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Volume 6, Number 1

TRAINING IN CARING COMPETENCE IN NORTH AMERICAN MEDICINE
Reforming the Reforms*

RENÉE C. FOX, PHD

We must learn the science to practice the art.
Our competence makes room for the growth of our compassion, our humaneness.
Samuel Shem, Introduction to Dell's Tenth Anniversary
Edition of The House of God

This Philippa Harris Lecture will explore the persistent problem of fostering the development of caring competence in physicians, and the manner in which the medical profession has recurrently tried to deal with it, in and through the process of medical education. Although I have no definitive solution to this complex problem, I will suggest a framework of reflection that I hope may lead to more insightful and effective ways of training physicians to be both compassionately competent and competently compassionate.

In our North American societies, the most fundamental challenges involved in training physicians to be caringly competent stem from nothing less than the imprint of Western thought upon our version of modern medicine. Out of this highly analytic, logico-rational way of thinking and viewing the world has come a chain of paired dichotomies, basic to our cultural tradition.

These dichotomies are also deeply institutionalized in the cognitive and the practicum structure of our system of medicine. They include

Body vs mind
Thought vs feeling
Objective vs subjective
Explanation vs understanding
Material vs spiritual
Self vs other
Individual vs social, communal, and societal

In our medical curriculum, such polarities have been reified in the split conceptions of health and illness, in their "biomedical" as opposed to "psychosocial" components, and in the sharp distinctions maintained between basic science and the clinical aspects of medicine. They have even penetrated the subject matter and vocabulary of medical science in such fields as immunology, with its "self" vs "not-self" terms for identifying the body's ability to recognize "foreign" tissue.

So obdurate are these dichotomizing tendencies that they do not yield easily, if at all, to theoretical, empirical, or technological medical advances, or to attempted reforms in medical education. For example, one of the major challenges facing psychiatry in the coming century is that of integrating the concepts of mind and brain. This was the recurrent theme at the 1988 meeting "Next Steps That Will Revolutionize Psychiatry in the 21st Century" (1). Writing about it in Science, Deborah Barnes noted that

the obvious benefits of high technology for rapid diagnosis and drugs for specific illness notwithstanding, some foresee a struggle to keep the humanity in psychiatry. ... [P]sychiatrists remind one another to maintain a broad, humanistic perspective and to integrate the basic, natural, and behavioral sciences in the clinical practice of medicine. (2)

At this same meeting Leon Eisenberg, Professor of Psychiatry at Harvard, observed that although the conceptual framework of psychiatry has been turned upside down in his own professional lifetime, its bedrock dichotomies have neither been altered nor bridged. In his words,

When I began as a medical student, psychiatry was brainless. The brain was not the object of study; it was seen as being in the head for ballast. That view has changed. But now psychiatry is getting mindless. (quoted in 2, p. 1013)

Seen in cross-cultural perspective, this dualism of our medical thinking and our difficulties in breaking through it are distinctively and oddly Western. In non-Western societies and medical systems whose world-views are more holistic than our own, there is no need for special fields, meetings, lectures, courses and rhetoric to "remind" and teach medical students and practitioners that human beings have bodies and minds, and minds and brains, that are dynamically interrelated; that ideally the prevention, diagnosis, and treatment of illness should be approached in a "biopsychosocial" framework; that medicine is "both a science and an art"; that "the patient is a whole person"; or that "patients have families."

In the repeated educational changes we have made to surmount our dichotomies, each curriculum reform has been triggered by another prise de conscience about an excessive emphasis on the biological and technical aspects of medicine, at the expense of its psychological and humanistic components. Some of these reforms have devised whole new programs, such as the "Comprehensive Care" programs instituted in the 1950s, or Harvard Medical School's "New Pathways" program of the 1980s. Key elements in such reforms include bringing student-physicians into earlier, more sustained relations with patients; locating more of their training in ambulatory-care settings; increasing their opportunities to collaborate with nurses, social workers, psychiatrists, and social scientists; and requiring a period of community service as part of becoming a doctor. New courses have been injected into the curriculum, as if they were magic bullets that could "cure" the dualism and redress the imbalance in medical training. Over the last three decades, in their search for new formulas, North American medical schools have moved in seriatim from psychiatry, to psychosomatic medicine, to social and behavioral science, to community medicine, to bioethics, to the humanities.

STRUGGLING WITH "DEHUMANIZATION" AND "BRUTALIZATION": A second source of the difficulties in integrating competence and compassion is the "dehumanizing" and "brutalizing" effects that our system of medical training can have on young men and women. In part, this phenomenon emanates from the encounters medical students, interns, and residents have with the "human condition" and the "uncertainty" dimension of health, illness and medicine (3). Ruth Charon, a doctor and writer, has described some of the basic and transcendent aspects of the human condition inherent to medical work in these terms:

Patients come to doctors for trivial or tragic problems. We occupy a peculiar place for them. We are the ones who diagnose and treat their physical problems, but we also stand for a level of the transcendent in their lives. We preside at scenes of human crisis - pain, loss, death, as well as joyous ones like birth and recovery. ... We are the gatekeepers not only to services of subspecialists and fancy technology but also ... to the land of the living. … Because of the nature of the work we do with patients, we are in touch with deep levels of meaning in their lives. (4)

Even before they start the clinical phases of their training - when they dissect a cadaver in the anatomy laboratory, for example, or participate in an autopsy -student-physicians "meet the mystery of life and the enigma of death in the form of a naked fellow human being who is laid out on a stainless steel table" (5, p. 13). As soon as they begin their course work in physical diagnosis, they enter inner chambers of patients' bodies and of their "stories" and feelings. Through these experiences, charged with existential and metaphysical as well as biological and emotional significance, young doctors-in-becoming also undergo what I call "training for uncertainty." They learn in a variety of concretely experienced ways that whatever they do as physicians will always be "accompanied by uncertainties that stem both from how much and how little they [personally] know, and [from] how much is [and] is not known in the field of medicine" (5, p. 16).

As they struggle, individually and collectively, to manage the primal feelings, the questions of meaning, and the emotional stress evoked by the human condition and uncertainty aspects of their training, medical students and housestaff develop certain ways of coping with them. They distance themselves from their own feelings and from their patients through intellectual engrossment in the biomedical challenges of diagnosis and treatment, and through participation in highly structured, in-group forms of medical humor. "Counterphobic and ironic, infused with bravado and self-mockery, often impious, defiant and macabre," this humor "characteristically centers on medical uncertainty, the limitations of medical knowledge, medical errors, … the side effects of medical and surgical interventions, the failure to cure, sex and sexuality, and, above all, death" (5, pp. 23-24). Here, young physicians seek the measure of objectivity and equanimity they need to do their work competently, without unduly undermining their capacity for empathy and compassion (6). The phenomenon called "dehumanization" begins when they overshoot the mark and become hyperdetached, as many of them do.

By and large, medical students and house staff are left to grapple with these experiences and emotions on their own. They are rarely accompanied, guided, or instructed in these intimate matters of doctorhood by mature teachers and role models. Generally their relations with clinical faculty and attending physicians are too sporadic and remote for that.

Many observers have associated the "brutal and brutalizing" process to which physicians-in-training are subjected with the years of internship and residency during which they battle for "survival as a human being" (7). In The House of God, the most renowned of the corpus of memoirs about the house-staff phase of training that have been written by young physicians, Samuel Shem calls this the "cycle of brutality" (7). Foremost among the conditions that he and numerous others have described is the "ordeal" of the "on-call" schedule, which the American Medical Association (AMA) acknowledges is an "exhausting and often onerous schedule" of "long hours and no sleep." This experience may have serious negative consequences for the technical competence and the quality of the care that physically and emotionally fatigued young physicians deliver to hospitalized patients (8). However, the arduousness of house-officer training constitutes what the AMA characterizes as a "historical pattern endured by generations of physicians" (8) that is highly resistant to change. It continues to be powerfully supported by the conviction of many physicians that such rites of passage have indispensable value in preparing young initiates into the medical profession for the highest, most exigent responsibilities of their vocation. These sentiments were expressed, for example, in the outpouring of mail that the Journal of the American Medical Association received from physician-readers in response to Norman Cousins's article "Internship: Preparation or Hazing?" In this paper, Cousins asserted that

the custom of overworking interns has long since outlived its usefulness. It doesn't lead to the making of better physicians. It is inconsistent with the public interest. It is not worthy of the medical profession. (9)

Many physicians who strongly disagreed with this opinion wrote letters to the editor insisting that

aspiring physicians should be prepared to undergo a reasonable degree of hardship in their ascent to a profession built upon a tradition of personal sacrifice. Since medicine is dedicated to healing and the alleviation of human suffering, the training of physicians should emphasize the subordination of their personal comforts and perquisites. (10)

Another serious kind of stress from which house staff suffer that adversely affects their ability to be caring derives from their intensive, minute-to-minute contact with an unending procession of hospitalized patients for whose physical, psychological, and social problems they can offer no satisfactory solution, and little relief. As noted earlier, a classic collective defense mechanism is the bitterly humorous, often scathing, in-group terminology they invent and use as "backstage" labels for patients. In studying the pejorative label "gomer," which internal medicine residents in one American university hospital applied to patients, Deborah B. Leiderman and Jean-Anne Grisso (young physicians with social science training) pointed out that

gomers were patients whose illnesses and management posed special frustrations for resident physicians. Gomers suffered irreversible mental deterioration; their illnesses were complex and intractable; they were unable to resume normal adult social roles; and they had no place to go after discharge. ... [Such patients constitute] profound threats to [the residents'] ideals of themselves as physicians. (11)

Interns and residents attest that the great physical and emotional demands placed upon them, and the resulting state of chronic sleep deprivation, distress, and desensitization to others in which they find themselves, are made all the worse by their sense of aloneness and of virtual abandonment by senior physician-teachers and models. "The important thing about brutalization is that we were alone," Samuel Shem has declared: "There was nobody there. The phrase that comes to mind is: 'Be with the patient.' The value of medicine is being with the patient. [But] if no one is with you, then you can't be with anybody" (12).

WHERE ARE THE TEACHERS? AND HOW ARE THEY TEACHING?: Interns, residents, and medical students feel keenly the absence of dedicated teachers and clinical supervisors. This is a long-standing problem in medical education. Particularly since World War II, medical schools and academic health centers have increasingly emphasized the importance of faculty involvement in biomedical research and in specialty practice, at the expense of teaching. During the 1980s this situation worsened so that, despite the enormous size of medical-school faculties and clinical departments, fewer and fewer senior physicians are now involved in serious teaching:

Senior faculty have been taken away from the teaching act ... . They are consumed by managerial and budgetary functions [including the obligation to generate their own salaries through clinical practice], and [they] do not walk the corridors of learning with their students. Medical students are being taught by house staff, and house staff are being taught by house staff. (13)

In a disquieting 1982 study, Teachers and Teaching in U.S. Medical Schools, based on a survey of several thousand full-time faculty, Hilliard Jason and Jane Westberg found that

  • 60 per cent of full-time faculty spent [fewer] than 5 hours per week teaching
  • the majority [attached little importance to] the kinds of attitudes developed by students about what it means to be a physician, and [to] their skills in dealing with ambiguity
  • a scant 3 per cent of the medical-school faculty polled [believed] that community service was of any importance ... , and most [concluded] that such service detracted from medical school activities. (14, pp. 31-32)
Even when faculty and attending physicians are present, the chief pedagogical methods often have the effect of distancing students, interns, and residents from their patients. In medical educator David E. Rogers's words,

We are force-feeding students with up to 8 hours of lectures a day, denying them the time to explore learning on their own. ... Gone are the go-at-your-own-pace problem-solving sessions, the informal after-hours get-togethers with faculty, and the leisurely laboratory work where students got to know faculty and learn more about the personal qualities of those who taught them. (14, p. 31)

Professor of Medicine Sherman M. Mellinkoff goes on to say:

In most places, the student and the teacher spend less time with patients and more time with blackboards and lantern slides. Patients have almost vanished from "grand rounds," which are now lectures-often very good ones. ... Other teaching rounds may be … conducted mainly in a conference room, not at the bedside ... . Ambulatory patients, with whom students in many medical schools used to spend almost a year, are usually seen very little or not at all in the study of internal medicine. ... From many of their teachers and from the hospital records, students receive the answers to a large number of questions they did not generate. Facts surround the students without vivid connections to their patients' stories. (15, p. 1089)

Many of these complaints about current medical education are not new. Nonetheless, Mellinkoff believes that, in medical education, we are more divided than ever between the desire "to produce the physicians we would like to see if we were sick" and the desire "[to create] an efficient, specialized staff member of a procedure-oriented care facility" (15). Thus we return full-circle to the dichotomies inherent to our medical culture and to the world-view of which it is a part, failing to recognize that in disjoining the art and science of medicine, we are pulling asunder technical competence and empathic caring.

REASONING TOWARD REMEDIES: These problems of training in caring competence are associated with ways of thought, shared values, beliefs and sentiments, modes of organization, and patterns of behavior institutionalized in distinctive, tenacious forms in our system of medical care and our process of medical education. The same relatively ineffective solutions to them have been proposed again and again.

This medical-educational equivalent of reinventing the wheel is illustrated in the recent "suggestions for overcoming shortcomings" made by the Josiah Macy Jr. Foundation National Seminar on Medical Education:

The education of future doctors should be an institutional, not a departmental, function. Any significant changes in clinical education at a medical school will require the creation of a centralized education unit with recognized responsibility and authority to develop the basic curriculum. Medical-student teaching must be recognized and honored by faculty in its own right- with stature, and with legitimacy for appointment and promotion, equal to that given research productivity and clinical excellence. ... Substantial amounts of clinical teaching ... should be moved to ambulatory settings. ... [T]he nation and its medical schools should [also] consider requiring a period of community service for students as part of becoming a doctor. (16; emphasis in original)

Neither the great scientific and technological advances in medical knowledge, clinical methods, and therapy since World War II nor the major social and economic changes that have taken place in our system(s) of health-care delivery have significantly improved the training offered for caring competence. Indeed, in certain ways, these advances and changes have augmented the problem. As sociologist Howard L. Kaye points out, the advent of the "biological revolution" and the pre-eminence of molecular biology in medicine that it has brought in its wake have deepened the split between scientific and clinical medicine, between micro-and macro-levels of observation and analysis, and between the biological and non-biological aspects of medicine:

[C]ulture is reduced to biology; biology, to the laws of physics and chemistry at the molecular level; mind, to matter; behavior, to genes; organism, to program; the origin of species, to macromolecules; life, to reproduction. ... The reductionism ... represents both a research strategy (one that has been spectacularly successful), and something more: a world view. (17)

In this perspective, non-biological factors are either biologized, or banished to a category of lesser importance. New forms of medical technology, in conjunction with this microview of molecular biology, have carried medicine further away from a holistic outlook. In the words of nurse Sallie Tisdale:

Our eye gets finer and finer every day, drawing us down until we are looking at smaller and smaller pieces of the whole. We ride it down the laser and scope and scanner, until we sit at the side of the cell and try to extrapolate from it the rest of the person. (18)

This is "a great relinquishment" (18).

The teaching of clinical medicine with a balanced, reciprocal respect for its science and its art has also been made more difficult. Educators like Mellinkoff note that

Teaching hospitals and allied institutions have been made vastly more expensive to build and operate by a variety of factors, including scientific ~and technologic advances, measures designed to rectify historical inequities such as the low salaries of nurses, the failure to work out adequately rational and moral mechanisms for ensuring medical care for all who need it while not squandering resources on the prolongation of death, the population surge among the aged, and competition for money and talent by profit-driven corporations. Escalations in the fractions of the gross national product spent on medical care under these circumstances have given rise to blunt cost-containment efforts. These sometimes manage simultaneously to be unsuccessful, harmful to the spirit and quality of medical care, and damaging to medical education, especially at hospitals caring for the poor. (15, p. 1091)

In the educational efforts that have been made to teach physicians to integrate competence and caring in their treatment of patients, we have continually failed to take non-medical factors sufficiently into account, and we have consistently expected panaceas from simple, mechanistically implemented educational reforms. We have parachuted into the medical curriculum courses in behavioral science, bioethics, human values, and the like, as if they were automatic and interchangeable promoters of humane and compassionate medical care (19).

I am not suggesting that nothing can be done to improve training in caring competence without restructuring all of our medicine and science. However, I do think that it would make a difference if medical faculty more fully recognized and accepted how profoundly the concepts, terminology, and methods of biomedicine are imprinted with dichotomies inherent in our cultural way of thought. This realization could lead to a new awareness of some of the bioscientific contexts in the curriculum that are inadvertently teaching medical students and house staff to split competence from caring. For example, as Professor of Medicine and Epidemiology Alvan R. Feinstein points out, "the devout reverence for hard data" that prevails in biomedicine produces "dehumanized science in patient care" (20, p. 490). The "hard data creed," Feinstein explains, often leads us to omit "soft" variables from the conduct of clinical research and from the way its findings are interpreted and taught:

Since all of the uniquely human phenomena of patients are expressed in soft clinical data [he goes on to say], the exclusion of such data creates biostatistical clinical science that is deliberately dehumanized. The results that emerge from the trials do not contain information about the things that a practicing doctor and a patient might want to know in choosing a treatment. (20, p. 493)

Sociologist Renée R. Anspach has made a comparable analysis of the language that interns and residents use in their formal presentations of case histories and of the implicit, unintentional consequences of their vocabulary for the way of thought and the values they learn (21). Case presentations are an important part of the routine of house staff. In addition, she has emphasized that because they are "self-presentations ... delivered before superordinates," they are "instrument[s] for professional socialization" (21, p. 372). In her analysis of case presentations by house staff in two intensive-care nurseries and an obstetrics and gynecology service, Anspach found that "many of the values and assumptions" in the language they employed "contradict[ed] the explicit tenets of medical education," Most particularly, the medical discourse both reflected and created a "world view" that "emphasize{d] science, technology, teaching and learning at the expense of interactions with patients." In this view,

biological processes exist apart from persons, observations can be separated from those who make them, and the knowledge obtained from measurement instruments has a validity independent of the persons who use and interpret this diagnostic technology. ... [T]hose who use the language of case presentation may be impelled to adopt an unquestioning faith in the superior scientific status of measurable information and to minimize the import of the patient's history and subjective experience. (21, p. 372)

The analyses of Anspach and Feinstein suggest that medical educators have paid too little attention to the effects that the cognitive content of medicine, the conceptions of science on which it is based, and the forms in which its knowledge is presented have on the attitudes, values, and beliefs that medical students, interns, and residents develop - including and especially those relevant to their physicianly competence to care. I believe that physicians-in-training should be given a systematic opportunity to explore the social and cultural matter embedded in the sciences they are studying, through courses in the philosophy, sociology, or intellectual history of medical science. This would be particularly suitable during the first two years of medical school, while students are immersed in the basic sciences. These courses might be more appropriate, and thus have more impact, than those in behavioral science and bioethics usually scheduled at this point.

It would also be both instructive and useful if medical educators knew more about the social, cultural, and psychological origins of the collective defense mechanisms that medical students and house staff characteristically develop in the course of their training. In addition, it would be helpful if they were more perceptive about the sociomedical situations out of which these group-patterned devices grow, and more thoughtful about their implications for the humane competence of the young women and men whose medical training and professional unfolding take place under their aegis.

Because the work physicians do confronts them with "basic human condition-associated stresses and dilemmas" inherent to medicine, they cannot "go naked" into it. "In order to do this sort of work, and do it well, they must develop intellectual and emotional 'clothing' that provides them with some degree of detachment and protection" (5, p. 35). But does this necessarily mean that the current ways of coming to terms with the stressful aspects of caring for patients that neophyte physicians adopt are inevitable - the only viable coping mechanisms that are available to them? For example, are the self-protective medical humor and the "gomer phenomenon" unavoidable? What other psychosocial means can young physicians employ to deal with the disease and death, pain and suffering, injustice and tragedy, and uncertainties and limitations inherent to their work? What can medical faculty and attending physicians do to help the women and men they teach to find ways of coping that would enable them to stay in more open, feeling contact with their own humanity and that of their patients?

In planning and in altering curriculum and training programs, medical educators need to recognize and systematically take into account the interrelationships that exist between the stresses of learning to be a doctor, the ways of coming to terms with these stresses institutionalized in the culture of medical students and house staff, and the difficulty of emerging from medical training with humane values, caring skills, and the capacity to put them into practice. With this kind of knowledgeable insight and the willingness to act upon it, for example, medical educators would be better equipped to arrange a more felicitous ordering and timing of the experiences to which students and house staff are exposed in the training process. In addition, they might organize opportunities for neophyte physicians to identify and analyze their shared stresses and modes of coping with them, in ways that could have both didactic and therapeutic value for them personally, and in their relationship with patients.

Finally, we return to what I regard as the most important questions of all: "Where are the teachers? How are they teaching?" And what can be done about the fact that so many of them have retreated from in situ involvement with student-physicians, interns, and residents? In my opinion, unless the teachers return to first-hand teaching, even the most inspired schemes for improving training in caring competence will fail.

I have not proposed any sweeping solutions to this basic and persistent problem in medical education. However, I hope that by casting it in a somewhat different sociocultural framework, I have suggested some approaches to "reforming the reforms" (22) that have repeatedly been applied to the goal of fostering caring competence in future physicians.

Renée C. Fox, PHD
Annenberg Professor of the Social Sciences
Department of Sociology
University of Pennsylvania
McNeil Building, 3718 Locust Walk
Philadelphia, Pennsylvania USA 19014-6299

ACKNOWLEDGMENT

I am grateful to Judith P. Swazey for her helpfully critical reading of this paper.


REFERENCES

  • This meeting (held October 7-10, 1988 in New York City) was sponsored by the Department of Psychiatry and Behavioral Sciences of the New York Medical College.
  • Barnes DM. Psychiatrists psych out the future. Science 1988;242(Nov. 18): 1013-14.
  • See Fox RC. Training for uncertainty. In Merton RK, Reader G, and Kendall PL, eds. The Student-Physician: Introductory Studies in the Sociology of Medical Education. Cambridge, MA: Harvard University Press, 1957, pp. 207-41; and Fox RC. The Human Condition of Health Professionals. Distinguished Lecturer Series. Durham: University of New Hampshire, 1980.
  • Charon R. To listen to recognize. The Pharos 1986(Fall) :12.
  • Fox RC. The Human Condition of Health Professionals.
  • Lief HI, Fox RC. Training for "detached concern" in medical students. In Lief HI, Lief VP, and Lief NR, eds. The Psychological Basis of Medical Practice. New York: Harper and Row, 1963.
  • Shem S. Introduction. The House of God. Tenth Anniversary Edition. New York: Dell Publishing, 1988.
  • Hinz C. Scheduling, supervision of residents to be examined. Amer Medical News 1987(Jul. 3-10):9.
  • Cousins N. Internship: Preparation or hazing? J. Amer Med Assoc 1981;245(4) :377.
  • Internship: Physicians respond to Norman Cousins. J. Amer Med Assoc 1981;246(19):2141-44. The quotation is taken from Norman Cousins's summary of and response to these recurrent themes (Norman Cousins responds, p. 2144).
  • Leiderman DB, Grisso JA. The gomer phenomenon. J Health and Social Behavior 1985(Sept.);26:222-32.
  • Watkins IC. Edited transcript of "The Physician as Writer" (a symposium held under the auspices of The Cooper Institute for Advanced Studies in Medicine and the Humanities and organized and chaired by Renée C. Fox; Naples, FL, November 10-12, 1988), p. 157.
  • Medical Uncertainty: An Interview with Renée C. Fox. Second Opinion 1987(Nov);6:1040.
  • Results of Jason and Westberg study are summarized in Rogers DE. Prescription for medical education. Issues in Science and Technology 1988( Winter) :31-33.
  • Mellinkoff SM. The medical clerkship. N EngI I Med 1987;317(17).
  • Rogers DE. Clinical education and the doctor of tomorrow. In: Gasterl B, Rogers DE, eds. Adapting Clinical Medical Education to the Needs of Today and Tomorrow: Proceedings of the Josiah Macy Jr. Foundation National Seminar on Medical Education, November 1988. New York: New York Academy of Medicine, in press.
  • Kaye HL. The Social Meaning of Modern Biology: From Social Darwinism to Sociobiology. New Haven: Yale University Press, 1986, pp. 55-56.
  • Tisdale S. The Sorcerer's Apprentice: Inside the Modern Hospital. New York: McGraw Hill, 1986, p. 245.
  • At the time that I was writing this part of the Philippa Harris Lecture, I received an announcement of a forthcoming American Board of Medical Specialties conference, "Teaching and Evaluation of Humanism," that typified this approach. It promised to "highlight" such topics as "The Importance of Humanism in the Physician," "How to Teach Humanism in Residents," and "How to Evaluate Humanism in Residents."
  • Feinstein AR. Hard science, soft data, and the challenges of choosing clinical variables in research. Clinical Pharmacology and Therapeutics 2977;22(4).
  • Anspach RR. Notes on the sociology of medical discourse: The language of case presentation. J Health and Social Behavior 1988;29(4) :357-75.
  • For articulating the need to reform the reforms that have been attempted in medical education, I am indebted to Ebert RH, Ginzberg E. The reform of medical education. Health Affairs 1988;7:5-38.
* The editors wish to thank Dr. Renée C. Fox for her gracious consent to the publication of this abridgment of her Philippa Harris Lecture delivered on March 31, 1989, at the Princess Margaret Hospital, Toronto, Canada. In preparing this shorter form, the editors have taken care to disturb as little as possible her distinctive writing style, which is well known to readers in medicine and the social sciences. The complete paper will appear in Educating Competent and Humane Physicians, edited by Hugh C. Hendrie and Camille Lloyd, forthcoming from Indiana University Press, Bloomington, IN. In that volume, Dr. Fox's paper is entitled "Training in Caring Competence: The Perennial Problem in North American Medical Education."