The Education of Health Professionals and Prospects for Transformation

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This is a guest blog post by Seiji Yamada, MD, University of Hawaii.

The Commission on the Education of Health Professionals for the 21st Century, chaired by Julio Frenk (Dean of the Harvard School of Public Health) and Lincoln Chen (President of the China Medical Board), published its report in the December 4, 2010 issue of the Lancet. Titled “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world,” the report was released in the centennial year of the Flexner Report of 1910. In contrast to the Flexner Report, however, the current report broadens its focus from medicine alone to include nursing and public health education. In addition, instead of focusing on the U.S., the report takes global health to be within its purview.

As noted by Richard Horton, the editor of the Lancet, "A strong case is made that the present content, organisation, and delivery of health professionals' education have failed to serve the needs and interests of patients and populations."

The commission reviews a century of reforms in health professional education, identifying the Flexner Report as a key document of the first generation. The Flexner report is widely credited with placing American medical education on a scientific basis and leading to the closure of institutions that did not meet its standards. (A critical view of the Flexner Report, that it was a means for allopathic medicine to enhance its dominance over competing philosophies of health and healing might be gleaned from Paul Starr’s The Social Transformation of American Medicine.)

The Commission associates the second generation of reforms with the “instructional breakthroughs” of problem-based learning (PBL) and disciplinarily integrated curricula. Identifying McMaster University as its pioneer, the key aspects of PBL are identified as its learner-centered philosophy and small groups. Newcastle and Case Western are identified as the pioneers of disciplinarily integrated curricula. Other second generation instructional innovations include the use of standardized patients, a focus on the patient-doctor relationship, earlier introduction to patients, and expanding clinical sites to include community settings. (p. 1932)

My own medical school experience (University of Illinois at Chicago, 1983-1987) was singularly uninspired and had none of these elements. I’m assuming (hoping) that UIC is doing better now. It was not until residency (family practice at Cook County Hospital, where Josh Freeman was one of my teachers) that I was introduced to training in the community setting (the South Lawndale Health Center). But it does make me wonder to what extent these “second generation” reforms have been instituted in U.S. medical schools.

I was introduced to PBL (as well as disciplinary integration, discussions about the patient-doctor relationship in the family medicine clerkship, clinical experiences for MS1s, and student rotations in community health centers) when I joined the faculty of the University of Hawaii John A. Burns School of Medicine (UH JABSOM). Initially skeptical, I have become a proselytizer for PBL in a way that only a former unbeliever can be. (My friend Mark Durand prefers to say that he once was a sinner, now he’s a preacher.)

I do know that PBL has become the organizing principle of medical education in only ten or so U.S. medical schools. The institutional barriers to changing over an entire curriculum to PBL are significant. Basic science departments generally have to give up ownership of courses, as disciplinary integration is inherent to PBL. In addition, the faculty resources for conducting small group tutorials are significant. PBL fails without faculty enthusiastic about serving as tutors.

The Commission calls for a third generation of educational reforms. They call for health professional education that is patient-centered and population-centered. By “population” is meant the global population. The goal is that all people around the world have access to health care. “The ultimate purpose is to assure universal coverage of the high-quality comprehensive services that are essential to advance opportunity for health equity within and between countries.” (p. 1924)

This point is what makes this report of interest for the readers of Medicine and Social Justice. Our educational system is charged with creating the next generation of workers who will transform the health care system into one that will serve all of humanity. This cannot be achieved without inculcating an ethic of social justice.

The Commission calls for two educational outcomes in this third generation of reforms: transformative learning and interdependence in education. “Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms.” (p. 1924) Generally, we tend to view our role as educators as informative and formative: we transmit knowledge to our learners (inform) and place them in settings to develop professional attitudes (form), so that they become competent and eligible for licensure. However, if we expect the next generation to lead the reform of the health system so that it delivers health for all, then we must train them to become agents of change, that is, we must inculcate transformative learning.

The second outcome called for by the Commission, interdependence in education, reflects the need for teamwork in the delivery of all health services. Disciplinary boundaries among the health professions can be overcome by interprofessional and transprofessional educational models. [The Commission defines interprofessional as teamwork with other health professional students and transprofessional as teamwork with "basic and ancillary health workers, administrators and managers, policy makers, and leaders of the local community" (pp. 1943-1944).] This will require integration of institutions as well as disciplines. Curricula will need to take more advantage of global flows of information and educational resources.

The University of Hawaii made a foray into community-based interprofessional education in the early 1990s, when the schools of social work, nursing, public health, and medicine collaborated education at community health centers. Initially funded by the Kellogg Foundation, then by the Area Health Education Center (AHEC), this effort petered out after about ten years. With external funding running dry, the various schools involved failed to commit resources to the effort.

With regards to the transprofessional educational model - in a separate piece, Marshall MacLachlan of Trinity College, calls for integrative expertise in research and research training for global health. Noting that global health is a composite field, MacLachlan proposes “integrating research about ‘what’ (content), with research about ‘where’ (context) and ‘how’ (process).” (p.2) As an example, he offers “Paul Farmer’s work on HIV/AIDS (Content), his socio-political analysis of power relations (Context), and his service delivery role in Partners in Health (Process).” (p.3) Of course, Farmer is a neo-polymath (to use MacLachlan’s term), but MacLachlan’s point is that “these people tend to emerge individually, we don’t have an explicit way of producing or encouraging such skills, or encouraging a more integrative orientation in general; and we don’t have a structure for teaching it.” (p.3)

But the fact of the matter is that our learners are demanding such teaching. As Skip Burkle points out (personal communication), young people and second career adults are demanding educational programs in humanitarian assistance. He notes that the majority of people responding to the Haiti earthquake were under thirty years old, and for many, it was their first experience in disaster assistance. Young people recognize that their working years will be spent in a globalized world, and that much of the world is characterized by poor governance and poor social and physical protections. Burkle, Clarke, and VanRooyen point out that humanitarian community inadequately translates humanitarian action into public policy. Young people recognize that they will also need to lead at the policy level.

At UH JABSOM, students formed their own organizations, the Global Health Interest Group (GHIG) and the Partnership for Social Justice (PSJ). Students in the PSJ are organizing their own leadership workshop to learn about how to improve the health system. They are motivated by a moral belief in health as a human right and the need for more social justice in health and medicine. The tasks in store for us as teachers are self-evident. Our students are demonstrating their commitment to globalism, to social justice, and to a conception of health that transcends narrow disciplines. We need to make sure that we can help prepare them to achieve these goals.
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Advice for building a new primary care based health system for Armenia: How "knowing the future" can inform our actions now

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This is a guest post written by Heidi Chumley, MD. Dr. Chumley is Senior Associate Dean for Medical Education at the University of Kansas School of Medicine.

Recently, my husband and I (both family physicians) and our colleague (a health systems researcher in our family medicine department) visited Armenia as guests of the Kansas National Guard and USAID. Our mission was to learn about the evolving Armenian health care system, develop relationships, and move towards an end goal of providing assistance to Yerevan State Medical University as family medicine continues to develop in Armenia. We knew a little about their health care system before we visited, as our colleagues had made two prior trips.

After the collapse of the Soviet system, the Armenian government endorsed the development of a primary care based health care system and chose family medicine as the discipline to provide that base. We knew they were interested in learning about the family medicine curriculum in medical school, residency, and after residency in the US and specifically at the University of Kansas. So, we prepared our presentations about family medicine training, packed our bags, and worked with the US embassy and YSMU to set up a schedule. We met with officials of YSMU and their department of family medicine, a representative from the ministry of health, and the chair of the department of family medicine at their “NIH”-equivalent. During the course of these meetings, we learned of their two major strategies: 1) retrain "narrow specialists" (their term for physicians who restrict treatment to patients based on age, gender, or organ system) in a one-year program with a national curriculum and 2) begin 2-year family medicine residency programs. Over the past decade, they had retrained 1200 narrow specialists as family physicians. Also, there are 2 government-sponsored family medicine residency programs, training a total of 9 residents per year.

As you might suspect, when there has been no family medicine before in a country seeking to develop family medicine, there are no family physicians to lead the movement. There are narrow specialists who have learned about the value of primary care, endorsed that system, and are working together with other narrow specialists to provide as broad training as possible. This reminded me of what might have happened in the US as family medicine became a specialty. Visiting Armenia was like being granted a rare opportunity: a glimpse into our past, with a known future, poised at an important moment in time. It gave me a chance to reflect on what happened in the US that led us to a specialty-centric health care system and what decisions may affect whether or not Armenia is able to transform to a family medicine based health care system. At our exit meeting with the director of USAID in Armenia, we mentioned that the best way we could help would be to outline pivotal decisions that will either be made or just come to be as if a conscious decision was made. I've scripted those insights into concrete “dos” and “don'ts” based on knowledge of what transpired in the US health care system. Here is my advice, for what it is worth:

· Don't train your primary care doctors in a system where they only rotate with narrow specialists.

· Do train your narrow specialists in primary care settings to help them keep a sense of probabilities.

· Don't make family medicine training shorter or less prestigious.

· Do shorten procedurally based specialty training when possible, creating a system where new narrow specialists continue to develop their procedural skills under a proctoring system funded by private practices seeking new partners instead of the government.

· Do provide a sufficient number of government sponsored family medicine residency positions to produce the physicians needed to provide care for the population.

· Don't provide government sponsored narrow specialty residency positions at a number greater than what is needed for the population.

· Do set goals or metrics for how much a family physician should be able to manage (80% to 90% of what walks in the door).

· Don't enable a system that supports narrow specialist to narrow specialist referral.

· Do a national educational campaign on primary care concurrently with the improvement in the training of primary care physicians.

· Don't pay narrow specialists more than primary care physicians.

· Do follow outcomes and reward improved health of a population.

· Don't financially reward overuse of services.

· Do seek to become a nation in the top 10 of all nations on important health care outcomes.

· Don't spend 8 times as much as the other nations and remain below 40 other nations on health care outcomes.

I was also struck with this amazing reality: only a country as economically blessed as the US could even fathom conducting health care as we do. It is irresponsible of us to hold up our version of western medicine as a model. It won't work except in a society where the people have too much.

In fact, it doesn't work in our society for the people who don't have too much. It often doesn't even work that well for those who do.
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