THE
FAMILY
IN MEDICAL EDUCATIONBy A. H. PARMELEE, JR., M.D.,#{176}ETHEL SWENGEL, M.S.W., AND JOHN M. ADAMS, M.D.
Los Angeles
387
EDUCATION
GROVER F. POWERS, M.D., Contributing Editor
This is the first of several presentations of
various forms of domiciliary and family
ex-perience for students now in operation or
being planned in several medical schools.
These programs are essentially modern
adaptations of older methods such as
ap-prenticeships and home-delivery services of
traimiing clinical students in what is
corn-rnonly called the art of medicine. Some
pro-grams have their center of operations in one
or amiother clinical department, some in
several departments with integrated
super-vision and others in departments of public
T
HE new medical school at theUniver-sity of California, Los Angeles, admitted
its first class of 28 students in September,
1951. As part of the new curriculum for
these students, a course was started which
is entitled “Family Medicine.” It was
de-signed to compliment the basic courses in
amiatomv, physiology and physiological
chemistry by providing the student with the
opportunity to see patients from the
begin-fling of his career and to introduce him to
the basic subject of growth and
develop-niemit This course continues throughout the
students four years of study.
“The sound fundamental principle of
ed-ucation that the best education is self
edu-cation” is woven into the design of the
family medicine course. The facilities are
available through the cooperation of the
University and the community; the stimulus
and guidance for the students are provided
by the University faculty and many
corn-From the Department of Pediatrics, School of
\le(licine and the School of Social Welfare,
Univer-sit of California, Los Angeles, California.
0 Ad(lress: Departmiient of Pediatrics, School of
\k(liCiflC, University of California, Los Angeles.
health or preventive medicine.
These programs undoubtedly are having
an impact on medical education, but several
years must elapse before an accurate
ap-praisal of values can be made. It may not
be out of order to point out that for the
great majority of students of medicine only
in the four undergraduate years do they
have experience in the basic sciences,
whereas they have a professional life-time to
perfect themselves in the “art” of medical
practice.
G.F.P.
munity sources. The doctor-patient
relation-ship in which the student participates and
gains personal experience is a valuable part
of the course. He witnesses the doctor and
the public health nurse in action and is
constantly exposed to the concepts of social
welfare and education. The student
gradu-ally becomes a family health advisor as he
establishes himself with the family by visits
to the home and as he grows in his medical
knowledge and confidence. To understand
and know people at any age, it is vital to
understand the basic concepts underlying
their development. Embryology, anatomy,
physioiogy and chemistry are fundamentally
courses in growth and development. When
they can be correlated and integrated in a
clinic, a school and a home with living
people, they represent what we consider an
essential part of medical education.
Tm FAMILY MEDICINE COURSE
The Family Medicine Course is
super-vised by a committee with members from
various departments of the School of
Medi-cine, City Health Department and School
duties rest with the Department of
Pedi-atrics. It is intended that this course be a
function of the entire medical school to
which it is admirably suited by its vertical
extension through the four year medical
school curriculum.
The course is carried on in the community
utilizing the city and county health
depart-ment facilities and the University
Elemen-tary School. The family which is the basic
unit of our society is the focal point of the
course, and the relationship of the family to
other larger institutions, such as the public
health department, the schools and
hos-pitais, naturally follows.
The actual mechanics of the course are as
follows. At the city well baby clinic, each
first-year student is introduced to a family
which he will follow for four years. These
clinics are operated especially for this
pur-pose by members of the medical school
faculty and they are so arranged that no
more than four to six students attend any
one session. The student attends once a
month on the specific day that his family
returns. In this way he observes the monthly
growth and care of the baby and has the
opportunity to talk individually with the
mother. There is, in addition, general
dis-cussion of all the patients by the students,
nurses and instructor together.
Each medical student also makes two to
three visits to the home of his family. The
first of these is made with the public health
nurse and subsequent visits by himself. He
is given no specific set of questions to ask
and no interviewing formula. However,
both he and the family have been informed
of the general purpose and mechanics of
the course. The patients have been screened
from the general city well baby clinic by
the public health nurses. The criteria for
selection are that the family have a small
infant, that the parents express a
willing-ness to participate, and that their residence
in the area is relatively permanent. There
are sufficient points of interest in every
family for the purposes of this course, and
problem families are not selected by design.
Once every month the entire class
con-TABLE I
MONTHLY CONFERENCES OF FIRST-YEAR STUDENTS
(I951-195)
I. The Doctor-Patient Relationship, an introductory
lecture.
2. Medical Facilities in a Community
Case: An infant with nutritional amiemnia diag-nosed when the patient was first seen in the
well baby clinic at nine months of age.
3. Tuberculosis and the Family
Case: A Mexican father with active tuberculosis
deserted the sanatorium at intervals anti
infected his infant son who died of
tuber-culous meningitis.
4. Workimig Mother
Case: A mother required to work following
hus-band’s desertion ; the grandnmotlier cared for the baby and denied the imiother her
role.
.5. A Family’s Reaction to Congenital heart l)isease
Case: A negro child with patent (lucius arteriosus
diagnosed in the well baby clinic. Parents initially opposed surgery despite the fact that the child was doing poorly.
6. l)isturbed Mother
Case: A mother disturbed out of proportion to
the problems she discussed in clinic.
Re-ferred to a psychiatric clinic amid given con-tinuing support in the well baby clinic. 7. Cultural Conflicts in Child Rearing
Case: An English war bride who was deteruhille(l to raise her 1)oys in this community by
English standards.
8. A Mother’s View of Her Fmimily
Case: A mother discussed her life, her marriage, and the adoption of a son followed by the
birth of two children of her own.
venes for a one-hour conference. A student
presents his family from the point of view
of special interest. These conferences for
the first year are listed in Table I. The
stu-dents ask further questions and conduct
their own discussion. At the various sessions
internists, surgeons, psychiatrists,
pedia-tricians, nutritionists, social anthropologists,
health educators, city and state public
health and social welfare personnel, student
counselors, and city housing authorities
par-ticipated. At the end of the year each
stu-dent writes a complete report of his
family.
In his second year the medical student is
TABLE III
TilE FAMILY FoLLow-up
TABLE II
MONTHLY CONFERENCES OF THE SECOND-YEAR
STUDENT
(1952-1953)
1. Aim Introduction to the Principles of Education, a lecture.
. Rea(liug Retardation
(‘misc : A third-grade boy reading at a low second-grade level with no obvious cause for aca-tieiiiic (lifhcuity.
3. ‘l’lw l)t-af (‘hid in School
(‘LS( : A seven-year-old child with comigemmital deaf-miess in a second-grade class with children
-ith imormal hearimig.
4. ‘l’he Social A(ljustmemlt of a Second-grade Child (‘ase: A bright second-grade boy with a short
at-tention span amid a tendemicy to disrupt the
class.
.5. ‘Flie School Child with Congenital Physical Defects Case : A sevemi-vear-old boy who was born with a
harelip, cleft palate amid club feet and had
fanmily and school adjustment problems.
6. ‘I’he lIucatioii of the Blimid Child
Case: A three-year-old girl with biindmiess due to retrolt-ntal fibroplasia in a nursery school for sighted children.
7. (‘,muses of Acadeiiiic Failure
CaSt’ :A nine-year-old girl with normal intellect and good social an(l physical skills but failing aca(iemnicallv.
S. lIi( Prol)lenms of an Intellectually A(lvaflced Child (‘:Ise: A I)O\ who was large for his age and
intel-lectually very a(lvance(1 but was immature in his social and physical skills.
Nursery and Elementary School which is
operated as a public school by the
Univer-sity for the purpose of training student
teachers. The age range of the children is
two years to 12 years and gives direct
con-timTluity to the student’s well baby clinic
observations of growth and development.
The medical students attend the school at
monthly intervals in groups of eight. At
this time they observe various classes and
witness education in operation. After each
observation session there is a discussion
pe-nod with the instructors and the teacher.
Each student observes the child of the
family he is assigned in the classroom. He
again makes two to three home visits, all of
them on his own. He also talks with the
child’s teacher, the school counselor, school
ntmrse and physician.
Duration of Follow-up
Souree oJ Family 1st nd 3rd 4th
yr. yr. yr. yr.
1st Family-Well baby //// //// ////
clinic //// //// /11/
//// /1/I 1/1/
I//I /1/I
/1/i
nd Family-University
Nursery and
Elemen-tary School
//// ////
‘///
I//I 1/1/ I//I
//// //// i1///
Srd Family-Prenatal
clinic
I//I 1/1/
I//I
I//I /1/I
I//I
Once a month the entire class convenes
for a conference and a student presents the
family and child he is following with
refer-ence to a point of special interest. Again
the students initiate the discussion and
resource people are present to help when
requested. The resource people at these
conferences are educators, psychologists,
psychiatrists, school principals, social
work-ers, physicians, and the parents of some of
the school children. The discussions during
the year 1952-1953 are listed in Table II.
The student also makes home visits to the
family he acquired during his first year and
he sees the mother and her baby in the
clinic at about three month intervals. The
student writes a detailed report on the
year’s experiences with his second family
and additional experiences with his first
year family.
In the third year of the program each
stu-dent is introduced to a third family in the
public health prenatal clinic. He sees the
mother during her prenatal period both at
home and in the clinic, attends the delivery,
and observes her post partum care and the
infant’s care. He continues to follow his
other two families by home visits and
oc-casional school and clinic visits.
During the third year the class meets
monthly in groups of eight with a team of
psychia-TABLE IV
‘FIlE STUDENT TIME IN THE FAMILYMEDKINE Crn’itsa
Medical ‘SClU))l
Year
Student Time
--
---
---- .-Clinic and se/moo! Conferences home Visits Total
First (3 hrs.X8)* 4 hrs. (1 hr.XS) S hrs. (1 hr.X8) S hrs. 35 hrs.
Secimd (‘2 hrs.X8)
(3 hrs.X3) ‘ hrs.
(1 hr.X8) H hrs. (1 hr.X’3) (1 hr.X) hrs.
38 hrs.
lhir(l
(2 hrs.X8) (I hr. X) ?() hrs.
(1 hr. X’2)
(1 hr.X8) S hrs.
(1 lir.X) (1 br.X2) 6 hrs. (1 hr.X)
34 hrs.
1’ourth
(1 hr. X)
(1 hr. X’2) 6 lirs.
(1 hr. X’2)
(1 hr.X1)
(1 hr.X1) 3 hrs.
(1 hr.X1)
9 hrs.
‘l’OT.iL 75 hrs. 24 hrs. 17 hrs. fl6 hrs.
* ‘I’he figures iii pareiitht-st-s iml(li(ate tl:e numnl)er of hours of ea(-h o1)servation times the frequemicy, iiIi(l each
parenthetic group represents a separate famih.
trist, a public health nurse and a social
worker. In these conferences the student
is guided in the management of the specific
problems presemited by his families, thus
he gains confidence and assumes a more
active role as a family health advisor.
In the fourth year each medical student
will follow his three families by home visits
and will see them in the clinic and hospital.
The medical school faculty will serve as
ad-visors to the senior student.
In this course no large amount of time is
concentrated in any one year. The family
follow-up is indicated in Table III and the
student’s time in the family medicine course
is presented in Table IV. In this table the
time spent in the clinics and school as well
as conferences and home visits is tabulated
separately. The curriculum hours for each
year is shown in the column on the right;
the total for the four years is 1 16 hours.
THE STUDENT’S EXPEJUENCES IN THE COURSE
Although various medical schools have
introduced into their curricula programs
similar to the one here described, no
ade-quate method of measuring the successes
or failures of such programs has appeared.
Thus, we can evaluate the student’s
experi-ences only in terms of how they describe
their experiences to us and how we observe
them. We are inclined to believe that more
objective evidences of the validity of the
program may appear during the student’s
third and fourth years when he has had
further opportunity to transfer to his
clini-cal experience that which he has learned
during his first two years and continues to
learn through participation in the course.
The majority of the students have
demon-strated a lively interest in the Family
Medi-cine course. A few find it hard to
main-tam an interest in a relatively “normal”
family group, although most of them do
become interested in the well child and his
family and find the early contacts with
people very gratifying. Quite naturally
these families do present certain problems
and the students learn to evaluate these
situations realistically. Such a family is
de-scribed by one of the first-year students in
his final report at the end of the year:
“Their most disturbing problems are related
to the health of both Billy and Paul (older
sib-hings) who are apparently afflicted with
the more important problem at present because
of his frequeiit absences from school due to the
condition. The parents have expressed
consider-able concern over this matter and are now
worried over Billy’s advancement in school.
Simice Billy has been receiving treatment in an
allergy clinic the parents have been much
happier amid show much more optimism in
con-nection with Billy’s progress.”
One of the objectives of the course-that
of teaching the medical student the
doctor-patient relationship and the importance of
environmental factors, is incorporated into
every phase of activity. A freshman student
tells us how he is beginning to think of this
matter.
“I can sum this up by repeating that I
be-lieve that the medical student’s and physician’s
understanding of the various forces acting upon
the family he sees and treats, and acting upon
the community in which the family lives is
es-sential not only for an appreciation of the
pa-tient’s problems but also for an understanding
of the patient himself.”
Along with the growth in the
understand-ing of the patient as a person comes a
be-ginning understanding of the meaning of
illness, both to the patient and to his family.
The first-year student begins to develop an
awareness of the doctor’s responsibility in
the prevention of certain problems arising
from illness or physical handicaps:
“It doesn’t seem unreasonable to me that if
early iii a child’s life a serious disease occurs
or a serious defect is suspected, the mother
would become over solicitous in caring for the
health of the child. It seems to me to be the
doctor’s responsibility to try to counteract the
development of such an attitude.”
Although the families assigned are aware
of the medical student’s status, many of
them will call the student “Doctor” and will
ask the student specific medical questions.
Thus, one of the first problems the student
faces is becoming comfortable in his role
as student in a situation where he feels a
great deal is expected of him. By the end
of the first year the student has ordinarily
worked out satisfactorily the question of his
own status and many students really want
to assume further responsibihitiy for their
family. It is only an occasional student who
will say, “I’ve never even considered what
I would do if I were the family doctor.”
More generally, by the end of the first year
one finds such comments as:
“I have gained much more from the C.
family than they have from me. It is somewhat
painful and frustrating to become aware of
situations within a family and not be able to
assist them,” or, “in the short time I have
known the S’s I have been able to do nothing
for them but listen; however, they have done
much for me.”
One of the chief values we recognize in
the program is the fact that the students are
able to observe one family over a long
pe-nod of time. It is both interesting and
grati-fying to observe the student as he forms his
opinions about his family group and then is
able later to modify these early impressions
as he learns more about the total
situa-tion. A student at the end of his second year
says:
“I’ve learned that a first impression of a
child can be misleading. My first observation of
J
effrey and the conclusions I drew therefromhardly did him justice. He is an intelligent,
generally happy child who is growing up in
what I consider is a healthy home environment.”
Another second-year student indicates the
value of the continuing contact with the
family:
“On the whole I feel that this course has
been much more valuable this year than last
for several reasons. Being able to visit my
Clinic family in the evening helped me a lot imi
my efforts to get a clear picture of their life
and problems. Several students have
com-mented that they are just now beginning to
establish a relationship with the family that
enables them to converse freely about private
family matters. This increased understanding of
our specific families has furthered our apprecia-tion of the basic problems that affect families in general.”
Through the experience of observing the
A second year student prior to his
ex-through his sustained contact with a family,
the student becomes aware of the
impor-tance of the doctor-patient relationship.
This was very dramatically demonstrated to
one of the second-year students when the
mother of the child assigned during his
first year gave birth to a baby with
mongol-ism. Because of the good relationship which
existed with the family the student was in
a position to be of some assistance. At the
en(I of his sophomore year the student
de-scribes the situation as lie sees it:
“Superficially, Mr. and Mrs. R. are reacting
(luite vel1 in regards to C’s condition.
Out-wardly they have the attitude that they want
to do all they can to give her good care.
How-ever, in conversation, Mrs. R. seems to give
the impression that she doesn’t believe that C.
is actually a mongol. Mrs. R. is very sure to
point out to me all the accomplishments that
C. has attained. Perhaps at this time this is a
very good attitude to take. A mother’s love for
a child is very valuable. But if this attitude
should become stronger in the future in face
of obvious lack of development, the attitude
may be harmful.”
In this particular instance it is also good
that the student will have the experience of
following the family closely for the next two
years and will observe the parents as they
come to grips with the problems facing
them.
The student from the beginning works
closely with other professional people both
in the program and in the community. He
learns the value of working cooperatively
with others. One student described his
ex-perience in this way:
“One idea which I feel is particularly
valu-able to me is that the physician has limitations
and cannot undertake to solve all aspects of
the patient’s problems, even though he must
often take these into account if he is to be
sue-cessful in restoring the patient to full
useful-ness. Fortunately, as this course has pointed
out, the physician need not face this task alone,
but can and should utilize the community
re-sources.”
perience in the elementary school program
and his assignment to the family of a blind
child had had no contact with a blind
per-son except for a beggar in the street. His
visits to the home of this family have been
illuminating to him and he concluded his
conference with us by inquiring:
“Don’t you think it’s a crime for a doctor
to try to treat a blind child if he’s never even
knowmi one before?”
COMMENTS ON THE EDUCATIONAL
EXPERIENcES
The two health clinics and an elementary
school provide for the medical students an
experience which is somewhat unique. The
student becomes aware of the doctor’s
re-hationship to the community as he becomes
a participant in its activities. An unusually
good working relationship exists between
the medical school, the public health clinics,
and the University Elementary School. This
has provided an atmosphere of friendliness
and acceptance for the student and an
ex-perience of observing and participating in a
team relationship.
Although various educational techniques
are employed in the course most of the
teaching is done in an informal way which
allows for individual variation in growth
and ability and allows the student to
as-sume more responsibility for his family as he
is ready to do so. He has an unusual
op-portunity to observe the doctor-patient
re-lationship in the clinics, to observe the
con-tributions of each of the disciplines
repre-sented to total patient care. He learns about
the community in which his family lives,
both through his observations in the clinics
and through his home visits.
There is ample opportunity for students
to discuss their own views on child
develop-ment, medical and social problems, and
educational policies. Many of the students
have strong views and it seems important
that they have an opportunity to discuss
them both in group conferences and as
in-dividuals. We have observed particularly
393
The physician in practice soon finds that
awareness of themselves and their emotions,
partly as a result of their freer participation
in the program and partly as a result of
their other courses, especially psychiatry.
We have discovered, as have most other
people who have carried responsibility for
such teaching programs, that it is important
that students have adequate time for the
course and that qualified instructors be
available to them. Our program has worked
out reasonably vell in this respect, although
we do have evidence that problems have
become intensified when we were not
avail-able or when the student’s time did not
per-mit his making an additional home visit or
arranging to talk with us early enough about
a problem.
The design of this course is basically
formulated on established teaching
princi-pies with emphasis on self-education which
we believe is being provided by adequate
facilities and faculty who stimulate and
pro-vide guidance for the student to learn. This
principle is self-education is carried into the
monthly conferences where the students not
only prepare the problem to be presented
from the families under study, but often
conduct the entire discussion with the aid of
the resource people in attendance.
DIscussIoN
The great mass of knowledge about the
physical aspects of health and disease in
man has been almost overwhelming. Yet we
are becoming constantly more aware that
knowledge of this aspect of health and
dis-ease is not enough to treat or prevent
ill-nesses successfully.
“Increasingly medicine has focused its
at-tention on man as a social organism. The
reali-zation is growing that, while there are volumes
yet to be learned about the physical aspects
of the life of man in health and disease, the
great contributions of the future lie in the
di-rection of the exploration of those subtle yet
real functions and forces which largely
de-termine man’s reactions and actions as a person
in a society.”2
these emotional and social factors are so
intertwined with physical disease that they
have to be effectively dealt with in order to
successfully treat a patient. Each physician
does this with varying degrees of skill,
de-pending on his innate ability, his general
background and his interest, but rarely
be-cause of planned training in this field.
Further evidence of the concern of the
medical profession in this aspect of
mcdi-cine may be found in many recently
pub-lished articles, committe reports, and books.
These have such titles as “The Attitude of
the Physician,” “The Education of the
Doe-tor in Social and Moral Responsibility,”
“Widening Horizons in Medical Education,”
and “The Family in the Training of Medical
Students.”313
Doctors in this country have always been
interested in patients as people, as a brief
review of some medical writings of the past
will reveal.1417 However, the very rapid
scientific advances that have been made
during the first half of this century have
focused medical education on the physical
properties of man’s organic diseases. We
have in the past relied on the ability of each
new doctor to learn to be a good
prac-titioner of medicine by virtue of practicing
a long time in a small stable community,
and for a while this seemed to be adequate.
During this same half century there have
been some major changes in our society
with trends toward urbanization and
re-currently shifting populalions.120 Add to
this the increasing amount of specialization
in medicine and we begin to realize how
difficult it is for a doctor to learn much
about the family’s home environment and
the cultural concepts of his patients, either
from them directly or from his own
obser-vations. Consequently we can no longer
rely on the doctor’s learning of the social
structure of the community, and the
cul-tural concepts and spiritual attitudes of his
patient, by simply practicing in one
com-munity for a long time.
It therefore seems necessary at this time
our past sound educational program. The
Family Medicine course as described was
designed to meet this need in medical
edu-cation.
Dr. Grover Powers, Chairman of the
Committee on Medical Education of the
American Academy of Pediatrics, has
clearly and succinctly stated the basic aims
and objectives of medical education. We
can most heartily concur in the following
appraisal:
“It should never be forgotten that whatever
else is important in chimiical medicine the most
fundamental of all our activities deals with
adequate, accurate histories and with careful,
skillful physical examinatiomi coupled with a
knowledge of pathology ; we start from there
no matter where we emid! Nothing a physician
can do SO firmly establishes rapport between
himself and his clients as careful histories and
skillful physical examimiations. That does not
in amiy respect whatsoever imply that
psycho-logic amid sociologic factors are not truly and
es-sentially vital aspects of sickmiess and health
care. We do not debate what is more, what is
less important, but sirnpl emphasize what is
always basic and comes first in the practice of
a doctor of medicine! How to orient and teach
in the less clearly defined areas and when to
begin the special programs are sub judice; but
they will come to fruition some day and in the
meantime are subject to experimental study
and appraisal. We must have open and
recep-tive minds; there is no one and only approach;
we must try many-understandingly,
sympa-thetically,
A course in the medical school curriculum
has been described. We have pointed out
the integration with the basic sciences,
growth and development and preventive
medicine, and we have emphasized the
re-lationship of the psychologic, economic and
sociologic aspects of the patient’s
environ-ment to disease.
The principle of self-education is
empha-sized throughout the four-year experience of
the student. The close guidance of the
stu-dent is provided by the active participation
of the faculty of the School of Medicine and
many additional people in the University
and community.
The experiences of the student in the first
two years of the course have been reviewed
in an attempt to evaluate their
achieve-ments.
The total curriculum time of the Family
Medicine Course for the four years is 116
hours. This represents approximately 23%
of the total curriculum time of the Medical
School.
ACKNOWLEDGEMENT
We are indebted to the Los Angeles City
Health Department and especially to Dr.
L. S. Goerke, Director of Medical Services,
and Dr. Byron Mork, Health Officer of the
West Los Angeles District; and to the Los
Angeles County Health Department,
es-pecially Dr. Adele Eilers, Director of
Ma-ternal and Child Health, and Dr. S.
Rochel-son, Inglewood District Health Officer; and
to the Nursing and Social Service Staffs of
these Health Departments.
We wish to recognize the cooperation of
the Department of Education, the
Ele-mentary School of the University of
Cali-fornia and especially Dr. Edwin Lee, Dean
of the Department of Education, and Dr.
J
esse Bond, Director of Teacher Training;Miss Corrine Seeds, Principal of the
Uni-versity Elementary School, and to the many
individual teachers who have contributed to
the Family Medicine Course.
REFERENcES
1. Weiskotten, H. G. : Experimentation in
medical education. J.A.M.A., 151:1488,
1953.
2. Allen, Raymond B. : Medical Education
and the Changing Order. New York, The
Commonwealth Fund, 1946.
3. Bartemeier, Leo H. : The attitude of the
physician. J.A.M.A., 145:1122, 1951.
4. Greene, T. M. : The Educatioin of the
Doctor in Social and Moral
Responsibil-ity. Trends in Medical Education. New
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