Medical and health care professional education in the 21st century: institutional, national and global perspectives

Abstract

I consider it a privilege to have this opportunity to share some pedagogical insights with readers in this special issue of the journal through my commentary on three articles published by, respectively, Bordages and Harris,1 Hodges et al.2 and Norcini and Banda.3 Firstly, the articles bear ample testimony to an urgent need for education reformers to consider how the global and local forces of change and rapid advances in the learning and management sciences will impact on the quality of education we provide and, consequently, on the quality of the health care we deliver to our respective communities. I will highlight more explicitly the implications of the issues raised by the respective authors and work towards developing a more comprehensive understanding of these themes by starting from a general perspective and moving on to the specific issues tackled by each paper. ‘…although the educational strategies Flexner proposed in 1910 were daring for the time…they need to be superseded by a more comprehensive set of standards to steer medical schools towards accomplishing their social mandates.’4 A critical review of Flexner’s wisdom on medical education, documented a century ago,5 is now required as much has changed in the ensuing years. Curriculum reforms in medical and health care professional education are now ongoing, not only intensively, but also extensively on a global scale. The big question then concerns how we should best educate today’s medical and health care professional students for their roles as tomorrow’s health care professionals and how we should ensure that they are equipped with the professional competencies (knowledge, skills, attitudes) they will require to meet the challenges and demands of health care delivery in the 21st century. The three articles5 raise several issues in this regard, with important institutional, national and global implications. The big question concerns how we should best educate today’s medical students for their roles as tomorrow’s health professionals All three articles also emphasise the need to incorporate a research agenda into any undertaking of education reform. Although this is probably good practice, it may not be feasible in some countries. The article by Norcini and Banda3 clearly highlights various constraints which may be inherently imposed in some nations and which make it very difficult for such countries to adopt a research agenda. In order to better understand the issues discussed by Bordages and Harris,1 it is best to start with some relevant lessons from history. Stephen Abrahamson, a doyen of medical education, has documented several significant recurrent problems in curriculum reforms commonly encountered in the past. In his insightful article ‘Diseases of the Curriculum’,6 Abrahamson identified ‘curriculosclerosis’ (‘an extreme form of departmentalisation’) as: ‘by far the most crippling disease, and tragically also one of the most prevalent.’ Abrahamson pointed out that departmentalisation ‘becomes a stifling, inhibiting influence on the normal development and function of the curriculum’ and that it ‘manifests itself in a kind of social territoriality’ (now commonly referred to as mental ‘silos’). He also lamented that the ‘design of the curriculum then can seem to be more a power struggle than an educational planning venture’, resulting in ‘the tragedy of impeded growth’. Another doyen of medical education, the late George Miller, also underscored the need for unity in diversity across departments (disciplines) in designing the undergraduate medical curriculum.7 In order to better understand some of the pertinent issues, it is best to start with some relevant lessons from history Perhaps, in the past, many of the recurrent problems of curriculum reform (as described by Abrahamson) resulted from education decision making which did not have the benefit of the advances in cognitive and management sciences that guide today’s curriculum change process. Education decision making then was based, more often, on ‘PHOG’ (prejudices, hunches, opinions, guesses) and ‘power politics’ (in which the ‘top’ clinician or scientist is the most powerful!), rather than on evidence-based best practices (e.g. Best Evidence Medical Education8). Knowing the relevant and valuable lessons of history, how then can we now avoid repeating the errors of the ‘old ways’? Bordages and Harris1 clearly recognise that the medical curriculum of today ‘has become more and more complex’. These authors therefore suggest that it is best to view the curriculum not only as an entity made up of interdependent elements, but also as a process which requires strategic nurturing to increase the likelihood of successful and sustainable reform. Indeed, the curriculum of today does not simply represent a static list of content, assessment and teaching–learning strategies, timetable scheduling, etc. Today’s curriculum consists of key interdependent elements existing in dynamic equilibrium. Any attempt to shift or change one key element is likely to result in perturbations in the system which can impact strongly on the functioning of one or more of the other interdependent elements, with the result that the equilibrium of the system will need to be restored to allow it to return to optimal functioning. Curriculum reformers should therefore bear this in mind when making changes to one or more aspects of the curriculum. Today’s curriculum consists of key interdependent elements existing in dynamic equilibrium Bordages and Harris1 also emphasise the need to view curriculum reform as a process of change which is highly sensitive to human manipulation and persuasion and which, thus, requires the strategic nurturing of all parties (stakeholders) involved in any proposed curriculum change process. In particular, the authors rightly underscore the importance of and recommend group deliberation and leadership skills as prerequisites for anyone leading the curriculum change process. When the prerequisites are applied, the curriculum change process is more likely to succeed and to be more sustained, thus avoiding the pitfalls of yesteryear. Four models of more recent curriculum reform in institutional settings provide useful lessons for health care faculty members intending to undertake curriculum reform in their respective institutions. All four models have strategically applied current curriculum principles and theories in designing new curriculum strategies intended for 21st century medical education. The four models of curriculum reform are recommended for insightful reading and were undertaken by faculty staff at the following institutions: the David Geffen School of Medicine, University of California at Los Angeles (UCLA);9 the University of Pittsburgh School of Medicine, Pittsburgh, Pensylvannia;10 Mayo Medical School, Rochester, Minnesota,11 and, more recently, the Johns Hopkins University School of Medicine, Baltimore, Maryland.12 The authors underscore the importance of group deliberation and leadership skills as prerequisites for leaders of curriculum change The paper by Hodges et al.2 is essentially based on a national (case) study commissioned by the Canadian health authorities (Health Canada) in collaboration with the Association of Faculties of Medicine of Canada (AFMC) under the umbrella of the Future of Medical Education in Canada (FMEC) Project (http://www.afmc.ca/fmec/). The research approach used by the authors was primarily intended to facilitate the forging of a national consensus for curriculum reform in Canadian medical education in order to better align the latter to 21st century medical practice. The major strength of this report lies in its triangulation of data inputs from various sources, which results in the identification of 10 ‘key issues’ used to generate ‘detailed review papers’ used by the AFMC to ‘create a blueprint for the evolution of medical education’ aimed at meeting the ‘health care needs of contemporary [Canadian] society’.2 There are many good lessons to be gleaned from this experience that pertain to the forging of a national consensus on leading curriculum reforms. However, only time will reveal whether the proposed reforms in medical education, as recommended in the AFMC blueprint, will ‘supersede the Flexner model’ of medical education implemented a century ago (http://www.afmc.ca/fmec/). Although it is too early yet to predict the outcome, the systematic approach to national curriculum reform adopted by the authors is likely to ensure success and sustainability for the model. In reviewing the article by Norcini and Banda,3 I sensed a tinge of the heartfelt passion expressed by the authors. They raise some important issues in medical education, which have global implications, and focus especially on societal needs and inequities in health care. In particular, the authors are highly concerned over the seemingly serious inequities in the distribution of trained health care personnel in the resource-poor countries that carry ‘the highest burden of disease’.3 They argue that the major challenge for medical education in the 21st century in resource-poor countries is to not only enhance the quality of education, but also to build health care personnel capacity in an effort to effect ‘the reconciliation of quality and capacity’.3 In order to resolve this double-edged problem in health care in resource-poor countries, the authors propose the implementation of ‘three research-driven educational reforms’, namely: the use of evidence-based best practices to guide education decision making in the selection of teaching strategies, rather than the current practice of retaining teaching methodologies on the basis of hardbound ‘tradition’, or the uncritical adoption of new methodologies simply on the basis of pedagogical ‘fashion’ (i.e. keeping up with the educational ‘Joneses’!); the institution of policies to increase trained health care personnel capacity as an integral component of strategies to improve the quality of education, thereby also enhancing the ‘relevance and utility’ of the education provided, and the use of appropriate quality assurance procedures to ensure the quality and standard of education programmes. In this context, the authors lament the fact that current accreditation and licensure procedures require ‘considerable resources’. Moreover, some of the accreditation processes ‘are so prescriptive that they are a barrier to improvement and for none is there evidence of effectiveness’.3 These issues have important implications for the global community of education scholars. The authors identify the initiatives of the Foundation for Advancement of International Medical Education and Research (FAIMER) (http://www.faimer.org/) to award study fellowships and set up regional institutes in developing countries as representative of good examples of efforts to achieve the aim of capacity building in resource-poor countries.3 The ‘postgraduate diploma in education for health professionals (PGDEH)’ implemented in Zambia is cited as another example of ‘a global collaboration of educators aiming to improve the health of communities’ which apply the strategies advocated in the Network Towards Unity for Health.3 Other organisations, like the International Institute of Medical Education (IIME) (http://www.iime.org/) and the World Federation of Medical Education (WFME) (http://wfme.org/) represent institutions with the requisite expertise to enhance the quality of education and to facilitate the process of capacity building in health care professional education. The issues raised have important implications for the global community of education scholars Although such outreach programmes are aimed at enhancing both the quality and capacity of health care professional education, the authors add a caveat that, in attempting to find solutions to these education-associated problems, it will be necessary ‘to establish processes that avoid’ the potential for ‘educational hegemony’.3 ‘The central mission of medical education is to improve the quality of health care delivered by doctors… [with] patients as the recipients of our skills – what doctors do, and how and when they do it, depends on the quality of medical education. We need to get it right.’13 Medical and health care professional education must prepare today’s students for their roles as doctors and health care professionals who can meet the demands and challenges of health care delivery in the 21st century. Ultimately, it is the quality of education that will determine the quality of graduates (the endproducts of education) and, therefore, the quality of the health care of a nation. Education research will have an important role to play in providing and guiding evidence-based education-related decisions and practices and can, therefore, contribute towards the resolution of pedagogical issues at the institutional, national and global levels. The resolution of the problems associated with inequities in the distribution of health care workers across the world will also require the institution of a research agenda. The global community of education scholars with the appropriate expertise must rise to this challenge and take up leadership in the effort to find and provide practical solutions for fellow educators who encounter such global education problems.