Journal of Clinical Psychology in Medical Settings, Vol. 2, No. 3, 1995
When Is Enough Enough? We Are Only Beginning John E. Carr 1
Sheridan (1995) presents the problem of the psychologist consulting to a medical residency program as an example of the difficulty one experiences in attempting to challenge, even from a data-based perspective, the calcification inherent in health systems and medical education in particular. This paper responds to her challenging questions, "How much should we get involved in changing health care and medical education, and at what level (local, national) should psychology intervene (if at all)?" It is suggested that psychologists pick up the challenge to bring about change, whenever possible, with the admonition--we are only beginning. KEY WORDS: health psychology;medical education; consultation; health care policy.
Sheridan's (1995) description of her consultation experience with a pediatric residency program has the poignant ring of frustrating familiarity. Legions of medical educators, including a number of psychologists, have documented the need for change, proposed numerous reforms, and decried the resistance to change in how and what we teach our future physicians (Bloom, i988; Fox, 1990; Enarson & Burg, 1992; Cart, 1994). Invoking behavioral laws leads one to conclude that there must be something inherently reinforcing in medicine's dogged maintenance of the status quo including the preservation of the institutions, dogma, rituals, and rites of passage of medical education. Fortunately, voices within medicine and the other health professions continue to challenge the sanctity and infallibility of many of these past practices. I am certainly not surprised by Sheridan's observation that health care systems and "medical residency programs seem to be examples of institutional calcification," but I am surprised that she (and many 1Department of Psychiatry, Universityof Washington, 4225 RooseveltWay, N.E., Suite 306, Seattle, Washington 98105-6099. 299 1068-9583t95/11900-0299507.50/0© 1995 Plenum Publishing Corporation
300
Carr
of us in medical settings) still ponders the questions of "Should I get involved? What good will it do? Why bother if nobody listens?" While serving a 4-year tour as the Acting Chair of a Department of Psychiatry (unusual for a psychologist), I wrote about the need for psychologists to become involved in health care and medical education at the national as well as the institutional level (Carr, 1987). For far too long, psychologists in medical settings had tended to see themselves as "expatriates," living in a "foreign culture," only superficially involved, barely speaking the language, and adhering to customs and beliefs sometimes different from the "host culture." All too often, we continue to accept passively our "adjunct" role and rationalize our "outlier" position as acceptable since it saves us having to be involved in burdensome policy decisions, committee work, or other distracting activities. But if we, and our physician colleagues who share our belief that change is not necessarily bad, are to have any impact on the health care system in general and medical education specifically, we must step forward and assume, as faculty members, all the "rights, privileges, and responsibilities thereunto pertaining." Our experience as psychotherapists teaches us that one insightful interpretation, no matter how brilliant, rarely effects change. Cognitive, as well as behavioral, advancement requires continuous and consistent repetition. Medical education will evolve via successive approximations gradually, perhaps even imperceptibly at times--but it will change, and only in response to tenacious and concerted efforts. Psychology can be a leader in effecting change because we are the leaders in the scientific study of human behavior, both within large organizations and in individual learning environments. Psychologists in medical settings who are interested in this challenge of influencing physician education and health care systems should contact the Association of Medical School Psychologists (AMSP). This organization has vigorously advocated the involvement of psychologists in medical school administration, research, and clinical care as well as teaching. It has sought to educate the American Psychological Association (APA) and American Psychological Society (APS), as well as the American Association of Medical Colleges, about the important role psychologists play in health care and medical education. Another important organization is the Association for the Behavioral Sciences and Medical Education (ABSAME), a multidisciplinary group that includes psychologists as well as physicians, anthropologists, sociologists, nurses, social workers, etc. Both AMSPP and ABSAME have been active in promoting the behavioral sciences in medical education and clinical care and recently joined together with the Association of Directors of Medical
When Is Enough Enough?
301
Student Education in Psychiatry (ADMSEP) to develop jointly a curriculum guide for the behavioral sciences in medical education. This unique collaborative effort is persuasive evidence of the extensive multidisciplinary support for change, innovation, and development. Sheridan (1995) asks, "When do we psychologists acknowledge that enough is enough?" We don't. How do we break through the institutional calcification of medical education? By continuing to chip away; by joining with others equally committed; by realizing it is persistence and tenacity that will eventually succeed; by continuing to call attention to the problems; by publishing reports as Sheridan has done; by continuing to highlight the need as this and other journals have done; by continuing to document the problems and offer solutions as many distinguished physicians, psychologists, sociologists, anthropologists, and other health care professionals have done before us. When is enough enough? We are only beginning.
REFERENCES Bloom, S. (1988). Structure and ideology in medical education: An analysis of resistance to change. Journal of Health and Social Behavior, 29(12), 294-306. Carr, J. (1987). Federal impact on psychology in medical schools. American Psychologis~ 42(9), 869-872. Carr, J. (1994). Basic behavioral science in medical education: The need for reform. Annals of Behavioral Sciences and Medical Education, I(1), 5-13. Enarson, C., & Burg, F. (1992). An overview of reform initiatives in medical education, 1906 through 1992. Journal of the American Medical Education, 268(9), 1141-1143. Fox, R. (1990). Training in caring competence: The perennial problem in North American medical education. In H. Hendrie & C. Lloyd (Eds.), Educating competent and human physicians (pp. 119-216). Bloomington: Indiana University Press. Sheridan, K. (1995). The clinical psychologist as program consultant: When is enough enough? Journal of Clinical Psychology in Medical Setting, 2(3), in press.
When Is Enough Enough? We Are Only Beginning John E. Carr 1
Sheridan (1995) presents the problem of the psychologist consulting to a medical residency program as an example of the difficulty one experiences in attempting to challenge, even from a data-based perspective, the calcification inherent in health systems and medical education in particular. This paper responds to her challenging questions, "How much should we get involved in changing health care and medical education, and at what level (local, national) should psychology intervene (if at all)?" It is suggested that psychologists pick up the challenge to bring about change, whenever possible, with the admonition--we are only beginning. KEY WORDS: health psychology;medical education; consultation; health care policy.
Sheridan's (1995) description of her consultation experience with a pediatric residency program has the poignant ring of frustrating familiarity. Legions of medical educators, including a number of psychologists, have documented the need for change, proposed numerous reforms, and decried the resistance to change in how and what we teach our future physicians (Bloom, i988; Fox, 1990; Enarson & Burg, 1992; Cart, 1994). Invoking behavioral laws leads one to conclude that there must be something inherently reinforcing in medicine's dogged maintenance of the status quo including the preservation of the institutions, dogma, rituals, and rites of passage of medical education. Fortunately, voices within medicine and the other health professions continue to challenge the sanctity and infallibility of many of these past practices. I am certainly not surprised by Sheridan's observation that health care systems and "medical residency programs seem to be examples of institutional calcification," but I am surprised that she (and many 1Department of Psychiatry, Universityof Washington, 4225 RooseveltWay, N.E., Suite 306, Seattle, Washington 98105-6099. 299 1068-9583t95/11900-0299507.50/0© 1995 Plenum Publishing Corporation
300
Carr
of us in medical settings) still ponders the questions of "Should I get involved? What good will it do? Why bother if nobody listens?" While serving a 4-year tour as the Acting Chair of a Department of Psychiatry (unusual for a psychologist), I wrote about the need for psychologists to become involved in health care and medical education at the national as well as the institutional level (Carr, 1987). For far too long, psychologists in medical settings had tended to see themselves as "expatriates," living in a "foreign culture," only superficially involved, barely speaking the language, and adhering to customs and beliefs sometimes different from the "host culture." All too often, we continue to accept passively our "adjunct" role and rationalize our "outlier" position as acceptable since it saves us having to be involved in burdensome policy decisions, committee work, or other distracting activities. But if we, and our physician colleagues who share our belief that change is not necessarily bad, are to have any impact on the health care system in general and medical education specifically, we must step forward and assume, as faculty members, all the "rights, privileges, and responsibilities thereunto pertaining." Our experience as psychotherapists teaches us that one insightful interpretation, no matter how brilliant, rarely effects change. Cognitive, as well as behavioral, advancement requires continuous and consistent repetition. Medical education will evolve via successive approximations gradually, perhaps even imperceptibly at times--but it will change, and only in response to tenacious and concerted efforts. Psychology can be a leader in effecting change because we are the leaders in the scientific study of human behavior, both within large organizations and in individual learning environments. Psychologists in medical settings who are interested in this challenge of influencing physician education and health care systems should contact the Association of Medical School Psychologists (AMSP). This organization has vigorously advocated the involvement of psychologists in medical school administration, research, and clinical care as well as teaching. It has sought to educate the American Psychological Association (APA) and American Psychological Society (APS), as well as the American Association of Medical Colleges, about the important role psychologists play in health care and medical education. Another important organization is the Association for the Behavioral Sciences and Medical Education (ABSAME), a multidisciplinary group that includes psychologists as well as physicians, anthropologists, sociologists, nurses, social workers, etc. Both AMSPP and ABSAME have been active in promoting the behavioral sciences in medical education and clinical care and recently joined together with the Association of Directors of Medical
When Is Enough Enough?
301
Student Education in Psychiatry (ADMSEP) to develop jointly a curriculum guide for the behavioral sciences in medical education. This unique collaborative effort is persuasive evidence of the extensive multidisciplinary support for change, innovation, and development. Sheridan (1995) asks, "When do we psychologists acknowledge that enough is enough?" We don't. How do we break through the institutional calcification of medical education? By continuing to chip away; by joining with others equally committed; by realizing it is persistence and tenacity that will eventually succeed; by continuing to call attention to the problems; by publishing reports as Sheridan has done; by continuing to highlight the need as this and other journals have done; by continuing to document the problems and offer solutions as many distinguished physicians, psychologists, sociologists, anthropologists, and other health care professionals have done before us. When is enough enough? We are only beginning.
REFERENCES Bloom, S. (1988). Structure and ideology in medical education: An analysis of resistance to change. Journal of Health and Social Behavior, 29(12), 294-306. Carr, J. (1987). Federal impact on psychology in medical schools. American Psychologis~ 42(9), 869-872. Carr, J. (1994). Basic behavioral science in medical education: The need for reform. Annals of Behavioral Sciences and Medical Education, I(1), 5-13. Enarson, C., & Burg, F. (1992). An overview of reform initiatives in medical education, 1906 through 1992. Journal of the American Medical Education, 268(9), 1141-1143. Fox, R. (1990). Training in caring competence: The perennial problem in North American medical education. In H. Hendrie & C. Lloyd (Eds.), Educating competent and human physicians (pp. 119-216). Bloomington: Indiana University Press. Sheridan, K. (1995). The clinical psychologist as program consultant: When is enough enough? Journal of Clinical Psychology in Medical Setting, 2(3), in press.
