Medical Education 1992, 26, 3-6
Skills necessary for contemporary health professionals L O U I S W. SULLIVAN Secretary of Health and Human Services, Government of the United States ofAmerica
fessional, life-long learning must be a hallmark of the practice of medicine. In order to continue to provide the best possible care, medical educators, government and private sector health officials, individual doctors and other health professionals need to strive for the widest range of skills, to become ‘renaissance health professionals’ if you will. As Pasteur once noted, ‘Chance favours the trained mind’, and w e must be prepared to meet the needs of the future. This is asking a great deal, especially when mastering today’s medicine is in itself a tremendous challenge, and when resources are scarce in many countries. Yet, health professionals must be technically competent, and knowledgeable in the basic and clinical sciences, life-long learners, excellent communicators, and health care visionaries.
Summary There is a constant need for all doctors to be ‘renaissance health professionals’, to have a mastery of a broad set of medical, communication and information-processing skills. Education in these areas must continue after graduation to produce the most effective medical care. With the changing face of medicine in the next few years, these skills will be more vital than ever before. Hence doctors and institutions of medical education must encourage the development of a wide range of skills as part of the learning and practice of medicine. Key words: *clinical competence; health personnel/*educ; health manpower; health care costs; health care rationing; United States
Introduction In many past issues of this Journal, there have been editorials and discussions about the need to encourage doctors to acquire a broad set of skills to meet the diverse needs of medical practice. Certainly, institutions for medical education have a large role to play, as do medical societies and other national and international organizations. The Edinburgh Declaration (Lancet 1988; World Federation for Medical Education 1988) underlined this responsibility: ‘Scientific research continues to bring rich rewards: but man needs more than science alone, and it is the health needs of the human race as a whole, and of the whole person, that medical educators must affirm.’ In addition, for every health pro-
The health care needs of the USA The need for renaissance health professionals is apparent. For example, in the USA, the cost of health care is overwhelming - more than $660 billion in 1990 - 12.3% of the U S gross national product. And m y department estiniates that, unless changes are forthcoming, health care costs will reach $1.5 trillion by the year 2000. In addition, there is considerable evidence that up to 25% of what we spend for health care does not buy needed care o r provide an increased measure of quality. The problem is that, even with the vast amounts of money being spent on health care in the USA, we still have a significant disparity in care received by our poor and minority citizens. For many of these citizens, poverty and disease are constant companions. The health status of black Americans did not improve from 1984 to
Correspondence: Louis W. Sullivan MD, Secretary of State for Health, Department of Health and Human Services, Office of the Secretary, Washington, DC 20201, USA.
3
L . M. Sullivntr
4
1988, the last year for which we have complete figures. There is a decline in black health status across the board; in almost every category of mortality listed, minority deaths are greater than those o f the white population. And, for the US population as a whole, ovcr 31 million Americans still lack health insurance: this at ‘1 time when cancer. AIDS, drug and alcohol abuse, heart disease, stroke, and many other diseases threaten us. O f course, many other countries facc similar problcnis.
The need for ‘renaissancehealth professionals’ But nowhere is it etched i n stone that these problcnis arc inevitable o r perpetual; high costs, poor health and disease must not put a vicc-grip on o u r culture. There is much that health professionals can d o to address these challenges. I;ivst, as health professionals w e must be perpctual students. We must never stop the learning process, ever-cognizant o f Einstein’s remark: ‘Whoever undertakes to set himself u p as a j u d g e of T r u t h and Knowledge is shipwrecked by the laughter of the gods.’ Graduation is only the beginning, not the end, of medical education. After graduation, we still need self-motivation and indepcndcnt acquisition and application o f new knowledge. This is critical now, but it will become absolutely csscntial as biomedical rcscarch continues t o revolutionize medicine during the next ccntury. Health professionals will practise nicdicinc in a greatly different world in the near future. Biomedical research is quickly - almost ovcrnight - changing the nicdical landscape. In order to prepare for the future, I have made strengthening o u r biomedical research enterprise a top priority in m y Department. We have developed a biomedical Rcsearch Initiative in the Public Health Service. We are working: strengthen the basic research foundation in the biomedical and behavioural sciences; assure the scientific integrity o f o u r research; educate thc public about the importance o f animal research and assure animal welfare;
(4) to promote scientific literacy and iniprovc biomedical science education; and (5) to improve the intramural research programmes of our Public Health Service. In President Bush’s budget for the fiscal year 1992 there is great emphasis on strengthcning biomedical and behavioural research at thc National Institutes of Health and the Alcohol, D r u g Abuse and Mental Health Administration, agencies o f the Public Health Service. Because o f the indispensable, uiidcniable need for this research, w e are requesting 89.8 billion for these activities in fiscal year 1992, a n increase o f $581 million o r 6.3% ovcr last year’s funding Icvcls, and a $2 billion o r 25% increase since I offered m y first budget at H H S in February 1989. O n e N I H project that interests m e personally is our effort t o m a p the human genome literally to understand the information encoded on a human chromosome (US Department o f Health and H u m a n Services and US Department of Energy 1980). Gene mapping will help us understand inherited disorders. It could lead to n e w strategies for thc prevention and treatment o f more than 3500 diseases of known gcnctic origin and to a much better understanding o f other diseases that have gcnctic components, such as infectious diseases, cancer, schizophrcnia, depression and hypcrtension. Thanks to some remarkable discoveries in genetics during the last 30 years, we are n o w ablc to locate individual genes on a chromosome and analysc their chemical components. We can isolate individual genes, and researchers can even dissect D N A at identifiable points that act as markers, mix and match fragments of D N A in various organisms, and g r o w large quantities of these fragments in bacteria. W e arc also cxploring the ‘sequencing’ o f D N A , to determine the linear order in which the chemical components occur in the D N A molecule. Powerful techniques n o w make thc sequencing of short stretches of D N A a routine laboratory procedure, although the technology is still inadequate for thc sequencing o f long stretches o f D N A at a reasonable cost. Because o f its potential impact o n o u r world, and because of the herculean nature o f the project, the London Ecorzornist has called this ‘big
Contemporary health professionals science’. Nobel laureate Walter Gilbert has described the human genome project as the ‘Holy Grail’ of genetics. But perhaps Norton Zinder of the Rockefeller University is closer when he calls it medicine’s ‘Rosetta Stone’. The initiative is under the able direction of Nobel laureate D r James Watson - codiscoverer with Francis Crick of the double helical structure of the D N A molecule. He has predicted that this programme could possibly produce a chromosome map within 5 years and a complete map of the sequence of all the D N A on the chromosomes in 15 years. This information will revolutionize the practice of medicine, and we must be ready to understand it and use it appropriately to help our patients. Second, the health professional must broaden his o r her interpersonal skills. The health professional must be a sensitive practitioner, empathic, a good listener, and a credible and effective communicator. So often I hear patients, and health care professionals themselves, comment on the inability of some practitioners to listen carefully to, and then talk clearly with, their patients, as if the health professional sees the patient only as a case study, and not as a person who may be confused or frightened. It appears that some health professionals have worked so hard in their studies and their medical activities that they have overlooked, o r have forgotten, the importance of effective communication skills in our social interactions with patients and our communities. We must never forget that so much of our work depends on a thorough understanding of the patient, and that requires effective communication. The health professional must learn from the patient, and then help the patient -motivate the patient - to fight illness effectively. This is central to being a successful health professional. I agree with D r Stanley Ryerson, who wrote in 1938: ‘It is not the doctor who fights the disease, it is the patient, the person in whom the disease occurs, who has to overcome its effects. The doctor is the auxiliary force who is brought in to help the person win the battle . . . In order to (best assist the patient), the doctor must know the human being from a scientific standpoint and from personal experience’. Third, the health professional must find ways
5
to stretch health care dollars to maximize avail-
able resources. In the United States, hospitals and doctors have been encouraged to find more efficient ways to deliver health care through the Prospective Payment System, which provides a fixed, predetermined payment for hospital services provided to Medicare beneficiaries (those over 65 who participate in the Federal health programme for the aged), and the recently enacted Physician Payment Reform legislation for the US Medicare system, which is intended to restrain the growth in compensation to doctors. But w e must do more, and health professionals will be increasingly called upon to find ways to provide health care more efficiently without compromising quality. I noted with some interest the following comment by the London Economist about the Pepper Commission report: ‘The care of America’s needy requires not more money, but a determined quest for a more efficient system’. There is a great deal of truth in that assessment, and health care professionals must look for new and better ways to reduce costs. Finally, the health professionals must do more to help patients stay healthy and prevent the onset of disease. Health professionals can help promote a new vision of health care where individuals exert more control over their lives. This means more empowerment of the individual, a ‘culture of character’, a climate of individual responsibility and community service. By this I mean we must make health promotion and disease prevention a national crusade - a top priority. That includes the adoption of better dietary behaviour; proper vaccination; a regular programme of physical exercise; the moderate use ofalcohol o r the absence of alcohol; the elimination of tobacco and illegal drug use; the consistent use of seat belts and other prevention practices. Many studies show that in the United States early detection and intervention, immunization and behaviour change could significantly reduce many of the leading causes of death and disability. It has been estimated that we could eliminate 45% of deaths from cardiovascular disease, 23% of deaths from cancer and more than 50% of the disabling complications of diabetes. For citizens in the USA, better control of fewer
h
L. W . Sirlliuari
than 1 0 risk factors - such as poor diet, lack of prenatal care, infrequent exercise, the use of tobacco, and alcohol misuse and drug abuse, failure to use seat belts - could prevent between 40 and 70% of all preniature deaths, a third of all dcutc disabilities and two-thirds of all chronic disabilities. Health promotion atid disease prevention are the greatest challcnges for all of us world-wide. Though the circumstances may vary from country to country, we must create a health-conscious culture world-wide in order to prevent disease and disability. This is the best way to maximize the hc21th status of our citizens.
Canadian students. Oslcr said “Po each one of you the practice o f medicine will be very much as you makc it - to one a worry, a care, a perpetual annoyance; to another, a daily joy and a life o f as much happiness and usefulness as can well fall to the lot of man. I n the student spirit you can best fulfill the high mission of our noble calling - in humility, conscious of weakness, while seeking strength; in cor!fiderrce, knowing the power, while recognizing the limitations of his art; i n pride, in the glorious heritage from which the greatest gifts to man havc been derived; and i n 5 1 1 arid ~ certnirr hop? that the future holds for us richer blessings than the past.’
Conclusion 1 havc described thc reasons w h y we need ‘renaissance healch professionals’. We must continuc our development as scholars, utilize cffcctivc coriiniunicatioii skills, beconic partners in iiatiorial and international efforts to provide high quality services and contain health care costs, and help our citizens create a hcalthicr society. I f w c do this, then we will be better and niorc effective practitioners of the healing arts. Sir Williani Oslcr expressed similar thoughts in his farewell address in 1905 to US and
References World Federation for Medicd Education (1988) Kcporf ($the World C h i j & m r c ~011 Mvdical Ediitatiori. World Federation for Medical Education, Edinburgh. Lariccr (1988) T h e Edinburgh Declaration. Lorrtct ii, 461.
US Department ofHedlth dnd Human Services dnd US Ilepdrtment of Energy (1990) Thr US Gcriorne Projerf: Thcr First Fioe Yrnrs 1991-1995. National Technical Information Service, Spriiigficld, Illinois.
Skills necessary for contemporary health professionals L O U I S W. SULLIVAN Secretary of Health and Human Services, Government of the United States ofAmerica
fessional, life-long learning must be a hallmark of the practice of medicine. In order to continue to provide the best possible care, medical educators, government and private sector health officials, individual doctors and other health professionals need to strive for the widest range of skills, to become ‘renaissance health professionals’ if you will. As Pasteur once noted, ‘Chance favours the trained mind’, and w e must be prepared to meet the needs of the future. This is asking a great deal, especially when mastering today’s medicine is in itself a tremendous challenge, and when resources are scarce in many countries. Yet, health professionals must be technically competent, and knowledgeable in the basic and clinical sciences, life-long learners, excellent communicators, and health care visionaries.
Summary There is a constant need for all doctors to be ‘renaissance health professionals’, to have a mastery of a broad set of medical, communication and information-processing skills. Education in these areas must continue after graduation to produce the most effective medical care. With the changing face of medicine in the next few years, these skills will be more vital than ever before. Hence doctors and institutions of medical education must encourage the development of a wide range of skills as part of the learning and practice of medicine. Key words: *clinical competence; health personnel/*educ; health manpower; health care costs; health care rationing; United States
Introduction In many past issues of this Journal, there have been editorials and discussions about the need to encourage doctors to acquire a broad set of skills to meet the diverse needs of medical practice. Certainly, institutions for medical education have a large role to play, as do medical societies and other national and international organizations. The Edinburgh Declaration (Lancet 1988; World Federation for Medical Education 1988) underlined this responsibility: ‘Scientific research continues to bring rich rewards: but man needs more than science alone, and it is the health needs of the human race as a whole, and of the whole person, that medical educators must affirm.’ In addition, for every health pro-
The health care needs of the USA The need for renaissance health professionals is apparent. For example, in the USA, the cost of health care is overwhelming - more than $660 billion in 1990 - 12.3% of the U S gross national product. And m y department estiniates that, unless changes are forthcoming, health care costs will reach $1.5 trillion by the year 2000. In addition, there is considerable evidence that up to 25% of what we spend for health care does not buy needed care o r provide an increased measure of quality. The problem is that, even with the vast amounts of money being spent on health care in the USA, we still have a significant disparity in care received by our poor and minority citizens. For many of these citizens, poverty and disease are constant companions. The health status of black Americans did not improve from 1984 to
Correspondence: Louis W. Sullivan MD, Secretary of State for Health, Department of Health and Human Services, Office of the Secretary, Washington, DC 20201, USA.
3
L . M. Sullivntr
4
1988, the last year for which we have complete figures. There is a decline in black health status across the board; in almost every category of mortality listed, minority deaths are greater than those o f the white population. And, for the US population as a whole, ovcr 31 million Americans still lack health insurance: this at ‘1 time when cancer. AIDS, drug and alcohol abuse, heart disease, stroke, and many other diseases threaten us. O f course, many other countries facc similar problcnis.
The need for ‘renaissancehealth professionals’ But nowhere is it etched i n stone that these problcnis arc inevitable o r perpetual; high costs, poor health and disease must not put a vicc-grip on o u r culture. There is much that health professionals can d o to address these challenges. I;ivst, as health professionals w e must be perpctual students. We must never stop the learning process, ever-cognizant o f Einstein’s remark: ‘Whoever undertakes to set himself u p as a j u d g e of T r u t h and Knowledge is shipwrecked by the laughter of the gods.’ Graduation is only the beginning, not the end, of medical education. After graduation, we still need self-motivation and indepcndcnt acquisition and application o f new knowledge. This is critical now, but it will become absolutely csscntial as biomedical rcscarch continues t o revolutionize medicine during the next ccntury. Health professionals will practise nicdicinc in a greatly different world in the near future. Biomedical research is quickly - almost ovcrnight - changing the nicdical landscape. In order to prepare for the future, I have made strengthening o u r biomedical research enterprise a top priority in m y Department. We have developed a biomedical Rcsearch Initiative in the Public Health Service. We are working: strengthen the basic research foundation in the biomedical and behavioural sciences; assure the scientific integrity o f o u r research; educate thc public about the importance o f animal research and assure animal welfare;
(4) to promote scientific literacy and iniprovc biomedical science education; and (5) to improve the intramural research programmes of our Public Health Service. In President Bush’s budget for the fiscal year 1992 there is great emphasis on strengthcning biomedical and behavioural research at thc National Institutes of Health and the Alcohol, D r u g Abuse and Mental Health Administration, agencies o f the Public Health Service. Because o f the indispensable, uiidcniable need for this research, w e are requesting 89.8 billion for these activities in fiscal year 1992, a n increase o f $581 million o r 6.3% ovcr last year’s funding Icvcls, and a $2 billion o r 25% increase since I offered m y first budget at H H S in February 1989. O n e N I H project that interests m e personally is our effort t o m a p the human genome literally to understand the information encoded on a human chromosome (US Department o f Health and H u m a n Services and US Department of Energy 1980). Gene mapping will help us understand inherited disorders. It could lead to n e w strategies for thc prevention and treatment o f more than 3500 diseases of known gcnctic origin and to a much better understanding o f other diseases that have gcnctic components, such as infectious diseases, cancer, schizophrcnia, depression and hypcrtension. Thanks to some remarkable discoveries in genetics during the last 30 years, we are n o w ablc to locate individual genes on a chromosome and analysc their chemical components. We can isolate individual genes, and researchers can even dissect D N A at identifiable points that act as markers, mix and match fragments of D N A in various organisms, and g r o w large quantities of these fragments in bacteria. W e arc also cxploring the ‘sequencing’ o f D N A , to determine the linear order in which the chemical components occur in the D N A molecule. Powerful techniques n o w make thc sequencing of short stretches of D N A a routine laboratory procedure, although the technology is still inadequate for thc sequencing o f long stretches o f D N A at a reasonable cost. Because o f its potential impact o n o u r world, and because of the herculean nature o f the project, the London Ecorzornist has called this ‘big
Contemporary health professionals science’. Nobel laureate Walter Gilbert has described the human genome project as the ‘Holy Grail’ of genetics. But perhaps Norton Zinder of the Rockefeller University is closer when he calls it medicine’s ‘Rosetta Stone’. The initiative is under the able direction of Nobel laureate D r James Watson - codiscoverer with Francis Crick of the double helical structure of the D N A molecule. He has predicted that this programme could possibly produce a chromosome map within 5 years and a complete map of the sequence of all the D N A on the chromosomes in 15 years. This information will revolutionize the practice of medicine, and we must be ready to understand it and use it appropriately to help our patients. Second, the health professional must broaden his o r her interpersonal skills. The health professional must be a sensitive practitioner, empathic, a good listener, and a credible and effective communicator. So often I hear patients, and health care professionals themselves, comment on the inability of some practitioners to listen carefully to, and then talk clearly with, their patients, as if the health professional sees the patient only as a case study, and not as a person who may be confused or frightened. It appears that some health professionals have worked so hard in their studies and their medical activities that they have overlooked, o r have forgotten, the importance of effective communication skills in our social interactions with patients and our communities. We must never forget that so much of our work depends on a thorough understanding of the patient, and that requires effective communication. The health professional must learn from the patient, and then help the patient -motivate the patient - to fight illness effectively. This is central to being a successful health professional. I agree with D r Stanley Ryerson, who wrote in 1938: ‘It is not the doctor who fights the disease, it is the patient, the person in whom the disease occurs, who has to overcome its effects. The doctor is the auxiliary force who is brought in to help the person win the battle . . . In order to (best assist the patient), the doctor must know the human being from a scientific standpoint and from personal experience’. Third, the health professional must find ways
5
to stretch health care dollars to maximize avail-
able resources. In the United States, hospitals and doctors have been encouraged to find more efficient ways to deliver health care through the Prospective Payment System, which provides a fixed, predetermined payment for hospital services provided to Medicare beneficiaries (those over 65 who participate in the Federal health programme for the aged), and the recently enacted Physician Payment Reform legislation for the US Medicare system, which is intended to restrain the growth in compensation to doctors. But w e must do more, and health professionals will be increasingly called upon to find ways to provide health care more efficiently without compromising quality. I noted with some interest the following comment by the London Economist about the Pepper Commission report: ‘The care of America’s needy requires not more money, but a determined quest for a more efficient system’. There is a great deal of truth in that assessment, and health care professionals must look for new and better ways to reduce costs. Finally, the health professionals must do more to help patients stay healthy and prevent the onset of disease. Health professionals can help promote a new vision of health care where individuals exert more control over their lives. This means more empowerment of the individual, a ‘culture of character’, a climate of individual responsibility and community service. By this I mean we must make health promotion and disease prevention a national crusade - a top priority. That includes the adoption of better dietary behaviour; proper vaccination; a regular programme of physical exercise; the moderate use ofalcohol o r the absence of alcohol; the elimination of tobacco and illegal drug use; the consistent use of seat belts and other prevention practices. Many studies show that in the United States early detection and intervention, immunization and behaviour change could significantly reduce many of the leading causes of death and disability. It has been estimated that we could eliminate 45% of deaths from cardiovascular disease, 23% of deaths from cancer and more than 50% of the disabling complications of diabetes. For citizens in the USA, better control of fewer
h
L. W . Sirlliuari
than 1 0 risk factors - such as poor diet, lack of prenatal care, infrequent exercise, the use of tobacco, and alcohol misuse and drug abuse, failure to use seat belts - could prevent between 40 and 70% of all preniature deaths, a third of all dcutc disabilities and two-thirds of all chronic disabilities. Health promotion atid disease prevention are the greatest challcnges for all of us world-wide. Though the circumstances may vary from country to country, we must create a health-conscious culture world-wide in order to prevent disease and disability. This is the best way to maximize the hc21th status of our citizens.
Canadian students. Oslcr said “Po each one of you the practice o f medicine will be very much as you makc it - to one a worry, a care, a perpetual annoyance; to another, a daily joy and a life o f as much happiness and usefulness as can well fall to the lot of man. I n the student spirit you can best fulfill the high mission of our noble calling - in humility, conscious of weakness, while seeking strength; in cor!fiderrce, knowing the power, while recognizing the limitations of his art; i n pride, in the glorious heritage from which the greatest gifts to man havc been derived; and i n 5 1 1 arid ~ certnirr hop? that the future holds for us richer blessings than the past.’
Conclusion 1 havc described thc reasons w h y we need ‘renaissance healch professionals’. We must continuc our development as scholars, utilize cffcctivc coriiniunicatioii skills, beconic partners in iiatiorial and international efforts to provide high quality services and contain health care costs, and help our citizens create a hcalthicr society. I f w c do this, then we will be better and niorc effective practitioners of the healing arts. Sir Williani Oslcr expressed similar thoughts in his farewell address in 1905 to US and
References World Federation for Medicd Education (1988) Kcporf ($the World C h i j & m r c ~011 Mvdical Ediitatiori. World Federation for Medical Education, Edinburgh. Lariccr (1988) T h e Edinburgh Declaration. Lorrtct ii, 461.
US Department ofHedlth dnd Human Services dnd US Ilepdrtment of Energy (1990) Thr US Gcriorne Projerf: Thcr First Fioe Yrnrs 1991-1995. National Technical Information Service, Spriiigficld, Illinois.
