Tuesday, 27.06.2017

Barry Blackwell: Joel Elkes: An Integrative Life

Barry Blackwell’s reply to Paul Grof’s comment

       I thank Paul for casting further light on Joel Elkes’ time at McMaster University and subsequently at Louisville. This was a period when Joel was incubating and evolving his innovative ideas about medical education, as well as recharging his batteries. It was not a time he chose to dwell on or speak much about. Although he was proud of his accomplishments at Johns Hopkins (the Department named him Emeritus Professor and has preserved his reputation), Joel’s exit was accompanied by bruised feelings. Neither the psychoanalysts nor the biological purists fully understood or appreciated the way his creative mind was moving on from pioneering work in neuroscience to a novel area of integrative thinking; the task of blending the arts and science to train a “complete physician”.

       There is irony to the fact that the Flexner Revolution in medical education, moving from an apprenticeship to a scientific model, put down its firm roots at Johns Hopkins at a time when Osler’s ideas foreshadowed  Joel’s. The model Osler espoused, involved seeing and talking to patients beyond the lecture hall, and is epitomized by one of his many pithy sayings: “He who studies medicine without books sails an uncharted seas, but he who studies medicine without patients does not go to sea at all.” Osler’s personal philosophy of inner tranquility, espoused in his valedictory address at Philadelphia: “Aequaimatas”, is prescient of Elkes’ late life adoption of Buddhist principles and practice of Mindfulness Meditation.

       Especially interesting is that the shared beliefs of Osler and Elkes provide evidence that from its earliest days, the Flexner tradition has struggled with a dark side as it strives to adapt to an ever expanding encroachment of technical advances. In 1927, Francis Peabody, in an address to medical students at Harvard, complained, “Young graduates have been taught a great deal about the mechanisms of disease but very little about the practice of medicine.” In 1978, over half a century later, George Engel echoed those words, “Medical education has grown increasingly proficient in conveying to physicians sophisticated scientific knowledge and technical skills about the body and its aberrations. Yet at the same time it has failed to give corresponding attention to the scientific understanding of human behavior and the social and psychological aspects of illness and patient care.”

       From the mid 1960’s to the mid 1970’s, the Federal Government funded over 30 new community medical schools with a goal of graduating humanistic primary care physicians. This was accompanied by a massive increase in the Behavioral Medicine curriculum, often interdepartmental, embracing Osler’s ideals, Engel’s biopsychosocial model and Elkes’ vision of uniting arts with science (Blackwell & Torem, 1982). In 1974, I became founding Chairman of Psychiatry in one of these schools and some years later, after graduation of the charter class, wrote a paper documenting the failure of the experiment titled, “Medical Education and Modest Expectations” (Blackwell, 1985).

       Well into the 21st century, things continue to deteriorate. Bedside teaching in the Osler tradition has virtually disappeared since the DRGs, with sicker inpatient populations and briefer stays, ushered in salaried Hospitalists, not paid or provided time to teach. Massive educational debt is driving medical students away from primary care and towards the more lucrative procedure oriented specialties. Independent primary care has given way to salaried employees of so-called, not-for-profit health care corporations, the “productivity” requirements of which value revenue over quality, discouraging doctors from teaching or from treating complex, time consuming patients, especially those on Medicare and Medicaid.

       I never discussed these gloomy thoughts with Joel, whose contributions to neuroscience and medical education will always stand as testimony to his unique ability to synthesize and integrate disparate disciplines in prescient ways.

References

Blackwell B, Torem, M. Behavioral Science teaching in U.S. Medical schools: A 1980 national survey. Am.J.Psychiat. 1982; 139: 1304

Blackwell B. Medical education and modest expectations. Gen.Hosp. Psychiat. 1985; 7: 1-3

 

Barry Blackwell

April 14, 2016