Canadian Medical Association Journal 1995; 153: 1433-1436
This essay is based on the inaugural Dr. J. Wendell MacLeod Lecture, given by Dr. Murray at the annual meeting of the Association of Canadian Medical Colleges in Vancouver on Apr. 25, 1994.
Paper reprints of the full text may be obtained from: Dr. T. Jock Murray, Professor of medical humanities, Dalhousie University, 5849 University Ave., Halifax NS B3H 4H7; fax 902 494-2074; murrayj@Tupdean1.Med.Dal.Ca
Is there a "community" or "population" to be served by medical schools?(1) I believe that there is such a community and have argued elsewhere that medical schools have entered a new era that requires them to be socially responsible and socially responsive.(2)
Many medical educators, including Dean Martin Hollenberg of the University of British Columbia, have spoken of the social contract between medical schools and society. Hollenberg noted that in essence this contract is "an implicit, if not explicit, agreement that in return for serving society, an institution and its members enjoy special status, rights, and other tangible benefits."(3) The medical profession has been given unprecedented status, large resources, high incomes, influence and power. In exchange, it must serve society. Some people are concerned that although the profession serves society it does so narrowly, in a way determined by its own goals -- which are not necessarily those of society. The call is for the medical profession to be more responsive to society's needs and to issues of population health.
Kerr White(4) has said that medical educators have no choice but to respond to the needs of their community and that there are many reasons why this is now inevitable. David Greer(5) has said that it is depressing to think how the academic elite will respond to this challenge, given its self-centred history of opportunities shunned, pressures resisted and humanitarian needs ignored. White and Greer agree that medical schools have been slow to respond to the community's needs, but they differ as to whether this opportunity will now be grasped. Which is it? Will the trend be irresistible, as White says, or will medical educators continue to resist, as Greer fears?
Why are medical schools so slow to respond despite all that has been written, the pilot programs that have been launched and their own professed agreement with this new direction? For decades there has been talk of medical schools altering their mission in favour of a population-health perspective; this goal has been emphasized in the Alma Ata declaration,(6) at the 1990 Royal Society of Medicine-Josiah Macy Junior Foundation conference in Florida,4 through the Educating Future Physicians for Ontario (EFPO) initiative,(7) in the organization of community-based medical schools and by almost every provincial royal commission on health care. Nevertheless, as the editors of Lancet have commented,(8) reforms in medical education "are seldom bold enough to depart from tradition and redefine the mission of medical education directly to address the needs of society today. Instead, educational changes are incremental ones, driven more by a need to keep up to date and to persuade funders (public and private) that something is changing." They list among factors that have militated against change "professional opposition, institutional obstacles, and government barriers."
I suggest that our medical schools have been slow to respond because they have been and continue to be internally driven. Medical schools have been operating within a paradigm according to which their methods of educating physicians, doing research and contributing to care in teaching hospitals are conceived as constituting a social good that will benefit the public. After all, faculty members spend a lot of time improving what they do in medical schools and know best how and where to use their energies and resources. Some faculty members do not agree that it is their job to respond to society's needs, and suggest that medical schools can avoid the problems presented by a disgruntled society and a stingy government by obtaining private support and funding to pursue their usual activities and research.
John H. Panabaker,(9) chairman of the Mutual Life Assurance Company of Canada and a member of the Corporate-Higher Education Forum, has articulately challenged universities to re-examine their internally driven approach; otherwise they must fear for their survival. The same applies to medical schools.
Thomas Kuhn,(10) the historian of science, talked about the need to shift paradigms to alter how we see things and how we behave in order to produce change. To use what has become an overworked phrase, medical schools need to make a "paradigm shift." They need to become socially responsible and socially responsive rather than driven from within. This is not a revolutionary concept, but it may take a revolution to put it into practice.
Medical schools grew, requiring large resources for their educational, research and clinical efforts. Exciting ventures in medicine, surgery, pharmacology and research impressed the public and decision-makers sufficiently to provide needed resources. These resources were never enough to keep up with opportunities for growth, but they certainly were greater than the support given to other areas of enterprise and, especially, other academic disciplines. The public, however, did not tend to see this allocation of funds as disproportionate, taking the view that an expensive, state-supported health institution should be in the forefront of public spending. Medical school faculty members are understandably uncomfortable with the suggestion that they take on all the concerns that society may raise. But perhaps they must share the responsibility for these concerns: if medical schools cannot solve a problem, they should support those who can. I am not suggesting that we medicalize all social problems, but simply that we recognize the impact of many social issues on health and ask ourselves "What can medical schools do to help?"
Society knows what it wants from physicians and the health care system. Medical professionals can no longer take the patronizing attitude that members of the public lack sufficient training and expertise to hold such opinions. People know that the health care system belongs to them and is paid for through their taxes; they feel that physicians, whose training is narrowly focused and who are bound up in their own specialties, may not be the best people to decide what the health care system should deliver. Patients have no trouble listing the qualities that should characterize physicians. They want well-trained, scientifically based physicians who are caring, empathetic and honest, who are good listeners, communicative, clear in their advice, honest, and willing to give their patients time, respect and support. But they often see a medical education system that concentrates on producing smart doctors and is unconcerned by doctors who are rude, insensitive, rushed, uncaring, inattentive and uncommunicative. Although this judgement may seem harsh, we all know physicians like that in our communities: we educated them and we graduated them.
Is assessing the needs and expectations of the public too big a job? The EFPO initiative made an excellent first run at this by asking many individuals, organizations, special-interest groups, government representatives and health care professionals what they expected of future doctors. The responses were very interesting: future physicians should fulfil the roles of expert, communicator, advocate, collaborator, educator, gatekeeper, learner, educator and person.(7)
It is also necessary to assess the nature of communities as well as the burden of illness and the challenges to healthy living they face. EFPO looked at the burden of illness in Ontario, and there are many examples of how this can be done elsewhere.(11) The possibility of developing health intelligence units in every medical school, as are now being developed in Ontario, is an exciting one that I hope will be taken up across the country. These units will be able to provide information on a continuing basis to direct action on curriculum development and research.
Although reasons can be brought forward to suggest that inviting public representatives to join decision- making groups such as faculty councils and curriculum committees may not be helpful or practical, I suspect that these objections would resemble those made in the 1960s to the suggestion that students have a voice in their education and be represented in faculty councils, committees and other decision-making bodies.
Moreover, as was found with student representatives 30 years ago, the mere presence of members of the public changes how the committee members think by prompting them to consider larger social concerns. Another benefit of including representatives of the public is that they in turn become strong advocates for the institution in the community.
Concern for other nations and their people is not entirely altruistic. Just as global interdependence has increased in the political and economic arenas, it is growing in health. Nations that aspire to better health cannot afford to ignore the public health problems of other nations. Patterns of disease in developing countries are beginning to resemble those in affluent populations. Threats include cardiovascular disease, cancer, environmental and occupational hazards, mental illness, accidents, substance abuse and violence. AIDS has no national boundaries, as much as governments might want to build such barriers and to hide prevalence rates.
It could be said that we have our own troubles these days, but this does not remove our responsibility toward other nations. We have a duty to assist health education systems abroad, and every Canadian medical school should have a major project in another country. To add to the wonderful slogan we used to hear so frequently, I would suggest that we think globally, act locally and, eventually, act globally as well.
The challenge is to move from our current paradigm, by which medical schools are driven from within, to a paradigm of social responsibility and social responsiveness. Some have told me that in this time of fiscal restraint we cannot meet this goal, however worthy it may be. But when resources are limited, it is even more important that we do things correctly and make our goals and directions clear. There is no consolation, when we are faced with limited resources and limited opportunities, in directing those limited resources inappropriately.
We have gone through many "ages" in medical schools in this century: the age of educational reform, the age of growth, the age of research and the age of consolidation. As Arnold Relman(13) has said, we are now in the age of accountability. Let us make the next age in our medical schools the age of social responsibility.