The training of doctors and other health care professionals must change dramatically to meet 21st-century medical and public health needs, according to a report issued in November 2010 in the Lancet. The conclusion came from an international commission of experts led by Harvard School of Public Health Dean Julio Frenk and Lincoln Chen of the China Medical Board.
Among the report’s highlights:
- $5.5 trillion is spent annually on health care globally, which is about 10 percent of the world’s economy.
- Only about 2 percent of the $5.5 trillion is used to train physicians, nurses, midwives, and other health professionals who determine how that vast sum of money is spent.
- Four countries have more than 150 medical schools; 36 countries have none.
- 25 percent of physicians practicing in the U.S. were trained outside the U.S.
- Some countries have unemployed doctors; others have almost no doctors.
“We are spending too little money on health professional education, and getting too little value for the money,” said Dean Frenk, at a conference at HSPH where the commission presented its report. “Health care is a labor-intensive and talent-driven activity. We simply have to spend more training these individuals, and do a better job of educating them for 21st-century needs.”
He continued: “We need a global perspective on health professional education. Donor countries like the U.S. and others are spending billions to pay for AIDS treatments in Africa, for example, but spending very little money relatively speaking on training the health professionals who will work with patients and run the programs to get these treatments to patients.”
At the same time, wealthy countries are importing doctors from poorer countries to take care of patients in the developed world. “If one out of every four physicians seeing patients in the U.S. is educated outside the U.S., efforts that focus primarily on how doctors are trained in the U.S. will miss a sizable percentage of the clinicians who are managing patients in this country,” noted Frenk.
Systemic Problems Leave Graduates Ill-Equipped
But these problems are just part of a broader issue that the research unearthed. Changes are needed, say the report’s authors, because of fragmented, outdated, and static curricula that produce ill-equipped graduates. “The problems are systemic,” the commissioners write. “[There is] a 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 labor 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—i.e., the tendency of the various professions to act in isolation from or even in competition with each other.”
A Remoralization of Health Education
In a commentary issued with the report, Lancet editor Richard Horton wrote, “What this Commission argues for is nothing less than a remoralization of health professionals’ education. For decades, health professionals have colluded with centers of power (governmental, commercial, institutional, even professional) to preserve their influence. The result? A contraction of ambition and a failure of moral leadership.”
The commission report was released to mark the centenary of the Flexner Report, which called for the transformation of medical education at the beginning of the 20th century. Medical education then was in many cases delivered by for-profit schools that did not focus on science-based teaching—and in many cases graduated practitioners more likely to harm than help their patients.
Commission report authors and conference attendees recommend a transformation in health professional education. This transformation needs to:
- Focus on competencies in areas such as leadership, problem solving, and teamwork, in addition to the technical and scientific information needed to be a good practitioner.
- Break down silos among medical specialists, and between professionals such as doctors, nurses, midwives, and community health workers.
- Train professionals to take advantage of the burgeoning availability of information and communication technologies, ranging from the ubiquitous cell phone to more sophisticated electronic medical records.
- Encourage the belief that patients and populations are the center of the health care team, and that health professionals have a social responsibility to provide excellent care under financially constrained circumstances, rather than focusing more narrowly on conducting procedures and billing for them.
- Coordinate with the goals of health ministries in individual countries.
- Encourage global partnerships between academic medical centers, health ministries, insurers, government payers, and others.
Interprofessionalism is Key
To reach these goals, education must be interprofessional—with doctors, nurses, and other health professionals interacting more frequently during their training. Health professionals also need to develop the competencies to work with community health workers and be closely connected with them so both groups can be more effective.
“When I was minister of health in Mexico and we passed legislation to fund universal insurance for millions of previously uninsured citizens, we quickly realized that all of our problems were not immediately solved,” said Dean Frenk. Mexico didn’t have enough primary care doctors and other health professionals to meet the increased demands for service. According to Dean Frenk, the U.S., with new health care reform laws, will experience similar difficulties because medical schools train many more specialists and far fewer primary care physicians than are needed to meet the needs of millions who previously did not have health insurance.
The Flexner Report came out in 1910. Only after decades and much public outrage were its recommendations implemented. According to Dean Frenk, “We will need many years and a global social movement to make these changes take place.”
Julie Fitzpatrick Rafferty is Associate Vice Dean for Communications at HSPH.
A Cure for Health Professional Education article pdf