At last month’s Convocation, we celebrated the beginning of 102 new medical careers. As the new graduates walked across the stage of Grant Hall, they stepped from their shared four-year undergraduate experience, into a diversity of career paths.
- Twenty-six will begin training programs in Family Medicine.
- Fourteen have chosen Internal Medicine.
- Eleven are entering Anaesthesia.
- Six in Pediatrics.
- Six in Urology.
- Five each in Emergency Medicine, General Surgery and Psychiatry.
- Four each into Obstetrics-Gynecology, Neurology and Diagnostic Radiology.
- Three will be entering Orthopedic Surgery, and three in Dermatology.
- Two of our graduates will be undertaking training in Plastic Surgery.
- One will be entering each of Ophthalmology, Cardiovascular Surgery, Neurosurgery and Radiation Oncology.
Over the next several years, they will differentiate further, into a potential of over 100 different practice disciplines now offered by the Royal College of Physicians and Surgeons and College of Family Medicine. This increasing diversification reflects the incredible expansion of medical practice, and the ever-expanding base of knowledge and skills we’re able to offer our patients. Although this is obviously welcome, it has caused many to question whether our current paradigm of medical education, beginning with a common three or four year, university-based curriculum, has kept pace or, perhaps more charitably expressed, should be reviewed.
In actual fact, our students’ educational experience in medical school is already differentiating, although unintentionally. Our current curriculum allows students considerable latitude to tailor their experience along lines of their choosing. Their 16 weeks of curricular electives, observerships and student-initiated interest groups allow each student to direct a significant proportion of their medical school experience. Although pedagogically intended to provide “learner-directed”, diversified educational experiences, it’s quite clear that these various elective options are used to explore and promote career interests, and are usually undertaken within the same discipline the student eventually enters. This is of obvious benefit to our students who struggle to come to career decisions and position themselves favourably in an increasingly competitive postgraduate matching process. Tampering with this largely unintended but nonetheless effective process could therefore disadvantage students and would bring considerable risk if considered in isolation.
However, we should recognize what’s happened by necessity rather than intention, reflect on what it’s telling us about the relevance of our current programs, and how we might intentionally design more effective training paradigms given the realities of current medical practice.
Central to this discussion is the need to grapple with the a key question: What are the knowledge components, skills and personal attributes that could be considered essential to every practicing physician, regardless of the discipline they eventually undertake? What qualities should we expect of every one of our graduates who walked across Grant Hall stage recently, or of those who will undertake our programs in the coming years? Put another way, one could consider what particular skills and qualities a physician should bring to patient care in an era of increasingly compartmentalized care provided by an expanding array of highly qualified professionals.
This reality was brought into particular focus for me last week by remarks made by Dr. Henry Dinsdale at a ceremony honouring his long and distinguished career. In his remarks, Dr. Dinsdale described his educational experience during an era when few specialty options existed, and a physicians training focused on core competencies common to all practitioners. Hearing of his many accomplishments in patient care, research and education, the message was clear: although knowledge expands and technology becomes more integrated, the core qualities that allow a physician to excel in his or her role are consistent, immutable, and should guide both our educational programs and selection processes.
And so, what are these attributes and qualities? I would suggest that any consideration of that question should be guided by three basic considerations: the responsibility to deliver excellent patient care; the responsibility to advance our profession through education and research; and the need to demonstrate a value-added role in an increasingly specialized health care workforce. With these considerations in mind, I would provide the following list for consideration:
- Curiosity. An insatiable and relentless drive to understand the human condition, in all its complexity from the subcellular to population levels, is the motivation that propels the lifelong pursuit of knowledge and skills and provides allows the physician to become the “medical expert”, both in breadth and depth of understanding. It also drives the desire to expand practice and share discoveries through research.
- Diligence. Getting into medical school requires persistence and hard work. Medical school itself and residency training that follows is even harder work. Medical practice, despite our increasing attention to maintaining health life balance, is the most challenging of all. Enough said.
- Communication. Arguably, the most important quality. A two way street – Doctors must be able to gather information and understand from all types of people, including those with limited ability to communicate themselves or understand their problems, and those of markedly diverse backgrounds. The greatest fund of information or technical expertise is useless without the ability to understand the patient in need or help them understand their needs. It’s also essential to effective education.
- Ability to deal with uncertainty. No two patients suffering with the same condition will present in exactly the same way. Each patient’s response to even the most accepted treatment will be unique to that patient. No diagnostic test is perfect. Physicians must therefore continually navigate in uncertain waters, balance risks with benefits, and guide their patients through that voyage.
- Judgement. Information about health issues is all around us, and universally available to our patients and the public. Knowledge is the considered consolidation of information into accepted practices, generally applicable to populations of patients with common characteristics. Judgement is required to extend that knowledge to individual patients. This may be the most difficult, but also singularly most characteristic quality of physicians.
- Composure under stress. One needs only to step into the Emergency Department or Intensive Care Unit of any hospital to see this quality in action, but it can also be found in Doctor’s offices, outpatient treatment units, research labs, medical schools, and any of the many places physicians undertake their diverse roles. In addition to being necessary to their own effectiveness, this quality provides a tone of stability for the patients and co-workers involved.
- Resilience. Things will go wrong, both personally and professionally. Effective physicians are not defeated by these experiences, but learn from them and become even more effective.
- Creativity. This speaks to the ability to think “outside the box”, extrapolating beyond commonly accepted approaches when the need (or opportunity) arises. Given the uncertainties inherent in clinical medicine noted previously, the physicians with single and inflexible approaches to each situation will find themselves both limited and frustrated.
- Humility. I struggled with this one, but in the final analysis, I felt that the ability to collaborate, work in teams, recognize personal limits and self-analyze (all of which are essential competencies) are made possible by this simple human quality which allows one to set aside personal gratification in the interests of the patient. In contrast, arrogance and relentless self-promotion make all these goals virtually impossible and underlie most complaints about physician performance.
- Compassion. Last on the list, but certainly not least. When asked what they expect of their physicians, patients consistently rate “compassion”, “caring” or similar qualities very highly. They expect, and deserve, their doctors to connect with them on a purely human level and share, in some way, in their suffering. Practically, it’s that sharing that provides true understanding and commitment.
And so, a long list of demanding attributes. Note the focus here is not on knowledge acquisition, skill development or even specific competencies, but rather on the personal qualities that make all those things possible. I provide it not to suggest that these qualities are unique to or only apparent in physicians. In fact, these qualities are exhibited and shared by many other professions, and particularly those engaged in health care. However, they are seen as essential to the effective physician and, as such, a valid starting point in establishment of selection processes, and educational programs common to the myriad roles that modern day medical graduates may undertake. This is, however, one person’s perspective. I welcome comment and refinement.