Culture and Psychiatric Education I. Harry Minas O ur current training programs prepare gradu- ates to work in a society that no longer exists and to work in ways that are no longer accept- able to those for whose benefit we work. One would think, by looking at our training programs, that there is a remarkable uniformity and consensus concerning what constitutes a life worth living and how such a life should be lived. One would also think that our ideas about health and illness, and what should be done in the presence of suffering, were universally applicable and uncontroversial. One would be justi- fied in assuming that communication is not a prob- lem worthy of much consideration. Further, it would seem, from what we choose to teach, that issues such as the politics of knowledge and of practice, privilege, and the distribution and proper use of power, were settled long ago. And finally, one would have to con- cede that psychiatry is essentially a technical disci- pline, no different really to any other occupation that requires some identifiable body of specialised know- ledge and a range of technical skills, the application of which can repair dysfunctional brains or minds. 1 The difficulty is that our local worlds, and the world at large, have changed beyond recognition. In the latter half of this century Australia and New Zealand have become much more open societies, with a greatly increased two-way flow across their bound- aries of information and ideas, money, goods and, most importantly for our purposes, people. Associ- ated with this increased openness of the system is an increased level of complexity, by which I mean a vast expansion in what is possible. 2 There are many examples of this, in the realm of ideas information exchange, commerce, religion and politics. When sick, it is possible to seek the assistance of a doctor, psychologist, herbalist, chiropractor, iridologist, faith healer, or accupuncturist. All this in a bewil- dering range of languages. And yet, the fact of enor- mous cultural and linguistic diversity has had surprisingly little impact on our conceptions of med- icine, the structure and operations of medical insti- tutions and health care systems, medical education and clinical practice. 3,4 Psychiatric knowledge and technical skills are as necessary as they ever were but are no longer sufficient. Assumptions that were com- fortably made by doctors and patients about each other, because they came from essentially similar backgrounds, can no longer safely be made. In culturally diverse societies, where there are no fixed, universally acceptable criteria for ethical judg- ment, 5,6 doctors and patients are likely to hold diverging views with regard not only to the moral probity of various acts and interventions, but also with regard to the moral significance of pain, suffer- ing, death, and life itself. 7 In the cross-cultural clinical encounter, one of the key difficulties is that the physician and patient meet as moral strangers, in that they cannot assume what the moral viewpoint of the other will be. Their views of what constitutes a life worth living and the purposes of health care are likely to appear strange and exotic to each other. The moral commitment of the physician in these cir- cumstances must be to the good of the patient as the patient conceives it. 8,9 The skill required of the clin- ician is in gaining an understanding of the patient’s conceptions of health, illness and treatment, and in being able to work collaboratively with the patient and family on those things that are most important to the patient. Beyond the clinical consulting room there are issues of equity and justice in which psych- iatrists must take a vital interest and play an active role. 1,10,11 How should we educate psychiatrists so that they can work effectively in such a world? The first point I would make is that we should no longer speak of postgraduate training but of postgraduate education. This is not a trivial change in language but reflects a different view of the purposes of education and of training. The definition of education that I prefer comes from Lloyd’s Encyclopaedic Dictionary, 12 published in London in 1895. It is still surprisingly relevant. Education is: “Properly the educing, leading out, or drawing out the latent powers of an individual … Education … begins when one enters the world, and continues all the time he is in it. In a more specific sense, it is used of a premeditated effort on the part of parents, teachers, professors to draw out one’s intellectual and moral endowments, encouraging what is good to oneself and to society, and discourag- ing what is hurtful. With this is combined an effort to give more or less of technical training to fit the scholar or student for the occupation by which he desires or is likely to support himself in life… [E]duca- tion comprehends … the formation of the mind, the regulation of the heart, and the establishment of the principles…” In our current education programs much time and effort is spent on the task of “formation of the mind” and, particularly, on fitting the scholar “for the occupation by which he desires or is likely to support himself in life.” However, the formation of the mind does not occur in a cultural vacuum. Mind is constituted by and realised in the use of human culture. 13 Learning is always situated in a cultural context and is always dependent on the use of cul- Australasian Psychiatry • Vol 8, No 3 • September 2000 204