Holistic Endeavour in Postgraduate Medical Education

John Heron

Published in The British Journal of Holistic Medicine, Vol 1 No 1, 1984, pp 80-85

Summary: An account is given of innovative educational development over the past seven years at the British Postgraduate Medical Federation, with a summary of overall objectives, sorts of courses run, numbers attending, principles of educational method applied, results of immediate post-course and follow-up evaluation. This is followed by a critique of the prevailing educational paradigm and by a proposal for an alternative educational paradigm together with some of its central consequences for educational practice.

The British Postgraduate Medical Federation is part of the University of London. It federates several teaching and research Institutes (with specialist hospitals attached) within London and a large number of hospital-based Postgraduate Education Centres distributed all over the four Thames Health Regions. I was invited to become an Assistant Director, from 1 January 1977, with a special responsibility for innovative educational developments within the Federation. The appointment was, and still is, controversial within the Federation, because of my non-medical background as an educationalist, and a fairly radical educationalist.

In May of 1977 I invited the Federation formally to adopt the following Six Overall Objectives for Postgraduate Medical Education. After a lengthy debate in the Education Sub-committee of the Central Academic Council, the Federation did formally adopt them, and they have been published every year in the Federation’s Annual Report. Here they are:

1. Academic and qualification support: to provide junior doctors with the educational resources to obtain their higher professional qualifications and to pursue research.
2. Clinical, theoretical and research up-dating: to provide all doctors with up-to-date knowledge of recent advances in medical practice, theory and research.
3. Educational development (course planning, teaching and learning, assessment; skills in health education – deprofessionalisation): to enable doctors who have a teaching role to be aware of, and be skilled in the application of, the wider range of educational methods now available for higher and continuing professional education.
4. Communication development (interpersonal skills, organisational skills): to make available within the profession modern methods of interpersonal skills training in order to improve the quality of communication between doctor/patient, doctor/relative, doctor/ doctor, doctor/staff.
5. Ethical and philosophical considerations in modern medicine: to examine and review the conceptual assumptions on which the practice of modern medicine is based.
6. Personal development as a self-directed activity: to encourage doctors to regard their own development as persons as an activity that can be consciously taken in hand.

The first two of these Objectives are obviously what the Federation is all about anyway – certainly in conventional terms. The addition of the last four Objectives makes the Federation, on paper at any rate, a very progressive educational institution.

The Education Department, which I have run in the Federation since 1977, has put on, as one of its primary endeavours, an annual programme of courses and workshops, most of them two-day events, which seek to implement the last four objectives. There have so far been five such annual programmes. Each year between 30 and 40 courses are run, involving some 25 tutors, with about 500 participants attending overall. Of these participants about 70% are doctors, the other 30% being a variety of health care professionals. Of the doctors some 80% are GPs and 20% hospital doctors.

Interms of content, it is somewhat arbitrary to separate out the four objectives. Nevertheless, a breakdown of courses in terms of these objectives looks roughly as follows. Some 55% of courses are concerned with communication development and focus strongly on the practice of interpersonal skills. It is clear that in very many of these courses there is a significant component of personal growth and development, which I believe is as it should be. Nevertheless the aim of the courses is the acquisition of human relations skills for application on the job.

About 25% of courses deal with education methods: lecturing, the use of audio-visual aids, small group teaching methods, peer learning and teaching, self and peer assessment, experiential methods, learning contracts, curriculum design and development. The aim here has been to improve the quality of the conventional teaching methods used by medical teachers, and also to introduce them to the notions of teaching as the facilitation of learning; of learning as fundamentally a self-directed activity; of the importance of developing student autonomy through increased student decision-making about learning objectives, learning methods, assessment methods and their application; and of learning as confluent, involving intellect, feeling and action.

Some 17 % of courses are concerned explicitly and primarily with participants’ personal development, with work on feelings and attitudes, dealing with unresolved and unfinished business from the personal past. Co-counselling, primal and rebirthing methods, together with other approaches drawn from humanistic psychology, have been used. The aim here is to improve skills in working with one’s own feelings, especially distress feelings, and the deep psychological processes which the conventional educational system overlooks. As I have said, much of this also goes on in the 55% of courses dealing with interpersonal skills.

Finally 3% of courses deal with philosophical issues in medicine, re-examining its conceptual foundations. These are mainly the workshops on holistic medicine. This small figure is rather misleading, since precisely these same sorts of conceptual issues occur again and again in the context of courses in all the other main categories. This, I think, is as much to do with the way the courses are run as it is to do with their content.

All these courses exemplify certain shared principles of educational method. Because of differences of topic and purpose, not every course will use fully each principle, but the ethos is there. Each of our tutors will have their own way of putting these principles, but I do not believe that many of them will dissent strongly from the following account.

1. There is a balance between didactic content, and active participation; between theoretical input from tutors and the experiential learning of the participants. (la) Understanding and consciousness-raising in participants through talk and discussion is balanced with skills building through the use of structured exercises. (lb) Abstract, general principles on the one hand, and participants’ actual experiences on the other, are brought to bear upon each other. Return to the experiential touchstone is fundamental.
2. Participants are encouraged to identify their own learning needs and learning goals, to influence decisions about how these needs and goals might be met, and to be involved in assessing whether they have been met.
3. Peer teaching and learning, through discussion, interaction, feedback, shared experience among participants is a primary mode of learning.
4. Work on task and content in the course is not separated off from work on personal and interpersonal processes that occur in participants during task and content work. Work on personal and interpersonal processes may itself be or become the task. (4a) Intellectual, emotional, interpersonal and decision-making issues are not cut off from each other. (4b) There is no arbitrary separation between personal material and professional material, between issues to do with personal development and issues to do with professional development. At certain critical points in the learning process, they may be seen as necessarily involved in each other.

The doctors who come on these courses respond very favourably. For some it is a liberation, a breakthrough, a Damascus experience, as if certain propensities for practice long since secretly harboured at the bottom of the heart have been given permission to come forward into action and receive their due acknowledgement.

In more sober terms, we did a modest self-report evaluation of a wide sample of all our courses in 1981 and 1982 using a simple questionnaire. An external Consultant Psychologist analysed the results. Some 580 immediate post-course questionnaires and 407 long-term follow-up questionnaires were analysed. On both the immediate and the long-term questionnaires three basic questions were asked: (1) Has the workshop been valuable to you in your work? (2) Has it had an impact on your personal development? (3) Was it a worthwhile educational experience? A ten-point scale was used for each question, from 1 (zero value or impact) to 10 (very high value or impact). Table I gives mean ratings over all courses evaluated.

On both questionnaires there was space for optional comments. No less than 68% of immediate post-course questionnaires and 78% of follow-up questionnaires had comments. Some 90% of both these sets of comments are positive. Critical comments were mostly allied with positive. The Consultant writes in her report on the questionnaires: “The major rationale for conducting a long-term follow-up was to discover how far the material in the courses had actually proved to be useful to the participants. This from the BPMF’s point of view must be the criterion against which the courses are judged, rather than any other…Nevertheless, the long-term follow-up questionnaire was not skewed in this direction, so that any emphasis on application comes from the respondents. The results were that the overwhelming majority of appreciative comments on the long-term follow-up related to successful application.”

It is clear from the comments that the main area of application has been in human relationships. Many doctors found that the courses provided a re-education in handling relationships that made a great difference in their work with patients, and also, many claim, in their personal lives. In relation to patients, the main shift has been from largely doctor-centred behaviour to a greater flexibility in moving between doctor-centred and patient-centred behaviour — seeking the patient’s viewpoint, greater sensitivity to and aware handling of the patient’s feelings, greater confidence and competence in dealing with psychosocial and relationship problems in patients, and so on. Of course, this is all based on doctors’ self-reports, and must be viewed with the proper caution to be attached to such material.

It is clear from another range of comments on the questionnaires that the methodology of the courses, which is unlike that on conventional postgraduate courses, was valued by the doctors participating. The Consultant writes: “The characteristics which especially distinguish these courses from others and were singled out by participants for appreciation were: (1) the educational method of the courses; (2) the range and choice of topics covered; (3) the treatment of topics; (4) the high level of learner participation, not just intellectually, but in the design of the learning process and in being able to bring personal experience to bear; (5) the multidisciplinary nature of the courses; (6) the skills building emphasis, particularly interpersonal skills building…also considerable appreciation for new ways of conceptualising and processing information; (7) the integral linking between the personal and the professional spheres, such that learning from each could be used to inform and enhance the other.”

TABLE  I

Course evaluation from self-reports: mean ratings combined for programmes in 1981, 1982

Numbers below relate, respectively, to the immediate post-course rating and the long-term follow-up rating

Value in relation to work                                            7.5                                                    7.1

Impact on personal development                                7.4                                                    6.4

Worthwhile educational experience                            8.1                                                    8.0

We have thus established over the past few years, that for several hundreds of doctors within London and the four Thames Health Regions, a radically revised approach to postgraduate medical education, both with respect to the range of topics covered and the range of educational methods used, has been very favourably received, both in terms of usefulness and applicability, and in terms of the approach per se. I would like now to look at the broader cultural context of education and examine why it is that this revised approach has been experienced by so many participants as a breakthrough, and why it is so necessary. What follows is a critique of the prevailing educational paradigm and a proposal for an alternative educational paradigm, together with some of its central consequences for educational practice.

Higher education in our society is still in a classic mould: it is Aristotelian through and through, resting on the ancient Greek view of human nature which illuminated the founding of universities in the Middle Ages. For Aristotle, intellect is that which supremely differentiates the human being from animals and the cultivation of intellectual excellence is the highest end in life. The incidental function of intellect is to control feeling and behaviour in accordance with a principle of good measure or the mean between extremes. Similarly for Plato, the intellect is the hierarchical head of the tri-partite soul, its job being first to pursue truth, and second to rule over the noble emotions and through them over the base passions.

Higher education follows this old hierarchical model of the soul. The formal curriculum is exclusively concerned with the cultivation of students’ intellectual competence, both theoretical and applied. It is assumed that such competence will enable students to control feeling and behaviour in accordance with prevailing norms of civilised conduct. So the widespread tacit norm about the secondary function of intellect is that it is to control feeling. But what such control means, how it is to be exercised, what is to be done if it breaks down — none of these basic issues form any part of the formal educational process at any level of the educational system.

So the formal curriculum does not include any concern with the cultivation of students’ emotional competence — awareness of and skill in handling their own feelings — or with the cultivation of their interpersonal competence — awareness of and skill in dealing with relations with other persons — or for that matter with the cultivation of their decision-making (or political) competence. All these are vast gaps in higher education. And this is as true of undergraduate medical schools as it is true of all other kinds of undergraduate schools. No-one is to blame. It is a long-standing historical and cultural phenomenon, the nature, consequences and crucial restrictions of which are only now beginning to dawn upon us.

One important consequence, in my view, is that where control is the only (tacit) guiding norm about how to handle feelings, with no emotional education to illuminate it, then as well as perfectly healthy control, there is also unhealthy, repressive control of feelings, especially distress feelings of fear, grief and anger. Such repression is relatively unaware and leads to displacement of the denied affect into a variety of compulsive and distorted forms of behaviour, some of which are seen as conventional and socially legitimated simply because everybody is involved in the same educational and socialising process. And this effect will be reinforced by the absence in higher education of any active interpersonal skills training, which extends a person’s range of interpersonal behaviour by practice across a wide repertoire.

Take any profession in our society, and I believe you could start to show the restrictive effects of these educational deficits in how that profession is practised. In medicine, it may well be evident in the following: restriction to a small range of doctor-centred behaviours in relation to patients (or, to put it in another way, the inability to balance a unilateral, authoritative approach to the patient with a bilateral, cooperative approach); restriction of the diagnosis and treatment of disease to the purely somatic and mechanistic; exclusion of the active, aware self-healing agency of the patient from the treatment process; difficulty in handling effectively upsurges of distress feeling in either the practitioner or the patient; and so on. If anything like this is true, then of course our revised approach to postgraduate medical education will be experienced by so many doctors as a very necessary and liberating breakthrough.

There is another consequence of the continued prevalence of the old hierarchical model of intellect-in-charge. Those who have cultivated their intellects exercise unilateral control over those who are still in the cultivation process. Academic staff run an authoritarian model of educational decision-making. They decide, without consultation with students, what students shall learn, how they shall learn it, by what criteria they shall be assessed, and then staff do the assessment entirely by themselves. This model has, I believe, a powerful tendency to sustain and reinforce the educational deficits to which I have already referred. For the authoritarianism in decision-making may itself, in part, be a displacement of denied distress, and as such will not only be sustained by that denial but will necessarily resist any opening up of the curriculum into the domains of the emotional and interpersonal.

For myself, I prefer a parity model of the soul —or, better, the person — as against the old Greek hierarchical model. I see the person as a being with co-equal capacities for understanding, for feeling, for making choices; and this in relation with other persons similarly endowed. These capacities mutually support and enhance each other. The healthy development and fulfilment of each is interdependent with the healthy development and fulfilment of the other two. And such development necessarily occurs in relation with other persons engaged in the same process.

It is important to note that such a parity model of the person is still only holistic in a restricted sense. It is basically talking about a holism in the domain of mind, of capacities for understanding, feeling and choosing; and in the domain of interactions between persons seen in this light. There is a wider educational holism that also takes into account both physical education and spiritual education. But the innovations in educational practice required to do justice to the modest holism which I am here putting forward are considerable in their challenge; and in my view it is important to begin in this middle ground.

What follows, then, from such a modest model is the notion of confluent education: intellectual competence, emotional competence, decision-making competence, and interpersonal competence are to be cultivated concurrently. Learning is not only through thinking, but also through various modes of being, doing and relating. Knowledge is not only propositional or theoretical, but also practical and experiential; not only a matter of knowing that, but also of knowing how, and of knowing persons, places and things through encounter. Sometimes the lines of development may be relatively separate, at other times they may be interwoven. In either case the holistic intent is there. Within the person, as between persons, there is a creative tension between the values of autonomy and of cooperation or interaction. One differentiates and distinguishes in order the better to unite and one unites in order the better to celebrate differences.

What also follows from such a model is the importance, during the educational process, of progressively cultivating student autonomy. If intellectual competence and decision-making competence are really to go hand in hand, then students need increasingly to be included in educational decision-making — about their learning objectives, about the learning methods they will use, about the criteria and methods of assessment to be used, about doing the assessment itself. In undergraduate education, this process can be phased and gradual, based on collaboration with staff. In continuing and postgraduate education, the case for it becomes even more obvious and pressing.

The parity-of-capacity argument for this approach can be stated another way: if students are competent to learn the content of a discipline. they are also competent to learn (a) what it is about the discipline they need to know; (b) how to go about learning it; and (c) how to assess whether they have learnt it or not. Indeed, I would argue that these three forms of meta-learning, or process learning, are more fundamental than content learning.

Also important during the educational process is student cooperation. There is nowadays a growing realisation that one of the best ways to learn is through peer learning and teaching, through student interaction in a variety of forms. One potent form of learning that balances autonomy and cooperation among students is self and peer. assessment. This has great relevance in on-going professional life when directly applied in peer review audit, in which a group of professional peers meet and use a self and peer assessment method for reviewing their actual practice and for clarifying standards of competent practice. My Department has run regular workshops on peer review audit over the years, and sponsored several pioneer audit exercises for doctors, dentists and other professionals. Our recent cooperative inquiry into holistic medicine by a group of sixteen doctors, referred to elsewhere in this publication, is a special case of peer review audit, in which the audit process is subsumed within a new research paradigm.

In the field of emotional education, I have found over some years of exploratory work in a whole range of courses and workshops that it makes sense to use a four-fold paradigm for the management of human emotion.

Firstly, control: control of feelings of all kinds where it is appropriate, with a dear differentiation between techniques of aware, intentional control on the one hand, and forced suppression or blind repression and denial on the other.

Secondly, expression, both in deed or word or both, especially of positive feelings of love, affection, admiration, delight, which are often under massive inhibition in our society.

Thirdly – and this in relation to an overload of distress feelings of fear, grief, anger – catharsis or the ability awarely and at an appropriate time and place to release the charge of distress.

Fourthly, as a complement to catharsis, transmutation or the ability to refine tense emotion into its opposite: the internal alchemy that turns base metal into gold. And I would argue that unless doctors and other health care professionals have acquired within themselves the rudiments of these skills, then their competence to help other human beings in travail is almost certainly going to be limited in some respect or other, and to some degree.

Finally, I wish to affirm the area of fundamental identity between the practice of education and the practice of medicine. The educator is ultimately concerned to facilitate self-directed learning in the student. The doctor who regards the patient as a potential self-healing agent will increasingly seek to facilitate patients to learn techniques of self-help. A classic example is the work of the Greens at the Meninger Foundation in educating and training patients in the self-regulation of high blood pressure through the use of biofeedback. This is only a start. There is a vast field of developmental work ahead that is simultaneously educational and medical, its purpose being to restore the afflicted person from diseased patient to self-regenerating agent.