Burnout in the Medical Profession Part 2: Medical School Curriculum Evolution

Burnout in the Medical Profession Part 2: Medical School Curriculum Evolution

Understanding the Phenomena of Burnout in the Medical Profession Series
Part 2: Medical School Curriculum Evolution

The medical school curriculum has evolved since the 1970s when I started medical school. The medical school curriculum was based on traditional learning, by subjects. I had done 2 years of undergraduate and I carried on with 4 years of medical school in a class starting at 167 students and finishing at 126 when we wrote our exams. The 5th year was a year of internship, followed by the Family Practice medical exams by the Royal College of Canada, and the LMCC, License of Medical Council of Canada. We would receive our marks in early September, our license and practice number and we would be ready for family practice if it is our choice.

I chose to do a 4-year residency in General Surgery at Laval University, Quebec City, followed by the General Surgery examination of the Royal College of Canada. The written exam was in September and the Oral exams were in November, receiving our General Surgery license by December. Toward my 4th year of General Surgery residency, I decided that a cardiovascular and thoracic surgery subspecialty was very interesting, challenging and appealing to me. So I applied for a CVT residency position at the University of Toronto, and I was accepted. I moved to Toronto with very little English, an obstacle in my training for a few months until I could converse. But the incentive to learn English was paramount to the success of my training. Under the advice of my mentor, I applied to do a year of fellowship in Cardiac Surgery at Tulane University, Ochsner Clinic, New Orleans, USA, which I undertook after 3 years of CVT training in Toronto.  When I was starting my training in New Orleans, I wrote my Royal College of Canada Cardiovascular and Thoracic Surgery Specialty Certificate. After completing my year of fellowship in New Orleans, I did not have a staff position in Quebec, neither in Canada. Knowing the Pediatric Cardiac Surgery division at the Hospital for Sick Children, Toronto, needed assistant help, I came back in Toronto and worked in the Pediatric Cardiac Surgery Division as Junior staff since I was a fully Canadian CVT certified surgeon. I worked a full year perfecting my pediatric cardiovascular and thoracic skills and found a Pediatric CVT staff position at the British Columbia Children Hospital, Vancouver.

It was a long way, it was the only way in the ’70s. Of the 167 students in my medical school class at Laval University, over 85% were from outside Quebec City surroundings and we all lived in a combination of University residence and apartments. Many of us got married in the 4th and 5th year. It felt like a big family, with pub nights, weekend outdoor activities according to the seasons. We all worked hard being used to be over 100 students per class, taking notes by handwriting as fast as we could, and studying with complementary books, obviously not computer technology then. I am seriously not aware of burnout discussion, depression, feeling isolated, but I do not know the details of the students who left: too difficult, running out of money, realizing it was not their career, family situations and else. I am not aware of any suicide, except one of our friend being admitted with our help to a psychiatric unit for a bout of a manic phase. He did complete his training and went in family practice in his home town.

So where are we today with the evolution of the curriculum? In the ’70s and ’80’s medical school curriculum, a trainee would get, after the internship, a family practice certificate and license to practice family practice. Then as an example, after 4 years of General Surgery, a trainee would get a General Surgery certificate and license to practice as a general surgeon. Furthermore, after 2 to 3 years of Cardiovascular and Thoracic Surgery residency, a trainee would get his CVT certificate and license to be a cardiovascular and thoracic surgeon.

The medical curriculum has greatly evolved over years with currently, 4 years of Medical School, with a Medical Doctor degree, 2 years of Family Practice with Royal College examination and licensure, 6 years of surgery subspecialty or medicine subspecialty with Royal College examination and licensure. Therefore, after 6 years, one has a Family Practice diploma and licensure, or after 10 years, one has a diploma of subspecialty such as cardiology, cardiac surgeon or urologist, and licensure. The culminating point after 2 to 6 years of residency training is based on the successful Royal College final examination and then licensing.

Medical education is changing rapidly and in Canada. The Can MEDS have been the product of an evidence-informed, collaborative process involving hundreds of Royal College Fellows, family physicians, educators, and other expert volunteers since its beginning in the 1990s. Its main purpose was to define the necessary competencies for all areas of medical practice and provide a comprehensive foundation for medical education and practice in Canada.

The Can MEDS were formerly approved by the Royal College in 1996 and has become the most widely accepted and applied physician competency framework in the world. The Can MEDS Framework was further enhanced in 2005 and in 2012 and a three-year plan was developed to update the Can MEDS 2005 Physician Competency Framework to ensure that it reflects the modern realities of medical practice. This most recent update — the third one in the 20 years since the framework was first released — was part of the Royal College’s Competence by Design initiative, a project to implement an enhanced model for competency-based medical education in residency training and specialty practice in Canada. The final draft of the Can MEDS 2015 Framework was released in early 2015.

What is Can MEDS?

Can MEDS is a framework that identifies and describes the abilities physicians require to effectively meet the health care needs of the people they serve. These abilities are grouped thematically under seven roles. A competent physician seamlessly integrates the competencies of all seven Can MEDS Roles: Medical Expert as the integrating role, Communicator, Collaborator, Leader, Health Advocate, Scholar and Professional.

Along with the Can MEDS framework, the Royal College began to develop and implement a new system of competency-based medical education (CBME) in 2013. CBME is an outcomes-based approach to the design, implementation, and evaluation of a medical education program that uses an organizing framework of competencies called Competence by Design, or CBD. Why making these changes? Over the last 100 years, demands on the health care system have changed significantly whereas the traditional model for special education has changed very little. According to the Royal College of Canada, physicians must meet different challenges in their practice, and skills and knowledge must meet the changing needs of patients and society. We also live in an age of accountability facing patient demands and knowledge through the Internet and media in which patient expectations have become more demanding. Years ago, the Royal College introduced the Can MEDS Physician Competency Framework, which describes the knowledge, skills and abilities that specialists need for better patient outcomes and developed a concept called the CBD Competency Continuum. This concept divides specialty and subspecialty training into four discrete stages: a transition to the discipline, a foundation period, a longer core period of training and, finally, a transition to practice. It is the modern version of the old training which was not divided in stages.  Frequent assessment and meaningful supervision by expert faculty; clearly defined targets for acquiring competency and meeting standards throughout training, are paramount to guide progression to next stage of training and a more flexible timeframe, which focuses on personal development.

Problem-based learning curricula have also been introduced in many medical schools around the world. However, their adoption was met with some concern, primarily because of the substantial manpower needed.

A meta-analysis by Koh and colleagues offers objective evidence that problem-based learning during medical school has positive effects on physician competencies after graduation, especially in the social and cognitive dimensions. The absence of evidence of positive effects of problem-based learning on physician competencies in the technical and teaching dimensions is likely due to these dimensions requiring psychomotor skills, taught during formal procedural skills training and preceptorships. The meta-analysis by Dochy and colleagues found robust evidence that problem-based learning had positive effects on knowledge acquisition, and also that the method had positive effects on students’ knowledge application. In Dochy’s study, graduates of problem-based learning curricula assessed themselves as possessing less medical knowledge than graduates from the control group; however, supervisors generally found little difference between the 2 groups because they used knowledge application as their measure of physician knowledge. One has also to remember that these groups are compared to each other and not to a traditional medical school curriculum as per 20 to 30 years ago.

Those who advocate problem-based learning (PBL) as an approach to learning have high expectations of the professional competencies of the graduates produced by such programs. Students graduating from problem-based medical schools are, for instance, expected to be more skilled in interpersonal communication, are thought to be better problem-solvers and to be better prepared for self-directed, lifelong learning. These expectations are based on the particular characteristics of PBL: students collaborate in small groups, their learning is centered on problems relevant to their domain of study, and they spend much time on self-directed learning.

The empirical evidence actually supporting these expectations is however, rather limited, in particular because many relevant competencies, such as the skills required to work in a team, are hard to measure and require extended observation periods.

Consequently, our knowledge of how well graduates of problem-based medical schools perform in professional practice can be summarized in a single paragraph. Firstly, graduates of problem-based medical schools feel “better prepared” for professional practice than their counterparts from conventional schools(what are conventional schools, what is their curriculum?).  Secondly, they think that they are able to communicate with their patients in a better way. Communication is a very difficult skill to assess without specific tests and assessment.  Woodward and McAuley from McMaster University, Ontario, Canada, demonstrated that supervisors characterize graduates from that problem-based school as better communicators with patients. Such an outcome was also suggested by a recent study at Harvard University: graduates of its PBL track rated their preparation to practice medicine in a humane fashion more highly than did graduates of its conventional track and expressed more confidence in their ability to manage patients with psychosocial problems.  Graduates of the problem-based school considered themselves to have much better interpersonal skills, better competencies in problem-solving, self-directed learning and information gathering, and better task- supporting skills, such as the ability to work and plan efficiently.

Unfortunately, what these reviews reveal most clearly shows that we still do not have very much rigorous research on the comparative effectiveness of PBL compared to other teaching and learning approaches to help us make decisions about how to design curricula or teach.

I think one of the other problems also highlighted by the reviews are a lack of clarity about exactly what is being ‘delivered’ and called PBL. Diana Wood is correct in highlighting the lack of control group descriptions as a problem, but her claim that PBL is being used all over the world belies another. That is that people are doing something and calling it PBL but that these programs may vary quite a lot. Howard Barrows has said before there is no longer PBL but a rather a variety of hybrids. I think it might be fruitful to start viewing PBL as a term used to denote a family of teaching approaches that share some common principles and to encourage descriptions of each individual approach on a series of consistent common dimensions. Only once we know what is being practiced will be able to untangle the more detailed questions about the impact of the variations that are obviously there in practice.

This information on the value of PBL teaching brings another question: is it time for another medical curriculum revolution?

Specialists whose expertise is very focused and at the cutting edge, could have limited exposure to general medical theory and practice and then focus primarily on learning their specialties. Front-line practitioners, on the other hand, need major exposure to the tools that will equip them to diagnose and manage the broad range of health problems that presents and could spend much less time on the finer points of dealing with advanced and complex diseases.

Core competencies can be defined as the essential knowledge and skills required of all medical practitioners in order to think, talk and act like a doctor. Every physician needs to be able to make a correct diagnosis, an essential first step to the next one: treatment and prognosis. Thereafter, it is the physician’s duty to teach the patient about the illness and its probable course. Core training should also ensure that all physicians are able to perform critical appraisals of medical literature, to communicate with their patients and other health professionals, to understand the ethics of their profession and to understand basic public health principles. How long should that take?

Are 4 years vital, particularly when graduation from medical school is but the first step on a much longer journey that requires a minimum of 2 additional years for family practice licensure and 5 to 6 additional years for specialists? No one has any hard evidence to answer this potential approach and many issues will need to be assessed, measured and discussed, a long road ahead.

In summary, the medical curriculum has moved from a traditional teaching approach to competency-based learning supported by 2015 Can MEDS improved framework. There are pros and cons as mentioned above but this new learning seems to meet the demand of changing health care for physicians and specialists. In relation to the understanding of burnout in the medical profession, I do not think these changes have increased or decreased the burnout rate. However, I can attest after being an examiner at the Royal College for 5 years and talking with trainees, that a single examination process at the end of 5 to 6-year residency, does increase the stress level and anxiety at the examination time.

References

1. Gerald Choon-Huat Koh, Hoon Eng Khoo, Mee Lian Wong and David Koh, The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ January 01, 2008
2. F Dochy, P van den Bossche, and M Segers, Problem based learning, BMJ2008; 336:971
3. DF Wood, Problem based learning. 2003 Feb 8;326(7384):328-30.
4. Tawfik, Essential Readings in Problem-Based Learning: Exploring and Extending the Legacy of Howard Barrows, Interdisciplinary J. of Problem-Based learning, 2015. Vol.9, Issue 2, Article 10
5. Woodward, R. G. McAuley, Characteristics of medical students who choose primary care as a career: The McMaster Experience., CMAJ, 1984, 130, (2), 129-131