Monday, December 13, 2010

Will this cause a change?

An article in Lancet sets forth the need to change medical education. It is authored by as auspicious a group as you could imagine.

The indictment has been handed down.
This is not news. Will they listen this time?

Here is the introduction:

100 years ago, a series of studies about the education of health professionals, led by the 1910 Flexner report, sparked groundbreaking reforms. Through integration of modern science into the curricula at university-based schools, the reforms equipped health professionals with the knowledge that contributed to the doubling of life span during the 20th century.

By the beginning of the 21st century, however, all is not well. Glaring gaps and inequities in health persist both within and between countries, underscoring our collective failure to share the dramatic health advances equitably. At the same time, fresh health challenges loom. New infectious, environmental, and behavioural risks, at a time of rapid demographic and epidemiological transitions, threaten health security of all. Health systems worldwide are struggling to keep up, as they become more complex and costly, placing additional demands on health workers.

Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions—ie, the tendency of the various professions to act in in isolation from or even in competition with each other.

Redesign of professional health education is necessary and timely, in view of the opportunities for mutual learning and joint solutions offered by global interdependence due to acceleration of flows of knowledge, technologies, and financing across borders, and the migration of both professionals and patients. What is clearly needed is a thorough and authoritative re-examination of health professional education, matching the ambitious work of a century ago.


Mary Ellen said...

From Facebook:

Thank you again for sharing the nuggets that come across your desk in a CEO's day. After a tough personal experience, when I went for my master's degree in education I focused my thesis on medical education, development of curricula and its direct impact on patient safety. Because of the volatile hidden curriculum of medical education, companion studies in alternative dispute resolution and peace building strategies was warranted & worthwhile.

Med Ed curricula could save time by moving away from requirements of rote memorization (after all we have handheld technology at our fingertips) thus opening space to develop clinicians with enhanced interpersonal skills (helps gather accurate histories quickly and improves collaborative skills with patients and peers, etc). There is so much. Sure hope they hear it "this time"

Frank said...

From Facebook:

This is an interesting opinion piece, but all it does is list a series of problems with the economics of health care. There is nothing specific to medical education here and not a single solution offered. Also the bit about gender stratification? I think the Lancet group should swing by the BI and take a look at our demographics.

Is health care broken? Yes. Is the focus on primary care lacking? Yes, from an economic standpoint, but my fellow residents and I are saturated with it in our training.

To me, as I mentioned above this article highlights the broken economics of health care, not its education, and I wonder if couching this as an "education" article is what gets it published in the Lancet.

EMS Man said...

I find the comments about the "tribalism of the professions" the most concerning part of the introduction. The integration of professions throughout the medical field is a daily occurrence. These many groups, that are all part of the healthcare system, tend to be introduced and integrated only in a fully educated capacity. Does this isolation in training of the healthcare provider, of all levels, lead to the “tribalism” that concerns this report?

Would an early introduction in the education process of this integration help in building a continuous and growing sense of professional respect to help in combining the many "tribes" of healthcare to provide the most efficient and appropriate levels of care regardless of worldwide geographic location? How does the human nature of the professional play into this “tribalism”? Does ego get in the way of factual information being transferred from a first provider to a doctor or nurse, due to perceived levels of education?

I ask these questions since I do not have the complete insight into any solution for the human element in professionalism.

Roy M. Poses MD said...

At least this article addressed some issues, including poor funding for education per se, the decline of primary care, the dysfunctionality of the health care system, commercialism, and health care corruption which have rarely been addressed together in a prestigious, widely-read medical journal.

For more thoughts on this, see this post on Health Care Renewal:

e-Patient Dave said...

Hey everybody, where are you?? Do none of you (well, 4 out of the thousands) have any thoughts about this?? Right on? Or are they all out of the minds, all of them, from the IOM to the Rockefeller Foundation to Hong Kong and South Africa?

I see one glaring omission, but I also sure see a lot of right-on-the-money analysis, at least from where I sit as a patient and 2-year student of how to make healthcare work better.

C'mon, folks, at least skim (as I did), search for your favorite keywords, and read the 10 Proposed Reforms in the box on pp 29-30. Ya can't be a serious reader of this blog without paying attention to this article, I think.

e-Patient Dave said...

More thoughts -

1. Med school curriculum: every time I propose adding participatory medicine / doctor-patient partnership into the curriculum I hear "There's no room. What would you take out?" That's such broken thinking... do you think EVERYTHING is now being taught? And if it is, at least 10% of it will be outdated by the time one's residency is completed. Rather, the useful skill is the ability to learn new stuff and integrated it into what you already know - just as the article suggests.

Anyone care to debate that? (Honestly, I'm open.)

2. Frank, please note the title of the commission. I doubt education was bolted on as an afterthought to get published. Please see, too, this Medscape article, which quotes Lancet's editor Richard Horton: "Reliable evidence from low-income and middle-income countries shows that the most important barrier to achieving health is the generation and application of knowledge..." The article isn't about fixing the economics of healthcare, it's about equity - about getting the job done of caring for all dem humans. Medscape cites that four countries have 150 schools each, and 36 countries have none. (See table on page 12.)

I'm currently attending a Salzburg Global Seminar on informing & involving patients in medical decisions, with delegates from all continents. Some say that their patients' main problem isn't being involved in decisions, it's getting access to care in the first place.

As we discussed patient decision aids today, it's clear that online will an important channel for these tools - consistent with a comment that Medscape says was posted by students from Austria and the Netherlands. That's not economics, it's bringing the information to the place where it's needed.

3. EMS Man, my experience confirms that in a great place like Beth Israel, we're indeed seeing more integration of professions (and much less gender gap) than 20 years ago. But data is data, and most of the world (and US) (and Boston area) is far behind. And note that Levy is periodically attacked by local competitors - a troublingly tribal behavior, imo.

btw, even at BIDMC, the different silo'd people who cared for me sometimes had no clue what their peers in another department were doing. It's just not part of the culture to think about the whole patient: absolutely "not my job."

Bottom line, what I like most about the article is its systemic thinking. Lean / systems thinkers like authors Mark Graban and Stephen Spear make pretty clear that with something as complex as modern healthcare, if you don't have system thinking you're going to have parts banging into each other all over the place, and an unhealthy whole.

(Jeeze, I didn't have time to write a post about this article, but I wrote two long comments...oh well.)

Anonymous said...

There are many pearls in this dense article; the one that I took out observed that medical education is outmoded because the very nature of illness has changed:

*the emergence of non-communicable disease, for which patient care becomes a series of transitions from home->hospital->rehab->back to home, engages a host of multidisciplinary professionals who must work together to provide a seamless web of health services.*

- as opposed to isolated episodes of care which better fit the previous predominance of infectious disease/trauma.

It also talks about monopolism among guilds of degree-based, rather than competency-based, professionals.

The discouraging fact is that those in control of medical education in the U.S. are the very ones who perpetuate the tribalism cited, as we have seen in recent arguments between physician and nurse associations.

To quote and agree with Dr. Poses:

"I do hope that the appearance of a publication as authoritative as the article by Frenk et al leads to some soul-searching by the leaders of health care around the world."

But I am not too hopeful.

nonlocal MD