Harriet Cooper reviews Medical Education, Politics and Social Justice by Alan Bleakley (Routledge, 2021).
Alan Bleakley’s latest book Medical Education, Politics and Social Justice (Routledge, 2021) presents a new vision for what medical education could be. In this re-imagining of medical education, Bleakley centres the formation of the ‘medical citizen’ (p. 170): that is, the engaged, politically aware doctor who understands the socio-material context in which medicine is practiced in the 21st century. What would the blueprint for a socially and politically-committed medical education look like? If anyone is qualified to lay this out, it is Alan Bleakley. In the early 2000s, he played a leading role in developing an innovative and holistic curriculum for the new Peninsula Medical School attached to Plymouth and Exeter universities. At that time, the classical model of medical education had students learning bench sciences for the first two years of the degree before they started to encounter patients in Year 3. Spurred on by the hope for a humanistic transformation of medicine outlined by the General Medical Council in their 1993 publication Tomorrow’s Doctors, colleagues at Peninsula sought to re-design medicine to encourage both early and sustained clinical contact with patients, as well as an emphasis on the importance of communication in the clinic.
Led by Bleakley, Peninsula Medical School sought to integrate modes of thought from the medical humanities as a Vygotskyian ‘second stimulus’ in the curriculum. The second stimulus is a theory of how students make use of auxiliary objects as they attempt to make sense of something that is uncertain or beyond their understanding. With reference to this concept, Bleakley examines how the introduction of an aesthetic dimension into the teaching of anatomy in medical schools might help to minimise the ‘dulling’ or objectifying effects of functional approaches to anatomy, and instead enable students to remain engaged with the ‘beauty of the human body’ (p. 152). Bleakley describes a range of interventions used at Peninsula to keep students engaged with ‘embodiment’ as well as ‘the body’ (p. 152), from life drawing, to collaborative drama workshops with performance art students, to teaching sessions about stigma led by disabled people. What is particularly striking about the way that Bleakley discusses this and other curriculum innovations is the emphasis on integrating the medical humanities into the sciences teaching, in this case via the double stimulation model. He recounts that:
The general pedagogical rule again was ‘appreciation before explanation’. The pedadogical question at play was ‘How can we expand the object of the activity of anatomy teaching without increasing curriculum content space devoted to anatomy teaching?’ (p. 152).
The medical humanities are not conceptualised here as a supplement, a ‘nice-to-have’ extra, which might have to be dropped if there is not enough time in the timetable. Instead, they are woven into the anatomy curriculum; they are methodologically essential in that they keep it lively (engaged with the living body).
Liveliness is mobilised as metaphorical frame with which to think ‘the curriculum’ in Medical Education, Politics and Social Justice. Bleakley is troubled by the ‘deadening effects upon learning of instrumentalism’ in medical education (p. 176). One example of this is the particular uses to which a notion of ‘professionalism’ is put in medical education. Elsewhere, Allitt and Frampton (2022) have explored the poor delineation of ‘professionalism’ in medicine, seeing it as an amalgam of emotions, values, behaviours and attitudes, and querying the effects of bringing together these diverse spheres under one heading. Bleakley, too, is wary of the uncritical use of professionalism, seeing it as a discourse that structures and disciplines feeling, and the senses, within medical education. He argues that in the early years of their training, medical students have ‘emotional integrity’ but that this ‘capital’ is then channelled into the production of a self-presentation that is socially acceptable within medical culture, assisted by the ‘historically conditioned approved patterns of behaviour’ that constitute professionalism (p. 17). This process is part and parcel of medicine’s notorious ‘hidden curriculum’: that is, those things that students intuit about how they should present themselves as they acclimatise to the clinical environment.
It is interesting to consider, when exploring the cultivation of medical professionalism, how the oft rehearsed imperative to ‘humanise healthcare’ might in fact be at odds with the demand for professionalism (on this, see Allitt & Frampton, 2022 and Goldberg, 2008). This perspective becomes available if we think of professionalism as a demand that emotion be performed in a particular way (reasonably, and not excessively). Relatedly, Allitt and Frampton (2022) suggest that the agenda to ‘humanise’ medicine gives primacy to the cultivation of empathy, without seeming to acknowledge that ‘humanity’ is also about negative emotions and flaws; they argue for the need to historicise medicine’s engagement with professionalism via its entanglement with classed ideas of ‘good character’. Meanwhile, for Goldberg (2008), medicine is dogged by its conflation of humanism and professionalism. Humanism ‘flows most naturally from a lay, rather than a professional, identity’ whereas ‘professionalism contributes to isolating the physician from the lay public’ (Goldberg, 2008, p. 717). When a medical student’s ‘integrity’ is being assessed as part of professionalism, in what sense does integrity then become part of a performance of authenticity, hollowing out the possibility of integrity as an experience of being emotionally connected to one’s values? What exactly do we want medical students to be when we assess their integrity? Bleakley’s book pays attention to these important questions, as well as to many others, highlighting what is needed for the human aspects of medical work to be fully integrated into the study of medicine.
The historically taboo question of medicine’s relationship with politics comes under scrutiny in Medical Education, Politics and Social Justice. There is a received wisdom that medical education should remain a-political, but, as Bleakley underscores, this logic is in tension with the fact that medicine, as an institution, is ‘riddled with’ hierarchies and power relations (p. xxiv). This is one of the key contradictions to which the book’s subtitle alludes. Bleakley argues powerfully for medical education to be re-conceptualised, in light of the climate crisis and increasing health inequity, as a practice focussing on ‘upstream’ public health issues and community care, rather than ‘downstream hospital-based acute care’ (p. xxiv). One of the barriers to this kind of wholesale re-thinking of medical education, Bleakley suggests, is a confounding of ‘curriculum’ and ‘syllabus’, which ‘takes our eye off the ball of meta-learning or learning to learn’ (p. 8). Bleakley is critical of an obsession with ‘curriculum as […] something to be ingested and regurgitated’, instead advocating for a notion of curriculum as ‘something to “think with”’ (p. 8).
If the medical humanities are to make a meaningful contribution to medical education over the coming decade, this could indeed be through facilitating new metaphors for learning and knowledge production to percolate into the space of medical education. Is learning about knowledge acquisition or knowledge application? Could it also be about developing the tools for deepening one’s understanding of the status of the sorts of knowledge one is encountering? For example, could it be learning about not just how a disease presents, but also how a disease presentation comes to acquire its associated symptomatology in the textbook? This would depend on understanding how studies have historically centred the able-bodied cis-male body as the norm (Gendered Innovations, 2022). Could it be about learning about how ‘empathy’ takes on a new meaning when clinical empathy is rated as part of a private healthcare system that ranks care providers (Banner, 2017)? Could it be about exploring how socialised medicine might alter people’s health-related decision-making? Could it be about building a critical genealogy of professionalism, that seeks to disentangle it from humanism (Goldberg, 2008) and to understand its roots in a deeply classed and raced aesthetics of the figure of the doctor (Allitt & Frampton, 2022)? As Bleakley demonstrates in this timely contribution, the medical humanities can offer medical students new lenses to understand the socio-material character of 21st century medical and health experience, yet, in order to facilitate this learning, medical education needs to build and maintain structures to integrate interrogative and dialogic modes of thought.
About the Author
Harriet Cooper is a Lecturer in Medical Education at the University of East Anglia (Norwich Medical School), where she teaches sociology and humanities to medical students. Harriet is an interdisciplinary academic working at the intersections of critical disability studies, medical humanities, medical sociology, and health services research. Her book Critical Disability Studies and the Disabled Child: Unsettling Distinctions was published by Routledge in 2020.
Allitt, M. & Frampton, S. (2022). Beyond ‘Born not Made’: Challenging character, emotions and professionalism in undergraduate medical education. BMJ Medical Humanities, 0: 1-10, doi:10.1136/medhum-2021-012365
Banner, O. (2017). Communicative Biocapitalism: The Voice of the Patient in Digital Health and the Health Humanities. Ann Arbor: University of Michigan Press.
Bleakley, A. (2021). Medical Education, Politics and Social Justice: The Contradiction Cure, Abingdon, Oxon: Routledge.
Gendered Innovations (2022) ‘Rethinking Standards and Reference Models’, http://genderedinnovations.stanford.edu/methods/standards.html
General Medical Council (1993). Tomorrow’s Doctors. London: GMC.
Goldberg, J. (2008). Humanism or Professionalism: The White Coat Ceremony and Medical Education, Academic Medicine, 83, pp. 715-722.