Editorial
The physician scientist revisited Tim Swanwick ‘Doctors look set to become much less central to health care’ argued a recent editorial in The Economist. The piece went on: ‘Resources are slowly being reallocated. Nurses and other health workers will put their training to better use. Devices will bolster care in ways previously unthinkable. Doctors meanwhile will devote their skill to the complex tasks worthy of their highly trained abilities. Doctors may lose some of their old standing. But patients will clearly win’.1 Healthcare professions have always questioned their role in society—it could be argued that it is a professional responsibility so to do—but in a world still reeling from the 2008 financial crash, such arguments are now framed as much in economic as philosophical terms. And as the most costly of the healthcare professions, it becomes more important than ever to have a clear answer to the question, what do doctors do? Or perhaps more provocatively: why are doctors necessary? What benefits do they bring to society? What is expected of a physician, let alone the ‘good’ one? This was, of course a question addressed by Abraham Flexner over 100 years ago in his report on medical education in North America.2 Flexner’s report went on to become profoundly influential and underpins much of the way in which doctors are educated today as well as the type of institutions in which they are trained and the pedagogical approaches adopted.3 But our assumptions of what society expects of us require continual review as medical education adapts to the evolving needs of populations within changing socio-economic contexts. Indeed, it is precisely in response to this challenge that there has in recent years been an introspective flurry of activity around defining the doctor’s role in holistic professional frameworks for medical education. Examples include the highly influential CanMEDS4—a revised 2015 edition of which is currently out for consultation— and the UK General Medical Council’s Tomorrow’s Doctors.5 Similar attempts to articulate the role of the doctor within a Correspondence to Dr Tim Swanwick, Health Education North Central and East London, 32 Russell Square, London WC1B 5DN, UK; [email protected] Swanwick T. Postgrad Med J May 2014 Vol 90 No 1063
multiprofessional healthcare workforce are a regular feature of policy documents, consensus statements, workforce plans and journal editorials. So what are these ‘complex tasks worthy of the doctor’s highly trained abilities’ to which The Economist alludes? What, uniquely, can doctors bring to healthcare systems that add value? Before addressing that question, two relatively recent curricula trends are worth highlighting. First, the humanisation of the curriculum by means of participatory practices that engage learners with people and the social world through communication skills, patient-centred consulting and so on. Secondly, a shift in focus from the doctor as individual to the doctor ‘in context’, one agent among many, an integral part of a team, organisation or system. Both these curricula re-emphases are vitally important for the continual improvement of healthcare quality and safety, but neither are necessarily the sole province of the medical profession. So despite these global trends in medical education, the route into this issue may not be through a liberal education, a focus on leadership or in broadening curricula content, but in reconsidering the fundamental position that doctors occupy in relation to science and to society. The United Nation’s International Standard Classification of Occupations6 describes doctors first and foremost as ‘clinician scientists’. Flexner did too, but argued for science as an attitude of mind rather than an accumulation of facts. The notion of the ‘scientist physician’ reflects a habit of enquiry, a curiosity about the world and a critical engagement with all its aspects. This is the obligation that patients hold us to. They don’t expect doctors to know everything. With the democratisation of knowledge, patients can now access most of what they need on their smartphones. They do, however, expect us to be able to navigate the scientific world, critically engage with it and above all communicate its concepts clearly and humanely—or to use Flexner’s own words—with ‘insight and sympathy’ ( p. 26).2 The notion of doctor as intermediary is one that warrants further exploration as perhaps one way to think about the scientist physician as a ‘go between’, working at the interface between the social world
of the patient and the universe of science and technology. In this space, the scientist physician has a number of social responsibilities, all aimed at bringing about improved health outcomes. The first of these is to facilitate a public understanding that enables effective and productive engagement with biomedical science, its constructs, products and processes. In the UK, this is the mission of organisations such as Sense about Science (http://www.senseaboutscience.org) and journalists such as The Guardian’s Ben Goldacre, but in a society dominated by a constant media feed of dubious scientific literacy, sense-making needs to be considered a duty for all doctors, the most trusted members of society. Second, doctors are expected to apply intellectual scientific tools such as clinical reasoning, critical appraisal and risk assessment. These should be as much a part of the medical armoury as taking an effective history or the ability to use a stethoscope. Medicine is an academic profession and if we all cannot be, or don’t want to be, clinical scholars, we can at least be scholarly clinicians. Third, doctors bring the world of science and technology directly to bear on patients through the application of acquired knowledge and skills. Robotic surgery, personalised chemotherapy or the eradication of Helicobacter pylori are all examples, but almost all therapeutic interventions could be included here. Finally, doctors are responsible for aligning healthcare resources, teams and systems in a way that marshals scientific and technological resources to best serve patient need. This may range from organising a palliative care team and their resources around an individual patient to the reconfiguration of cancer services across an entire health economy. All four social responsibilities require doctors to bring the patient (or population) and biomedical science into apposition in order to maximise health benefit. This is where doctors, and by inference medical education, can add value. But it is not simply a question of how scientific (or not) we train our doctors to be, but how we can develop physicians with a broader conception of what it means to work at this interface, and how we can equip them with the ability to do so in a beneficial way. Sure, the role of the doctor is set to change, and maybe we will become ‘less central’ to healthcare. The role for a trusted intermediary operating between society and the increasingly complex world of science and
243
Editorial technology, though, has never been more important.
Received 10 March 2014 Accepted 31 March 2014
Competing interests None.
Postgrad Med J 2014;90:243–244. doi:10.1136/postgradmedj-2014-132679
Provenance and peer review Not commissioned; internally peer reviewed.
REFERENCES 1
2
Squeezing out the doctor. The Economist, 2 Jun 2012. http://www.economist.com/node/21556227 (accessed 6 Mar 2014). Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching. Boston: Updyke, 1910.
3 4
5 6
Ludmerer KM. Understanding the Flexner report. Acad Med 2010;85:193–6. Frank JR, ed. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. 2nd edn. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2010. General Medical Council. Tomorrow’s doctors. London: General Medical Council, 2009. International Labour Organization. International Standard Classification of Occupations ISCO-08 Group Definitions Occupations in Health. http://www.ilo.org/ public/english/bureau/stat/isco/draftdoc.htm (accessed 6 Mar 2014).
To cite Swanwick T. Postgrad Med J 2014;90:243–244.
Warwick University Short Course 14–17 July 2014: ‘Techniques and Applications of Molecular Biology: A Course for Medical Practitioners’. A four-day course for those in the medical profession wishing to improve their understanding of the principles and applications of genetic engineering techniques. Optional accreditation leads to a masters level Postgraduate Award. Details: Dr Charlotte Moonan, School of Life Sciences, University of Warwick, Coventry CV4 7AL, UK; Tel: 024 7652 3540; Email: [email protected]; Website: http://www2.warwick.ac.uk/fac/sci/lifesci/study/shortcourses/molecularbiology).
244
Swanwick T. Postgrad Med J May 2014 Vol 90 No 1063
Copyright of Postgraduate Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
The physician scientist revisited Tim Swanwick ‘Doctors look set to become much less central to health care’ argued a recent editorial in The Economist. The piece went on: ‘Resources are slowly being reallocated. Nurses and other health workers will put their training to better use. Devices will bolster care in ways previously unthinkable. Doctors meanwhile will devote their skill to the complex tasks worthy of their highly trained abilities. Doctors may lose some of their old standing. But patients will clearly win’.1 Healthcare professions have always questioned their role in society—it could be argued that it is a professional responsibility so to do—but in a world still reeling from the 2008 financial crash, such arguments are now framed as much in economic as philosophical terms. And as the most costly of the healthcare professions, it becomes more important than ever to have a clear answer to the question, what do doctors do? Or perhaps more provocatively: why are doctors necessary? What benefits do they bring to society? What is expected of a physician, let alone the ‘good’ one? This was, of course a question addressed by Abraham Flexner over 100 years ago in his report on medical education in North America.2 Flexner’s report went on to become profoundly influential and underpins much of the way in which doctors are educated today as well as the type of institutions in which they are trained and the pedagogical approaches adopted.3 But our assumptions of what society expects of us require continual review as medical education adapts to the evolving needs of populations within changing socio-economic contexts. Indeed, it is precisely in response to this challenge that there has in recent years been an introspective flurry of activity around defining the doctor’s role in holistic professional frameworks for medical education. Examples include the highly influential CanMEDS4—a revised 2015 edition of which is currently out for consultation— and the UK General Medical Council’s Tomorrow’s Doctors.5 Similar attempts to articulate the role of the doctor within a Correspondence to Dr Tim Swanwick, Health Education North Central and East London, 32 Russell Square, London WC1B 5DN, UK; [email protected] Swanwick T. Postgrad Med J May 2014 Vol 90 No 1063
multiprofessional healthcare workforce are a regular feature of policy documents, consensus statements, workforce plans and journal editorials. So what are these ‘complex tasks worthy of the doctor’s highly trained abilities’ to which The Economist alludes? What, uniquely, can doctors bring to healthcare systems that add value? Before addressing that question, two relatively recent curricula trends are worth highlighting. First, the humanisation of the curriculum by means of participatory practices that engage learners with people and the social world through communication skills, patient-centred consulting and so on. Secondly, a shift in focus from the doctor as individual to the doctor ‘in context’, one agent among many, an integral part of a team, organisation or system. Both these curricula re-emphases are vitally important for the continual improvement of healthcare quality and safety, but neither are necessarily the sole province of the medical profession. So despite these global trends in medical education, the route into this issue may not be through a liberal education, a focus on leadership or in broadening curricula content, but in reconsidering the fundamental position that doctors occupy in relation to science and to society. The United Nation’s International Standard Classification of Occupations6 describes doctors first and foremost as ‘clinician scientists’. Flexner did too, but argued for science as an attitude of mind rather than an accumulation of facts. The notion of the ‘scientist physician’ reflects a habit of enquiry, a curiosity about the world and a critical engagement with all its aspects. This is the obligation that patients hold us to. They don’t expect doctors to know everything. With the democratisation of knowledge, patients can now access most of what they need on their smartphones. They do, however, expect us to be able to navigate the scientific world, critically engage with it and above all communicate its concepts clearly and humanely—or to use Flexner’s own words—with ‘insight and sympathy’ ( p. 26).2 The notion of doctor as intermediary is one that warrants further exploration as perhaps one way to think about the scientist physician as a ‘go between’, working at the interface between the social world
of the patient and the universe of science and technology. In this space, the scientist physician has a number of social responsibilities, all aimed at bringing about improved health outcomes. The first of these is to facilitate a public understanding that enables effective and productive engagement with biomedical science, its constructs, products and processes. In the UK, this is the mission of organisations such as Sense about Science (http://www.senseaboutscience.org) and journalists such as The Guardian’s Ben Goldacre, but in a society dominated by a constant media feed of dubious scientific literacy, sense-making needs to be considered a duty for all doctors, the most trusted members of society. Second, doctors are expected to apply intellectual scientific tools such as clinical reasoning, critical appraisal and risk assessment. These should be as much a part of the medical armoury as taking an effective history or the ability to use a stethoscope. Medicine is an academic profession and if we all cannot be, or don’t want to be, clinical scholars, we can at least be scholarly clinicians. Third, doctors bring the world of science and technology directly to bear on patients through the application of acquired knowledge and skills. Robotic surgery, personalised chemotherapy or the eradication of Helicobacter pylori are all examples, but almost all therapeutic interventions could be included here. Finally, doctors are responsible for aligning healthcare resources, teams and systems in a way that marshals scientific and technological resources to best serve patient need. This may range from organising a palliative care team and their resources around an individual patient to the reconfiguration of cancer services across an entire health economy. All four social responsibilities require doctors to bring the patient (or population) and biomedical science into apposition in order to maximise health benefit. This is where doctors, and by inference medical education, can add value. But it is not simply a question of how scientific (or not) we train our doctors to be, but how we can develop physicians with a broader conception of what it means to work at this interface, and how we can equip them with the ability to do so in a beneficial way. Sure, the role of the doctor is set to change, and maybe we will become ‘less central’ to healthcare. The role for a trusted intermediary operating between society and the increasingly complex world of science and
243
Editorial technology, though, has never been more important.
Received 10 March 2014 Accepted 31 March 2014
Competing interests None.
Postgrad Med J 2014;90:243–244. doi:10.1136/postgradmedj-2014-132679
Provenance and peer review Not commissioned; internally peer reviewed.
REFERENCES 1
2
Squeezing out the doctor. The Economist, 2 Jun 2012. http://www.economist.com/node/21556227 (accessed 6 Mar 2014). Flexner A. Medical education in the United States and Canada: a report to the Carnegie Foundation for the advancement of teaching. Boston: Updyke, 1910.
3 4
5 6
Ludmerer KM. Understanding the Flexner report. Acad Med 2010;85:193–6. Frank JR, ed. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. 2nd edn. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2010. General Medical Council. Tomorrow’s doctors. London: General Medical Council, 2009. International Labour Organization. International Standard Classification of Occupations ISCO-08 Group Definitions Occupations in Health. http://www.ilo.org/ public/english/bureau/stat/isco/draftdoc.htm (accessed 6 Mar 2014).
To cite Swanwick T. Postgrad Med J 2014;90:243–244.
Warwick University Short Course 14–17 July 2014: ‘Techniques and Applications of Molecular Biology: A Course for Medical Practitioners’. A four-day course for those in the medical profession wishing to improve their understanding of the principles and applications of genetic engineering techniques. Optional accreditation leads to a masters level Postgraduate Award. Details: Dr Charlotte Moonan, School of Life Sciences, University of Warwick, Coventry CV4 7AL, UK; Tel: 024 7652 3540; Email: [email protected]; Website: http://www2.warwick.ac.uk/fac/sci/lifesci/study/shortcourses/molecularbiology).
244
Swanwick T. Postgrad Med J May 2014 Vol 90 No 1063
Copyright of Postgraduate Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
