The curriculum of the modern medical school draws from the work of Abraham Flexner, published in the US in 1910 by the Carnegie Foundation. The Flexner Report laid the guiding principles for modern medical schools, and its science-based biomedical foundations remain valid today. However, a hundred years of scientific progress has created a “biomedical school on steroids”, with multiple clinical disciplines each demanding more space in the conventional five-year medical programme.
Despite an already packed medical education system, we would still recommend that doctors would benefit from a more structured introduction to social science and the humanities in the medical education system to complement the focus on the “hard sciences”. We define the medical education system as comprising four parts: undergraduate medical school, postgraduate specialist training, lifelong medical education (continuing professional development or CPD) and targeted skills for physician leaders such as hospital directors or state health directors.
We suggest several fields and disciplines necessary for physicians in the 21st century. These are sociology, cultural and social anthropology, economics, political science, public policy and administration, law, music, art and literature. Other fields such as the psychospiritual sciences, futures studies and technology studies may be equally significant.
These would buttress the knowledge and future-proof the set of skills of a whole person called the medical practitioner, who not only cares for the patient but is aware that health is determined by great forces outside the hospital or clinic. The physician must be conscious that health is a problem of modern civilisation. The interplay of social forces shape our consciousness on health and illness. These forces include culture, society, technology, the environment, politics and economics, as well as notions of diet and food, work and play, and social relationships.
As health cannot only be science-driven, medical education in Malaysia needs a hard look at itself, and to ask if it needs more medical social science and the humanities. In the immediate sense, these can bring critical insights into daily medical practice. The prospective physician or medical practitioner would be able to develop an appropriate sense of social and cultural needs, apart from psychological ones. It brings values, a greater sense of empathy and humanity to the profession.
Biomedical education is necessary, but insufficient, for healthcare
Today’s five-year medical programme in Malaysia typically consists of two years of theory instruction and three years of practical experience at the bedside. The first two years consist of learning what is normal (for example in anatomy, physiology or biochemistry) and the basics of managing the abnormal (for example in pathology, microbiology and pharmacology).
The next three years consist of clinical experience in hospitals and clinics with rotations in medicine, surgery, paediatrics, obstetrics and gynaecology, orthopaedics, surgery, public health, family health, ophthalmology, emergency medicine, psychiatry or other clinical disciplines.
We can see that there is a significant focus on the biomedical, scientific and hard sciences aspect of healthcare, and an unspoken desire to “cram all clinical disciplines into five years”. Communication skills, professional skills, ethics and thinking skills are either taught as short standalone modules or embedded within clinical rotations, and could be under-prioritised as a result.
The Covid-19 pandemic has demonstrated that a biomedical focus on healthcare delivery is insufficient. Doctors and health systems struggle to respond to fake news, anti-vaxxer campaigns and the Ivermectin black market.
During a prolonged pandemic, doctors and public health specialists had to navigate complex situations where conventional medical science alone could not provide all the answers. Among the issues were who should receive the first vaccine doses, and how to encourage companies to meet minimum housing standards for their workers. How should the Prevention and Control of Infectious Diseases Act be used to compel citizens to observe the standard operating procedures of the new normal?
Doctors have a high status in Asian and Malaysian society, and monopolise leadership positions in Malaysia’s health system. All directors-general of Health so far are physicians, as are the deputy directors-general and all 14 state health directors, 145 hospital directors and 190-odd district health officers. Doctors also occupy the highest policymaking, strategy-setting and enforcement roles in the Health Ministry in Putrajaya, leaving dentists, pharmacists, nurses and paramedics to lead only their respective disciplines.
There are three other reasons to systematically provide a practical understanding of social sciences and the humanities. First is to impart communication skills, humaneness and a sense of compassion. Second is to provide inter-, multi- and transdisciplinary understanding of the complexities in our world. Finally, is to embed a sense of collegiality and teamwork among equals, when the doctor is interacting with economists, lawyers, policymakers or sociologists. Medicine, it must be remembered, is an imprecise science. It is the art of healing.
Embedding social sciences in four groups of doctors
We can begin by adding small doses of social science and the humanities in the undergraduate medical education system. The intention is to introduce our medical students to the existence, concepts, interlinkages with medicine and even the beauty of social science and the humanities. This can be done through introductory mini-modules of six to 12 hours per discipline taught by social scientists anytime in the five-year programme, or offering social science electives similar in importance to clinical electives, or offering coursework without examinations or grades. What is important is the engagement and literacy in relation to medicine.
Second, we should also add small doses of social sciences and the humanities in the postgraduate medical education system. The intention is to teach our future specialists about the deeper concepts of the disciplines, provide them with a practical framework to use in their daily work, and to create a useful contact network for them. This can be done through compulsory mini-modules in the four-year specialist Master’s and Doctorate programmes, of eight to 12 hours per discipline. These mini-modules can be taught by social scientists and can be either graded or ungraded. Different specialties can emphasise different social sciences more, like surgeons learning medical law, public health specialists learning economics and futures studies, and family physicians learning sociology. In an era of pandemics, foresight studies and scenario planning would be essential for those in public health and health policies.
A similar principle can be applied to parallel pathways (like the Royal College pathways for physicians or paediatricians) and to sub-specialist training (which is the additional three to four years of training after a specialist finishes a Master’s or parallel pathway).
Third, we should also add small doses of social sciences and the humanities into the CPD pathways for all doctors. The typical doctor graduates at age 25 but may practise until they are 65. CPD was created to provide lifelong medical education, as medicine progresses very rapidly and knowledge becomes obsolete. The Malaysian Medical Council requires that each doctor obtain a minimum of 20 CPD points per year. Each CPD point is roughly equivalent to one hour of scientific meetings, congresses, workshops, self-directed learning or even delivering a public lecture. We propose adding social sciences into the CPD-qualified points. For example, 10% of all CPD points can be based on a social science or humanities subject of the doctor’s choice.
Finally, another group of physician-leaders needing some structured social science and humanities learning are those who become senior administrators like heads of departments, hospital directors or state health directors. These senior leaders will benefit from ungraded mini-modules of social science and the humanities to equip them with the non-clinical and non-science skills to run a department, hospital or state. For example, modules like a two-hour introduction to economics or public finance, accounting, health policies, sociology of disease or medical law can be taught by practitioners from other government agencies or scholars in universities.
Will and foresight are required
Restructuring the curriculum and subsequently implementing these changes require political will and foresight from practitioners and leaders, including the Malaysian Medical Council, Malaysian Qualifications Agency, the Deans Council and the Ministries of Higher Education and Health. The changes can begin with doctors and progress to the curricula of other health professions, like nurses, pharmacists, dentists and allied professionals. Medical professors, academics, consultants and the regulatory bodies must dismantle some of the orthodoxies and the notion of the irrelevance of areas that fall outside biomedicine and the life sciences. This warrants an ongoing dialogue between conventional medicine and social science and the humanities, which we are certain will improve the way health is managed and delivered in Malaysia.
Professor Datuk Dr Mohamed Hatta Shaharom is a medical doctor and a professor of psychiatry. Datuk Dr Ahmad Murad Merican is professor of social and intellectual history at International Institute of Islamic Thought and Civilization, International Islamic University Malaysia (ISTAC-IIUM). Dr Khor Swee Kheng specialises in health policies.