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David Gordon¹

¹President-elect, World Federation for Medical Education, Copenhagen, Denmark.
EMHJ, 2014, 20(3): 149-150

Most of us who work in medical education delight in the life it gives us. What could be more interesting than to help able and committed young men and women learn the art and science of medicine? Few are privileged to work in something as useful. Medical education keeps our minds active and keeps us at the forefront in medical practice. Often, we also have the possibility to do research that will take medicine forward.

This is so absorbing from day to day that it is difficult to pause and think why we are doing what we do; but we must. If we do not consider and understand what medical education is for, then how will we stop ourselves from going in the wrong direction?

First, what is a doctor for? Wherever in the world you might to stop a person in the street and ask, “What does a doctor do?” – whether in Cairo or Manila or Copenhagen – the answer would be much the same. The doctor is a person to whom you go when you feel ill: he or she will ask you about your symptoms, may examine you, might do tests, and will give advice and treatment to help you get better.

But we need to think what is changing in what a doctor does. Medicine is advancing at an ever-increasing rate. At the same time, the gap between high-technology medicine, as practised in some rich countries, and the basics of medical care that should be available to everyone in the world is growing [1]. Also, we know that expensive high-technology medicine does not always give improved outcomes, either in the relief of symptoms or in the prolongation or quality of life [2].

Therefore, the first challenge to medical education is to understand what will be the future role of the doctor in the health-care team [3]. If we do not work out what the doctor is likely to be doing, we cannot know what should be the content of medical education; we cannot even know how many doctors we will need. The answers to these questions depend critically on our understanding of what society needs from its doctors [4].

How many doctors do we need? There is no absolute answer, although it is clear that some countries and regions have too few doctors and other health-care workers, and it is arguable that some countries have too many. The obvious deficiencies in some parts of the world were the stimulus to the World Health Organization initiative on transformative scale-up of health professional education [5]. However, we still do not understand how many doctors are needed by society and therefore how many students we should educate. This is the second challenge to medical education.

We also need to know how many medical students we are educating at the moment. Our information on how many medical schools and how many medical students there are in the world is not good, and we have even less information on the quality of medical education [6]. There are global [7] and regional initiatives to get better information [8]: this is to meet what I define as our third challenge, to know how many doctors are already being educated, where and how well.

A fourth challenge is the global nature of medical practice. Doctors are mobile: a trained physician can be employed almost anywhere in the world. We must educate our students to globally acceptable standards, while being sensitive to the local culture, situation and practical possibilities for medical education in each country. The growing emphasis on the essential need for medical education to be at an internationally acceptable standard means that processes for quality assurance of education, and accreditation of medical education institutions, are of increasing importance, and therefore are promoted by WHO [9]. Education must include understanding of the moral obligation of the newly qualified doctor to his or her society. We cannot be educating students just for export to rich countries.

Finally, our fifth challenge is to understand the way in which medicine and medical practice is no longer limited to the straightforward and reductionist biological model of disease and cure, but must include the understanding of the psychological and social circumstances of the patients and populations for whom we are educating our students [10].

In summary, these five main challenges are

• What are doctors for, both now and in the future?
• When we have defined the functions of the doctor, how many doctors do we need?
• What are we doing now to meet this need: how many doctors are being educated, where and how well?
• How do we educate doctors to a globally acceptable standard, while also meeting the local needs of society?
• How will we ensure that our students have a holistic view of medicine, always considering psychological and social factors in health and disease?

These challenges are about the mission of medical education, and not about the day-to-day practice, but once we have defined this mission and the objectives, then the structures in which education is delivered and the methods to be used will follow. There is an extensive literature about changes in medical education [11], prompting a robust debate [12], but we must look above the detail: what are doctors for, and what should medical education try to do?

References

1. Farmer P et al. Reimagining global health. Berkeley, University of California Press, 2013
2. Wennberg JE. Tracking medicine: a researcher’s quest to understand health care. Oxford University Press, 2010.
3. Lindgren S, Gordon D. The doctor we are educating for a future global role in health care. Medical Teacher, 2011, 33(7):551–554.
4. Global Consensus for Social Accountability of Medical Schools [website] (http://healthsocialaccountability.org/, accessed 21 March 2014).
5. Transformative scale up of health professional education. An effort to increase the numbers of health professionals and to strengthen their impact on population health. Geneva, World Health Organisation, 2011 (http://www.who.int/hrh/resources/transformative_education/en/, accessed 21 March 2014).
6. Gordon D et al. Educating health professionals: the Avicenna project. Lancet, 2008, 371, 966-967.
7. World Federation for Medical Education. News. The World Directory of Medical Schools (http://www.wfme.org/news/general-news/277-wdms-planning-meeting-2013, accessed 26 March 2014).
8. Eastern Mediterranean Medical Education Study (http://www.emro.who.int/; http://www.emro.who.int/entity/educational-development/index.html).
9. World Federation for Medical Education. Accreditation. WHO/WFME Policy (http://www.wfme.org/accreditation/whowfme-policy, accessed 26 March 2014).
10. Engel GL The clinical application of the biopsychosocial model. American Journal of Psychiatry, 1980, 137:535–544.
11. Frenk J et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet, 2010, 376(9756):1923–1958
12. Gordon D, Karle H. The state of medical and health care education: a review and commentary on the Lancet Commission Report. World Medical & Health Policy, 2012, 4(1):1–18.