WFME International Conference: Global Standards in Medical Education for Better Health Care
March 15-19, 2003
Copenhagen, Denmark | |
The Conference was hosted by the University of Copenhagen with the Preconference Symposia taking place at the University of Lund, Sweden |
IIME PRESENTATION
Medical Professionalism in Time of Globalization: New Challenge for Medical Schools
Authors:
David T. Stern, M.D.
Andrzej Wojtczak M.D., D.MSc.
M. Roy Schwarz, M.D.
Medical professionalism and professional development are recently considered as the priorities at all levels of medical education starting from undergraduate, through graduate education and CME. The topics appear often on conference programs and in different medical journals. It is so, because there is growing concern that education of "professionalism" should not be anymore left to the chance that undergraduate students will model themselves on ideal teacher-physicians. It must be fostered by students' engagement with defined elements of curriculum content as "professionalism" cannot flourish without proper knowledge foundation, which calls for intellectual widening of a medical curriculum beyond biomedical and clinical knowledge and skills.
The role of physician from the ancient time was considered to be fiduciary, and protection and promotion of the patient's health-related interests was considered to be the primary concern of doctor and the blunt self-interest was seen as a secondary consideration. This humanistic view together with respect for others, empathy, compassion, honesty and integrity, and professional excellence are at roots of present concept of medical professionalism.
It is broadly accepted that the statement of the Hippocratic Oath: "I will use treatment to help the sick according to my ability and judgment; I will keep them from harm and injustice" indicate an essence of ethics of medical care. But it is less known that almost 2,500 years ago, Plato in his Book IV of The Laws recognized that a good doctor-patient relationship is the foundation of medical practice. He describes the inadequate doctor-patient relationships as a "slave medicine," when "The physician never gives a slave any account of his complaints, nor asks for any; he gives some empiric treatment with an air of knowledge in the brusque fashion of a dictator, and then is off in haste to the next ailing slave". He contrasted this with what he called "the physician -patient relationship for free men", when "The physician treats their disease by going into things thoroughly from the beginning in a scientific way and takes the patient and his family into confidence and learns something from the patient. He never gives prescriptions until he has won the patient's support, and when he has done so, he aims to produce complete restoration to health by persuading the patient to comply".
There is nothing to add to this description in a time when we are rediscovering the importance of medical professionalism in medical education and practice. It is once more clearly obvious that the best clinical medicine is practiced when the scientific and technical aspects of care are placed in the context of a personal relationship and trust between a physician and a patient. While medical knowledge, clinical skills and clinical judgment have fundamental importance, however, the issue how they are used is even more important. The doctor-patient relationship represents a mechanism wherein a joint decision is reached that patient is placing his or her care in the hands of a particular physician and the physician affirms his or her obligation and ability to care for this patient.
This relationship as well as a role of the medical profession in human societies regardless of advances in medical sciences and despite social, economic and political transformations remains virtually an unchanging event in medicine since ancient times. Also the physician's core professional values such as altruism, compassion, truthfulness, respect for others, responsibility, courtesy, duty, honor and integrity, and professional excellence constitute the essence of medical professionalism. However, one is tempted to ask: how are these professional values are applied in the practice in present time of globalization of medicine and health care?
The globalization has penetrated different areas of our life, among others science, public health and medicine. Medical knowledge, research and education have traditionally crossed national boundaries. However, quiet recently we have been witnessing the advances of a corporate transformation of medical care with growing changes towards a more and more business-oriented health care system. This transformation of medicine raises concerns and questions about the basic professional values and physician's social role.
No doubt, there is an inherent clash of values between business and medicine. When among the key business values are cost, profit and competition, among the traditional values of the medical profession are service, advocacy, and altruism. These strategies run directly counter to the professional standards and are a potential threat to reduce the status of patients to commodities rather than people with an affliction. However, as business interests have already gained an important place in medicine despite the existing concerns that self-interest of health professionals is being encouraged, one can hope that physicians adopting a more business approach in their work will not lose traditional professional virtue.
All these changes have a great impact on medical education forced to step into an uncertain and potentially hostile new environment of "managed care." While occurring changes inevitably bring some sense of loss, this process should be seen as the opportunity to utilize positive elements of the entrepreneurial spirit, as managed care may help to eliminate certain medical vices, such as arrogance or sense of entitlement. It also brings an opportunity to incorporate into medical education process the issues that since recently have not been adequately considered in medical schools.
Despite of fact that in the past 50 years medical schools intermittently have changed their curricula unfortunately little progress has been made toward a fundamental reappraisal of how physicians are educated. Medical education still places too great an emphasis on the biological and technical aspects of medicine at the expense of psychosocial and humanistic qualities such as caring, empathy, humility, compassion, and sensitivity that have taken a back seat. The medical students' initiation into medicine is first engineered by basic scientists. In lecture halls and labs, "real knowledge-scientific" - is gained through rational inquiry. When medical students are taught, explicitly and implicitly, that the only true medical knowledge comes from empirical, objective, quantitative inquiry, they naturally distrust all knowledge that is gained by so call "soft sciences and methods". To ask students to develop compassion, communication skills, and social responsibility within the confines of a biomedical discourse is unrewarding. To foster professionalism the 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.
The graduates must be aware of the conflict between traditional professional values and the imperatives of the market, so they will be better prepared to defend these values in the new business climate. They should know the important ethical, legal, and professional issues rose by the industrialization of health care and should be introduced to the economic dimensions of health care, where the money comes from and how it is spent, understand how different forms of managed care work. With regard to explicit professional values, more attention must be paid to medical ethics, humanities, and social issues.
So, the medical schools face unprecedented challenges of preparing the future physicians how to utilize the positive elements of the entrepreneurial spirit to improve the availability of health care services while do not let the emphasis on finances erode the fundamental professional values of medicine. It is necessary to think about how to manage occurring changes rather than resisting them, and to ensure the benefits of being a profession and not a trade.
In the past decade a few important projects have been launched. It is worthwhile to mention some of them such as: the Project Professionalism developed by the American Board of Internal Medicine (1990), Association of American Medical Colleges - Medical School Objectives Project (1999), the strong focus on the professionalism given by the American Board of Pediatrics (2000), the Outcome Project launched by the Accreditation Council for Graduate Medical Education (2000) or the project carried on by the Institute for International Medical Education (IIME) - the Global Minimum Essential Requirements (1999). This last one is trying to answer the question "what kinds of core or essential competences are required by physicians throughout the world". This is also an answer to present frustration of many physicians in practice that is due to fact that their education has not prepared them properly to work in complex delivery systems when often their values are in conflict with their daily work.
The Institute for International Medical Education (IIME) developed a long-term educational project consisting of three phases. During first phase, 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. During 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. Among these seven priority domains, the one entitled "Professional Values, Attitudes, Behavior and Ethics" was considered as an essential to the practice of medicine. 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.
The supportive role for "professionalism" of domain titled "Interpersonal Communication Skills" is 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, advice and counsel patients, families and the public about health, illness, risk factors and healthy lifestyles.
The "Population Health and Health Systems" domain reflects 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 and understand the conflict between the culture of business managers and that of practicing physicians.
Finally, "Critical Thinking and Research" as a priority domain reflects the need of critical evaluation of existing knowledge, technology and information. Graduates have to learn how to critically evaluate various data and information, and to understand the role of research in quality medical practice. Medical students and residents must also learn to think critically about themselves and their profession, recognize the strengths and limits of scientific knowledge realize and act on the humanistic dimensions of medical practice, and integrate their social responsibilities as physicians into the context of their personal goals.
However, 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 importance of three other domains "Scientific Foundation of Medicine" and "Clinical skills" and "Management of Information" are obvious, since they create the foundation for effective medical care and efficient management of care. Regrettably, the assessment of professionalism is not easy. No single method exists for the reliable and valid evaluation of professional behavior. Sometimes it is considered as part of clinical performance but in the most situations the single elements of professional behavior such as humanism, self assessment, dutifulness, altruism, empathy and compassion; honesty and integrity, ethical behavior as well as communication skills is being evaluated.
The second phase of the project - experimental implementation - already has begun in eight leading medical schools in China. In this Phase, the 'GMER' will be used to evaluate graduates' competences of several leading medical schools in China. The assessment of competencies formulated in the "GMER" should ensure that educators will focus on these outcomes when planning educational program, and students will try to acquire them before the time of evaluation. Although the project foresees, primarily, the evaluation of students, it may be necessary in the beginning to use an aggregation of data from many students for the evaluation process. Once the initial evaluation is completed, efforts then will be made to improve all areas of weakness that are found. There will be a continuous process of improvement and evaluation.
The IIME-initiated project is an experiment. The project focusing on competences as outcomes of medical education would have significant implications for medical school curricula. The "GMER" domains and learning objectives present a new conceptual framework for the outcome-oriented educational process. At present, the results of implementation are difficult to predict. However, the challenge before the medical education community is to use globalization as an instrument of opportunity to improve the quality of medical education and its outcomes.
I would like to end up with the words of Professor Jordan Cohen - President of the Association of American Medical Colleges (AAMC) who in his 1998 Annual Report well summarizes the present obligation of medical profession urging "to cultivate the core values of professionalism in future practitioners.... [and] stand firmly in support of the values that make our profession honored and honorable".
Institute for International Medical Education.
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