Traditional approaches to medical education need a radical overhaul if we are to develop a sustainable health system that truly helps those with the greatest needs.
But trying to turn around the “Titanic” of a hospital-centric system that encourages hierarchical specialisation is no small task.
Dr Kimberley Ivory has been involved in developing a new Population Medicine curriculum at the University of Sydney medical school, outlined below, that aims to “put the patient at the centre of the equation and train doctors to see themselves as part of inter-disciplinary teams rather than occupants of the top deck staterooms”.
Medical education must change so the ‘Katies’ don’t continue to miss out
Kimberley Ivory writes:
Turning the Titanic with oars might be easier than attempting to change the course of traditional medical education to best address the future health of Australians.
The iceberg in this case is already upon us: an epidemic of chronic disease in an ageing population; and just like the Titanic, it is those in steerage who will suffer most if we do not change course.
To me, the story of the Titanic has always represented hubris, but embedded in the tragedy is also a classic description of the impact of the social determinants of health: the rich and powerful inevitably do better than the poor and disenfranchised.
Dr Tim Senior’s recent comments in this blog (How “Katie” misses out when we don’t talk health and policy) demonstrated poignantly the how and why of ordinary Australian people suffering within our current health system.
Good GPs like Dr Senior and his registrar, Dr Michael Bonning, are the valiant but unfortunate captains in this tragedy: going down with the ship despite their best efforts to avoid a disaster created largely by external forces.
It was the third class passengers on the Titanic who died as they tried to make their way to non-existent lifeboats through a maze of unfamiliar passageways.
The lesson here is that if we are to offer protection to the most vulnerable patients as the iceberg strikes, we need a system that is clear and simple to navigate.
Currently we are training more specialists in ever-narrower subspecialties in a hospital-centric teaching model, and forcing patients to navigate through a maze of disconnected services.
Instead, we must put the patient at the centre of the equation and train doctors to see themselves as part of inter-disciplinary teams rather than occupants of the top deck staterooms.
The simple fact is that the patient and their family or carers manage most chronic disease in the community. The 15 minute consultation with their specialist twice a year, or even monthly visits to their GP are a tiny part of their daily lived experience of illness.
GPs like Dr Tim Senior get this, and tailor their management plans to suit the individual patient as best they can. But without a system that contextualises and privileges the patient’s experience, they are doomed to drown in the attempt.
Good mentoring in post-graduate GP training produces doctors like Tim Senior, but does little to produce systemic change.
When trying to convince medical students who have been raised on a diet of cutting edge medical research and a side serve of Grey’s Anatomy that good clinical practice must respect the patient’s social and cultural context, it often feels like someone has stolen your oars.
GPs get it because they see it in practice every day. Specialist medical educators rarely get it because they never see the patient at home and are rarely responsible for the patient outside the hospital bed or are scrubbed up for the follow-up consultation.
Hearing the patient’s story
Our new Integrated Population Medicine curriculum in the Sydney Medical School is outlined in this recent article, ‘A clinical approach to population medicine’ (abstract is here and PDF is available from author, see details at bottom of this article).
It is an attempt to redress the imbalance and let students hear the patient’s story for more than the solitary hour of a long case history.
Students starting the third year of the Sydney Medical Program are now required to recruit a person living with a chronic health condition and work with that person over the next 14 months to build a complete picture of their illness experience over time.
Students talk to the person about things like their access to services, the cost of their care and how they manage that, the pressures illness places on their work and family and recreation, what support services they have or need and whether health promotion messages and prevention and management strategies are working for them.
What they hear often challenges the black and whiteness of evidence-based guidelines they hold dear. What they hear is the flip side to what doctors like to call ‘poor compliance,’ which in reality is frequently more about doctors having unrealistic expectations of what the patient can reasonably afford, get to or achieve in the day-to-day reality of their lives.
Students are not asked to ignore or abandon the evidence base. Rather, they are challenged to reflect on why it may not be working in this person’s case and what individual or systemic changes may be needed to provide this person with the best possible outcomes.
Sharing these reflections with their fellow students builds a picture of the myriad different issues faced by people with even the same chronic disease. It builds, to some extent, a virtual general practice.
Patients universally love this program; students, not so much … yet.
Patients see it as a chance to be part of the change needed to benefit others with their condition. Students see it as dragging them away from the ‘important stuff’ they have to learn: the ‘real’ curriculum.
But if understanding the social determinants of health in medical practice was really ‘just common sense’ as they like to suggest, why do we have a hospital-centric health system and funding structures that ignore the many external forces driving the ship inexorably towards the iceberg?
• Dr Kimberley Ivory is a Lecturer in Population Medicine at the Sydney Medical School. For a copy of the article mentioned, please contact kimberley.ivory AT sydney.edu.au
PS from Croakey: If other medical schools are making similar changes, perhaps you could leave the details in the comments section below…