British Journul of Medical Edircutiotr, 1972, 6, 264-267

A look to the future‘ MOSHE PRYWES Department of Medical Education, Hebrew University- Hadassah Medical School, Jerusalem, Israel

A new science, Futurology, has come into being. Conferences and symposia, books and re- ports on Futurology, have become part of the current scene. The approach of the year 2000 makes this science even more meaningful. Besides marking the end of a millenium, what will happen in 2000 may directly concern many of us who are here today and will certainly affect our students and the world in which they will practise medicine. The deliberations of this Conference demonstrate, however, the extra- ordinary complexities inherent in any attempt to define the future.

While contemporary scientific knowledge pro- vides a basis upon which to forecast the future of technology, the future progress of science is almost unpredictable. Had we known more about the science of tomorrow, we probably would have it here today.

Yet forecasting, unlike planning, does not seek to actively influence the future directly and it takes into account the entire spectrum of pos- sible options, both objective and subjective. Thus, intuition, vision, and extravagant ideas must not be ruled out since, as in the past, they may spark off genuine ‘breakthroughs’.

Medical education, as has been well demon- strated during the first two of the three sessions of the Conference, is a sociocultural complex of values and interrelationships, and only partially a scientific discipline. Hence, when dealing with medical education as a mission-orientated endeavour, due consideration has been given by the participants to the human and social im- plications of the scientific and technological

‘Closing Address OF the Fourth World Conference o n Med- ical Education. 25-29 September 1972, Copenhagen.

revolution. Finally, they have constantly remin- ded us that one cannot ignore the political ele- ments and processes which affect every nation’s way of life, or public opinion of consumers which serves as the feed-back channel for its decision-making bodies. As a result, the art of prediction in health care and health education is conceptually and technically complex.

When asking ourselves ‘what is desirable’ in our age of change and choice, we had better take another look at existing values. Thus, while becoming futurologists, we should not forsake history, past and present.

When I was a small boy I loved to watch busy street traffic. I used to wonder about the lack of logic in so many people rushing somewhere with as many already returning from whence the others are going. By comparing opposite trends in international medical education one may ask the same question. Medical education is not a one-way street where everyone goes, per- haps at different speeds, but all in the same direc- tion trying sometimes to pass one or more drivers ahead of him. It is rather a large two-way high- way, where many vehicles run in many lanes in opposite directions. Recently, common themes and more universal values have been emerging in discussions on medical education in all countries. This, however, has not prevented a paradoxical situation which is most perplexing to the medical man : since each of the particular shortcomings of medical education has its own characteristic aetiology in each country, what is regarded as a cause of trouble in one place may be considered a remedy in another. Thus, it is only natural that what seems desirable for some of us in the future may have already been widely used and some- times even discarded by others, and vice versa. To enumerate only a few such examples.

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1. Many countries believe that national health insurance may become a panacea for better health for all, but countries which provide ‘free service’ to all ROW realize that free accessibility to such services still does not mean better health care. 2. Many consider the lack of wide research facili- ties and funds as a major handicap in providing better health and medical education, but sufficient funds for medical research do not provide the solution to all medical problems. The gap even widens between the best which medicine could offer and what is actually available to the population at large. 3. The Communist countries probably succeeded more than others in keeping medical education relevant to the needs of medical care through direct governmental control of their medical schools, but this may be hardly conceivable in countries where academic freedom and a uni- versity setting are considered as the most im- portant asset in medical education. 4. Russia has solved its shortage of health man- power by educating ‘feldshers’ (equivalent to assistant physicians). Some developing countries follow the same pattern. This was frowned upon by western countries for half a century, but recently the USA embarked upon a vigorous programme of physician assistant training, while the USSR is rather limiting their proliferation. Moreover, while up-grading is, more or less, an accepted pathway in the American programmes (and will probably create numerous problems in the future) it is only marginally encouraged in the USSR. 5. In the American systems, there is an explosion of allied health professions (over 200!) and a growing tendency for them to penetrate into the academic setting be it college or university, while the Europeans, are trying to remain consistent, preserving the unity of health care and centering its functions mainly around the physician and the nurse by adapting them to new polyvalent needs. 6. Early clinical exposure and training, the old French system (‘clinicism’), once rejected by the British and Americans, is now in ‘high fashion’ in the USA and elsewhere, but has recently been reduced in France where broader basic science preparation has been introduced.

7. A growing number of American medical schools are ready to relinquish the objective of educating a ‘basic doctor’ and are considering provisions for various ‘tracks’ of medical educa- tion within the same institution. This is the exist- ing system in the USSR and Eastern European countries (with the recent exception of Poland), but they do not permit free transfer from one track to another. 8. Elective subjects are a recent development in the USA but they will become probably the first victim of the growing trend to shorten the medical curriculum. 9. While ‘open admission’ into medical schools has been an accepted tradition in European and Latin American countries and restricted selective admission has been a matter of principle in the USA, we may observe recently a reversal of attitudes in both locations. Americans are speak- ing now of introducing ‘open admission’ and ‘active recruitment’ with the hope of increasing the heterogeneity of the entering class. Para- doxically enough, French universities, like some of their Latin-American counterparts, recently instituted selection in admission to medical schools. 10. We have heard at the Conference that Turkey is now introducing the internship, while Japan and the USA are abandoning it.

One should not become frustrated by all of these paradoxes which are known to many as the ’oscillating pendulum’ of medical education. They were mentioned again in order to gain a better perspective with regard to the assump- tions upon which a model of prediction can be constructed. All the participants of this Con- ference on ‘Educating tomorrow’s doctor’ have successfully identified the different components of ongoing changes. We shall now try to find some consensus of opinion to determine the direction in which change will probably move in the future. 1. Viewing medical education as a social endeavour to serve growing national health needs is thefirst foreseeable challenge. Therefore, medical education will inevitably become more involved in shaping better health care for all. This involvement will increasingly invest the academic medical centre with a new responsibility -the search for new models of health care

266 Moshe Prywes

delivery - in addition, the key words being ‘in addition’, to its traditional role of creating new models of molecular biology and expert clinical performance.

Academic medicine too often complains that it has not been given the opportunity to regulate, or the responsibility to direct health delivery systems outside its own sphere. Actually, in the majority of countries, it only very seldom tried to assume this responsibility and often turned its back on such opportunities when they presented themselves. Medical academicians have preferred to remain in the comfortable micro-environment of their university hospitals and research laboratories. If they continue to disregard the community’s demand for better, less expensive, and more easily accessible health care and do not educate health professionals who are aware of their community role, medical education will not fulfil its obligations and will retreat into a no-man’s land. Or, as one speaker said at this Conference: ‘You will be just left out.’ Medical educators of tomorrow are thus called upon to integrate fully health care and medical education, two systems which for too long turned in separate orbits, into a more har- monious and effective coexistence. In some countries, like in my own, attempts are already being made to merge completely medical care and education on a regional basis.

One feels that if only the academic medical community could find the strength and vigour to fight for the priviledge of deeply penetrating into and moulding medical care delivery systems in the same way it has traditionally defended its research and teaching privileges, we might enter a new and much improved era in medical educa- tion. 2. The second challenge, a direct outcome of the first, will be to seek new, realistic approaches in relationships between academic and govern- ment sectors. Since one system cannot survive without the other, both must contribute to better communication and understanding. The concepts of government as a benevolent bill- paying agency and the academic medical centre as a luxurious ivory tower, must both be replaced by a new bilateral partnership. It is the responsi- bility of the medical educators of tomorrow to educate the government in the goals and objec- tives of medical education. This will lead to a greater success in our appeal to government to

ultimately accept major responsibility for financ- ing the growing costs of medical education. It probably will happen when government not only knows how much it has to pay but when it has become convinced that the kind of ‘pro- duct’ it is paying for is actually serving the nation’s health needs.

3. The third foreseeable change will be the extension of medical schools’ educational res- ponsibility beyond the traditional undergraduate level. This expansion will encompass a few direc- tions.

First, it will move upwards, into graduate, postgraduate, and continuing education. The medical schools involvement in residency train- ing and continuing education programmes is a rational development and the demand for a fully-fledged partnership (together with pro- fessional medical organizations and government) cannot be denied. It may move ‘downward‘ into the premedical phases to assume more relevant preparation of future students of health pro- fessions.

Second, it will move within the university setting developing an ever-growing interaction with other academic disciplines: the natural, behavioural, and social sciences and engineering and computer sciences. The advantages for medical education are many, but one must not deny the multiple contributions which medicine can offer in exchange.

Third, medical education will move towards what has recently been called ‘The Greater Medical Profession’. We shall witness the transformation of the traditional medical school into a Regional Multischool Medical Centre providing education not only for physicians but also for a multitude of health professions both academic (PhDs, dentists, pharmacists, and public health workers) and vocational (nurses and allied professions). 4. A few basic changes will occur in the future medical curriculum.

Firstly, the uniform curriculum structure, will slowly but steadily lose its sanctified position. More and more medical schools will abandon it in favour of an increasingly flexible programme which is adaptable to the needs of individual students. This will probably include different designs like ‘core’ and ‘elective’ courses, multiple tracks in undergraduate education, different

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rates of student advancement - all leading to less rigorous frameworks and rules.

Secondly, we shall witness a trend to erase the existing lines of demarcation between the tradi- tional basic science disciplines and departments. I t is already out of date to speak about physio- logy, biochemistry, pharmacology, microbiology, immunology, etc. A more integrated entity of life sciences or human biology will replace the old structure. In a parallel fashion the teaching of sequentially arranged disciplines will disappear and a more integrated system will come into being.

Thirdly, the strict schedule of long laboratory hours, identical and obligatory for all students, will become more liberal, and more of the basic sciences will be taught in relation to patient problems and thus become patient-orientated. This will enhance also a better integration of behavioural sciences within the medical cur- riculum. Consequently, fundamental biological, behaviourai, and social concepts will become more essential to the understanding of health and disease. Finally, a growing number of scientifically trained clinicians will participate in basic science teaching. We may also expect that PhD students in fields related to medicine will be given the opportunity to learn some clinical medicine so they may contribute more effectively to teaching and research within medical schools.

Fourthly, in the clinical curriculum more atten- tion will be given to education in ambulatory care (primary, comprehensive care) and to work in community hospitals. This will mean much more cooperation or integrated relationships, through affiliation, between medical schools, regional and community hospitals, and com- munity health centres and clinics. As a result, one might expect from tomorrow’s doctors a restored concern for humane considerations and a ‘new balance between the elements of in- dividual and cbmmunity health needs’.

5. As for new teaching techniques, they will con- tinue to attract some of the teachers and students. They will, however, contribute effectively as long as they succeed in enhancing the self-learning process which ultimately must become the lead- ing objective of any educational programme. Evaluation of medical education will continue to be improved by the design of new and more scientificially based techniques and systems.

6. Much of the leadership in curriculum changes, introduction of new teaching techniques, pre- paration of teachers to teach, and evaluation of educational programmes will become the responsibility of departments of medical educa- tion which will be established in an increasing number of medical schools the world over.

7. What is called ‘student participation’ will evolve into a deeper, more intellectual, and more mature factor in the shaping of the social and academic systems of medical education institu- tions. One outcome of the campus riots at the end of the 60s, which we are already witnessing, is a kind of sublimation of feelings and relation- ships within the teacher-student community, where each group has discovered that they have a lot to learn from each other. The main challenge will be both to give our students the feeling that the medical school belongs also to them, and that they, equally, belong to it. 8. Medicine will always develop along parallel lines with the progress of science and technology, and thus medicine will become more and more specialized. This in turn will call for strong safe- guards in the future to preserve the essential nature of medicine as a science and an art. In this context - and aware of medicine’s humane and social obligations - problems of medical ethics and morals as outlined in Lord Rosenheim’s Opening Address, will become one of our fore- most preoccupations. 9. Medical education will become in the future more global, international, and regional. Ways and means will be found leading to equivalence of medical diplomas and licensing procedures, closer cooperation of national and regional medical education associations and better ex- change of experience among them. Ultimately we shall probably all become members of a World Federation of Medical Education. 10. Freedom, Experimentation, Flexibility, and Diversity will for ever remain the key forces con- ditioning medical education’s progress and moulding its future. Since medical education is a dynamic process dealing with living people, it can never achieve a static balance and stop. Therefore the most sure forecast for the future is that at the coming Conferences on medical education, tomorrow’s doctors will speak again and again about ‘educating tomorrow’s doctors’.