people can um
1:12:26practice as clinicians in a way that's
1:12:28more equitable
1:12:30um fair and um
1:12:34and they dealt with relative deals with
1:12:35well-recognized problems like racism and
1:12:37medicine
1:12:38and when you put it like that i mean um
1:12:40it sounds
1:12:42it sounds very it sounds nice and
1:12:44important
1:12:45um but of course a lot of what we were
1:12:46doing was really um
1:12:48pointing out the structures within
1:12:50medicine that
1:12:51themselves were probably responsible for
1:12:54a lot of the problems that we then
1:12:55discussed
1:12:56so i mean part of it's kind of selling
1:12:58what you're doing in a way that makes
1:12:59sense to
1:13:00those who are kind of in positions of
1:13:02power in the curriculum i think
1:13:04because you know potentially what you're
1:13:06offering is is critical
1:13:07and in some cases um i like your word
1:13:10subversive because
1:13:11um i mean what i'm not sure what i'm
1:13:13suggesting here is not just to
1:13:14recapitulate what
1:13:16um people are already doing but to
1:13:17improve upon it um which will mean
1:13:19criticizing um in a constructive way
1:13:22what the way that things are currently
1:13:23done
1:13:27great thanks um i might let myself have
1:13:29a very short question before we have to
1:13:31end this but um
1:13:33i really like the way you're framing
1:13:34this as um
1:13:36you know it's a question of teaching
1:13:37sort of the basic theoretical principles
1:13:39of of medicine and basic conceptual
1:13:42ideas
1:13:43and i'm just wondering sort of on this
1:13:45note but also in reference to what other
1:13:46people have been saying about
1:13:48making sort of philosophy palatable for
1:13:50medical students and for medical schools
1:13:53whether framing it in that way might
1:13:55actually be quite
1:13:56useful i'm thinking for example if you
1:13:59as a medical student
1:14:00in your first in your second year and
1:14:02you have a course called something like
1:14:04theories and concepts and medicine
1:14:06whether that might not trigger the kind
1:14:07of like
1:14:08hostility and sort of you know
1:14:11perception this is not important that
1:14:12you sometimes get with medical students
1:14:15at that level
1:14:18right so maybe you're pointing out the
1:14:20kind of um
1:14:23how framing it as a theory of medicine
1:14:24might be potentially
1:14:26risky in immediately kind of triggering
1:14:29this kind of reaction no i'm thinking
1:14:32the opposite actually that yeah okay
1:14:34you know because i think philosophy is
1:14:35triggering you know
1:14:37for right yeah little sciences well at
1:14:39least people who
1:14:41maybe are at kind of early early stages
1:14:43you know that people kind of have a
1:14:44perception that it's not
1:14:45you know it's ethics it's philosophy
1:14:47it's not real
1:14:49really of relevance to what we're doing
1:14:51right i mean okay so yeah i think
1:14:52framing is
1:14:53is essential here um so i'm not
1:14:56suggesting that
1:14:57it be called a medical humanities or
1:15:00philosophy of medicine curriculum
1:15:02um even that even though covertly that's
1:15:05essentially what it is
1:15:07um what i'm suggesting is that we um i
1:15:09mean it's just the term theory medicine
1:15:11because i think it kind of
1:15:12makes sense but even but even that term
1:15:14i have some worries about
1:15:16um so sometimes i thought maybe like
1:15:19foundations of medicine would be a
1:15:20better idea although that's maybe a bit
1:15:22too
1:15:22ambiguous but you know okay setting
1:15:25aside just what we call the curriculum
1:15:26itself i mean
1:15:28what what i want to propose is not you
1:15:30know teaching sessions like
1:15:32um what is the concept of disease
1:15:34phenomenology of illness
1:15:36um logic of clinical reasoning but just
1:15:40really put this in terms
1:15:41and that people already appreciate as
1:15:43being important
1:15:44like medical reasoning evidence which is
1:15:46a term that people use values a term
1:15:48they use
1:15:49decision making something they obviously
1:15:50do and so on um so
1:15:52so part of this is kind of structuring
1:15:54in such a way that it already falls into
1:15:56the kind of categories that people
1:15:58recognize is important
1:16:00and i think that's not just about about
1:16:01salesmanship i think that's
1:16:03i think it's actually important i think
1:16:04people need to you know not learn
1:16:07um um you know what
1:16:10alex broadbent's theory of medicine is
1:16:12and then
1:16:13um they'll say okay that's interesting
1:16:15then go off on their way i think they
1:16:17need to learn
1:16:18something like okay so you know what's
1:16:20the scope
1:16:22of the kinds of problems that a
1:16:25physician ought to deal with in the
1:16:26clinic what falls within
1:16:28the scope of a medicine um you know if
1:16:31a person is presenting and their chief
1:16:34problem is
1:16:35um that they're impoverished and that's
1:16:37why they
1:16:39are in poor health what role does
1:16:41medicine have to play in that kind of
1:16:42context
1:16:43and that's a more focused kind of
1:16:45question and not
1:16:47one that's framed in such a way to be
1:16:49lofty and therefore may be off-putting
1:16:51and frankly also just um maybe not
1:16:55not not so relevant i mean if people if
1:16:57we're just teaching this in the abstract
1:16:58they're never gonna apply it to the
1:17:00things that they're actually doing so we
1:17:01need to teach things like concepts of
1:17:03health but we need to teach in the
1:17:04context
1:17:05in which they're understanding well what
1:17:07relevance does this have to
1:17:08um to diagnosis for instance so it
1:17:11really is about understanding diagnosis
1:17:13and diagnostic reasoning rather than
1:17:14more abstractly what is disease and then
1:17:18separately um
1:17:21you know how how should one reason has
1:17:23to be done in such a way that it's
1:17:24integrated already into the kinds of
1:17:25skills that they need to learn
1:17:28thank you very much john um thanks
1:17:31thanks
1:17:40so um i think i'm gonna hand over to
1:17:43alexander i think he wants to say a few
1:17:45words yes
1:17:47just to um thank
1:17:50everybody who's who's participated so in
1:17:52particular
1:17:53our full speakers i thought that that
1:17:55was
1:17:57an excellent day and i'll say a few more
1:17:59words in just a moment
1:18:01um but i'd really like to to
1:18:04actually mention harriet who's done
1:18:06really all the organization for this
1:18:08event and in fact just had to do it
1:18:10several times over as we've
1:18:12had to postpone and then move from being
1:18:14um
1:18:15[Music]
1:18:16in person to online and so thank you
1:18:19very much
1:18:19indeed harriet so yeah more the the
1:18:22the same uh um congratulations and
1:18:25thanks are
1:18:26due to you as to the as to the four
1:18:29speakers
1:18:30uh anyway so um
1:18:33i just wanted to conclude with some
1:18:35thoughts
1:18:36um so i actually i thought today was
1:18:38particularly
1:18:39rich and i thought there was quite a
1:18:41number of overlapping
1:18:42themes that i won't repeat because
1:18:44you'll be able to pick those out
1:18:45yourselves
1:18:47um but i do think that um
1:18:50that does suggest that this is your
1:18:52fruitful area for
1:18:53further discussion and uh research
1:18:57um so we heard in a number of places a
1:19:01little bit of
1:19:02um stuff about national data on what's
1:19:05done in
1:19:06the teaching of philosophy to medical
1:19:08students it'd be interesting to
1:19:09to expand on that and possibly make
1:19:12international
1:19:13comparisons um but perhaps
1:19:17we'll say get some more qualitative
1:19:18research after that to to help us
1:19:21do more philosophical research in
1:19:23thinking about what the
1:19:25possible roles for philosophy are
1:19:28in medical uh education and then of
1:19:31course as
1:19:32several people have mentioned and
1:19:34thinking about what the evidence base
1:19:36there is for whether philosophy can
1:19:39fulfill any of these
1:19:41uh roles but it's worth thinking that
1:19:43there are a lot of areas
1:19:45where one could do this research a lot
1:19:46of constituents one might
1:19:48appeal to indeed lots of potential aims
1:19:50correspondingly
1:19:52so it's been natural to think you we're
1:19:55teaching
1:19:56trainee doctors it does what we do
1:19:59make them better doctors um then of
1:20:03course what as
1:20:04you as uh juliet and
1:20:07uh alex and others been saying what what
1:20:10counts as a better doctor
1:20:11use itself up for some uh some
1:20:14discussion
1:20:15but one of one of the the in the chat
1:20:18one commentator
1:20:19um alifa isaac's ichira
1:20:23um also said look one might put an
1:20:25emphasis on
1:20:26whether syrian philosophy makes the more
1:20:29well-rounded and happier doctors who are
1:20:31able to
1:20:32demonstrate increased resilience it
1:20:34might be good for the doctors to
1:20:35study philosophy and only indirectly a
1:20:38question of whether it benefits their
1:20:40patients it would still be worth doing
1:20:42if that were the case and of course
1:20:44uh there's research on the students then
1:20:48so so one of
1:20:51the participants had is who
1:20:54microphone isn't working so couldn't get
1:20:56to answer requests ask a question
1:20:58did want to ask don juliet and then i
1:21:00think also of
1:21:01um you know actually it might have been
1:21:04rafaela and then then
1:21:06of um of john um
1:21:09what the data is already
1:21:12uh about what the views and perspectives
1:21:14of medical students are in terms of how
1:21:16willing they are to engage
1:21:18you with philosophy teaching
1:21:21um you know as this will likely impact
1:21:24how much they will benefit
1:21:25from from its teaching you know what
1:21:27factors you
1:21:28make certain medical students more
1:21:30likely to to in
1:21:32engage and i mean i think that's a
1:21:34really important
1:21:35question we've touched on several times
1:21:37because rafaela that they gave us
1:21:40these sort of contrasting you know four
1:21:42comments you
1:21:43fell into two contrasting groups and
1:21:45that that matches my experience of
1:21:47you the response to medical students to
1:21:49this teaching is
1:21:51bimodal there are those who just love it
1:21:54because
1:21:55yeah they're intelligent all these young
1:21:56people are intelligent but yeah they've
1:21:58they're they're being asked to use their
1:21:59intelligence in ways that
1:22:01they find stimulating um in comparison
1:22:04to
1:22:05the way that they've been taught
1:22:07medicine and for others for whom it's
1:22:08just
1:22:10where the facts yeah and it's quite uh
1:22:13it's question about how you trans uh
1:22:16formed the latter group into the into
1:22:18the first
1:22:19group and then then this number of
1:22:21people have said i think that there's
1:22:23room for us connecting with people who
1:22:25are experts in medical education
1:22:27yeah uh um i i don't think we can do
1:22:29this without their
1:22:31uh their help so there's lots of future
1:22:32researcher perhaps raphaela or someone
1:22:34else will take this on as an erc project
1:22:37um
1:22:38i mean i think that really seriously you
1:22:40think was worth us talking about
1:22:42something
1:22:42uh like that and
1:22:46all who are here engaged so welcome to
1:22:48contribute to such a thing
1:22:50but i think that's also um room for
1:22:53thinking about how
1:22:54we might be able to create a forum
1:22:58by which we can help each other in
1:23:01in doing this you know we've we we've
1:23:03also talked about the obstacles we've
1:23:05faced and so there might be room for
1:23:07sharing uh
1:23:08experiences uh indeed doing some very
1:23:11basic helpful things like sharing
1:23:13curriculus as
1:23:14gabriella was was asking about i mean
1:23:16that's why not you know that seems a
1:23:18sensible thing
1:23:20for us to be able to uh uh to do
1:23:23um so yeah so sharing curriculum share
1:23:26experiences
1:23:27particularly about what works and
1:23:28possibly what what doesn't
1:23:30and perhaps it's an opportunity to
1:23:33mention again
1:23:34the new journal that john mentioned
1:23:37that he and uh alex
1:23:41are um exploring that letters
1:23:44are um have recently launched
1:23:48um so that's a fantastic uh venture and
1:23:51i hope that that will provide
1:23:52a a venue for
1:23:56the various things that we've been
1:23:57talking about today and possibly the
1:24:00research i've been mentioning and
1:24:01possibly also a forum for
1:24:03sharing um you could practice
1:24:06with regard to medical education okay so
1:24:09that's
1:24:10that's my um
1:24:13sort of summary um thanks very much
1:24:16again to
1:24:17all the parties all of you who
1:24:18participated in particular the speakers
1:24:20and to
1:24:21how i think this is going to be a
1:24:22fruitful area we should we should
1:24:24continue not just sort of
1:24:26say well that was a nice day and then to
1:24:28disperse um and in fact
1:24:31um we are going to enable we are going
1:24:34to enable this the project
1:24:35the sauer peter salvi philosophy in
1:24:38medicine project
1:24:39kings is going to enable continuing
1:24:41discussions of these things
1:24:43um as harriet is about to explain
1:24:47how can you yes of course um yeah so we
1:24:50have
1:24:51um running a cloakroom series on this
1:24:54theme
1:24:55so we're gonna have kind of regularly
1:24:56throughout the semester we're going to
1:24:58have some sort of themed
1:24:59colloquia that look at sort of you know
1:25:01issues particular to phenomenology or
1:25:03ethics or psychiatry
1:25:05um and then we're going to conclude with
1:25:07a um
1:25:10with a workshop um on sort of
1:25:13the relationship between philosophy and
1:25:14medical education and teaching questions
1:25:16related to race
1:25:17and gender and bias and and questions of
1:25:20that nature
1:25:21so i hope that you'll all sort of stay
1:25:23involved i'll definitely send out an
1:25:24email to
1:25:25the participant list and just um keep
1:25:27you posted on
1:25:28what we're doing and hopefully we'll see
1:25:30many of you at those things as well
1:25:34well that brings it to a close thank you
1:25:37very much everybody for
1:25:38for participating and let's all
1:25:42keep in touch perhaps we couldn't um
1:25:45magically unmute ourselves um
1:25:49and just sort of give ourselves a
1:25:51general
1:25:52round of applause particularly to the
1:25:53speakers and harriet but
1:25:55we can think of that
1:26:03thanks everyone nice to see you all and
1:26:06i hope to see
1:26:06as many of you as possible in due course
1:26:09and at the
1:26:10um colloquia that harriet is organizing
1:26:14thanks a lot thank you very much
1:26:19bye thank you

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