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'Hands on Learning' in Medicine: Who Benefits?

Patients who access the teaching hospitals are often examined by more than one doctor - usually a group of medical students who learn on the patient. This raises serious issues about taking consent, the patients' agency and ethics in practice. It is explained away, however, on the grounds that since these patients get subsidised/free treatment, they should shoulder the responsibility of letting doctors learn on their bodies. But do these patients have no rights to demand or deny anything? How can the situation be addressed, given that doctors really need to learn?

COMMENTARY

‘Hands on Learning’ in Medicine: Generating new knowledge(s) of the human body, the anatomy, of life, of health,
Who Benefits? disease and death is the mandate of biomedical sciences. Modern medicine traces
its birth to the late 18th century. In The
Birth of the Clinic, Foucault talks of how
Rakhi Ghoshal and why the clinical gaze is born (1973:

Patients who access the teaching hospitals are often examined by more than one doctor – usually a group of medical students who learn on the patient. This raises serious issues about taking consent, the patients’ agency and ethics in practice. It is explained away, however, on the grounds that since these patients get subsidised/free treatment, they should shoulder the responsibility of letting doctors learn on their bodies. But do these patients have no rights to demand or deny anything? How can the situation be addressed, given that doctors really need to learn?

I thank Anup Dhar and Neha Madhiwalla for having knowingly and unknowingly helped me to think and write about this issue. Thanks also to an anonymous referee for comments on an earlier version of this article.

Rakhi Ghoshal (rakhi.ghoshal@gmail.com) is with the Centre for Studies in Ethics and Rights, Mumbai.

T
eaching hospitals are mostly public hospitals and medical students, residents and young medical professionals learn on the patients there, as part of their training. It is common to see a group of young doctors each in turn palpating a patient whose diagnosis is already known as a part of their training. However, for patients, this can be an unwanted intrusion and a painful one at that. But this is a catch-22 situation, and a refrain one hears both from doctors and from the non-medical community is that since patients coming into the public hospital receive “free treatment”, this is a form of payment. Besides, how else would doctors learn? Historically, it began the other way round – doctors wanted to learn and therefore started treating patients for free. This situation is commonsensical at one level and loaded with a range of assumptions and normative expectations at another.

The primary issue here is one of “learning” – doctors of tomorrow need to learn, need to know, they need to have what Aristotle calls “techne” or know-how. This calls for a distinction between knowledge (episteme) and techne – the art of handson-knowledge, or practical knowledge. While episteme, having etymological roots in Greek, means knowledge or science, techne is usually translated as craftsmanship or art. Thus, obviously, for the artisan or the craftsman, to learn means to practice; learning cannot remain restricted to knowledge without the know-how. Just as one cannot learn swimming by reading a book one cannot become a doctor without “practising” on the human body. And the difference between the swimmer and the medical practitioner is that while the former requires a pool of water to learn in, the latter requires a human body – and certain specific things inevitably have to be learnt on the human body. And thus we are faced with issues of consent, agency of the patient, power relations and ethics.

october 15, 2011

xiii-xv): formation of new knowledge(s) became the mandate for setting up clinics and hospitals, with the human body as the site for examination and learning; but this body is not just the anatomical body; it is also the “sociological body”: “that which is the site where power relations are instantiated, is not the simple physical body” (Sundar Sarukkai, Chapter 2 from a manuscript of a book to be published, emphasis added). This body is a social body, a body that bears and plays out “social responsibilities” (so one is urged to lend the body for the enhancement of medical knowledge), a body that is on the one hand shaped through the contours and explanations of the anatomo-clinical paradigm, and on the other anchors a titled power equation and a body that helps in generation of new knowledge and consolidation of others’ skills. This twofold understanding of the body is vital for science – for its development and growth.

The ‘Twofold’ Body

It is this very body in its two-ness that makes this particular knowledge form – biomedical knowledge – stand at the intriguing cusp of the subjective and the objective; being a science, medicine necessarily has to be objective, see exactly what all others trained in that science can see, say what anybody else trained in it would say. Yet, to touch, to feel and then to say, involves subjective conclusion-making as well. The symptoms that provide the ground to start diagnosis are both objective and subjective – they are both mentioned in details in medical books and journals (hence objective) and yet are necessarily to be felt and understood by each doctor on his own, in a subjective manner. In the moment of touching and palpating – say, a lump deep inside the other’s body, without having cut open the body, and to decide whether the lump requires surgery or not – the doctor is completely alone in his touching, in feeling the lump, in his pronouncement of the diagnosis. The medical gaze

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(that shapes and guides modern medicine) flows through the doctors’ fingers and the more adept he is in making the correct pronouncement and taking the correct decision, the better and more valued a doctor will he be. And thus, so that he can do his best, he requires years of training and practice. Naturally this training involves what is called hands-on learning, and by a logical turn, requires human bodies on which to learn, along with a trained pair of hands that guides him through, so that, what this young doctor sees and reads under the guide/gaze of his supervisor, he can take as “true knowledge” and later practise, unguided, on his own, based on the memory of that one first, supervised touch.

However, certain problems begin to surface when we start thinking of this human body as something more than mere resource for generating new knowledges. Foucault says,

clinical experience...was soon taken as a simple, unconceptualised confrontation of a gaze and a face, or a glance and a silent body...free of the burdens of language, by which two living individuals are ‘trapped’ in a common but non-reciprocal situation (ibid: xvi).

The issue here is of a skewed powerrelation; however, at a commonsensical level, the system tries to address this too, and we have the mandate of consent-forms in place. The picture is thus something like this: patients come to the teaching hospitals and are expected to let the young doctors learn on them; the patient’s consent is obtained. In effect it seems a foolproof situation. But one would like to reflect on whether the process of consent-taking really speaks anything of the agency of the patient or in fact even offers any option to the patient to refuse being “taught upon”. Given the power dynamics, the inherently tilted gradient of authority and power, what are the chances that the economically backward patient, with some severe physical ailment, in pain and discomfort, and in dire need of treatment, would refuse the doctor? A graduate from a medical college in Kolkata shared with me how when some “case” of suspected breast tumour would come in, all of those who otherwise might miss classes, would flock in to palpate and try to learn all

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october 15, 2011

about breast lumps and potential cancerous growths. For the say, 23-year-old socioeconomically marginalised woman, who is already overwhelmed by her own pain and discomfort and by the doctors and all the bonhomie around her, “cooperation” would naturally come through silence.

The ‘Free’ Patient

Let us look at the argument that since

people receive free/subsidised treatment

they should remain obliged to the hospital

and shoulder the responsibility of helping

doctors learn on them: most of those who

access public hospitals are from the lower

socio-economic class. People who access

the (usually more efficient and structured)

private healthcare set-ups avoid coming to

public hospitals and so do not demand any

accountability from this sector. The state

of the public hospitals does not bother

them on a day-to-day basis, and it is only

those who cannot afford the private

healthcare who end up accessing this

space since they do not have the means to

avail of other options (this is because the

socio-economic profile of patients who ac

cesses state-run health services has changed

after the private health service boom post

globalisation). And thus it has sort of

come to be mapped as lower-class: public

hospital and middle/upper-class: private

hospitals. Healthcare in India has thus

become divided between the ones with

access to capital and those without, the

former having the options to access health

care proportionate to the money they are

able to spend, and the latter being provided

for by the State. Invariably, services for the

poor in effect turn out to be poor services.

A common perception is that the poor

do not pay taxes towards the nation’s fis

cal growth and so should remain satisfied

with the subsidised health services offered

by the State. They thus are left with no

right to deny, protest or demand account

ability. How ever, several people who ac

cess the public hospitals are labourers,

daily wage-earners, small time traders,

domestic helps and so on – people who do

not work in white-collared jobs but who

contribute to the economy and also pro

vide services that the rest of us need on a

daily basis. The population that now

a ccesses the public hospitals has the rights

to do so at the subsidised rates that it gets,

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and also the rights to demand accountability for lapses in services – much like the upper class.

The Beneficiaries

The poor shoulder the “responsibility” of helping in the generation and validation of knowledge; but who benefits from this? Having informally talked with junior doctors, I can say with some certainty that for many of these young practitioners, the coveted future lies in either being part of the private healthcare system or setting up one’s own independent private set-up, since monetary returns are more. Thus, while students vie to get a seat in the government teaching-hospital – where hands-on learning is more varied and rich since a variety of diseases and complications are accommodated there – the same people, once adept in skills of diagnosis and surgery, move on to the private set-ups, to ensure a return of the investments made. While each individual is indeed entitled to his or her own thinking and decision, in reality what happens is that while the poor patients provide their bodies for the generation of knowledge, once the know ledge/skill has been acquired satisfactorily, they often do not receive the benefits. Keeping aside the empirical exceptions of doctors who have been different, it appears that according to the most common pattern, while poor bodies carry out the abovementioned social responsibility, it is only the affluent and richer bodies who reap the benefits of the same – and so, contributing to, and benefiting of know ledge in effect becomes a politicised question of socio-economic classes.

The phenomenon of thrusting social responsibility on poorer bodies has existed for a long time: from the various state interventions like the range of programmes on sterilisation – the argument has been that population-growth needs to be controlled, forcibly if need be, but empirics have usually shown the targeted population as always constitutive of the lower socioeconomic class. During cleaning up of cities it is the slums that are demolished, during building dams and factories it is the tribal and the farmer who loses her/his land and livelihood, during developing multistoreys and shopping malls it is the small plots of agricultural lands that silently vanish,

COMMENTARY

during restricting population-growth it is the poor who are targeted.

Conclusions

If the responsibility for generating knowledge lies with people from the lower socio-economic class and the benefits of the same are to be reaped by people from the upper socio-economic class, and given that doctors will indeed have to learn, what can be the middle way? Is there one at all?

On the one hand there might be rules put into place, that could restrict the number of doctors examining a patient at the public hospitals, the process of consent-taking could be monitored and awareness spread among the patient community about their rights, and assurances could be given and maintained that patients have the right to refuse and those who refuse shall suffer no adverse effects. But on the other hand, and at a deeper level, this is a question of (medical) ethics and mere rules and surveillance strategies imposed from the outside might not be sufficient to tackle the problem. Those with the power balance tilted towards them need to realise in the first place that it is a problem. If it is a question of gratitude – for treatment received – the gratitude should also arise in the hearts of those who are getting to learn off these bodies, and to whet their skills and knowledge. And acknowledgement cannot be imposed from outside; it is a question of ethics, a realisation of the fact that the relation (between doctors and “poor” patients in this case) is strongly reciprocal. Finally, when it comes to bearing the social responsibility of helping doctors learn, maybe the well-off classes too could finally step in to do their bit of sharing the same responsibility? Perhaps it could be made mandatory that even in the private spaces one resident would accompany the visiting doctor? Agreed, that most of us would not like being examined unnecessarily, but if the concern is one of sharing social responsibility, too many “other” people have mutely bared their bodies for relentless examinations.

While this is not offering “solutions”, the article wishes to evoke some concern if possible. The author, herself part of the moderately well-off middle class, would prefer to be seen by the minimum number of people when at the clinic, but also feels that she should train herself to share the social responsibility, the benefits of which she and her class have reaped thus far. The onus of initiating change would lie majorly with the class that has been at the better end of the responsibility-benefit divide and also with the medical service providers, since the equation of power is invariably tilted in their favour. For long now a particular social class has remained “responsible” and the other has “benefited” from the knowledge reaped; perhaps it is time we evened out the distinction? Perhaps only then will we make that transition from techne to “phronesis” – which, according to Aristotle is the most important factor by which instrumental rationality is balanced by value-rationality, the ethical, since such balancing is crucial for the sustained well-being of any society.1

Note

1 According to Aristotle phronesis is the only quality

– apart from episteme and techne, and slightly beyond of them – that, in its meaning as practical wisdom, takes the political well-being of the citizen into account and in terms of value, exceeds mere techne – technological know-how – and episteme – which is only scientific wisdom, removed from notions of the political and thus by extension, the ethical. Bent Flyvbjerg (2001) discusses this in his book.

References

Flyvbjerg, Bent (2001): Making Social Science Matter: Why Social Inquiry Fails and How It Can Succeed Again (New York: Cambridge University Press).

Foucault, Michel (1973): The Birth of the Clinic: An Archaeology of Medical Prescription (London: Tavistock).

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