Leaving Psychiatry. J. R. Ó’Braonáin. M.D.

or telos or value in the cells that constitute the body let alone the body as a whole, the student hopefully acquires the raw materials to appreciate the clinical problem when they take up their stethoscope and are unleashed upon the hospital. An example of the clinical problem might be the matter of chest pain. The student has learned from basic anatomy that the heart is in the centre (more or less) of the chest, the lungs either side, all enveloped in a sheath of muscle, bone, skin etcetera. They learn this in great detail, or at least they did when anatomy was taught properly. By the mid 2000’s even the best medical schools had replaced long hours of expensive invaluable dissection with very limited “dissection experiences”, for flesh and blood and time gets in the way of abstraction and assembly, and corporatized universities have become a business or mass production factory churning out as many medical students as the hierarchy will allow, whist specialty guilds pull up the drawbridge that might otherwise challenge the exclusivity of their own little clique. The student will have learned from basic physiology and cellular biochemistry to appreciate that the heart is a (kind of) muscle, and as such requires a constant supply of oxygen or lactate will accumulate, this triggering certain nerves to a state of activation that eventually be followed by the conscious phenomena of pain. The clever student may adduce from first principals what might be the cause of the pain, and from this what might be the remedy. To elaborate; the clever student may conclude that given the pain oscillates with a periodicity of breathing and is phenomenologically experienced as a pain spatially located to the chest wall, then it may relate to some structural pathology or inflammation of the chest wall itself. On the other hand, the pain may be steady and central, varies with exercise intensity and by extension the demands placed upon the heart. And so they may conclude the pain is that of angina of the cardiac variety. The really clever student who excelled in embryology might infer from first principles why the chest pain is perhaps also experienced as pain referred down the arm, or why pathology about the diaphragm (the muscle essentially dividing chest from abdomen) might be experienced in, of all places, the neck also. But these clever students are, believe it or not, very much the exception. In the majority of cases, the prior study of the basic medical sciences simply provides the raw materials from which to understand the reasoning and evidence behind vast lists of diseases and diagnostic reasoning that they are not expected to generate by their own synthetic cognitive devices, as opposed to simply remember and apply in a kind of algorithm/flow chart. Nowadays they are not even expected to generate the algorithm themselves from studying multiple sources. One will have already been published for them. They will learn that chest pain can be a manifestation of X, Y or Z pathology. They will memorize which signs (what can be seen/heard etc) and what symptoms (i.e. what the patient reports) correspond to narrowing the differential diagnosis from X, Y or Z to a single explanation of X (OR Y OR Z). And from the diagnosis of, say, angina what will follow is another memorized algorithm or pathway of what to do next, a treatment pathway. To this end the basic medical sciences are nothing more than lubricant to move through a pathway.

      The same pedagogical journey towards pathway/algorithm arises from the more contemporary method of medical education known as problem based learning. Only in this case the student is confronted from the outset with the clinical problem (e.g. chest pain), perhaps in some cases with no prior learning of the basic medical sciences whatsoever, much less the basic or first order sciences of chemistry, physics and so on. What follows, without either word of an exaggeration, let alone a lie, is for the medical student to first learn what the chest is precisely, what is within it and so on. Often the student is almost expected to teach themselves, with lectures and such renamed as “learning resources” and the very structure of the students learning plan left to the devices of the student themselves. They may even be placed in “problem based learning” groups, with a facilitator at the helm who is explicitly instructed not to instruct, and rather sit there as the blind lead the blind, much like the marriage counsellor who sits, listens and asks each spouse what they think, all the while gagged from telling anyone what they (i.e. the counsellor) thinks or what they (the couple) ought to think, much less what they ought to do, though it may well be blindingly obvious. The hope of such a model of education is to cultivate an internal locus of self-organization, motivation towards so called “lifelong learning” and finally the capacity to think critically and synthetically, much like the clever students alluded to above. The reality is that such a model of education is just another road to pathway and algorithm, albeit from a different starting point. The student starts with clinical problem and the pathways to diagnose and treat it, reaches back into conceptual space to teach themselves the basic medical sciences (albeit never deeply) before returning again to the problem, this time with a greater understanding of what the clinical problem “means”.

      Several points arise from the above. The first is that medicine and what it is to be a doctor becomes almost mechanized, even cybernetic in a sense, and notions of intuition, individuality and such become antiquated and silly, if not reproached as dangerous. Such a mechanized state of affairs becomes the case in virtue of the cognitive schemata of lists and pathway alone, without even approaching the influence of so called “evidence based medicine” dogma on the student’s psyche, or even the reliance on standardized diagnostic and treatment approaches not so much for cognitively expedient reasons, yet rather as a group survival mechanism in a litigious world. That is to say, we do things so that the patient will recover. This is granted. But often we do things more so as to avoid getting into trouble by instead locating ourselves in the centre of herd activity. Often these two goals and their outcomes only weakly overlap.

      The second is that the medical student deals with the physical body as a kind of engineer of sorts. Despite the drive to abstractions they become in some sense at least grounded in something that has a material basis in reality. The more classically trained medical student will learn that there really is something called a heart. After all, they poured their concentration over it over a lengthy dissection process in some basement of an anatomy department where their olfactory apparatus was partially killed off by formalin, and their fingers became pickled like the cadavers if the gloves weren’t up to the task. Parts of my thumbs remain hardened still. The same student will see under the microscope the cells that comprise it and what a heart looks like when necrotic (i.e. dead). They will learn about processes by which the heart muscle needed and utilized oxygen, and see the arterial and microvascular roads of supply for cellular demand. The same student will take the ECG, and quite rightly so, as the electrical representation of activity of the organ that’s sustains them in its beating from the moment of birth (indeed from only weeks post conception) to the moment of death. After anatomy classes the medical student may never actually see a heart again as a material thing in the world, as opposed to an abstraction in a diagnostic or treatment pathway. All they might encounter is a patient in pain, what the blood investigations shows, what the physical examination finds etc. They will know what this probably “means” and be sure of the horizon of potentiality. No one would be foolish enough to question the existence of a heart attack qua dead or dying heart muscle as something concocted or confected by some vested interest group, a pharmaceutical company or as some “social construct”. They know all too well that if push comes to shove (and it often does), the cardiologist will run a dye up the leg and demonstrate that there is a heart there just as they remember and that this heart is perfused with less than its fair share of blood. Beyond this the pathologist will have the final word in the pronouncement of the physical groundings to disease. In summary, the medical student becomes complacent in the justified confidence that in all that might be called disease, pathology or illness, they are working with the reality of a material, albeit biological, machine.

      These symptoms, signs, investigations to be ordered, potential diagnoses and so on (all the many pathways and elements of pathways) amount to a formidable information overload to even the best and brightest of medical students, who are usually the best and brightest at school and college. The task is to survive, remember, regurgitate, and apply correctly. Though all this requires a mind of above average intellect in the sense of short term memory for “cramming” exams and superior information processing capacity, there is nothing remotely approaching authentic critical thinking of the philosophical kind, let alone to recline in the garden of academe pondering the metaphysical questions that might, nay should sometimes, be applied to the vocation of medicine. There is neither the time nor the energy nor the compulsion, much less the inclination. Long gone are the days of the appropriately famous medieval medical school of Salerno, the