Routledge International Handbook of Medical Education

LOOKING TOWARD THE FUTURE OF MEDICAL EDUCATION

Stewart Mennin

A reflection on and analysis of the practices in medical education around the world with regard to the roles of teachers and students and what students should learn, how they should learn, how we know they have learned, and how a curriculum should be developed, organised, and evaluated; an outline of key potential changes in medical education over the next decade.

You walk into the future with your back because the only thing you can see is the past.

Traditional Māori proverb

The long history of healing, medicine and science woven together with the more recent history of contemporary healthcare practices and health systems in local cultural contexts has produced the pattern of medical education observed around the world. The Routledge International Handbook of Medical Education explores contemporary patterns of what is working in a wide variety of settings and conditions. We turn now briefly to explore possible futures of medical education based on what we understand today and to consider conditions that could promote the emergence of future practices and theories in medical education. Looking to the future of medical education, one becomes acutely aware that the present and future can co-exist only in our shared imaginations and that the further into the future one looks, the less predictable it becomes. The gap between the present and the future of medical education is influenced and shaped by existing local and regional conditions. Questions and adaptive actions disturb those conditions such that resilience and innovation continuously emerge as fit for the function of medical education in the future.

Inquiry in the present tense (tension)

Questioning and inquiry based on present tensions and gaps between what is and what could be will create the future of the field of medical education. Medical education will continue to mature, becoming flexible enough to accommodate new and varied contexts and also capable of adapting to a strong grounding in established and proven practice (Hamilton and Yasin, Chapter 20, this volume). It is critical that medical education emerges as a valued and essential professional career in the education and health systems of the future. Future practices of medical education will be more closely linked to the underlying assumptions and theories that inform and explain them. At the same time, theories of medical education will be played out and tested in action research and practice. Together practice and theory will continue to be a productive interdependent pair of activities promoting learning, understanding in and on action through, rich, relational, recursive and robust study, scholarship and research (Doll 1993). A few questions may serve to illustrate this point:

• How can teachers and students best work together to learn across and within the full range of conditions and settings in health practices and in health professions education?

• Who decides, and how, who goes to medical school?

• How is it decided what needs to be learned, where and when?

• How can we know learning for students, teachers, practitioners and researchers is happening, has happened and will continue to happen?

• How best can we use current resources to plan, develop, organise and evaluate medical education?

• How can advances in science and technology best serve the process of preparing present and future physicians?

• Who can be a teacher of medical students and how can the teacher best be prepared for this social responsibility?

• How do we explore and understand change?

• How do we deal with inequities in access to health and education at local, regional and global levels?

• How best can we sustain the relevance of the relationship between medical education and the health of the public?

And there are many more questions.

Students are the future: whose future? When?

Medical students are the future of medical education. Yet for most of them, their projection into the future may be focused on relatively short-term goals, and specific competencies and outcomes necessary to qualify and become a practising physician. How well prepared and how comfortable will they be as individuals and in collaborative groups to recognise and work with uncertainty? The part of the future that for them begins now can increase their experience recognising, working and learning with and from uncertainty. This is especially important early in their medical education experience as it fits seamlessly with the sciences basic to medicine and basic clinical skills (Mennin, Chapter 13, this volume). Traditionally medical education has reserved learning in authentic scenarios, i.e. those scenarios characterised as having high degrees of uncertainty, for students in the latter part of their education. This educational strategy is based on the assumption that learning, teaching, assessing and curriculum structure are additive, i.e. a step-by-step series of phases that build a foundation piece by piece over time (Bloom et al. 1954; Miller 1990). Some of medical education fits this concept; however, most of it does not (Mennin 2013). The growing importance of early authentic clinical and community experiences and assessment in the workplace has introduced higher dimensions of uncertainty earlier into the landscape of medical education. In addition, longitudinal clerkships rather than the traditional 2- or 3-month rotations have moved in this direction. This is a trend we believe will continue to grow in the future.

There are presently many programmes in place to reduce the gap between the profile of the local and regional populations being served by the health system and the socio-economic profile of students entering the medical professions. The assumption is that promoting equity of access to medical education among capable and qualified people around the world will decrease elitism in the selection of people who have the means to enter the present healthcare system and will foster more collaboration. Another way medical education can reach toward the future now is to focus on and select medical classes and students who are interested in working in areas of greatest need. Governments and their Ministries of Education and Health are challenged to allocate resources for health and the development of the health workforce necessary to meet the demands of the health of the public. In the near future, socially responsive admissions processes and committees will have found effective ways to collaborate to move future student and medical class profiles in this direction.

The future of medical education and technology

In the future, technology and its application will accelerate the rate at which the future appears to arrive. Some of this is already happening. It takes much longer to figure out the best application and fit for function of new technology than it does to develop the new technology itself. Medical students today are more comfortable, familiar and fluent with technology and social media than are their teachers and mentors, who are predominantly one or two generations older. Students and young teachers are more likely to be sensitive to the demands for the development and application of new technology in medical education, for example, different types of virtual classrooms, distributed learning, low- to high-tech simulation, social networking. Many forms of technology will get smaller, less costly and more accessible and as yet unimagined applications will appear. How we use them for the common good will be a continuing imperative for medical education in the 21st century.

Teaching, assessing and curriculum in, of and for the future of medical education

Medical education has moved from the large lecture hall, where communication was from one person to many, to small groups, where communication is many to many. Distributed knowledge will continue to grow and be more accessible. Fragmented curricula and isolated disciplines will be less prominent, while integration and interprofessional education will continue to grow. There is much discussion about and attention to social responsibility in medical education. What kind of social responsibilities will medical students and medical education be facing 10–20 years from now? Curriculum structure will become more fluid and capable of fitting both the learners’ needs and the needs of the local population/health system. The capability to be sensitive to and act adaptively to changing circumstances will be necessary for graduates of the future. The scenarios and places in which learning experiences take place are moving toward primary integrated healthcare featuring more early clinical and community authentic learning and working experiences.

The recent recognition of the interdependence of student assessment and learning has made, and will continue to make, a significant difference for students, teachers and the field of medical education (Schuwirth and van der Vleuten 2004). This change has successfully challenged the status quo of assessment as predominantly a summative measurement problem (Schuwirth and van der Vleuten 2006). It has also raised the challenge for institutions to design assessment programmes that are fit for purpose. As assessment in the workplace and authentic practice increases, the reliance by medical educators on reductionist approaches to assessment fails to deliver data sufficient to make the inferences necessary for medical education to assure society that it is fulfilling its social contract with trust and integrity. The ability of the faculty/staff of a medical school to design and conduct a meaningful institution-wide assessment programme will be one of the more immediate future challenges in practice and research (Schuwirth and Ash 2013). Continued innovation in assessment thinking together with teaching, learning, curriculum planning and programme evaluation are and will continue to be important, especially as new medical schools are being created; hopefully walking into the future rather than running into the safety of the past.

Collaboration and the sustainability of medical education

Medical education and the practising health professions are social and collaborative by nature. Collaboration is the RNA of medical education. In the future of medical education, the tension between general practice and special interests and between autonomy and group collaborative work will be a productive and useful resource contributing to the well-being of society. The ability of medical education to study and promote a healthy workforce capable of meeting the needs of society in a rapidly changing future world is and will continue to be challenging and compelling. Well-defined outcomes for graduates of medical schools must continue to be relevant to regional health issues and vigorous in pursuit of high standards and quality. There will continue to be tension between those who hold conservative and traditional ideas and practices in medical education and those interested and willing to explore new ideas and their expression as methods and approaches that may be more fit for the future functions of a medical school. Collaboration and the recognition of the significance of cultural history are (Bleakley et al. 2008, 2011) and will be more important as international or transnational medical education evolves.

Leadership for and in the future

The formal and informal leadership (Heifetz 1994) of medical education and among health practitioners will be more and more challenging as responsibilities and duties continue to grow faster than the resources to support them. It will become essential for leadership to learn that not all problems can be solved with quick-fix, technical solutions. Working well in groups, leadership that is fit for purpose together with an enhanced sensitivity to and ability to work with both bottom-up local agents around issues and challenges and system-wide top-down influences will be a useful measure (metric) of the future of medical education and its leadership. The viability and sustainability of medical education in the future will most likely depend on how well collaboration that meets the needs of all concerned occurs. Furthermore, how medical schools, hospitals, clinics, laboratories and communities of all kinds identify, create and adapt what works and what sustainability looks like in medical education will be a useful topic of scholarship and research.

External standards and accreditation

The importance of and the role for external standards and accreditation will continue to grow in the future. Challenges will be related to the coherence of the dynamics of interactions among local needs for medical education and healthcare services and those of the greater whole of medical education in the national and international context. Whether the trend for schools in the future will be to specialise as an institution or to remain more general is not yet clear. The evaluation of institutional programs over time and of innovations in progress will become more and more important in the future as a vital source of data in decision making and resource allocation.

Collaboration

Collaboration in the future will occur among many interdependent pairs (Kelso and Engestrom 2006) co-embedded in many systems. For example:

• undergraduate–postgraduate;

• postgraduate–continuing medical education;

• continuing medical education–permanent education (Otero Ribeiro and Mennin 2010);

• personal responsibility–social responsibility;

• stability–innovation;

• familiarity–novelty;

• curative care–preventive care;

• individual–group/team;

• learning–assessment;

• urban–rural;

• primary care–tertiary care;

• hospital–ambulatory;

• local community needs–greater urban centre needs;

• and many more.

The challenge in the future will be how well individuals, departments and institutions, originally formed as independent, autonomous agents, are able to collaborate. To what extent will they be able to mobilise and value collaboration and semi-autonomy to address shared and significant problems, without feeling threatened by the fear of loss of their identity and status? This is a fundamental challenge that reaches well beyond medical education to embrace all of humanity. It’s about how we get along and work together for the common good.

The future may be uncertain; however, we can be fairly comfortable about some things. The pace of change in medical education lags behind global, regional and local changes. Global conflicts, migration, displaced populations, levels of daily stress and competition for limited resources will most likely increase. Maldistribution of access to and distribution of healthcare resources by geography, economics and specialty choice will most likely continue. The need for equity of access to primary care and local healthcare workers will increase, as will the need for access to specialists. Advances in research and technology will appear more quickly than our ability to apply them most effectively. The movement toward collaboration in how we teach, learn and work together has begun and needs to grow faster and bigger. The world is becoming more, not less, complex and the challenges of cooperation, collaboration and working for the common good will require a paradigmatic change, not a programmatic change. We look forward to a future in which ‘Nobody owns the truth and everyone has the right to be understood’ (Doll 1993: 155).

Take-home messages

• Medical education must continue to mature and emerge as a valued and essential professional career in the education and health systems of the future.

• A closer linkage and relationship between practice and theory in medical education are a necessary interdependent pair of activities.

• Increased comfort with uncertainty across the full spectrum of medical education and practice is fit for the functioning of learning and practising in a rapidly changing world.

• Early and sustained learning experiences with authentic scenarios are important for integration, transdisciplinary and interprofessional education.

• Admission into medical school will move toward greater equity of access for all students and focus on selection of medical classes and students interested in working in areas of greatest need.

• Assessment and learning will continue to co-evolve.

• Effective collaboration and teamwork in learning, health practice and health systems will be an important measure of success.

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