The future for medical
education: speculation
and possible
implications
Richard Smith
Editor, BMJ
www.bmj.com/talks
What I want to talk
about
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Dangers of looking to the future
How to look to the future
Possible futures for health care
The old world and the new
world
• Reinventing medical education
Dangers of predicting the
future
• Sam Goldwyn
Mayer
• “ I never make
predictions,
especially about
the future.”
Predictions of Lord Kelvin,
president of the Royal
Society, 1890-95
• Radio has not future
• X-rays will prove to be a hoax
• Heavier than air flying machines
are impossible
What was predicted
• The leisure society
• The paperless office
• The death of the novel
What wasn’t predicted
• The end of communism
• The rapid spread of the
internet
• September 11
Looking to the future:
common mistakes
• Making predictions rather than
attaching probabilities to
possibilities
• Simply extrapolating current
trends
• Thinking of only one future
Looking to the future:
common mistakes
• People consistently
overestimate the effect of short
term change and underestimate
the effect of long term change.
• Ian Morrison, former president of the
Institute for the Future
Why bother with the
future?
• "If you think that you can run an
organisation in the next 10
years as you've run it in the
past 10 years you're out of your
mind."
• CEO, Coca Cola
Why bother with the
future?
• “The future belongs to the
unreasonable ones, the ones who
look forward not backward, who are
certain only of uncertainty, and who
have the ability and the confidence
to think completely differently.”
• Charles Handy quoting Bernard
Shaw
Why bother with the
future?
• The point is not to predict the
future but to prepare for it and
to shape it
How best to think about
the future?
• No answer to the question, but one
way
• Think of the drivers of change
• Use the drivers to imagine different
scenarios of the future
• Imagine perhaps three; each should
be plausible but different
• Extrapolate back from those future
scenarios to think about what to do
now to prepare
Drivers of change in health
care
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Internet
Beginning of the information age
Globalisation
Cost containment
Big ugly buyers
Ageing of society
Managerialism
Increasing public accountability
Drivers of change in health
care
• Rise of sophisticated consumers
• 24/7 society
• Science and technology -particularly molecular biology and
IT
• Ethical issues to the fore
• Changing boundaries between
health and health care
• Environment
Examples of future
scenarios for
information and health
Three possible futures:
titanium
• Information technology develops fast
in a global market
• Governments have minimal control
• People have a huge choice of
technologies and information
sources
• People are suspicious of government
sponsored services
• There are many “truths”
Three possible futures:
iron
• A top down, regulated world
• People are overwhelmed by
information so turn to trusted
institutions--like the NHS
• Experts are important
• Information is standardised
• Public interest is more
important than privacy
Three possible futures:
wood
• People react against technology
as against genetically modified
foods
• Legislation restricts technological
innovation
• Privacy is highly valued
• Internet access is a community
not an individual resource
• There are no mobile phones
Pictures of the future of
health care
Fee for service for the rich
Marks and Spencer style managed care
for the middle classes
Safety net service for
the poor
The old world (that we
were trained for) and
the new world
• Old world:
Doctors
practice
primarily as
individuals
• New world:
Doctors work
predominantly
in teams
• Old world:
The doctor is
on top within
his institution
• New world:
The doctor is
part of a
complex
organisation
• Old world:
Doctors work
long hours,
put their
patients
before family,
and have
considerable
freedom
• New world:
Doctors “want
a life,” put
their families
first, and are
highly
accountable
• Old world:
Source of
knowledge is
expert opinion
• New world:
Source of
knowledge is
systematic
review of
evidence
• Old world:
Clinical skills
are seen as
semi-mystical
• New world:
Clinical skills
can be
audited and
managed
• Old world:
Most of what
doctors need
to know is in
their heads
• New world:
Doctors must
use
information
tools
constantly
• Old world:
Only lip
service is paid
to keeping up
to date and
learning new
skills
• New world:
Essential to
keep learning
new skills
• Old world:
Most
medical care
is assumed
to be
beneficial
• New world:
Widespread
recognition that
the balance
between doing
good and harm
is fine
• Old world:
Doctor patient
relationship is
essentially
master/pupil
• New world:
Patient
partnership
is the norm
• Old world:
Patients do
not have easy
access to the
knowledge
base of
doctors
• New world:
Patients have
as much
access to the
evidence base
of medicine as
doctors
• Old world:
The doctor
is smartest
• New world:
Often the
patient is
smarter
Reinventing medical
education: the Witten
experience (courtesy of
Christan Koeck)
The old model
• Trainee doctors study the
natural sciences
• They apply the natural sciences
to solve people’s medical
problems
Problems with the old
model
• Doctors aren’t scientists
• (How many of you are scientists?)
• People are not machines: they are
complex adaptive systems
• So are the families of the patients
and their social groups
• So is the system within which
doctors work
What is a complex
adaptive system?
• A system--unlike a mechanical
system--in which any given
input will produce unpredictable
consequences, which may be
far reaching
• Anything to do with humans is
usually a complex adaptive
system
Skills needed by doctors
• Technical skills--mainly taught
in medical skills
• Adaptive skills--tools and
mindset needed to facilitate
adaptive processes in systems-mostly not taught
Problems faced by doctors
• Problem and solution clear--for
example, an uncomplicated
fracture
• Problem clear but solution unclear-for example, diabetes
• Problem and solution unclear (very
common in medicine)
• (Vote on which are the most
common)
Julian Tudor Hart
• “My medical education began
three times. What I learnt at
medical school was no use in
the hospital. What I learnt in the
hospital was no use in general
practice.”
• Julian Tudor Hart (paraphrased)
Result
• Doctors are trying to solve unclear
problems with unclear solutions
with technical skills
• Often/usually they fail
• Leads to paternalism, grandiosity,
pseudoempathy, inappropriate
treatment
• And burnout in doctors and
organisational problems in
hospitals
Question
• Would you prefer that a medical
student knew all about clinical
governance or hypertension in
pregnancy?
Finally
• What are the three
most important words
in medical education?
I don’t
know
Final thought
• “If you aren’t confused you don’t
know what’s going on.”
• Jack Welch, former CEO
General Electric