Seventh Annual International Summit on Public-Private Partnership for Health Gain
December 8-11, 2002
Miami Beach, FloridaIIME PRESENTATION
New Challenge for Medical Schools:
Graduates' outcome competences in health leadership
Andrzej Wojtczak M.D., D.MSc.
Medical education stands at the doorstep of profound change, forced to step into an uncertain and potentially hostile new environment. These changes have nothing to do with scholar self-reflection, but rather are a direct consequence of the process of globalization visible also in medical education and the revolution in health care financing for which we use the general term "managed care".
On one hand, globalization has penetrated different areas of our life, among others including science, public health and medicine which is a global profession. Medical knowledge, research and education have traditionally crossed national boundaries. Many aptitudes of physicians are universal, as well as the core competencies required by physicians throughout the world. The question is "what kind of core or essential competences are required for "global physicians". To answer this question, we need the agreement of the international medical education community on the spectrum of essential competencies that encompass all important domains of medical practice. Besides medical knowledge and basic clinical skills, professionalism, interpersonal communication skills, context of care, information management, understanding a health system, etc. also need to be addressed.
On the other hand, there is a growing concern that the corporate transformation of medical care, especially related to the impact of the changing and more business-oriented health care system, may lead to the decline and death of traditional professional values, such as fidelity, altruism, confidentiality, and integrity. No doubt, there is an inherent clash of values between business and medicine. The key business values are profit and competition, while among traditional medical values in the medical profession are service, advocacy, and altruism. However, as business interests have already gained an important place in medicine despite the existing concern that self-interest of health professionals is being encouraged, we can hope that physicians progressively adopt a business mentality without losing professional virtue.
While occurring changes inevitably bring some sense of loss, it also brings an opportunity to help reshape medical education to better meet the health needs of society. This process should be seen as the opportunity to utilize positive elements of the entrepreneurial spirit to enhance professional values, as managed care may help to eliminate certain medical vices, such as arrogance or sense of entitlement. Nonetheless, we have to be aware that managed care has, and will continue to have, important ethical and social implications.
Therefore, academic medicine faces the unprecedented challenges of incorporating into medical education process issues that, since recently, have not been adequately considered in medical schools. It is necessary to think about how to manage occurring changes rather than resisting them, focusing on the positive aspects of change while keeping sight of the fundamental professional values of medicine and maintaining a cool, rational judgment of the occurring changes.
Presently, many physicians are unhappy in practice, feeling that their education has not prepared them to lead complex delivery systems or that their values are in conflict with their daily work. Very often, it is a result of the lack of many needed competencies. Competence builds on a foundation of basic clinical skills, scientific knowledge, and moral development. Professional competence is developmental and context dependent. Competence develops over time and is nurtured by reflection on experiences - it is a habit. For each of the competencies, there are rules that must be learned (novice, advanced beginner, competent, proficient, expert, and master). A good medical school facilitates the students' progress from novice to advanced beginner. If competence is a developmental process, how can physicians assure society and themselves that a given individual is competent enough to practice?
To answer some of these questions, the Institute for International Medical Education (IIME) developed a long-term project consisting of three phases. First, the IIME Core Committee, consisting of 14 international medical education experts, was assigned the task of defining a set of global essential competencies to be demonstrated by students at graduation. After very lengthy deliberations during a series of meetings and consultations, a document entitled "Global Minimum Essential Requirements" was completed. The selection of seven (7) domains as priority areas was made and includes a set of sixty learning outcomes under those seven broad educational domains. Consensus was also reached on a set of global attributes, expressed in a set of sixty (60) learning objectives reflecting competencies that graduates must acquire during medical studies to start graduate training or practice medicine.
The importance of two domains called "Scientific Foundation of Medicine" and "Clinical skills" are obvious, since they create the foundation for effective medical care and efficient management of care. However, among the other five priority domains, the domain entitled "Professional Values, Attitudes, Behavior and Ethics" is essential to the practice of medicine and has gained increasing interest and support. Many complaints against physicians and medical services relate to this area. The public traditionally granted professional autonomy in exchange for a commitment to high ethical and professional standards and a personal obligation to responsible public service. The more recent decline in public esteem for some professions reflects, perhaps, not only allegations of individual malpractice and incompetence, but a more serious drift toward what is seen as antisocial behavior and self-serving activities.
It is then no wonder that professionalism and professional development are recently considered priorities in medical education at all levels from undergraduate to CME. The topics appear often on conference programs and in medical journals. Many schools now have professional development programs. However, over the past few decades, medical education has placed too great an emphasis on the biological and technical aspects of medicine at the expense of psychosocial humanistic qualities such as caring, empathy, humility, compassion, sensitivity, critical thinking about oneself and the medical profession. Physicians must be well prepared to meet the consequences of the rapid advances in biomedical sciences, information technology, changes in organization and management of health care under increasing economic constrains. Awareness of the conflict between traditional professional values and the imperatives of the market is necessary to be better prepared to defend these values in a new business climate. With regard to explicit professional values, more attention must be paid to medical ethics, humanities, and social issues. Professionalism, rather than being left to the chance that students will model themselves on ideal physicians, must be fostered by students' engagement with certain kinds of curriculum content. It calls also for intellectual widening of the medical curriculum beyond scientific and clinical knowledge and skills.
The importance ofthe "Interpersonal Communication Skills" domain is also obvious as effective communication with patients, their relatives, members of the health care team, colleagues and the public is essential. It helps to understand the context of the patients' beliefs and their family and cultural values. In addition, physicians must be able to teach, advise, and counsel patients, families and the public about health, illness, risk factors and healthy lifestyles.
The "Population Health and Health Systems" domainreflects the growing conviction that it is no longer sufficient to focus on the understanding of diseases, but how they affect individuals and their diagnosis and management. There is a need for broader knowledge and skills in the area of health of populations where physicians must work in teams with other health professionals to promote, maintain, and improve the health of individuals and populations.
Students should be introduced to the economic dimensions of health care, e.g., where the money comes from, how it is spent, and the structure and function of the health care delivery system. Graduates should understand the different forms of managed care and how they work; understand the conflict between the culture of business managers and that of practicing physicians; and consider the recent efforts to achieve "quality control" as a balance to the emphasis on price.
In addition, the domain "Management of Information" is justified by the fact that the practice of medicine and management of health systems, now and even more in the future, depends on the effective flow of knowledge and information. Therefore, physicians need to know how to use modern communication and information technology to access and manage medical information, and to support clinical decision making. They also have to understand the capabilities and limitations of information technology, and to be able to use it for medical problem solving and decision-making.
Finally, "Critical Thinking and Research" as a priority domain reflects the need of critical evaluation of existing knowledge, technology and information to be able to solve health problems. Graduates have to learn how to critically evaluate various data and information, and to understand the role of research in quality medical practice. To retain and advance competencies acquired in medical school, graduates have to be committed to life-long learning.They have to be aware of their own limitations, be ready for regular self-assessment and peer-evaluation, and must be willing to undertake continuous self-directed study and integrate their social responsibilities as physicians into the context of their personal goals.
The "GMER" domains and learning objectives present a new conceptual framework for the outcome-oriented educational process. Using outcomes of undergraduate medical education as the focus, medical school graduates must demonstrate professional competencies. The assessment of competencies formulated in the "GMER" should ensure that educators will focus on these outcomes when planning educational programs, and students will try to acquire them before the time of evaluation. Well chosen assessment tools should permit evaluation of all these competencies, also providing guidance and support to address learning needs.
The second phase of the project - experimental implementation - already has begun with the preparation for evaluation of graduates' competencies in eight leading medical schools in China. Although the project foresees the evaluation of students, the intention is to use the aggregated data to evaluate relative strengths and weaknesses of the educational process of a given school. Efforts will then be made to improve all areas of weakness before a second evaluation is made. This will be a continuous process of improvement based upon the experiences gained through the evaluation. The project is supervised by the Steering Committee, and overall advice is provided by the Advisory Committee, composed of Presidents or Senior Representatives of major national and international educational organizations.
Although at present is impossible to foresee the results of this long-term educational experiment, there is already growing interest to develop competency-based medical education. It will also increase the frequency of the combined-degree programs (e.g., MD-MBA and MD-MPH) to meet the growing need for physician administrators because as Lewis Munford has indicated, there is the danger of a life "governed by specialists, who know too little of what lies outside their province to be able to know enough about what takes place within it".
Institute for International Medical Education.
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