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MEDICAL EDUCATION
Year : 2021  |  Volume : 19  |  Issue : 3  |  Page : 207-210

Redefining “Health”: A critical reflection exercise for 1st year MBBS students


Department of Community Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu, India

Date of Submission15-Mar-2021
Date of Decision20-Apr-2021
Date of Acceptance08-May-2021
Date of Web Publication05-Jul-2021

Correspondence Address:
Dr. Vijayaprasad Gopichandran
Department of Community Medicine, ESIC Medical College and PGIMSR, KK Nagar, Chennai - 600 078, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_30_21

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How to cite this article:
Gopichandran V. Redefining “Health”: A critical reflection exercise for 1st year MBBS students. Curr Med Issues 2021;19:207-10

How to cite this URL:
Gopichandran V. Redefining “Health”: A critical reflection exercise for 1st year MBBS students. Curr Med Issues [serial online] 2021 [cited 2021 Oct 27];19:207-10. Available from: https://www.cmijournal.org/text.asp?2021/19/3/207/320648




  Introduction Top


The recently implemented competency-based medical education has several positive aspects in it. One of them is the emphasis on critical thinking and reflection. Through the Attitude, Ethics, and Communication module that runs through all the years of medical education, important topics of significance are discussed, and students are encouraged to think broadly and develop a social consciousness.[1] Critical reflection exercises as described by Paulo Freire, the Brazilian educator, greatly contribute to developing a socially conscious professionalism among medical students.[2],[3] Critical reflection is defined as the ability to assess statements and definitions and make objective judgments on their validity based on logical reasons. It is the ability to identify flaws and loopholes in the claims. It fosters the ability to be creative and constructive. It helps in implementing these critical abilities in everyday life.[4] One of the areas which demand critical reflection is the question of “what is health?” “who is a healthy person?” and “what is disease?”

The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”[5] However, this definition has elicited strong criticism in the global public health community.[6] The major point of contention has been that “health” has been defined as an absolute and complete state, which makes it ambitious and difficult to achieve for most people. This disconnects the construct of health from practical reality and makes it a utopian ideal.[7] This definition was proposed in an era of predominance of communicable diseases, which have definite cure. With emerging epidemiological transition, increasing chronic noncommunicable diseases, this definition becomes moot, as people with many chronic noncommunicable diseases such as diabetes, hypertension, chronic obstructive pulmonary disease, now live long and fulfilling lives which can be called “healthy,” but by this definition, it would not fit into the “healthy” category.[8] The idea of well-being itself is not completely understood and so defining “health” as a state of well-being makes it vague.[9] Given these strong criticisms, there is a need to clearly redefine health for the current epidemiological situation. Such a redefinition exercise will require critical reflection and broad thinking. Therefore, the topic of “re-defining health” was taken up for the critical reflection exercise among 1st year medical students as part of the Community Medicine group discussion session. The key objective of this session was to inculcate critical enquiry into the definition of health.


  Session Description Top


Competency-based revised MBBS curriculum has been in vogue since 2019. In the subject 'Community Medicine', the competency number CM1.2 refers to “Define health; describe the concept of holistic health including concept of spiritual health and the relativeness and determinants of health”.[10] It is defined under the knowledge domain and the level is described as “Knows How.” It is core competency and is recommended to be instructed as lecture or small group discussion.

To implement this session, we planned a critical reflection exercise through small group discussions. We divided the students into small groups of 10–15 participants in each and gave them 4 case vignettes describing individuals with an ambiguous state of health. These case vignettes are provided in [Table 1]. We instructed the students to discuss all four case vignettes in their small groups and write down whether they thought these 4 individuals were healthy or not. Then, we introduced the WHO definition of health and instructed the students to match this definition with the 4 case vignettes. We asked them to then comment on whether they would classify them as healthy or not, based on the WHO definition. The groups were then asked to make a presentation in the class about their discussions. They looked at the definition of health critically based on the case vignettes. This process of critical reflection is evidence of higher-order thinking.
Table 1: Case vignettes for discussion

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We took extensive notes during the full class discussion and debriefing session. The notes were then analyzed, and we present the key findings of the discussion below. This critical reflection exercise lasts about 2 h. The session plan is provided in [Table 2].
Table 2: Session plan of Critical reflection on definition of health

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  Summary of the Discussion Top


Health as a subjective notion

Many students felt that health must be defined subjectively. Each person must be able to decide whether they are healthy or not. In the case vignettes of the young man living with disability, the elderly man with diabetes and hypertension, and the elderly lady with visual and hearing disability, the students preferred to define them as healthy, as they were subjectively living a healthy life as per their preference. None of them had any complaints about their lives and were very positive. The mere presence of diseases or disability should not influence the decision on whether they are healthy or not.

Health is a relative construct, not absolute

One of the groups mentioned that health is a relative state. Often people make decisions whether they are healthy or not relative to others and not in an absolute manner. In comparison to someone who is completely disabled due to loss of a limb, the young man in the case vignette who lost his limb but still is socially productive and active is healthy. Compared to a patient who is prevented from going about his normal life because of complications of diabetes and hypertension, the elderly man in the vignette who won the Sudoku championship is healthy, despite his illnesses.

Health is context specific

Several groups came up with the idea, that health must be defined based on the context, situation, and circumstances of the person. The same parameters of defining a healthy person that would apply in a rich socioeconomic background cannot apply for someone from a marginalized section of the society. If a person without a limb goes to work and is economically productive with adequate social support and lives in a stable financial situation, like in the vignette, he may be called healthy. On the other hand, a man with a similar disability may be pushed by poverty to endure severe hardships and push himself to go to work without any social support, but he cannot be classified as healthy.

Health extends beyond just physical, mental, and social

One of the groups demanded that the scope of the definition of health should be expanded beyond physical, mental, and social well-being. There are other important dimensions such as spiritual and emotional which also need to be considered. Within the social domain, there is a need to focus specifically on family, friends, society, community, economic status, caste, gender, and other determinants. Since health is so complex, it must not be reduced to a simple statement that makes it seem oversimplified.

Health as self-actualization

One of the groups came up with an interesting theory that the goal of human life is self-actualization or the ability to function optimally to achieve one's fullest potential. Therefore, good health must be defined as everything that leads to self-actualization. In all case vignettes, the persons are trying their level best to be functional in an optimal fashion so that they can achieve their full potential. This definition would clearly mark them as healthy. However, one's full potential will continue to remain a subjective, context-specific, and individualistic notion.

Health as adaptation to situations

One group specified that health must be defined as ability to cope and adapt. In the era of chronic diseases, it is not possible to imagine a person who does not have any diseases. Diabetes and hypertension are so common in the community. Therefore, we must define health only as the ability to cope with the diagnosis, adapt their lives to adjust to the demands of the disease, and live an optimal life. This is true of the man who lost the limb, the person who lives normally with diabetes and hypertension, and the elderly lady who is hard of hearing and has visual impairment. Some students felt that the pregnant woman who had episodes of crying due to grief of her father's death several years ago did not adapt to her father's demise and that is not a healthy state.

Health as a time-dependent state

One of the groups interpreted health as a state at a particular point of time. It has to be defined as a time-dependent state. People move in and out of health at different points in their lives and they cannot be labeled “healthy” or “unhealthy” permanently. The elderly man with diabetes and hypertension in the vignette is currently well adjusted and healthy, but he may develop a complication or may decompensate over time and may become unhealthy. Similarly, the pregnant woman is experiencing dizziness and vomiting, thus leading to an unhealthy state. However, she may pass through the first trimester of pregnancy and become well-adjusted soon, becoming healthy.

Health as a socially defined construct

Students in one group emphasized on the fact that health is a socially defined construct. While they argued that subjective perception of health is important, it is not enough. When a person perceives themselves to be healthy, it must also coincide with what the society considers as healthy. On the other hand, a person may perceive themselves to be unhealthy, but as per social parameters, they may be healthy.

Health as an inter-dependent state, not individual

One set of students felt that the definition of health as an individual state is highly over-simplified. In countries like India, where people are socially tied together strongly to one another in families, neighborhoods, and communities, health must be viewed as a collective inter-dependent state. A person with disability is very well cared for in a rural community and can lead a very productive and meaningful life. Therefore, she can be said to be healthy in the inter-dependent state of communal life. An individual-based definition of health would apply only in largely individualistic societies, like some urban societies in India.

Refining the definition of health

Following this discussion, we instructed the students to get back into their small groups and frame their own alternative definitions of health. While they were framing this alternative definition, we requested them to keep in mind the key points of the discussion, which we quickly summarized for them. After much deliberation, ten different small groups of the students came up with separate definitions of health. The author has amalgamated the content from various definitions that the students proposed and the final definition was,

Health is a time dependent, relative state of optimal physical, mental, social, emotional and spiritual human functioning, adapting appropriately to life situations, to achieve the goal of self-actualization, in a socially acceptable manner which is contextually appropriate.


  Conclusion Top


Critical reflection is a very useful method to evoke higher-order thinking among medical students. The use of simple case vignettes, without including much clinical details, but focusing on broad social aspects was helpful in getting the students to think on health and definition of health. Once they identified the disparity between the apparent state of health of the persons in the vignettes and the WHO definition of health, they could very effectively reflect on the strengths and limitations of the definition. This reflection helped them propose a refined definition of health. This refined definition reveals a higher-order thought process on health and well-being.

Acknowledgment

The author would like to acknowledge the intellectual contributions of the 1st-year students of the batch of 2020-21 of the ESIC Medical College and PGIMSR, KK Nagar, Chennai.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Medical Council of India. Competency Based Undergraduate Curriculum for the Indian Medical Graduate. 2018. pp. 1-3. Available from: https://www.mciindia.org/CMS/information-desk/for-colleges/ug-curriculum. [Last accessed on 2021 Mar 05].  Back to cited text no. 1
    
2.
DasGupta S, Fornari A, Geer K, Hahn L, Kumar V, Lee HJ, et al. Medical Education for Social Justice: Paulo Freire Revisited. J Med Humanit 2006;27:245-51.  Back to cited text no. 2
    
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Cavanagh A, Vanstone M, Ritz S. Problems of problem-based learning: Towards transformative critical pedagogy in medical education. Perspect Med Educ. 2019;8:38-42. doi:10.1007/s40037-018-0489-7.  Back to cited text no. 3
    
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Scriven M, Paul R. Defining critical thinking: A Draft statement for the National Council for Excellence in Critical Thinking. Available from: https://www.criticalthinking.org/pages/defining-critical-thinking/766. [last accessed 2021 Apr 10].  Back to cited text no. 4
    
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World Health Organization. Constitution. Geneva: World Health Organization; 1946.  Back to cited text no. 5
    
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Sartorius N. The meanings of health and its promotion. Croat Med J. 2006;47:662-4.  Back to cited text no. 6
    
7.
Fallon CK, Karlawish J. It's time to change the definition of 'health.' STAT: Stat News; 2019. Available from: https://www.statnews.com/2019/07/17/change-definition-health/. [last accessed 2021 Apr 10].  Back to cited text no. 7
    
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Card AJ. Moving Beyond the WHO Definition of Health: A New Perspective for an Aging World and the Emerging Era of Value-Based Care. World Medical & Health Policy, 2017;9:127-137. https://doi.org/10.1002/wmh3.221.  Back to cited text no. 8
    
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Dodge R, Daly A. Huyton J, Sanders L. The challenge of defining wellbeing. International Journal of Wellbeing, 2012;2:222-35. doi:10.5502/ijw.v2i3.4.  Back to cited text no. 9
    
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National Medical Commission. Competency Based Under Graduate Curriculum. New Delhi: Competency Based Undergraduate Medical Curriculum; 2019.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]



 

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Summary of the D...
Conclusion
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