Medicine Needs Critical Thinking, not Critical Theory

There are indications that the Pluralistic Ignorance that has characterized the past 4 years is at last coming to an end. More and more people are openly questioning the veracity of our response to Covid. Trust in physicians and hospitals has plummeted. The credibility of our Public Health institutions has been squandered. It will only be regained through a combination of insistence on accountability for past actions, the abolition (not just declaration) of conflicts of interest, the untangling of the influence of Big Pharma on public policy, and reform in organized medicine and medical education.

To a large extent, we find ourselves in these straits due to a failure of leadership in academic and organized medicine. The actions of the past four years were built upon the philosophy of the preceding decades. It is time we examine the criteria for entrance into, and advancement within, the health professions in general and medicine in particular.

In 1999, the Accreditation Council on Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) endorsed a change from a structure-based format to a competency-based one in which time spent in each activity was not a sufficient method to test for learning the material. Objective demonstrations of ability were required. The Six Core Competencies originally were described as:

• Patient Care
• Medical Knowledge
• Interpersonal and Communication Skills
• Professionalism
• Practice-Based Learning and Improvement
• Systems-Based Practice

This spread throughout the medical education arena. Having been actively involved in its adoption in the department in which I was employed at the time, I had great hopes it would greatly improve things.

In 2011, the American Association of Medical Colleges (AAMC) developed a list of 15 Core Competencies for entering medical students. These were:

• Service Orientation
• Social Skills
• Cultural Competence
• Teamwork
• Oral Communication
• Ethical Responsibility to Self and Others
• Reliability and Dependability
• Resilience and Adaptability
• Capacity for Improvement
• Critical Thinking
• Quantitative Reasoning
• Scientific Inquiry
• Written Communication
• Knowledge of Living Systems
• Knowledge of Human Behavior

In 2013 a plea for inclusion of “Cultural Competence” was made. This was at first highly subjective and varied with program and geographic area. However, these Core Competencies for entering medical students were reorganized and updated in 2023 to:

• Professional Competencies
  • Commitment to Learning and Growth
  • Cultural Awareness
  • Cultural Humility
  • Empathy and Compassion
  • Ethical Responsibility to Self and Others
  • Interpersonal Skills
  • Oral Communication
  • Reliability and Dependability
  • Resilience and Adaptability
• Science Competencies
  • Human Behavior
  • Living Systems
• Thinking and Reasoning Competencies
  • Critical Thinking
  • Quantitative Reasoning
  • Scientific Inquiry
  • Written Communication

Students applying to allopathic medical schools use a standard application developed by the American Medical College Application Service (AMCAS). Background Information makes up the first three sections of the application, including student identifying information, schools attended, and biographic information. Coursework and official transcripts are entered in the fourth section. In section five, the applicant can highlight up to 15 separate Work and Activity experiences, including extracurricular activities, employment, medically-related experiences, volunteer work, internships, and/or research. Confidential Letters of Evaluation are sent directly to the application service and included in section six. The final section is for the Personal Statement and Essays.

Detailed tools and tutorials on the process can be found on the AMCAS website. 

The AAMC includes a very informative “Inspiring Stories” on their website giving a look into 93 applicants who made a difference and were successful in their application. These will be encouraging to those who are worried that the majority of successful applicants are straight white males.

The important question, however, is how do the admissions committees use this information to evaluate applicants? Do they pay attention to the aforementioned Core Competencies? If they do, how do they score the individual elements? How do they weigh them? What do they understand to be Cultural Awareness and Cultural Humility?

One coaching organization emphasizes that admissions committees evaluate applicants holistically, meaning….exactly what?? That makes me even more curious about what importance Cultural Awareness and, especially, Cultural Humility take in the process. In looking at the 93 successful “Inspiring Stories” from the AAMC, I would say they matter quite a bit.

Many of the inspiring stories deal with individuals who have overcome diverse personal adversities in order to become medical students. As noble as some of these stories are, there can be a danger, at least in my opinion, when pushed beyond the limit. There is an increasing call against “ableism” in medicine. A number of articles, such as this one, in mainstream medical journals seem to approach the practice of medicine more from the viewpoint of the physician’s needs rather than those of the patient. The author of this article suggests:

There continue to be important systemic and cultural barriers to full inclusion of physicians with disabilities. The medical community should improve equity for physicians with permanent or temporary disabilities, which may include physical, cognitive, or mental health conditions. As sustainable well-being planning advances, improving accessibility and accommodations for physicians with disabilities offers important opportunities for further progress. (emphasis added)

We have seen the effects of Diversity, Equity, and Inclusion (DEI) on the scholastic integrity of some of the formerly most prestigious institutions of learning in this country. Where is the line between equity for the physician and health for the patient? When does a tremor or a problem with eye-hand coordination in a microsurgeon cease to be something that can be overcome with “accommodation?” When does a cognitive decline for an internist become severe enough to curtail prescribing medications?

These are uncharted waters. I speak from experience as a herniated cervical disc and resulting numbness and weakness in my dominant hand immediately alerted me to the fact I could no longer practice oculofacial microsurgery safely and effectively and I needed to alter my own professional trajectory. But what if I insisted on “accommodations” instead? 

There is no doubt that many physicians with disabilities have made tremendous achievements benefiting both individual patients and society and can offer unique and valuable perspectives. The problem is who decides on the balance between the patient and the physician’s rights and needs?

The Pluralistic Ignorance on the universal adoption of DEI and the tyranny of Equity seems to have, if not ended, at least become finally questioned. An appreciation for the real, tangible advantages of a system, not based on DEI but MEI (Merit, Excellence and Intelligence) has been unashamedly introduced to the admissions policy for the University of Austin.

In retrospect, the enthusiastic superimposition of the rigid ideology of DEI upon the medical profession over the past 5 years may have had an additional and very troubling result. In The Dying Citizen: How Progressive Elites, Tribalism, and Globalization Are Destroying the Idea of America, Victor Davis Hanson traces (pages 43-45) the concept of the Clerisy from its introduction by Samuel Taylor Coleridge to describe the rise of the free-thinking scholars of his time who, though their field was secular and not spiritual, had more in common with the medieval clerics than the working middle class. Joel Kotkin and Fred Siegel applied the term to the elite intellectuals of today, with Kotkin seeing the new Clerisy comprised of those in “secure high-paying jobs predicated on degrees and certification such as teaching, consulting, law or medicine.”

Hanson makes the astute observation that “the certification of a JD, MBA, MD, or PhD does not necessarily equate to inculcation with a superior morality a traditional liberal arts education, common sense, or much less, increased awareness about the effects of globalization on the less credentialed.”

David Logan and his co-authors articulated a related facet of the same idea in Tribal Leadership: Leveraging Natural Groups to Build a Thriving Organization. They showed that Organizational Culture, divided into 5 stages, was the critical determinant in the building of Organizational Performance. A linear progression through the stages was necessary to maximize performance. The “certified” professions, such as those mentioned by Hanson, are virtually ossified (or perhaps fossilized!) at Stage 3 where the tagline is “I’m great…and by the way, you aren’t!”

When a rigid ideology such as Critical Theory is imposed upon individuals who, despite their high level of certification may remain intellectual adolescents, is there any wonder that a catastrophe occurs? The real tragedy is we should have seen it coming. Almost a century ago, a similarly rigid ideology was grafted into the medical profession with horrible results.

In this essay, the physician, medical educator, and bioethicist Ashley K. Fernandes explores the problem that more physicians than any other profession joined the Nazi Party. He makes the point that this was not coerced but due to a willful attraction to the pseudo-scientific nature of Nazi philosophy. To use the modern vernacular, they were “following the science.” Enactment of the Nuremberg Laws added the weight of the legal system to the philosophy of the Nazi state. Unethical behavior was whitewashed with legality.

Fernandes quotes the medical ethicist, Edmond Pellegrino:

We see here the initial premises that law takes precedence over ethics, that the good of the many is more important than the good of the few…The lesson (from the Holocaust) is that moral premises must be valid if morally valid conclusions are to be drawn. A morally repulsive conclusion stems from a morally inadmissible premise. Perhaps, above all, we must learn that some things should never be done.

To prevent a repeat of this dark history, Fernandes recommends several steps:

• We must insist that the ultimate unit of value is the individual, not the collective.
• We must have rigorous conscience protection for physicians and health care professionals.
• Between good and evil, there is no “safe space” in which to stand…no neutral void in which to escape ethical duties.
• Morality must assert dominion over the law.
• Science is not a “god.” Science cannot answer of itself whether a particular medical practice is morally good. 
• We must resist the dehumanization so prevalent in medicine’s culture. Again, consistent with David Logan’s thesis that language determines culture, any disparaging reference to a patient must be corrected. Language alters perception and perception affects our ethical calculus.
• The physician must serve the individual patient and not some abstracted idea of society or the “good of the herd.”

It is easy to see that the medicine of today, and especially that practiced under Covid, comes dangerously close to failing every one of the above recommendations. 

Twenty years ago, when I was Director of Resident Education for our department, we were surprised to see that those we thought would be fantastic residents (based on board scores, recommendations, and ranking) oftentimes turned out to be only mediocre whereas those who didn’t sparkle on our evaluation turned into superstars. 

A paper by Self and Baldwin in 2000 suggested a significant relationship between the Defining Issues Test, which evaluated moral reasoning skills, and clinical performance. While used by some programs, this seems to have lost acceptance. One can only wonder if such a test should be re-evaluated.

As the failures of all branches of healthcare seem directly linked to a failure of leadership, intentional education in leadership skills must be included in the optimum preparation for a position in healthcare. Physicians need to view themselves not as a treater of disease but as a leader of patients. Only then will physicians who rise to leadership in the profession itself understand their role.

Moving forward, we must insist that evaluation for admission into, and advancement within the health professions, add the qualities of critical thinking, moral reasoning, ethics, courage, and leadership in addition to competencies reflecting Merit, Excellence, and Intelligence. It is impossible to achieve this if it only starts in professional school. It must begin during the undergraduate level at the latest and preferably in secondary or even middle school.

Studies on the formation of a “worldview” indicate that it is a pull rather than a push process and takes place very early in life. While these studies primarily focused on the distinction between a “religious” and a “secular” worldview, there is no reason to believe it is limited to that. Therefore, it is imperative that if we wish to reverse the present orientation of healthcare professionals, it must begin early through a positive pull process and not be relegated to a late push process in professional or post-graduate education. 

Few organizations possess the type of vertical and horizontal reach to accomplish such a major reform of the healthcare professions during that critical early period. Hillsdale College is one such organization and has as its stated goal: Learning, character, faith, and freedom: these are the inseparable purposes of Hillsdale College. It reaches from Hillsdale College vertically down to the K-12 Hillsdale Classical Schools and Barney Charter Schools and up to the Hillsdale Academy for Science and Freedom. 

Those in the healthcare professions are faced with unique and vexing challenges to the underlying worldview of the importance of critical thinking, moral reasoning, ethics, courage, and leadership. Targeted supplemental material could be added in a graduated fashion to provide additional pull influences for those interested in a career in health care. By the time an individual reaches the point of application to medical school, the level of competency would far exceed the core competencies currently recommended by the AAMC. They will be well-prepared to continue the journey to become Leaders of Patients and not just Treaters of Disease.