The F.R. School of Medicine

Schools of doctors' dreams

The Christmas issue, BMJ 2001;323:1456-1457 (22-29 December 2001), contains three people's description of their ideal medical school. Read the descriptions:
Renaissance School of Medicine
François Rabelais  School of Medicine
Confucius School of Medicine

The François Rabelais School of Medicine

Jeremy Anderson, Director, Centre for Clinical Effectiveness, Monash Institute of Health Services Research, Monash University, Clayton, VIC 3168, Australia

The Rabelais School will produce graduates who are as comfortable in the shit as they are in the stars - and understand that the pathology they observe in  humanity is equally present in themselves

This medical school takes François Rabelais (c 1494-1553), Franciscan monk, Bachelor of Medicine, and humanist, as its muse. Although his inspirational work Gargantua and Pantagruel celebrates his abilities as a satirist and misogynist, his role as an educationalist has been overlooked. "He was a man intoxicated by every sort of learning and theory," according to one translator, "who, at the same time, had the earthy common sense of a peasant." In an increasingly divided world, with medicine increasingly preoccupied by technical elitism, Rabelais stands as a cogent model.

The Rabelais School follows the "mischievous rascal" tendency of scientific humanism, through Voltaire ("The art of medicine consists in amusing the patient while nature cures the disease") to Sir William Osler ("One of the first duties of the physician is to educate the masses not to take medicine"). It acknowledges Osler as the seminal medicinal nihilist of the modern era, whose general iconoclasm and demand for proof of efficacy before using a drug anticipated the later glories of evidence based practice. An eminently qualified heir to this tradition, David Sackett, encapsulates the approach of the Rabelais School with his remark, "Textbooks don't smell as their contents rot, so readers will need to develop alternative crap detectors to avoid poisoning their minds and robbing their patients of current best care."

But there are times when even this approach will fail. Faculty members of the Rabelais School exemplify those strategies of decision making that Isaacs and Fitzgerald nominate as alternative to evidence: eminence, vehemence, eloquence, providence, diffidence, nervousness, and confidence. Role modelling plays a crucial part in the pedagogic framework of the Rabelais School - we choose our clinical skills' tutors with care.

The role of research

In the new millennium the research endeavour exemplifies all that is best in modern medicine. Rabelais anticipated this 450 years ago. Much of his inspirational Gargantua and Pantagruel is an investigation of the research hypothesis that all husbands are inevitably cuckolds. To investigate the question Pantagruel convenes a multidisciplinary expert panel, which provides conflicting advice. After this he embarks on an allegorical journey, rich with incident, eccentricity, and treasure, a metaphor for the process of scientific discovery. It ends at the Temple of the Bottle, dedicated to Bacchus, where the waters of the fountain of knowledge taste of different varieties of wine according to the preconceptions of the drinkers. The research question remains unresolved but clearly in need of further study.

The Rabelais School teaches students to spin the straw of unanswered questions into the gold of medical research. Students know that the pharmaceutical industry, the most lucrative industry in the United States, earns profits of around 20% of its revenues. They also know that, like the fountain of knowledge, industry funded research seems to reflect the preconceptions of its sponsors. They fully appreciate that a few years of ballpoint pens and free lunches through medical school can translate into a practising lifetime of sponsored conferences and overseas travel, with all costs borne by their patients and other taxpayers. Accordingly, an important part of the Rabelais curriculum will be the research semester, during which student groups undertake research projects that are graded according to the amounts of sponsored funding, equipment, meals, and air miles generated.

Personal and professional development

The unique approach of the Rabelais School of Medicine will find its highest expression in the personal and professional development curriculum. Pastoral care is taken seriously and is based on the Rabelais commitment to move beyond theoretical study to experiential learning. Rabelais wrote movingly of food (war declared over a disputed recipe; coveted dishes like "couilles d'eveque" - bishop's testicles) but reserved his best praise for wine, which is to be consumed in huge amounts on every conceivable occasion. He extolled the medicinal properties of drink at length, saying, "A hundred devils leap into my body if there aren't more old drunkards than old physicians." His intoxicated spirit would have relished those more recent doctors who extended his preoccupation to other substances. The Rabelais School takes inspiration from this and the opinions of naive subjects like Richard Smith ("a world without drugs is unachievable and probably intolerable") and the experience of drug misusers like cocaine addict Sigmund Freud, father of psychoanalysis; morphine addict William Halsted, father of radical mastectomy; and LSD maven Humphrey Osmond, father of psychedelics.

Communication skills workshops, university transition training, teamwork groups, community immersion projects, and business practice mentorships will all have a place but it is the neuropsychopharmacology practicum that sets the curriculum apart. This is a compulsory, three month, residential placement for first year students at Thélème Hall (motto: "Do as you will"). The practicum provokes students to explore self expression, personal relationships, group work, and their choice of recreational drugs in an experiential, "Inward Bound" learning environment. Closed circuit television cameras capture all aspects of the practicum to provide postmodern self referentiality and subsidise teaching. Expenses are realised by repackaging the material as a TV series, Big Intern (billboard slogan: "Snorting . . . Coupling . . . Auscultating"; theme tune: Robert Palmer, "Bad Case of Loving You").
Alcohol and substance misuse are often defined as levels of consumption greater than those of one's doctor. By this measure the neuropsychopharmacology practicum stands ready to reduce prevalence of these disorders at a stroke.

Competing interests: None declared.
References

Rabelais F. Gargantua and Pantagruel. London: Penguin, 1955. (Translated by J M Cohen. Originally published 1532-51.)
Hogan DB. Did Osler suffer from "paranoia antitherapeuticum baltimorensis"? A comparative content analysis of the Principles and Practice of Medicine and Harrison's Principles of Internal Medicine. CMAJ 1999; 161: 842-845.
Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone, 1998.
Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ 1999; 319: 1618.
Angell M. The pharmaceutical industry - to whom is it accountable? N Engl J Med 2000; 342: 1902.
Bodenheimer T. Uneasy alliance: clinical investigators and the pharmaceutical industry. N Engl J Med 2000; 342: 1539.
Smith R. The war on drugs. BMJ 1995; 311: 1655-1656.
Freud S. Über Coca. Vienna: Verlag von Moritz Perles, 1885.
Rutkow IM. Moments in surgical history: William Stewart Halsted. Arch Surg 2000; 135: 1478.
Osmond H. A review of the clinical effects of psychotomimetic agents. Ann N Y Acad Sci 1957; 66: 418-434
@ BMJ 2001