A Call to Define the New Clinician for a New Century
The health professions are currently facing enormous pressure to adapt to a rapidly evolving society. Don Berwick’s “three eras” paradigm describes how this dilemma is influencing medicine. Berwick’s era 1, which is no longer present, evoked the paternalistic, self-regulating image of the profession dating back to Hippocrates. We have since progressed to era 2, a measurement-based system in which clinicians now operate. The blind faith in experts and concomitant blind eye toward abuses of privilege of era 1 produced the backlash of red tape and managerial meddling of era 2. The result: a modern-day institution of medicine rendered ineffective and impersonal. In his treatise, Berwick offers a solution: create a third, moral era that transcends these failings by renewing the noble calling and unflinching dedication to science that is the foundation of a good physician. Such a vision has been championed over the past two centuries by many clinicians, including Virchow, Lown, and Barton, but we as health professionals have failed to induce the necessary paradigm shift to move towards era 3.
We believe education in all health professions can be the instigation, rather than the capstone, of this new era of medicine.
When medical schools adopted rigorous standards of scientific method with the Flexner Report in 1910, medical societies were able to leverage the associated prestige to enforce licensure and thereby control the ownership of medical care. Medical school reform not only motivated a vast improvement in the quality of patient care, but also transformed a disorganized smattering of clinicians into a credentialed medical profession. Unfortunately, these changes have created a legitimized monopoly in disaccord with era 3’s ideals of transparency, quality, civility, and selflessness. Contemporary reform in medical education is necessary to usher in this new era.
Thus, success in achieving this goal will require fundamental shifts in the way health professionals are educated. As clinical care struggles to keep pace with changes in society — the democratization of knowledge via the internet, the expansion of coverage with the Affordable Care Act, the growing and increasingly conflicted evidence base — the method of educating clinicians has, unfortunately, remained stagnant. An increasingly thorough reductionism through “high-yield material” and exam buzzwords has suppressed the human values that first motivated the profession’s embrace of objective science and its associated pathways and processes. As a result, students now emerge well versed in the technical nature of their calling, overburdened with exposure to basic science, and too often lacking a well-developed style and method of connecting with and caring for patients in their own communities.
What’s worse, topics related to social justice and stewardship of health care as a public good, such as the sweeping changes in access and delivery of care, consolidation of academic medical centers, and growing awareness of the social determinants of health, are given token acknowledgement at best in lecture halls.
This educational structure must be modified in medical schools, nursing schools, pharmacy schools, and other health professional schools. We must ask ourselves: how can we induce a revolution in values to bring into being a new moral era for students of the health professions? We must not simply wait for the wheels of history to creak along.
To effectively revise medical education to accommodate the rapidly changing environment in which clinicians operate, we must first envision and describe those qualities that clinicians should espouse. For example, we suggest that the present-day clinician must demonstrate empathy, but also social and political engagement in the best traditions of Virchow, Lown, Barton and Nightingale; must promote the science of medicine, untainted and free of conflicts; and must be dedicated to clinical excellence and health care as a public service.
We believe this redefinition should not exclusively involve clinician input and effort, and should not wait for deans’ offices and curriculum committee recommendations. For the most part, these administration-focused methods reinforce a tone-deaf approach from academicians who are far removed from the energy of current realities. Instead, we require input from all those who participate in clinical care – patients, community members, clinicians, caretakers, students and more. We must gather these stakeholders in a single location to initiate these discussions and achieve a well-rounded, consensus description of the “new clinician.”
To respond to this need for a new definition of the ideal clinician of the 21st century, we call upon interested parties to participate in Beyond Illness Roundtables. These Roundtables will provide a concrete platform for discussions about the “new clinician” and will allow participants to express their voices on a national platform through essays published on in-Training, an online publication managed by medical students. We encourage all those who wish to improve clinical care to become involved with this pilot program, either as facilitators responsible for leading these meetings, or as vocal attendees.
The following is a description of our Beyond Illness Roundtables pilot project:
Vision: The future of the health professions is the training of a more diverse and relevant clinician who can take advantage of era 3.
Mission: To create a definition of the ideal clinician of the 21st century.
Operation: To hold a series of face-to-face group discussion events at health care institutions, medical and nursing schools, regional, national, or medical society meetings, to elucidate the identity of the ideal compassionate, committed clinician. Facilitators will be provided with an online toolkit to help them facilitate these discussion groups.
Facilitators: Any individual in health care who is interested in facilitating a discussion event and is willing to summarize the findings of the discussion in an essay for the public.
Audience: We ask that these events be open to all members of the health care community, including students, patients, physicians, nurses, pharmacists, caretakers, administrators, and clinicians of all specialties.
We are asking that interested facilitators and participants contact our coordinator Stephanie Aines at firstname.lastname@example.org to get started.
We believe that students — their talent, their energy, and their compassionate commitment to making a difference — remain one of the greatest untapped resources for change in health care. It is our hope that these Roundtables take a step towards mobilizing this resource.
We look forward to working together.
Vikas Saini, MD
President of the Lown Institute
Aaron Stupple, MD
Fellow of the Lown Institute
Jane Muir, RN
Organizer of the STAR Project
Ajay Major, MD, MBA
Founder and Editor-in-Chief Emeritus of in-Training
Andy Kadlec, MD/PhD Candidate
Managing Editor of in-Training
Stephanie Aines, MEd
Organizing Manager of the Lown Institute