|Year : 2014 | Volume
| Issue : 1 | Page : 59-63
Why is it taking so long for healthcare professional education to become relevant and effective? What can be done?
Jean-Jacques Guilbert MD, PhD
Honorary Member of The Network: TUFH, Educational Consultant, Geneva, Switzerland
|Date of Web Publication||11-Jun-2014|
Dr. Jean-Jacques Guilbert
15 avenue du Mail, CH-1205 Geneva
Source of Support: None, Conflict of Interest: None
For about a half century the World Health Organization (WHO), supported by the literature in the field of health personnel education, has argued for the benefits of a learner-centered and community-oriented approach to professional education. Nevertheless, change has not happened in the vast majority of schools and countries. This paper describes the obstacles and constraints to change in health professional education: Obsolete administrative rules, the low profile of public health, the lack of real decision power of faculty, a dearth of faculty trained in the field of education, the arbitrary separation between so-called basic sciences and clinical practice, the disciplinary orientation of learning objectives, a lack of explicit definition of desirable professional competencies, and, above all, too little value placed on the evaluation of educational programs. The recent literature continues to argue for change but action does not follow. Only very few training institutions currently put newer approaches into practice. The university culture remains an environment that stifles change.
Keywords: Administrative rules, basic sciences, clinical practice, evaluation, faculty decision power, learning process, professional competencies, administrative rules, faculty decision power, evaluation
|How to cite this article:|
Guilbert JJ. Why is it taking so long for healthcare professional education to become relevant and effective? What can be done?. Educ Health 2014;27:59-63
For about half a century, authors publishing within medical education journals have presented principles, concepts and methods for improving the relevance and effectiveness of the education of physicians and other health personnel. This thrust in the literature started in the early 1960s, thanks to two teachers, Georges E. Miller and Stephen Abrahamson, who were, respectively, a clinician and an educator at the University of Buffalo (New York). Their new school of thought opened a field of research in education within the health professions at a time before most of today's university teachers were born. Their fundamental innovation was to emphasize the importance of the learning process being under the control of the student and with the teacher's help. This was quite different from the situation of their time and remains so today: health professions educators predominantly focus on teaching. Miller and Abrahamson's approach also emphasized the emotional factors that influence learning. Their innovative theoretical concepts remain valid today. 
When Miller and Abrahamson wrote, the concept of the relevance of health professions education had not yet appeared. The relevance of health professions education to the health needs and demands of the population appeared later on. It is the basis of the WHO 'Health for All' policy presented at the World Assembly in May 1976 by H. Mahler, then Director General of WHO, and subsequently approved as Resolution WHA 29/72.  The World Federation for Medical Education confirmed these guidelines in the Declaration of Edinburgh (1988).  Despite numerous supportive articles and publications, ,,,, the concept of relevance still remains to be implemented in most health personnel education institutions.
These guidelines are now no longer revolutionary. They are today used by convincing speakers, from one conference to the next congress, across all latitudes. The principles of the relevance of health professions education are almost 'fashionable'; it is trendy to extol their benefits during coffee-breaks of medical congresses. Nevertheless, among the more than 1600 medical schools and tens of thousands of schools training other health personnel worldwide, very few have yet implemented these principles.
Faculties, which have succeeded in introducing 'innovations' along these lines, sometimes publish information on their programs in academic journals. But they rarely explain how they overcame obstacles so that their programs survived despite the many hurdles they surely faced. The process of successful change remains a mystery to readers and is simply ignored by most of their younger colleagues. And most of those who were not successful in their attempts to introduce educational innovations do not publish their failures even though others would benefit from learning of their unsuccessful attempts to overcome obstacles and deal with constraints.
The goals of this paper are to present the obstacles and constraints to making fundamental changes in health professions education, and then make recommendations.
An analysis of the ministerial health professions regulations in countries around the world concerning national curricula and certification exams reveals the obstacles on the path to relevance to population health problems. It finds first that the evaluation process is the weakest element of the full education process. Ministerial regulations are, in many countries, expected to be applied by each school. Such a centralized approach in controlling schools and practitioner outcomes is an obstacle to any attempt at educational curricular experimentation by individual schools.
Of course it is expected that certification tests will assess relevant professional competences of practitioners. A centralized approach is meant to protect the population against incompetent health practitioners. Relevant professional competencies could be assessed centrally for all schools in a community of states. But centralized ministerial regulations are typically silent on such relevant professional competencies as the acceptable level of performance of graduates.  In too many cases, final certification exams only verify learners' success in memorizing isolated factual information. They do not verify their 'professional competencies' performance (intellectual skills, sensory-motor skills and interpersonal communication skills).
For about 40 years, the WHO has recommended the construction of lists of professional competencies relevant to the specific needs of countries  but one had to wait until the Dutch "Blueprint 1994"  was published for guidance. Since then professional profiles for other health professions have been proposed in Europe. The International Federation of Medical Students Associations (IFMSA) produced "The students" perspective at the Bristol Conference on the Bologna process.  In Italy, lists were published for nurses,  physiotherapists,  health educators  and dieticians.  In 2001, a Joint Commission of the Swiss Medical Schools worked from the Dutch Blueprint and published a Catalogue of Learning Objectives for Undergraduate Medical Training. 
As a second obstacle to innovation in health professions education, medical schools and other health personnel training institutions, like many other administrative organizations, are organized in a hierarchical structure. The current basic structure of medical schools dates back to the European medieval period. Even though the structure of health professions educational institutions is not that of a typical military hierarchy, during official ceremonies uniforms are worn with a chromatic indication of rank. As in a commercial enterprise, the "boss" (e.g. the dean, director) is elected or appointed for a limited period, sometimes renewable, between 2 and 5 years. This is too short a period to make fundamental changes in the organization. Leaders in these types of organizations are often chosen because they are known for not making too many waves or favoring great changes. Deans often have no personal agenda, or if they have one it remains unstated or expressed in politically correct and artistically vague language. They are rarely trained in the science of education or in business management. Sometimes they are the oldest, and almost always closer to retirement age than the rest of the faculty. They are surrounded by a small staff not specifically trained to implement strategies for change. Their power to act is generally limited by numerous government and internal regulations.
Some leaders in academic health professions organizations are motivated for change and have a real program with innovative ideas. The lucky ones are supported by a Dean's Council and by their students. Those that will be successful have extensive experience, skills in educational planning, the qualities of a leader and a reputation as a researcher. Leaders in these favorable settings are rare, which explains in part why real change in health professions education is rare too. A few leaders have reported how they overcame obstacles and succeeded despite constraints ,,,, or have described a failure to affect change.
A policy for change, when there is one, is typically stated in inaugural speeches in politically correct and general terms. This policy usually includes the wish to "meet the needs and problems of population health". Can you imagine hearing a declaration to the contrary? How, then, is it that this fundamental orientation for schools is so seldom reflected in their educational objectives, teaching methods and evaluations?
The answer starts with a lack of clear and relevant goals for the expected changes and lack of resources (personnel, facilities and budget) applied to make change happen. By agreeing to devote time and effort to clarifying relevant goals (e.g. producing graduates with professional competencies promoting the health of the population), schools must avoid prematurely introducing curricular changes that prove to be insufficiently related to the end objectives. For example, creating educational programs to "train family physicians" or "train public health nurses" who will work in the community to serve population needs may not meet a university hospital's objective to serve population needs. The ability of an organization to evaluate its effectiveness and attainment of goals is hampered when targets have not been explicitly expressed and presented for endorsement by the faculty. In such cases, an organization is likely to make ritual decisions, rational in appearance but in reality not based on a sound and ultimately successful processes.
Problems stemming from the separation between basic sciences and clinical practice will continue to plague health professions education as long as there are teachers from differing backgrounds and training, with different point of views reflecting their different experiences and interests. To a question like "Is too much curriculum time given to the basic sciences?", basic science faculty generally do not provide objective data to support their common position asking for more time. They advocate for the importance of "scientific thinking", which they feel their courses will provide to students. I personally agree with the importance of scientific thinking, if this means that students' and physicians' decisions will be coherent with the principles of basic sciences. But more often basic scientists simply defend their territory within the curriculum. Their anisognosy (deficit of self awareness) keeps them from realizing that they suffer from "an overwhelming desire to cover a teaching subject exhaustively" (coveritis), which wrongly focuses on the quantity of information taught rather than its relevance. 
In addition to the problem of the quantity of curricular time devoted to the basic sciences, there is the question of when such learning is most useful for students. It is occupying most of the first two years in the curricula of most schools delays and reduces students' formative contact with practitioners and learning from real practice situations. Further, the prevalence of the lecture method of teaching impedes the acquisition of scientific thinking.  It leads students to memorize facts of each subject field. Students know that their exams will principally measure the degree to which they have memorized facts in the basic science subjects rather than their ability for scientific thinking. From the first day and throughout the curriculum, students should be confronted with health problems in real clinical situations, with real patients and healers. Through a gradual problem solving process, they would have to justify to the faculty, who might or might not be a basic scientist, the coherence of their intended professional actions about the case with the principles and concepts of the basic sciences.  Basic science faculty generally remains deaf to such proposals for change.
Training institutions have a range of sometime conflicting goals in patient care, teaching and research, which often compete for funds, personnel and space. The culture and environment of universities are such that the intentions of programs are often not explicitly revealed. Programs within academic health centers rarely overtly state their goals and concrete objectives, as goals for one program can be quite different and even threatening to the goals of another. To avoid confrontation, educational goals are generally not expressed in clear and measurable terms.
The lack of clarity in program goals is largely responsible for the poor correlation between educational objectives and strategies. The situation is further complicated by the lack of consensus on the choice of theories considered best in guiding the direction of curricular change. In general, training institutions arrive at program changes through committees. Members are appointed on the principle of representation by subject or department. For a broadly representative committee, attempts to integrate the curriculum may be seen as a threat to the independence of the departments. The traditional and closely guarded autonomy of departments and their broad inclusion on curriculum committees then inhibits the process of evolution in the curriculum for the benefit of students and education.
Often students complain that the curriculum is too full and overloaded, and that the content is poorly cast for the ultimate-and usually not defined-goal of their studies. This is a symptom of "curriculitis".  Individual teachers recognize that the curriculum could be better organized but they do not work for improvement, having learned that to spend time on educational initiatives rather than research and clinical activities reduces their chances for career advancement.
Another major constraint to fundamental change in health professions education is that teachers are rarely trained in the science of education. When hired, no one checks if they know how to devise strategies for change or how to teach. It is not surprising then, that the notion that training of health personnel should be oriented toward the health needs of populations does not come naturally to teachers as they design training programs. They often do not feel the need, as they prepare curricula, to be guided by more experienced educators. Teachers and students are generally accustomed to the classic process of education wherein the idea of facilitating self-learning is foreign. They fear a problem-based curriculum might mean that students will not be exposed to some portions of a topic. A fairly common sentiment from students: "What worries me in the use of a problem solving approach is the idea that there may be holes in my knowledge and skills…so that the current system by classroom conferences is very systematic and covers (I hope) all the knowledge to have".  It seems that students, like their teachers, suffer from "coveritis".  When these students finally graduate and become teachers themselves, they do not then seem to realize that when they obtained their diplomas that no one had validly measured their professional competence level.
Concerning the list of professional competencies (professional profile), students might reasonably think that their explicit definition would lead to change for the better in their education. But teachers feel that if professional competencies are explicitly defined it "will undermine the freedom to teach (.) lead to a 'low level' approach and transform the University into vocational schools", even if these teachers never explain which essential "qualities" of the university are absent from 'vocational schools'. 
Another central problem is the "system" itself, or the "university culture".
"It is not the teachers who are at fault. It is the system! Teachers behave in conformity with the rules of the system. The System anoints them with the title of teachers, as professors, and recruits them to teach. Then they realize that the success of their careers in the system will depend on their work as a clinician or researcher and that they will be judged by their peers in terms of their scientific publications. The reality is that the system penalizes them if they spend time preparing their teaching and to teach. And if they express criticism against the system they run the risk of being ejected from the system". 
In the academic medical world it is well known that it is profitable to build a career on the basis of clinical expertise and scientific publications. Having one's interests in education become known to colleagues is professional suicide. Even for committed teachers, there is no career advantage to devote time to the education field.
There is an old saying that "There is none as deaf as he who will not hear". Readers of the healthcare professional education literature are generally not those who most need to read these publications. In "Education for Health", the persuaded talk to the believers. At the annual education congress we sing "old war songs" to reassure ourselves. The lyrics of speakers warm the room. In long speeches we hear a great boss defend a 'holistic approach' to education, while he may not even try to explain what has prevented him from using his power to implement this approach in the school that he has led for many years and which remains on a traditional path. Other performers impress by their eloquence and their philosophic and literary high-culture. They speak of 'epistemological humility' without taking the trouble to define what that means. Americans do not fail to praise Florence Nightingale and, even more, Abraham Flexner, whose legacy is the harmful separation between basic sciences and clinical practice. The vagueness and smoky jargon of their messages prevent the most attentive listeners from seeing how some are firmly opposed to the approach sung by the choirs of convinced believers. They enjoy raising "students at the highest possible level of meta-knowledge". They scatter their texts with frequent references to "epistemology". They stigmatize their opponents by marking them with negative labels ("behaviorist"; "Skinnerian"), which is a form of intellectual racism. They condemn their adversaries for their "excessive rigor in a desire to evaluate everything".They stress "the pleasure of thinking" and wish that their students "celebrate their own feelings". 
Of course I always did and still enjoy "the pleasure of thinking". I prefer that my students "think before acting". Do not tell anyone, but I even once wrote a book on 'metacognition'.  But I cannot tolerate that the traditionalist authorities referenced in the paragraph above remain silent in the face of the low validity of the examinations that they still use with students. It is not ethically acceptable to take the excuse that "all is not quantifiable or measurable" and that "everything is not definable". My priority is what the health personnel 'do' (and how they 'do' it in a humane manner, respectful of the values of the patient) and not what these authorities 'think'. 
If, in absolute terms, "all is not quantifiable" it is also true that there are enough skills that are observable, and therefore measurable. All 'patients', our fellow citizens, should be protected by certification exams that validly assess students. The evaluation systems found in most training institutions lack validity: The exams do verify students' memory for facts (saper), but hardly ever their metacognition and almost never their performance of professional competencies (that remain undefined). Too many authors speak more often of 'knowledge' rather than of 'competence'. A focus on professional competencies would imply defining an 'acceptable level of performance' in three areas: Intellectual skills (use of knowledge), sensory-motor skills and interpersonal communication skills (with patients and colleagues in the health care team).
The following are my recommendations for courageous and charismatic deans interested in making fundamental reforms in the educational processes of their schools:
- Construct a set of evaluation tools (to be divided into two equal parts, one for training and the other to be used for certification) capable of measuring, with an adequate level of validity the performance of the professional competencies
- Make the first half freely available to students for formative evaluation purposes
- Use the second half as a certification test to check the gain in professional competencies of students between their university entrance and the end of their basic program of studies. Success on this certification test gives students the right to sit for a later national examination and to continue on to postgraduate training. Use this procedure until national exams do measure professional competencies validly. National exam should be retaken at specified intervals (like recertification for pilots: Safety first!)
- Let teachers teach "what" and "how", according to their choice
- Identify learning sites for observation and practice (placements in the community, in facilities outside hospitals and within hospitals) where students are supervised during their activities (diagnostic skills, treatment, promotion of health, prevention, rehabilitation, research, etc.)
- Allow students the freedom to use or not the proposed teaching program and freely choose among learning sites, taking into account their performance through formative assessments tests and until they have demonstrated mastery of competencies identical to those that will be tested on certification tests.
I advise the dean to take the elementary precautions to start by forming a congenial team of colleagues and to share his/her views with them. They would then assist in the many choices to be made in the reorientation of the education processes and their implementation. And, of course, the 'teaching skills' of these colleagues deserve due attention in order to provide an efficient collaboration.
| Acknowledgment|| |
The author wishes to acknowledge, with thanks, Professor Donald Pathman for his editorial assistance.
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