20th century medical education and training will not work in the 21st century

November 29, 2010

In a major new report, 20 professional and academic leaders call for major reform in the training of doctors and other healthcare professionals to equip them for the 21st century. This Lancet Commission report is written by Professor Julio Frenk, Dean of Harvard School of Public Health, Boston, MA, USA, and Dr Lincoln Chen, China Medical Board, Cambridge, MA, USA, and their colleagues.

Worldwide, 2420 medical schools, 467 schools or departments of public health, and an indeterminate number of postsecondary nursing educational institutions train about 1 million new doctors, nurses, midwives, and public health professionals every year. Severe institutional shortages are exacerbated by maldistribution, both between and within countries. High-income countries are struggling to adapt to increasing costs and changing demographics of their populations, while in poorer nations it is obviously much worse. A large proportion of the 7 billion people who inhabit our planet are trapped in health conditions of a century ago.

Changes are needed, say the authors, because of fragmented, outdated, and static curricula that produce ill-equipped graduates. They say: "The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance."

They add: "Laudable efforts to address these deficiencies have mostly floundered, partly because of the so-called tribalism of the professions--ie, the tendency of the various professions to act in isolation from or even in competition with each other."

The authors suggest a number of reforms, both instructional and institutional. Instructional reforms (1 to 6 below) should encompass the entire range from admission to graduation, to generate a diverse student body with a competency-based curriculum that, through the creative use of information technology (IT), prepares students for the realities of teamwork, to develop flexible career paths that are based on the spirit and duty of a new professionalism. Institutional reforms (7-10 below) should align national efforts through joint planning especially in the education and health sectors, engage all stakeholders in the reform process, extend academic learning sites into communities, develop global collaborative networks for mutual strengthening, and lead in promotion of the culture of critical inquiry and public reasoning.

  1. Adoption of competency-based curricula that are responsive to rapidly changing needs rather than being dominated by static coursework. Competencies should be adapted to local contexts. The present gaps should be filled in the range of competencies that are required to deal with 21st century challenges common to all countries.

  2. Promotion of interprofessional and transprofessional* education that breaks down professional silos (ie, the barriers between various healthcare professions and specialties) while enhancing collaborative and non-hierarchical relationships in effective teams.

  3. Exploitation of the power of information technology (IT) for learning through development of evidence, capacity for data collection and analysis, simulation and testing, distance learning, collaborative connectivity, and management of the increase in knowledge.

  4. Adaptation locally but harnessing of resources globally in a way that confers capacity to flexibly address local challenges while using global knowledge, experience, and shared resources, including faculty, curriculum, didactic materials, and students linked internationally through exchange programmes.

  5. Strengthening of educational resources, since faculty, syllabuses, didactic materials, and infrastructure are necessary instruments to achieve competencies. Many countries have severe deficits that require mobilising resources, both financial and didactic, including open access to journals and teaching materials.

  6. Promote a new professionalism that uses competencies as the objective criterion for the classification of health professionals, transforming present conventional silos. A set of common attitudes, values, and behaviours should be developed as the foundation for preparation of a new generation of professionals to complement their learning of specialties of expertise with their roles as accountable change agents, competent managers of resources, and promoters of evidence-based policies.

  7. Establishment of joint planning mechanisms in every country engaging ministries of education and health, professional associations, and the academic community, to overcome fragmentation by assessment of national conditions, setting priorities, shaping policies, tracking change, and harmonising the supply of and demand for health professionals to meet the health needs of the population. In this planning process, special attention should be paid to sex and geography. As the proportion of women in the health workforce increases, equal opportunities need to be in place--eg, through more flexible working arrangements, career paths that accommodate temporary breaks, support to other social roles of women such as child care, and an active stance against any form of sex discrimination or subordination. With respect to geographical distribution, emphasis should be placed on recruitment of students from marginalised areas, offering financial and career incentives to providers serving these areas, and deploying the power of IT to ease professional isolation.

  8. Expansion from academic centres to academic systems, extending the traditional discovery-care-education continuum in schools and hospitals into primary care settings and communities.

  9. Linking together through networks, alliances, and consortia between educational institutions worldwide and across to allied actors, such as governments, civil society organisations, business, and media. Regional and global consortia need to be established (especially for developing countries as a part of institutional design in the 21st century, taking advantage of information and communication technologies. The aim is to overcome the constraints of individual institutions and expand resources in knowledge, information, and solidarity for shared missions. These relations should be based on principles of non-exploitative and non-paternalistic equitable sharing of resources to generate mutual benefit and accountability.

  10. Nurturing of a culture of critical inquiry as a central function of universities and other institutions of higher learning, which is crucial to mobilise scientific knowledge, ethical deliberation, and public reasoning and debate to generate enlightened social transformation.

All the above reforms need to be driven by mobilising leadership (local, national and global), enhancing investments, aligning accreditation systems, and strengthening global learning. In terms of investments, only around 2% of the total world health expenditure of US$5.5 trillion is spent on professional education, a situation described by the authors as "not only insufficient but unwise". All countries should move to align accreditation and licensing, with bodies such as WHO and UNESCO driving global co-operation. Metrics, research and evaluation are the key components in strengthening global learning.

The authors say: "At this crucial time, on the centenary of major reforms, we invite all concerned stakeholders to join us in much needed rethinking for reforms of professional education in the 21st century."

They also acknowledge that professional educators are key players since change will not be possible without their leadership and ownership. Students and young professionals are also important, since they have a stake in their own education and careers. Other key players include professional bodies, universities, non-governmental organisations, international agencies, and donors and foundations."

The authors conclude: "Ultimately, reform must begin with a change in the mindset that acknowledges challenges and seeks to solve them. No different than a century ago, educational reform is a long and difficult process that demands leadership and requires changing perspectives, work styles, and good relationships between all stakeholders. We therefore call on the most important constituencies to embrace the imperative for reform through dialogue, open exchange, discussion, and debate about these recommendations."

In a linked Comment, Dr Richard Horton, Editor of The Lancet, says: "What this Commission argues for is nothing less than a remoralisation of health professionals' education. For decades, health professionals have colluded with centres of power (governmental, commercial, institutional, even professional) to preserve their influence. The result? A contraction of ambition and a failure of moral leadership."

He concludes: "Frenk and Chen's Commission sets out the nature of the predicament facing the health professions and its possible solutions. Their work deserves serious attention."

In a second linked Comment, a group of students, represented by Robbert J Duvivier, Maastricht University, Netherlands, say: "Students, such as us, can play a vital role in implementing the recommendations of this report. The report highlights the importance of the instructional and institutional recommendations for students, the necessity of involving students within the entire process, and the possible courses of action taken by students on either a personal or organisational level.

The students encourage the proposed team-based education to break down professional silos, adding: "Working in health care means working in multidisciplinary and interdisciplinary teams. As teamwork is a soft skill which can be learned, its development should be fostered by the proposed interprofessional courses starting at an early stage."

They conclude: "As health-care students, we encourage all stakeholders to use the Global Commission's report as a basis for further discussion and action. We emphasise the importance of involving students from different healthcare professions in the implementation process, and the contribution students already provide to meet the recommendations. We strongly believe in the benefits of this effort, based on the understanding that the ultimate goal of health professionals' education is to improve the health of society."
For Professor Julio Frenk, Dean of Harvard School of Public Health, Boston, MA, USA, please contact Todd Datz, Media Relations T) +1 617 998 8819 / (cell) +1 617 201-2191 E) TDATZ@hsph.harvard.edu

Alternative contact for Prof Frenk: Julie Rafferty, Associate Vice Dean for CommunicationsHarvard School of Public Health T) +1 617 549-1387 preferred contact via e-mail due to US Thanksgiving Holiday E) RAFFERTY@hsph.harvard.edu

Dr Lincoln Chen, China Medical Board, Cambridge, MA, USA. T) +1-617-979-8000 E) lchen@cmbfound.org

The Lancet Press Office T) +44 (0) 20 7424 4949 E) tony.kirby@lancet.com

Robbert Duvivier, Maastricht University, Netherlands. T) +31 628359428 E) robbertduvivier@gmail.com


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