To many, the answer to this question may seem obvious. For those who feel an emphatic “yes” is called for, let me pose a scenario for your consideration. Imagine an airline flight about 3 hours from destination. A call goes out for someone who might assist a young woman who’s gone into premature labour. Two people respond. One is a mid career physician who underwent standard obstetrical training during medical school, delivering about 50 babies during that time, but subsequently trained as an Ophthalmologist and has had no obstetrical experience in the past 20 years. The second is a registered nurse who graduated about 10 years ago and works in a busy hospital, mostly in the emergency department, but with frequent “float” shifts in Labour and Delivery. Based on this scenario:
Who is more capable of providing competent care to the patient?
Who will most people aboard the plane (including the patient) assume is most qualified?
The point of this scenario and these questions is not to suggest some simmering interprofessional conflict. One would expect that these two professionals would recognize each other’s strengths and work together for the benefit of the patient. The point of this story, which could involve any subspecialty not involved in obstetrical care, is to highlight how much medical practice has evolved, and to suggest that our approach to medical education may not be keeping pace. This point is made even more apparent by imagining a similar scenario playing out 50 or so years ago when there was much less specialization, the practice patterns of all physicians was much more homogeneous, and physicians were fully qualified to practice at the end of medical school.
My colleague Richard VanWylick is a pediatrician and curricular leader. He and I have established a running joke regarding the toddler assessment in medical school. The examination of small children, like the ability to deliver a baby, is an aspect of medical practice that will be ultimately provided by a distinct minority of our medical class. Further, those who do provide those services in their career will undertake considerable further postgraduate training before doing so.
So, one must ask, why do we devote so much curricular time and resources to these components of medical practice? I would suggest there are a number of valid justifications:
- It’s important that our students experience all aspects of medical practice in order to make valid career decisions
- An appreciation of these areas of practice provides insights and awareness that makes us all better Doctors, and better able to understand the needs of our patients, regardless of their presenting problem or our area of interest. When I consult on cardiac issues during pregnancy, for example, it’s important to have had a practical understanding of the principles of labour and delivery.
- There exists a societal expectation that all doctors should be able to provide a minimal level of service, particularly in emergency situations. That “minimum level”, it must be said, is completely undefined.
- Our students very much appreciate the opportunity to experience all aspects of medical practice, and expect the opportunity to do so
On a purely pragmatic note, medical schools are required to provide a comprehensive exposure in order to achieve accreditation status in Canada and the United States. To quote from “Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree” (the bible of accreditation):
ED-15. The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle that will prepare students to recognize wellness, determinants of health, and opportunities for health promotion; recognize and interpret symptoms and signs of disease; develop differential diagnoses and treatment plans; and assist patients in addressing health- related issues involving all organ systems.
Although schools are expected to define for themselves what constitutes adequate preparation “to enter any field of graduate medical education”, I think any program would be hard pressed to exclude active participation in basic obstetrical care and child assessments as components of that preparatory process.
However (and this is a big “however”), with the massive increase in knowledge and emergence of over 60 recognized specialties, medical education is becoming increasingly expansive and expensive. More and more, medical schools are required to make choices regarding what components of education are relevant to every physician, regardless of what specialty they chose to practice. Such decisions are being made in isolation since we lack any accepted framework or value assumptions that would support such decisions.
But (and this is a big “but”), things are changing. Leadership organizations such as the Association of Faculties of Medicine of Canada, Royal College of Physician and Surgeons, College of Family Physicians and Medical Council of Canada, are all acknowledging the need to recognize more explicitly the continuum of education from medical school entry through to full qualification. The Future of Medical Education in Canada initiative is calling for sweeping reform, including the recommendation to “Ensure Effective Integration and Transitions along the Educational Continuum”. Three committees have recently been established to develop strategies to implement this key recommendation. These groups are just beginning to grapple with some very difficult and discomfiting questions, such as:
What knowledge, skills, approaches are common and essential to all physicians, regardless of specialty?
How should physicians progress through training, and when should various training streams begin to diverge?
How should the number of specialty training opportunities be determined, and how should learners be selected for those specialties?
When should medical students be expected to declare their area of interest, and what, if any, provision should be made for those who wish to transition between specialties?
These issues will require considerable thought and reflection by all involved in medical practice, including students, postgraduate learners and teaching faculty. All involved should feel free to contribute to this dialogue, which has the potential to reform our educational systems in rather profound ways, hopefully leading to a much more aligned, efficient and relevant process. As a co-chair of one of those implementation groups, I would certainly welcome input on these issues. In the meantime, I will continue to hope to be sitting next to an experienced ER nurse if someone goes into labour during a future flight.
Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education
An excellent discussion of an emerging issue in medical education. I’ve been waiting since 1974 (when I did my first delivery as a med student at Queen’s) to get called to a delivery on a plane. The only calls I get are for cardiac issues!!
Thanks Bob. It’s emerging quickly – in fact, practically upon us. In the meantime, sounds like we should try to take the same flights.
Tony,
I am so pleased that you are wading into this topic. I happen to think that early streaming in medical education is not only inevitable, but also practical and entirely justifiable. The person removing my cataracts in 20 years (or my gall bladder) may be a graduate of a streamlined program, an operating technician, or a robot. They will not have spent 13 years in post-secondary education.
Let me be devil’s advocate – and question your 4 justifications for our current ‘general’ curriculum:
1. The work of the ophthalmologist is as different from that of the obstetrician as the work of the engineer is from that of the architect. Although the architect and engineer will certainly share some training, neither is afforded 4 years of common education about building in order to sort out a preferred career. Why should medical students have that expensive luxury?
2. An appreciation of the principles of labour and delivery can surely be learned without weeks of educational immersion. And given the fallibility of unused knowledge and skills implied in your example, the teaching of a connected system is likely better delivered later, and in context, just as the engineer surely develops an appreciation of architecture as it becomes required in her career.
3. Our profession should take responsibility for failing to refocus societal expectations, if they are indeed stuck in the 1950’s. We do our patients, our colleagues and ourselves a disservice in allowing anyone to imagine that I would be more useful, say at a road accident scene, than an ER nurse. Let’s help the public to distinguish between the level of competence one achieves after a single clerkship rotation, and that of a professional who performs skills routinely to the point of expert automaticity.
4. The expectations of current medical students should have little bearing on the ultimate relationship between our society and the medical professionals that it requires, and pays. If we were to change the system tomorrow – to one requiring a specialty choice from medical students upon entry, does anybody think the application pool would dry up?
I wonder which specialty will lead the way? Which will be first to drag medical accreditation groups into the 21st century by designing and getting approval for a foreshortened and specialized pre-residency curriculum? Which medical school will be their pilot site?
Hello Mike. Thoughtful commentary, as usual. On your specific points:
1. Agree that four years of common education is likely excessive, but we can’t really judge until we give careful thought as to what should constitute the essential and common components of every physicians training and competency set. As you’re well aware, that’s a rather contentious issue, with many parties invested in the result.
2. You point is well taken but, must say, I’m continually impressed by the value and durability of contextual, experiental learning.
3. Would caution that the refocusing of those societal expectations should extend to valuing the assessment preceding and ongoing care associated with those services from the provision itself.
4. I think we need to ensure we have physicians who are suited for and personally comfortable with their specialty career choice. Frankly, I’m not sure how early that can or should happen, or how forced it should be. I am certain we can do a better job in informing and guiding those decision processes for our students.
Look forward to discussing further with you.
I am honored for the “shout out” in the blog! But I might still argue, in the spirit of keeping the running joke going, that Pediatricians, Family Physicians, ENT Surgeons, Orthopedic Surgeons, General Surgeons, Emergency Physicians, Neurosurgeons and Ophthalmologists, particularly outside academic settings, are all likely to see toddlers at least occasionally. Sounds like a majority to me!
Thanks Richard. Point taken. However, I note that four of those groups have pediatric subspecialties, so perhaps we shouldn’t declare a majority quite yet.
Tony, as you know, I completely agree that much work is needed to refocus pre-residency medical training for the very reasons you, and Mike, have so clearly articulated. Good luck to you and your committee on this important work.
Thanks Richard. We’ll need your contributions to that process.