In a major new report, 20 professional and academic leaders call for major reform in the training of doctors and other healthcare professionals to equip them for the 21st century. This Lancet Commission report is written by Professor Julio Frenk, Dean of Harvard School of Public Health, Boston, MA, USA, and Dr Lincoln Chen, China Medical Board, Cambridge, MA, USA, and their colleagues.
Worldwide, 2420 medical schools, 467 schools or departments of public health, and an indeterminate number of postsecondary nursing educational institutions train about 1 million new doctors, nurses, midwives, and public health professionals every year. Severe institutional shortages are exacerbated by maldistribution, both between and within countries. High-income countries are struggling to adapt to increasing costs and changing demographics of their populations, while in poorer nations it is obviously much worse. A large proportion of the 7 billion people who inhabit our planet are trapped in health conditions of a century ago.
Changes are needed, say the authors, because of fragmented, outdated, and static curricula that produce ill-equipped graduates. They say: "The problems are systemic: 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 labour 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—ie, the tendency of the various professions to act in isolation from or even in competition with each other."
The authors suggest a number of reforms, both instructional and institutional. Instructional reforms (1 to 6 below) should encompass the entire range from admission to graduation, to generate a diverse student body with a competency-based curriculum that, through the creative use of information technology (IT), prepares students for the realities of teamwork, to develop flexible career paths that are based on the spirit and duty of a new professionalism. Institutional reforms (7-10 below) should align national efforts through joint planning especially in the education and health sectors, engage all stakeholders in the reform process, extend academic learning sites into communities, develop global collaborative networks for mutual strengthening, and lead in promotion of the culture of critical inquiry and public reasoning.
All the above reforms need to be driven by mobilising leadership (local, national and global), enhancing investments, aligning accreditation systems, and strengthening global learning. In terms of investments, only around 2% of the total world health expenditure of US$5.5 trillion is spent on professional education, a situation described by the authors as "not only insufficient but unwise". All countries should move to align accreditation and licensing, with bodies such as WHO and UNESCO driving global co-operation. Metrics, research and evaluation are the key components in strengthening global learning.
The authors say: "At this crucial time, on the centenary of major reforms, we invite all concerned stakeholders to join us in much needed rethinking for reforms of professional education in the 21st century."
They also acknowledge that professional educators are key players since change will not be possible without their leadership and ownership. Students and young professionals are also important, since they have a stake in their own education and careers. Other key players include professional bodies, universities, non-governmental organisations, international agencies, and donors and foundations."
The authors conclude: "Ultimately, reform must begin with a change in the mindset that acknowledges challenges and seeks to solve them. No different than a century ago, educational reform is a long and difficult process that demands leadership and requires changing perspectives, work styles, and good relationships between all stakeholders. We therefore call on the most important constituencies to embrace the imperative for reform through dialogue, open exchange, discussion, and debate about these recommendations."
In a linked Comment, Dr Richard Horton, Editor of The Lancet, says: "What this Commission argues for is nothing less than a remoralisation of health professionals' education. For decades, health professionals have colluded with centres of power (governmental, commercial, institutional, even professional) to preserve their influence. The result? A contraction of ambition and a failure of moral leadership."
He concludes: "Frenk and Chen's Commission sets out the nature of the predicament facing the health professions and its possible solutions. Their work deserves serious attention."
In a second linked Comment, a group of students, represented by Robbert J Duvivier, Maastricht University, Netherlands, say: "Students, such as us, can play a vital role in implementing the recommendations of this report. The report highlights the importance of the instructional and institutional recommendations for students, the necessity of involving students within the entire process, and the possible courses of action taken by students on either a personal or organisational level.
The students encourage the proposed team-based education to break down professional silos, adding: "Working in health care means working in multidisciplinary and interdisciplinary teams. As teamwork is a soft skill which can be learned, its development should be fostered by the proposed interprofessional courses starting at an early stage."
They conclude: "As health-care students, we encourage all stakeholders to use the Global Commission's report as a basis for further discussion and action. We emphasise the importance of involving students from different healthcare professions in the implementation process, and the contribution students already provide to meet the recommendations. We strongly believe in the benefits of this effort, based on the understanding that the ultimate goal of health professionals' education is to improve the health of society."
For Professor Julio Frenk, Dean of Harvard School of Public Health, Boston, MA, USA, please contact Todd Datz, Media Relations T) +1 617 998 8819 / (cell) +1 617 201-2191 E) TDATZ@hsph.harvard.edu
Alternative contact for Prof Frenk: Julie Rafferty, Associate Vice Dean for CommunicationsHarvard School of Public Health T) +1 617 549-1387 preferred contact via e-mail due to US Thanksgiving Holiday E) RAFFERTY@hsph.harvard.edu
Dr Lincoln Chen, China Medical Board, Cambridge, MA, USA. T) +1-617-979-8000 E) firstname.lastname@example.org
The Lancet Press Office T) +44 (0) 20 7424 4949 E) email@example.com
Robbert Duvivier, Maastricht University, Netherlands. T) +31 628359428 E) firstname.lastname@example.org
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