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Contemporary Medical Training And Societal Medical Requirements – How Does One Balance The Manifest Need for General Practitioners With Modern Super-Specialist Trends

For all of my career, since starting as a medical student at the University of Cape Town as an 18 year old fresh out of school many years ago, I have been involved in the medical and health provision and training world, and have had a wonderful career first as a clinician, then as a research scientist, then in the last number of years managing and leading health science and medical school research and training. Because of this background and career, I have always pondered long and hard about what makes a good clinician, what is the best training to make a good clinician, how we define what a ‘good’ clinician is, and how we best align the skills of the clinicians we train with the needs and requirements of the country’s social and health environments in which they trained. A few weeks ago I had a health scare which was treated rapidly and successfully by a super-specialist cardiologist, and I was home the next day after the intervention, and ‘hale and hearty’ a few days after the procedure. If I had lived 50 years ago, and it had happened then, in the absence of modern high-tech equipment and the super-specialists skills, I would probably have died a slow and uncomfortable death treated with drugs of doubtful efficacy that would not have much benefited me much, let alone treat the condition I was suffering from. Conversely, despite my great respect for these super-specialist skills which helped me so successfully a few weeks ago, it has become increasingly obvious that this great success in clinical specialist training has come at the cost of reduced emphasis on general practitioner-focused training, and a reduction in the number of medical students choosing general practitioner work as a career after they qualify, which has caused problems both to clinical service delivery in a number of countries, particularly in rural areas of countries, and paradoxically put greater strain on specialist services despite their pre-eminence in contemporary clinical practice in most countries around the world. My own experience with grappling with this problem of how to increase general practitioners as an outcome of our training programs, as a Head of School of Medicine previously, and this recent health scare which was treated so successfully by super-specialist intervention, got me thinking of how best we can manage the contradictory requirements of the need for both general practitioners and specialists in contemporary society, and whether this conundrum should be best managed by medical schools, health and hospital management boards, or government-led strategic development planning initiatives.

It is perhaps not surprising, given the exponential development of technological innovations that originated in the industrial revolution and which changed how we live, that medical work also changed and became more technologically focused, which in turn required both increased time and increased specialization of clinical training to utilize these developing technologies, such as surgical, radiology investigative and laboratory-based diagnostic techniques. The hospital (Groote Schuur) and medical school (University of Cape Town) where I was trained was famous for the achievements of Professor Chris Barnard and his team’s work performing the first heart transplant there, using a host of advanced surgical techniques, heart-lung machines to keep the patients alive without a heart for a brief period of time, and state-of-the-art immunotherapy techniques to resist heart rejection, all specialist techniques he and his team took many years to master in some great medical schools and hospitals in the USA. Perhaps in part because of this, our training was very ‘high-tech’, consisting of early years spent learning basic anatomy, physiology and pathology-based science, and then later years spent in surgical, medical, and other clinical specialty wards, mostly watching and learning from observation of clinical specialists going about their business treating patients. If I remember it correctly, there were only a few weeks of community-based clinical educational learning, very little integrative ‘holistic’ patient-based learning, and almost no ‘soft-skill’ training, such as optimal communication with patients, working as part of a team with other health care workers such as nurses and physiotherapists, or learning to help patients in their daily home environment and social infrastructure. There was also almost no training whatsoever in the benefits of ‘exercise as medicine’, or of the concept of wellness (where one focuses on keeping folk healthy before they get ill, rather than dealing with the consequences of illness). This type of ‘specialist-focused’ training was common, particularly in Western countries, for most of the last fifty or so years, and as a typical product of this specialist training system, for example, I chose first clinical research and then basic research rather than more patient-focused work as my career choice, and a number of my colleagues from my University of Cape Town medical training class of 1990 have had superb careers as super-specialists in top clinical institutions and hospitals all around the world.

This increasing specialization of clinical training and practice, such as the example of my own medical training described above, has unfortunately had a negative impact both on general practitioner numbers and primary care capacity. A general practitioner (GP) is defined as a medical doctor who treats acute and chronic illnesses and provides preventative care and health education to patients, and who has a holistic approach to clinical practice that takes all of biological, social and psychological factors into consideration when treating patients. Primary care is defined as the day-to-day healthcare of patients and communities, with the primary care providers (GP’s, nurses, health associates or social workers, amongst others) usually being the first contact point for patients, referring patients on to specialist care (in secondary or tertiary care hospitals), and coordinating and managing the long term treatment of patient health after discharge from either secondary or tertiary care if it is needed. In the ‘old days’, GP’s used to work in their community often where they were born and raised, worked 24 hours a day as needed, and maintained their relationship with their patients through most or all of their lives. Unfortunately, for a variety of reasons, GP work has changed, and they now often work set hours, patients are rotated through different GP’s in a practice, and the number of graduating doctors choosing to be GP’s is diminishing, and there is an increasing shortage of GP’s in communities and particularly rural areas of most countries as a result. Sadly, GP work is often regarded as being of lower prestige than specialist work, the pay for GP’s has often been lower than that of specialists, and with the decreased absolute number of GPs, the work burden on many GP’s has increased (and paradoxically with computers and electronic facilities the note and recording taking requirements of GP’s appears to have increased rather than decreased) leading to increased level of burnout and GP’s choosing to turn to other clinical roles or to leave the medical profession completely, which exacerbates the GP shortage problem in a circular manner. Training of GP’s has also evolved into specialty-type training, with doctors having to spend 3-5 years ‘specializing’ as a GP (often today called Family Practitioners or Community Health Doctors), and this also has paradoxically potentially put folk off a GP career, and lengthens the time required before folk intent on becoming GP’s can do so and become board certified / capable of entering or starting a clinical GP practice. As the number of GP’s decrease, it means more folk go directly to hospital casualties as their first ‘port of call’ when ill, and this puts a greater burden on hospitals, which somewhat ironically also creates an increased burden on specialists, who mostly work in such hospitals, and who end up seeing more of these folk who could often be treated very capably by GP’s. This paradoxically allows specialists less time to do the specialist and super-specialist roles they spent so many years training for, with the result that waiting list and times for ‘cold’ (non-emergency) cases increases, and hospital patient care suffers due to patient volume overload.

At a number of levels of strategic management of medical training and physician supply planning, there have been moves to counter this super-specialist focus of training and to encourage folk to consider GP training as an appealing career option. The Royal College of Physicians and Surgeons of Canada produced a strategic clinical training document (known as the ‘CanMeds’ training charter) which emphasizes that rather than just training pure clinical skills, contemporary training of clinical doctors should aim to create graduates who are all of medical experts, communicators, collaborators, managers, health advocates, scholars and professionals – in other words a far more ‘gestalt’ and ‘holistically’ trained medical graduate. This CanMeds document has created ‘waves’ in the medical training community, and is now used by many medical schools around the world now as their training ‘template’. Timothy Smith, senior staff writer for the American Medical Association, published an interesting article recently where he suggested that similar changes were occurring in the top medical schools in the USA, with clinical training including earlier exposure to patient care, more focus on health systems and sciences (including wellness and ‘exercise is medicine’ programs), shorter time to training completion and increased emphasis on using new communication technologies more effectively as part of training. In my last role as Head of the School of Medicine at the University of the Free State, working with Faculty Dean Professor Gert Van Zyl, Medical Program Director Dr Lynette Van Der Merwe, Head of Family Medicine Professor Nathanial Mofolo, Professor Hanneke Brits, Dr Dirk Hagemeister, and a host of other great clinicians and administrators working at the University or the Free State Department of Health, the focus on the training program was shifted to try to include a greater degree of community based education as a ‘spine’ of training rather than as a two week block in isolation, along with a greater degree of inter-professional education (working with nurses, physiotherapists, and other allied health workers in teams as part of training to learn to treat a patient in their ‘entirety’ rather than as just a single clinical ‘problem’), and an increased training of ‘soft skills’ that would assist medical graduates not only with optimal long term patient care, but also with skills such as financial and business management capacity so that they would be able to run practices optimally, or at least know when to call in experts to assist them with non-clinical work requirements, amongst a host of other innovative changes. We, like many other Universities, also realized that it was important to try and recruit medical students from the local communities around the medical school in which they grew up, and to encourage as many of these locally based students as possible to apply for medical training, though of course selection of medical students is always a ‘hornets nest’, and it is very challenging to get it right balancing marks, essential skills and community needs of the many thousands of aspirant clinicians who wish to do medicine when so few places are available to offer them.

All of these medical training initiatives to try and initiate changes of what has become a potentially ‘skewed’ training system, as described above, are of course ‘straw in the wind’ without government backing and good strategic planning and communication by country-wide health boards, medical professional councils, and hospital administrators who manage staffing appointments and recruitment. As much as one needs to change the ‘focus’ and skills of medical graduates, the health structures of a country need to be similarly changed to be ‘focused’ on community needs and requirements, and aligned with the medical training program initiatives, for the changes to be beneficial and to succeed. Such training program changes and community based intervention initiatives have substantial associated costs which need to be funded, and therefore there is a large political component to both clinical training and health provision. In order to strategically improve the status quo, governments can choose to either encourage existing medical schools to increase student numbers and encourage statutory clinical training bodies to enact changes to the required medical curriculum to make it more GP focused, or build more medical schools to generate a greater number of potential GP’s. They can also pay GP’s higher salaries, particularly if they work in rural communities, or ensure better conditions of service and increased numbers of allied health practitioners and health assistants to lighten the stress placed on GP’s, in order to ensure that optimal community clinical facilities and health care provision is provided for. But, how this is enacted is always challenging, given that different political parties usually have different visions and strategies for health, and changes occur each time a new political party is elected, which often ‘hinders’ rather than ‘enacts’ required health-related legislation, or as in the case of contemporary USA politics, attempts to rescind previous change related healthcare acts if they were enacted by an opposition political party. There is also competition between Universities which have medical schools for increases in medical places in their programs (which result in more funding flowing in to the Universities if they take more students) and of course any University that wishes to open a new medical school (as my current employers, the University of Waikato wish too, and who have developed an exciting new community focused medical school strategic plan that fulfills all the criteria of what a contemporary focused GP training program should be, that will surely become an exemplary new medical school if their plan is approved by the government) is regarded as a competition for resources by those Universities who already run medical training programs and medical schools. Because of these competition-related and political issues, many major health-related change initiatives for both medical training programs and the related community and state structural training requirements are extremely challenging to enact, and are why so many planned changes become ‘bogged down’ by factional lobbying either before they start or when they are being enacted. This is often disastrous for health provision and training, as chaos ensues when a ‘half-changed’ system becomes ‘stuck’ or a new political regime or health authority attempts to impose further, often ‘half-baked’ changes on the already ‘half-changed’ system, which results in an almost unmanageable ‘mess’ which is sadly often the state of many countries medical training, physician supply, and health facilities, to the detriment both of patients and communities which they are meant to serve and support.

The way forward for clinical medical training and physician supply is therefore complex and fraught with challenges. But, having said this, it is clear that changes are needed, and brave folk with visionary thinking and strategic planning capacity are required to both create sound plans that integrate all the required changes across multiple sectors that are needed for the medical training changes to be able to occur, and to enact them in the presence of opposition and resistance, which is always the case in the highly politicized world of health and medical training. Two good examples of success stories in this field were the changes to the USA health and medical training system which occurred as a result of the Flexner report of 1910, which set out guidelines for medical training throughout the USA, which were actually enacted and came to fruition, and the development of the NHS system in the UK in the late 1940’s, which occurred as a result of the Beveridge report of 1942, which laid out how and why comprehensive, universal and free medical services were required in the UK, and how these were to be created and managed, and these recommendations were enacted by Clement Attlee, Aneurin Bevin and other members of the Labour government of that time. Both systems worked for a time, but sadly both in the USA and UK, due to multiple reasons and perhaps natural system entropy, both of these countries health services are currently in a state of relative ‘disrepair’, and it is obvious that major changes to them are again needed, and perhaps an entire fresh approach to healthcare provision and training similar to that initiated by the Flexner and Beveridge reports are required. However, it is challenging to see this happening in contemporary times with the polarized political status currently occurring in both countries, and strong and brave health leadership is surely required at this point in time in these countries, as always, in order to initiate the substantial strategic requirements which are required to either ‘fix’ each system or create an entirely new model of health provision and training. Each country in the world has different health provision models and medical training systems, which work with varying degrees of success. Cuba is an example of one country that has enacted wholesale GP training and community medicine as the centerpiece of both their training and health provision, though some folk would argue that they have gone too far in this regard in their training, as specialist provision and access is almost non-existent there. Therein lies an important ‘rub’ – clearly there is a need for more GP and community focused medical training. But equally, it is surely important that there is still a strong ‘flow’ of specialists and super-specialists to both train the GP’s in the specific skills of each different discipline of medicine, and to treat those diseases and disorders which require specialist-level technical skills. My own recent health scare exemplifies the ‘yin and yang’ of these conflicting but mutually beneficial / synergistic requirements. If it were not for the presence of a super-specialist with exceptional technical skills, I might not be alive today. Equally the first person I phoned when I noted concerning symptoms was not a super-specialist, but rather was my old friend and highly skilled GP colleague from my medical training days, Dr Chris Douie, who lives close by to us and who responded to my request for assistance immediately. Chris got the diagnosis spot on, recommended the exact appropriate intervention, and sent me on to the required super-specialist, and was there for me not just to give me a clinical diagnosis but also to provide pastoral care – in other words ‘hold my hand’ and show me the empathy that is so needed by any person when they have an unexpected medical crisis. In short, Chris was brilliant in everything he did as first ‘port of call’, and while I eventually required super-specialist treatment of the actual condition, in his role as GP (and friend) he provided that vital first phase support and diagnosis, and non-clinical empathic support, which is so needed by folk when they are ill (indeed historically the local GP was not just everyone’s doctor but also often their friend). My own example therefore emphasizes this dual requirement for both GP and specialist health provision and capacity.

Like most things, medical training and health care provision has like a pendulum ‘swung’ between specialist and generalist requirements and pressures in the last century. The contemporary perception, in an almost ‘back to the future’ way, is that we have perhaps become too focused on high technology clinical skills and training (though as above there will always be a place and need for these), and we need more of our doctors to be trained to be like their predecessors of many years ago, working out in the community, caring for their patients and creating an enduring life-long relationship with them, and dealing with their problems early and effectively before they become life-threatening and costly to treat and requiring the intervention of expensive specialist care. It’s an exciting period of potential world-wide changes in medical training and the clinical health provision to communities, and a great time to be involved in either developing the strategy for medical training and health provision and / or enacting it – if the folk involved in doing so are left in peace by the lobby groups, politicians and folk who want to maintain the current unbalanced status quo due to their own self-serving interests. Who knows, maybe even clinicians, like in the old days, will be paid again by their patients with a chicken, or a loaf of freshly baked bread, and goodwill will again be the bond between the community, the folk who live in them, and the doctors and healthcare workers that treat them. And for my old GP friend Chris Douie, who is surely the absolute positive example and role model of the type of doctor we need to be training, a chicken will heading his way soon from me, in lieu of payment for potentially saving my life, and for doing so in such a kind and empathetic way, as surely any GP worth his or her ‘salt’ would and should do!


A Career in Medicine – The Sisyphus Paradox

Our new first year Medicine students attended their welcome ceremony at our University yesterday, and it was wonderful to witness and experience their excitement at starting studying the career of their dreams. Watching them and being involved in the ceremony got me thinking about medicine as a career, and I was reminded of an excellent piece of philosophical writing published at the time I was training to be a medical doctor myself, by Professor Johan Koeslag, a Physiology Professor at the University of Cape Town whose teaching had a profound positive effect on me. In this article he compared a career in medicine to the Myth of Sisyphus, with the role of clinician being likened to that of Sisyphus in the myth.

In Greek Mythology, Sisyphus, who was King of Ephyra (modern day Corinth), attempted to cheat death, and for this and other roguish behaviour he exhibited during his reign as king, Zeus punished him by forcing him to roll a heavy boulder up to the top of a hill. Each time he reached the top of the hill, the boulder rolled down again, and the task had to be repeated continuously for eternity. Therefore, Zeus by this punishment had consigned Sisyphus to performing what was an inherently useless action for eternity, the goal of which was to create an eternity of frustration for the miscreant Sisyphus. With time the Myth of Sisyphus became representative of any activity that is inherently pointless, repetitive and interminable. An analogy was drawn by Johan from this to the daily work of a medical doctor, namely that no matter what a clinician does, they can never ‘cheat death’ / permanently cure anyone, as even if they cure a patient of one disease, they will eventually die of something else. From this perspective, if saving life is the job description of a clinician, then medicine must represent the ultimate failure as a profession, with a one hundred percent long term mortality and therefore failure rate. As in the Myth of Sisyphus, clinicians are thus caught in an absurdist paradigm, as they are ‘saving’ people to face certain death. In his article Johan described this as the Sisyphus Paradox of Medicine, namely that because they wage a losing battle against death in all those that they treat, all clinicians resemble Sisyphus, eternally condemned to perform an impossible task in a repetitive manner until their own point of eternity, or to be more moderate, their retirement day.

This may sound a somewhat depressing view of medicine, but Johan did not stop there. He (and others who have taken forward these ideas) then went on to clarify what clinicians should do to maintain ‘faith’ while having awareness of this Sisyphus paradox in their daily working life. He suggested that clinicians need to accept this perspective, and understand that their ‘lot in life’ is to maintain commitment to their work, and to their patients, even with this awareness of its ultimate futility, and by doing so they would make themselves as clinicians more balanced and more close to their own state of perfect grace. Second, the clinician would need to focus more on creating a pain or illness free environment for their patients, to the best of the clinician’s ability. While there may be a teleological reason for pain and suffering, possibly in the context of learning some perspective or self-understanding that would not occur in pain-free routine existence, there would clearly be comfort produced in a clinician’s patients by reduction of their pain and suffering, even if at some point in the future the patient’s death is inevitable. Thirdly, there would perhaps be benefit in clinicians incorporating scientific analysis into their work life, in order to try and understand better (if possible) such difficult concepts as ‘life’ or ‘death’. Science, as opposed to medicine, philosophy or theology, is likely to be the only method we have which can potentially explain such complex issues as life and death in a ‘material’ manner, or at least the physiological and anatomical mechanisms related to these ‘big’ concepts. Fourthly, and finally, clinicians perhaps need to concern themselves more with educating their patients on the certainty of death, in order to better prepare them for this inevitability. In modern times death and dying are almost ‘taboo’ subjects, and death occurs usually ‘behind closed doors’, which may in effect be creating an increased fear of death and dying either due to ignorance or avoidance of the issue. if clinicians educated patients (and healthy individuals) about their own inevitable mortality, and that dying is in itself the culmination of life, however paradoxical this observation may be, they may potentially remove their patients fear of death, or at least make them be more comfortable with their own dying, when their time eventually comes, as it does for all of us.

So watching those folk yesterday at the start of their medical careers, with my own awareness of the Sisyphus paradox inculcated in me by Johan’s thought-provoking work, that would likely be an absolute contradiction to the inherent reason most of them probably chose medicine as their preferred career choice, I wished them luck on their own clinical journey, and hoped that by working daily rolling their own ‘boulder up the hill’ in a never-ending way, that they would all eventually understand the Sisyphus nature of their work, and by doing so attain their own state of perfect grace, and become the best doctor they can be, doing medicine for the right reasons in the best possible way.

Technology and the University Environment

Seeing our medical students graduate earlier this week, and reading a Tweet later that evening from a University advertising a one year online Masters, got me thinking again of something which has been a lot on my mind lately, namely what the role and benefits of technology are in the University environment. Mirroring the changes to our daily life caused by the advent and astonishing growth and proliferation of first computers and then personal electronic devices, along with the associated internet and electronically interactive features they carry, these computer related and technology led developments have in many way enhanced the way we do business in the University environment. Beyond most of our daily communication being performed using email and other means of internet communication (such as this blog!), there is now a proliferation of purely online courses available at most Universities, and discussion of the benefits and need to embrace potential current and future developments such as flipped classrooms and massive open online courses (MOOCs) occupies a significant portion of our daily debate in University education management discussions.

There are obvious benefits to all of these developments, for example University learning can be extended to a greater number of students, a paperless environment is both cost-effective and more environmental friendly, and there is enhanced capacity to have uniformity and quality assurance of teaching material – these ‘online’ educational developments would ‘banish’ the day of the eccentric Professor giving a rambling lecture on on topic no-one in lecture room could understand, and on a topic that was not completely relevant to the core learning requirements of the course that the lecture was being given for.

But in this concept and example of ‘banishing’ the rambling eccentric Professor lies the paradox and inherent concern raised from this future utopian electronic, online environment for Universities in the future, that forcibly struck me when I was watching the students at their graduation ceremony, and in particular the smiles on the faces of each of them, as they got their degrees and diplomas, and the vocal jubilation of the parents when they children were walking accross the stage – that what University environments are also for is developing the human dynamic in both students and in those prileged to work with them as lecturers and teachers. I don’t believe the memories of those students walking accross the stage on Thursday in a few years time will be of the time spent in their rooms staring at their lecture notes or electronic lectures on their laptop. Surely these times were crucially important for them to develop their technical knowledge as required by the course they registered for. But, what they will remember, and perhaps as important for their own personal development, will be the memories of the physical time spent on the campus of the University they went to – sitting around on the grass in summer commiserating with each other on how hard it was to understand that eccentric Professor in the lecture that just happened, the time their student group sat together and went through their notes together to pass exams, the role model clinical doctor who inspired them with his or her bedside lecture on the causes of lung cancer, and perhaps more importantly, the effect of the cancer on the patient and how this also needed to be thought of and managed (such great teachers would surely become future positive role models for them), and all the fun and social times one has as a student during ones years physically on campus – jumping into the campus fountain during Freshers week, cheering on the medical student rugby team on inter-varsity sport day, or heck, maybe even that first cup of coffee in the medical school cafeteria with the person that would eventually become their life partner.

So perhaps like in every component of life and society, balance is everything, and while as Universities we need to embrace and use technological development to enhance our teaching and learning practice, we also need to perhaps remember the human development side which has the potential to occur on campus in our students, and make sure we maintain a University environment where not only students develop the technical skills which will be vital for their future success in their chosen career, but also an environment where personal and social skills are developed either formally or informally, with memories created of a unique period of their life that will serve them well in the challenges they face in their future workplace and social milieu, which will almost certainly not be only technically related.

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