The future for medical education: speculation

and possible implications

Richard SmithEditor, BMJ

www.bmj.com/talks

What I want to talk about

• Dangers of looking to the future• How to look to the future• Possible futures for health care• The old world and the new world• Reinventing medical education

Dangers of predicting the future

• Sam Goldwyn Mayer

• “ I never make predictions, especially about the future.”

Predictions of Lord Kelvin, president of the Royal

Society, 1890-95

• Radio has not future• X-rays will prove to be a hoax• Heavier than air flying machines

are impossible

What was predicted

• The leisure society• The paperless office• The death of the novel

What wasn’t predicted

• The end of communism• The rapid spread of the internet• September 11

Looking to the future: common mistakes

• Making predictions rather than attaching probabilities to possibilities

• Simply extrapolating current trends

• Thinking of only one future

Looking to the future: common mistakes

• People consistently overestimate the effect of short term change and underestimate the effect of long term change.

• Ian Morrison, former president of the Institute for the Future

Why bother with the future?

• "If you think that you can run an organisation in the next 10 years as you've run it in the past 10 years you're out of your mind."

• CEO, Coca Cola

Why bother with the future?

• “The future belongs to the unreasonable ones, the ones who look forward not backward, who are certain only of uncertainty, and who have the ability and the confidence to think completely differently.”

• Charles Handy quoting Bernard Shaw

Why bother with the future?

• The point is not to predict the future but to prepare for it and to shape it

How best to think about the future?

• No answer to the question, but one way• Think of the drivers of change• Use the drivers to imagine different

scenarios of the future• Imagine perhaps three; each should be

plausible but different• Extrapolate back from those future

scenarios to think about what to do now to prepare

Drivers of change in health care

• Internet• Beginning of the information age• Globalisation• Cost containment• Big ugly buyers• Ageing of society• Managerialism• Increasing public accountability

Drivers of change in health care

• Rise of sophisticated consumers• 24/7 society• Science and technology --particularly

molecular biology and IT• Ethical issues to the fore• Changing boundaries between health

and health care• Environment

Examples of future scenarios for

information and health

Three possible futures: titanium

• Information technology develops fast in a global market

• Governments have minimal control• People have a huge choice of

technologies and information sources• People are suspicious of government

sponsored services• There are many “truths”

Three possible futures: iron

• A top down, regulated world• People are overwhelmed by

information so turn to trusted institutions--like the NHS

• Experts are important• Information is standardised• Public interest is more important

than privacy

Three possible futures: wood

• People react against technology as against genetically modified foods

• Legislation restricts technological innovation

• Privacy is highly valued• Internet access is a community not

an individual resource• There are no mobile phones

Pictures of the future of health care

Fee for service for the rich

Marks and Spencer style managed care for the middle classes

Safety net service for the poor

The old world (that we were trained for) and the

new world

• Old world: Doctors practice primarily as individuals

• New world: Doctors work predominantly in teams

• Old world: The doctor is on top within his institution

• New world: The doctor is part of a complex organisation

• Old world: Doctors work long hours, put their patients before family, and have considerable freedom

• New world: Doctors “want a life,” put their families first, and are highly accountable

• Old world: Source of knowledge is expert opinion

• New world: Source of knowledge is systematic review of evidence

• Old world: Clinical skills are seen as semi-mystical

• New world: Clinical skills can be audited and managed

• Old world: Most of what doctors need to know is in their heads

• New world: Doctors must use information tools constantly

• Old world: Only lip service is paid to keeping up to date and learning new skills

• New world: Essential to keep learning new skills

• Old world: Most medical care is assumed to be beneficial

• New world: Widespread recognition that the balance between doing good and harm is fine

• Old world: Doctor patient relationship is essentially master/pupil

• New world: Patient partnership is the norm

• Old world: Patients do not have easy access to the knowledge base of doctors

• New world: Patients have as much access to the evidence base of medicine as doctors

• Old world: The doctor is smartest

• New world: Often the patient is smarter

Reinventing medical education: the Witten

experience (courtesy of Christan Koeck)

The old model

• Trainee doctors study the natural sciences

• They apply the natural sciences to solve people’s medical problems

Problems with the old model

• Doctors aren’t scientists• (How many of you are scientists?)• People are not machines: they are

complex adaptive systems• So are the families of the patients

and their social groups• So is the system within which doctors

work

What is a complex adaptive system?

• A system--unlike a mechanical system--in which any given input will produce unpredictable consequences, which may be far reaching

• Anything to do with humans is usually a complex adaptive system

Skills needed by doctors

• Technical skills--mainly taught in medical skills

• Adaptive skills--tools and mindset needed to facilitate adaptive processes in systems--mostly not taught

Problems faced by doctors

• Problem and solution clear--for example, an uncomplicated fracture

• Problem clear but solution unclear--for example, diabetes

• Problem and solution unclear (very common in medicine)

• (Vote on which are the most common)

Julian Tudor Hart

• “My medical education began three times. What I learnt at medical school was no use in the hospital. What I learnt in the hospital was no use in general practice.”

• Julian Tudor Hart (paraphrased)

Result

• Doctors are trying to solve unclear problems with unclear solutions with technical skills

• Often/usually they fail• Leads to paternalism, grandiosity,

pseudoempathy, inappropriate treatment

• And burnout in doctors and organisational problems in hospitals

Question

• Would you prefer that a medical student knew all about clinical governance or hypertension in pregnancy?

Finally

•What are the three most important words in medical education?

I don’t know

Final thought

• “If you aren’t confused you don’t know what’s going on.”

• Jack Welch, former CEO General Electric