In 2009, 20 experts from around the globe gathered to create a roadmap for transforming health professional education for advancing health. Their ideas were captured in the Lancet Commission report on health professions education for the 21st century (Frenk et al., 2010). According to Richard Horton, editor of Lancet, the commissioners had certain guiding principles to adhere to in producing a report that would address population health needs from a global perspective, while considering a systems approach to education reform within the context of a changing health workforce.
One of the commissioners of the report, Susan Scrimshaw, provided opening remarks at the Forum’s public workshop taking place in Washington, DC, on April 23–24, 2015.2 Titled Envisioning the Future of Health Professional Education (HPE), this workshop aimed to
- Explore the implications that shifts in health, policy, and the health care industry could have on HPE and workforce learning.
1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the rapporteur (with acknowledgment of the assistance of staff as appropriate) as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any group consensus.
2 For the list of Forum members and their affiliations, please see the Forum roster on pages vii and viii.
- Identify learning platforms that could facilitate effective knowledge transfer with improved quality and efficiency.
- Discuss opportunities for building a global health workforce that understands the role of culture and health literacy in perceptions and approaches to health and disease.
In her remarks, Scrimshaw reflected on the development of the Lancet Commission report and the desire of many of the commissioners to expand the report’s messages beyond medicine, nursing, and public health. But due to time and financial constraints, they were forced to focus their messages and hope a more diverse group, such as the Global Forum, would expand upon the messages of the report. Scrimshaw expressed great satisfaction in knowing the National Academies of Sciences, Engineering, and Medicine is continuing the commission’s work through convening and consensus activities.
Scrimshaw and others believed that more was needed from the less formal sectors, such as traditional healers and midwives who fill key roles in health systems around the world. She also felt the social determinants of health deserved greater recognition in the report. And while the commissioners anticipated some of the ensuing societal changes, they did not fully anticipate the pace of change in health care delivery and intense economic pressures driving change. For example, the commissioners discussed the effect of technology on health professions education and the work of health professionals, but they did not anticipate how rapidly technology would transform these and other sectors. Similarly the commissioners talked about pandemics but could not have imagined the destruction of health care systems and the loss of health professionals that occurred in Guinea, Liberia, and Sierra Leone as a result of Ebola.
As Scrimshaw speculated about the task ahead—envisioning the future of HPE—she encouraged the group to consider the challenges she just mentioned as well as a very major challenge that some Forum members recently referred to as a “chasm.” This chasm is the increasing gap between what future health care professionals are being taught and what the health care delivery system and the social and local environments currently look like. Students are being prepared for a system that no longer exists. It is a system that is changing far more rapidly than the context of HPE as outlined by the Lancet Commissioners:
Professional education has not kept pace with these challenges, largely because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The problems are systemic: mismatch of competencies to patient and population needs; poor teamwork; persistent gender stratification of professional status; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous
care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labour market; and weak leadership to improve health-system performance. (Frenk et al., 2010, p. 1923)
This, said Scrimshaw, is our challenge.
Some of today’s HPE may not be relevant even by the time students graduate, said Scrimshaw, further hampering change because tomorrow’s faculty are also not being trained in a relevant environment. To remain relevant, educators would have to anticipate what the health and medical systems would be like in 10, 20, and 30 years, and structure an education that allows health professionals to adapt to unanticipated changes. The goal is to create lifelong learners. But that does not alleviate the current challenge of working with existing health professionals to bring them into the world that has changed tremendously since their educational experience.
Chris Olsen, with the Association of American Veterinary Medical Colleges (AAVMC) and associate director for One Health at the University of Wisconsin–Madison Global Health Institute, is part of the current educational workforce. He offered his own metaphor in how he and his generation were taught to think about evolutionary change. “It was like this big, gently rolling ball that moved across the landscape at a gentle, consistent pace. That is how change happened.” Olsen went on to say that his thinking has since shifted. Evolution is more like taking a big heavy square block and putting pressure on one side until eventually, it tips over to the next side. It is more of a punctuated process. Olsen compared his square evolutionary rock to changes in health and well-being around the world, as well as changes in health policy, health care workforce education, and health care systems. These have not been gentle rolling balls in recent decades, but more like massive bricks that require intense outside pressure to move. When enough force is placed on the system, there is a jolt into a new world order. What will be the outside pressure that compels education to change? And might it be possible, asked Olsen, to shift HPE from a reactive mode that follows trends in health care to one that is proactive and leads changes in health systems and societies?
Remarks of Scrimshaw and Olsen provided some of the big picture ideas that were considered by the planning committee charged to structure a workshop agenda based on the statement of task in Box I-1. The Lancet Commission report mentioned in Scrimshaw’s opening comments as well as the Institute of Medicine’s (IOM’s) The Future of Nursing report (2011) drove the establishment of the Global Forum and underpinned many of the
Statement of Task
An ad hoc committee under the auspices of the Institute of Medicine (IOM) will plan and conduct a 2-day public workshop to explore recent shifts in the health and health care industry and their implications for health professional education and workforce learning. The workshop will likely explore such topics as:
- Opportunities for new platforms of communication and learning
- Continuous education of the health workforce
- Global health professional education, training, and practice and the role of culture in perceptions and approaches to health and disease
- Opportunities for team-based care and other types of collaborations
- Social accountability of the health professions
These issues will be examined in a 2-day public workshop that will be planned and organized by an ad hoc committee of the IOM. The committee will develop a workshop agenda, select and invite speakers and discussants, and moderate the discussions. Following the workshop, an individually authored summary of the event will be prepared by a designated rapporteur in accordance with institutional guidelines.
topics explored by workshop presenters and participants at the workshop. In particular, Laura Magaña Valladares from the Instituto Nacional de Salud Pública described the recommendations in the Lancet Commission report as validation for why the health professional system of education must change.
The Lancet Commission Report: Where Do We Go Next?
Laura Magaña Valladares, M.S., Ph.D.
Instituto Nacional de Salud Pública
Laura Magaña Valladares began by summarizing why change is necessary for improving health care. This led to a description of how improving health involves pressure and challenges in both the health and education systems, as well as a review of recommendations that promote innovations from the Lancet Commission report. She closed with a description of what could potentially create the radical change she envisions that would reinvent HPE.
Health Care System Forces Pressuring HPE to Change
Within the health system, Magaña identified four main forces pressuring HPE to change. The first involves global epidemiologic and geographic transitions. There is a growing elderly population and therefore a greater number of age-related ailments requiring care. Similarly, the health impacts of more people living with chronic disease and obesity have already begun to overwhelm health systems around the world. Second is the challenge of poverty and the huge disparities between and within countries. The World Health Report 2006, Working Together for Health called to light a variety of indicators for health disparities that were socially determined (WHO, 2006). For example, the life expectancy of a girl born in Sierra Leone is half as long (42 years) as a girl born in Japan (86 years). And the chance of a child dying before age 5 in Angola is 90 times higher than in Finland. Such disparities exist within high-income countries such as the United States; according to Michael Marmot (2006), life expectancy rises roughly 1.5 years for each mile traveled from Washington, DC, to the more affluent suburb of Montgomery County, Maryland.
The third main area of pressure on HPE stemming from health systems involves access and quality of care. This affects all countries around the world. There has been a shift in health services needed by the population; instead of care being focused on short, acute episodes, appropriate care for long, chronic diseases is required. Most health institutions and the health workforce have not yet made this transition. Besides, health systems are struggling to find ways to give services to all people in economically constrained times. The fourth area of pressure Magaña identified is globalization. Every global event has local consequences, and every local action has global implications, which leads to globalization. Globalization creates challenges to local health systems attempting to provide culturally sensitive care in a cost-conscious world.
Education System Forcing a Revolution
Magaña expressed a belief that the emergence of information and communication technologies is forcing a revolution within education. A new type of society has been created through Internet accessibility. However, many institutes of higher learning are having to be pushed to acknowledge other nontraditional sources of information and remain slow adapters of education that will prepare students to become lifelong learners. Such preparation might include demonstrating an ability to find accurate information and discriminate between biased and unbiased sources. It might also involve exhibiting competency in collecting, analyzing, comparing, and judging information from a variety of traditional and nontraditional
sources. These sorts of skills, says Magaña, could position the next generation to be creative, imaginative thinkers rather than focusing on filling the curriculum with more content.
Another component of the technological education revolution is that mobile technology has enabled schools to move away from the traditional classroom into a virtual environment. And while learning is no longer associated with a physical facility, universities continue to request funds to build newer and larger facilities. This is in conflict with the technological revolution, as are paper handouts that continue to be used despite cloud-based technology enabling new ways to access, store, and share information. Having a mobile society in an increasingly interconnected world opens the classroom to global sharing of resources and greater integration of new actors and multiple stakeholders.
Enhanced collaboration holds the potential for minimizing fragmentation. There are examples where this is done effectively by making global connections through networks and alliances; but there are also examples—as in joining the planning mechanism between the Ministry of Health and the Ministry of Education—where fragmentation is the norm and collaboration remains inadequate. In education, technology provides opportunities to more easily integrate new professions into the curriculum, but it should be emphasized that it is not just about the technology. Technology is the platform by which connections can be made, but it is the pedagogy that engages students in learning. There have been great advances in education and cognitive sciences; it is now known how people learn, and what can be done to design learning environments that engage different audiences and provide meaningful and significant learning.
To remain relevant, education has to reflect changes in the professional work environment, said Magaña. Work is increasingly multidisciplinary and collaborative, thus curricula, learning, and activities have to include approaches that reflect what students are likely to encounter after graduation. Much of this can be facilitated now by technology and by pushing students to work together toward a common good. Linkages would not just be with people from the health sector, but would also include nonhealth professions, such as architecture and engineering. However, to accomplish this, she said, the educational system must change along with professors’ roles; faculty now need to concentrate on how to design learning environments and how to motivate, accompany, and coach students to facilitate learning.
A New Approach to HPE
When designing a new approach to HPE, Magaña stated that the educator also has to take into consideration changes in student populations in recent decades. There are now basically two kinds of students: adults re-
turning to school for retraining, and technologically oriented young people eager to continue their formal training. She said this latter group is generally more comfortable with digital networks than a face-to-face discussion. They are usually accustomed to multisensory environments and have little patience. They tend to also be a more practical group and are ready to demand the fulfillment of their own needs.
Are educators creating environments that facilitate learning for all the varied students they are likely to encounter? Have they considered moving to certification of competencies that are not constrained by physical boundaries and maximize e-learning so for example, learning might be conducted through a massive open online course (MOOC), through another virtual university, or in the workplace? The important element across all the environments would be competency—a recommendation of the Lancet Commission report (Frenk et al., 2010). In the report, commissioners identified instructional and institutional reforms that along with enabling actions would lead to transformative and interdependent professional education. Recommendations from the report are noted in Box I-2. Magaña explicitly wondered what HPE is doing to nurture a culture of critical inquiry. She then reiterated that education has not kept pace with a changing society; while she realizes that money and political power are important elements to instigate change, it is still possible to propel HPE forward using the tools educators have available to them today.
The first tool accessible for educators is the curriculum. Making it less content specific and more about crosscutting competencies would improve the applicability of the learning, said Magaña. Every bit of information cannot be included in each curriculum. According to Densen (2011), it took 50 years—from 1900 to 1950—for medical knowledge to double. In 1980 and 2010, it took 7 years and 3.5 years, respectively—but in 2020, it is projected that knowledge will double every 73 days. Magaña said that to her, this means students have immediate access to information, so thinking about how to reduce the content of the curriculum while increasing experiential learning would provide more of the crosscutting competencies. This would create “thinkers” and “problem solvers” rather than “regurgitators.”
The second available tool would make better use of other health and non-health professionals and professions in a more transdisciplinary or transprofessional manner. The third tool would be to realize that the epidemiology of disease has shifted from acute, often infectious episodes to more chronic disease. Magaña said that this calls for greater emphasis on health promotion and lifestyle choices that will deter the development of future diseases.
Being flexible with the curricula would facilitate what Magaña called a kaleidoscope view, meaning that it does not matter where the students enter
Recommendations from the Lancet Commission Report: Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World
- Adopt competency-based curricula.
- Promote interprofessional and transprofessional education.
- Exploit the power of information technology for learning.
- Adapt locally but harness resources globally in a way that confers capacity to flexibly address local challenges.
- Strengthen educational resources, because faculty, syllabi, didactic materials, and infrastructure are necessary instruments to achieve competencies.
- Promote a new professionalism that uses competencies as the objective criterion for the classification of health professionals.
- Establish joint planning mechanisms in every country.
- Expand from academic centers to academic systems, extending the traditional discovery–care–education continuum, strengthened through external collaboration.
- Link together through networks, alliances, and consortia between educational institutions worldwide and across.
- Nurture a culture of critical inquiry as a central function of universities and other institutions of higher learning.
SOURCE: Frenk et al., 2010, pp. 1951–1952, as presented by Magaña on April 24, 2015.
the system, but rather what skills they have when they enter. In this way, education is more personalized and emphasizes needed competencies of the learner rather than a tubular view that forces all learners to follow the same curriculum and have the same prerequisites regardless of past experiences and previously obtained competencies. A flexible curriculum would also consider the evidence around active learning that has been shown to be of greater benefit than traditional, more passive techniques of education (Melo Prado et al., 2011). In the end, students need to be engaged regardless of the learning platform used.
For these changes to occur, the faculty would need the competencies for educating in this manner. This new faculty would understand different forms of pedagogy, technology for knowledge transfer, and the role of the educator as focusing less on “teaching” and more on “student learning.” Professors would concentrate on designing learning environments, motivating and coaching students, and accompanying them on their journey
of learning. The emphasis would not be on academia and research for publishing papers, but instead on connecting with policy makers to push for real change.
Magaña concluded by encouraging the audience to take advantage of the workshop as a space where educators, students, and other stakeholders can come together to think through what the future holds and how changes in society affect HPE. In this way, faculty can prepare students to address current and future health challenges using the most effective learning tools and techniques for a given situation. By sharing what works and what does not work, others can learn from the successes and failures of others, which is necessary for promoting health and treating patients in this rapidly changing world.
SCOPE OF THE REPORT
An overarching theme that started with Susan Scrimshaw but perpetuated throughout the presentations was the notion that we are preparing learners for a health system that no longer exists. The tragedy, as described by Malcolm Cox, is that not only are we preparing people incorrectly, but we are also spending large amounts of money on education in a wasteful fashion. Throughout the workshop, many attendees expressed that the way learners are prepared needs to change in order to create a very different workforce than the current workforce. Cox also remarked on the relevance of Olsen’s metaphor termed punctuated evolution. Olsen asked, how do you roll a square ball? And how do you get to the tipping point so it falls over? HPE is not yet at the tipping point, but that, according to Cox, is the real work of the Forum—to illuminate ideas on how to move education to where learners are prepared for the current and future health system.
Examples of how to make education more relevant were presented at the workshop and appear in Chapters 1 and 2 of this report. Many of the described models and programs involved partnerships inside and outside of academia. Francisco Eduardo de Campos, former National Secretary of Labor and Education Management in Health of the Ministry of Health, Brazil, talked about the similarities and differences among health care systems around the world and focused on his work in Brazil. Brazil’s political commitment to primary health care has forced Campos and his colleagues to think creatively about how to respond to the call for universal health coverage. They instigated family health teams composed of a physician, nurses, dentists, and community health workers (CHWs), and redesigned the curricula for all the health professions so they are prepared to work within the new system of community-based care.
Susan Skochelak, representing the American Medical Association, moderated a panel of speakers who described unique curriculum designs and
structures that get students out of the classroom and into the community. One of the speakers, David Asprey, also discussed how he and his colleagues went about designing a more cost-efficient curriculum. While he focused on combining curricula of physicians assistants and medical students, the concepts could be applied more broadly. Tied to these presentations were small table discussions led by Timi Agar Barwick from the Physician Assistant Education Association. These questions included
- Who are the educators of the future, and how will their roles be different from the traditional teacher?
- How will these evolving roles affect the educational process and the community?
Participants’ responses to these questions appear in Chapter 2. The third chapter looks at a changing health workforce. The first section of Chapter 3 describes using a debate format to actively engage the audience on important topics for health professions educators. Deborah Trautman from the American Association of Colleges of Nursing managed the debate on work–life balance, where Richard Talbott (Association of Schools of the Allied Health Professions) and Richard Valachovic (American Dental Education Association) presented extreme viewpoints on whether or not health professional schools should adjust their curriculum and training to provide greater work–life balance for their learners. This issue was also contemplated by speakers representing perspectives from Nigeria and China.
The second debate was moderated by Holly Wise from the American Council of Academic Physical Therapy. This debate, presented by Liza Goldblatt (Academic Consortium for Complementary and Alternative Health Care) and Elaine Tagliareni (National League for Nursing), looked into the pros and cons of creating new worker roles for supporting health professionals versus expanding the jobs of health professionals to meet individual and community health needs. A perspective from Nigeria was again presented.
Later in this report, Andrew Pleasant—who joined the workshop through a collaboration with the Academies’ Roundtable on Health Literacy—provided some remarks on globalization and challenges to HPE that he felt would be best dealt with through a health literacy framework. Clifford Coleman and Jennifer Cabe described how they each put health literacy into their health professional training programs and argued that health literacy should be the organizing framework of HPE. However, in Chapter 4 there were numerous presentations by veterinarians promoting One Health as the appropriate framework for organizing the health professions and their education. This education would broaden current curricula
to integrate human health, animal health, and ecosystem health in a global structure.
It should be further noted that in an effort to create a smoother flow of the statements made at the workshop and captured in this report, not all of the text follows the chronological order in which the discussions took place or appear in the agenda found in Appendix A. The biographies of speakers can be found in Appendix D.
Appendix B includes the IOM and Society for Simulation in Healthcare Gaming Arcade and Showcase game descriptions. The Gaming Arcade took place during the April 23 evening session of the workshop, and showcased 26 games and technologies that educate health professionals. Appendix C is composed of abstracts that are written versions of the webcast presentations provided by some of the members of the Forum or their organizational affiliate. Each abstract is an example of an activity that exemplifies envisioning the future of HPE, and authors were given flexibility in defining what this means for their context and in determining the material to be presented.
Densen, P. 2011. Challenges and opportunities facing medical education. Transactions of the American Clinical and Climatological Association 122:48-58.
Frenk, J., L. Chen, Z. A. Bhutta, J. Cohen, N. Crisp, T. Evans, H. Fineberg, P. Garcia, Y. Ke, P. Kelley, B. Kistnasamy, A. Meleis, D. Naylor, A. Pablos-Mendez, S. Reddy, S. Scrimshaw, J. Sepulveda, D. Serwadda, and H. Zurayk. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376(9756):1923-1958.
IOM (Institute of Medicine). 2011. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Magaña Valladares, L. 2015. The Lancet Commission Report: Where do we go next? Presented at the IOM workshop: Envisioning the Future of Health Professional Education. Washington, DC, April 24.
Marmot, M. 2006. Interview with Sir Michael Marmot. In Unnatural causes: Is inequality making us sick?, edited by Unnatural Causes. Cambridge, MA: PBS.
Melo Prado, H., G. Hannois Falbo, A. Rodrigues Falbo, and J. Natal Figueiroa. 2011. Active learning on the ward: Outcomes from a comparative trial with traditional methods. Medical Education 45(3):273-279.
WHO (World Health Organization). 2006. The world health report 2006: Working together for health. Geneva, Switzerland: WHO.