Kanter, Steven L. MD
Although predicting the future is a risky business, the journal is plunging head-first into the task. To that end, this issue of the journal presents the first of an occasional series of articles: “The Future of Psychiatry as Clinical Neuroscience.” Reynolds et al. envision a future for psychiatry in which there is, at least in part, a reintegration across the artificial boundary between psychiatry and neurology. They point out that both specialties rest on a common foundation of clinical neuroscience, and discuss important implications for education and training, health and science policy, research practice, clinical practice, and the academic health center as an institution.
All of us in academic medicine – educators and investigators, clinicians and administrators, residents and students – can benefit from such an article. Educators must prepare learners to work in an unknown future. If educators have a more thorough and robust understanding of the possibilities that may lie ahead, they will be able to develop more relevant and meaningful curricula and educational experiences. Scholarly thought about the future could provide investigators with a more fertile framework for thinking about important problems, clinicians with a richer context for planning for clinical service needs, and administrators with a more sophisticated perspective for planning and allocating resources more effectively. And, of course, today’s residents and medical students will practice medicine and science in tomorrow’s world.
In this editorial, I explore why it is important to consider possible futures, discuss a few examples of methods used to study the future, and describe the kinds of articles about the future that would be of interest to the journal.
A rigorous, comprehensive, and critical examination of the future of academic medicine offers several advantages. First, thinking critically about the future sharpens thinking about the present. Anticipating what may occur, in a disciplined and scholarly way, enables those of us who have a stake in medical schools and teaching hospitals to make better decisions and pursue better practices in the here and now. It can help us clarify goals and objectives and to examine whether those aims can withstand critical analysis.
Second, studies of the future can foster more meaningful and focused thinking about the forces driving change and their accompanying uncertainties and instabilities.
Third, analytic thinking about the future helps us best position ourselves to take advantage of unknown opportunities in an uncertain future. Absent a purposeful approach to studying the future, we may not recognize opportunities as they arise, and even if we do recognize them, we may not be prepared to act quickly and effectively. However, a disciplined approach to examining the possibilities that we may confront could enable us to perceive an emerging situation as an important opportunity.
Fourth, creating and analyzing a set of possible future states can raise awareness about issues that otherwise might not receive sufficient attention (see my comments on scenario planning below). This approach can help us to think about the full range of possibilities that we may face for a discipline, emerging field, medical school, or health system.
And fifth, high-quality, deep thinking about the future would enable those who work in academic medicine to contribute more effectively to the development of rational health and science policy. Policymakers and futurists share common concerns: structured approaches to anticipating what may occur and to understanding the full range of possibilities put us in the best position to make decisions and develop policies that are more likely to broaden rather than restrict options for future generations of physicians and scientists.
Given the value of studying the future, what methods are available to do so? A variety of approaches have been used to develop a deeper and more meaningful understanding of the future. Two examples of the more widely known approaches are the Delphi method and scenario planning.
The Delphi method forecasts the future by using sequential rounds of structured questioning and feedback to elicit and refine informed judgments from a group of experts. Developed in the 1950s at the Rand Corporation by Olaf Helmer and Norman Dalkey, the technique has been used in a wide range of forecasting and other projects, from national defense to educational innovation, particularly to inform policy decisions.1
Scenario planning, used extensively in the business world, is a structured approach to imagining and describing a broad range of possible states or sets of conditions that may unfold in the future.2 In scenario planning, the emphasis is not on prediction but rather on the construction of narratives that explain possible situations that may occur in the future. A typical implementation combines perceived current trends with key uncertainties to develop several scenarios; then, the advantages, disadvantages, consistency, plausibility, implications, and other aspects of each scenario are examined and compared and contrasted. In 2005, the Milbank Memorial Fund published “The Future of Academic Medicine: Five Scenarios to 2025,” in which the authors use scenario planning, combining instabilities of the present system with important drivers of change, to develop and examine five alternative futures for academic medicine.3
Scenario planning aims to capture the subtleties and nuances of the uncertainty inherent in complex situations by blending objective analysis with subjective inference. The technique is particularly useful for studying complex environments—like those of academic health centers—since it is designed to explore the impact and interaction of several variables.4
In their article in this issue on the future of psychiatry, Reynolds et al. employ another technique, a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis, to examine the current state of psychiatry. They use the results of this analysis to inform the development of their argument that psychiatry’s future lies in the context of clinical neuroscience.
In addition to the techniques described above, I suggest that thought experiments5 (also known as gedanken experiments) could play an important role in the scholarly consideration of the future of academic medicine. Thought experiments have played an important role in the fields of philosophy, physics, mathematics, and other areas. They provide a way to manipulate different variables in thought – variables that may not be amenable to manipulation in practice for ethical, pragmatic, or other reasons – and to examine the consequences of these changes. For example, one could project the potential effects on primary care of altering such variables as who delivers that care or how much training is required to deliver it, or by changing policies that determine access to or cost of care.
What kinds of articles about the future are of interest to the journal? The journal seeks manuscripts that provide rigorous, critical, and discerning perspectives on the future of important aspects of academic medicine. Manuscripts may compare and contrast alternative futures of an established or emerging discipline, may construct and evaluate possible future scenarios for medical schools or teaching hospitals, or may analyze an important trend in academic medicine and extrapolate potential future paths. Authors may wish to focus their exploration of the future on one or more of the journal’s key focus areas: education and training issues; health and science policy; organizational administration, management, and values; research practice; and clinical practice in academic settings. The journal is interested especially in publishing articles that have the potential to extend thinking and practice in new directions.
The journal does not seek manuscripts that try to predict, soothsay, or otherwise foresee the future – that is best left in the hands of fortune tellers. Rather, the journal is interested in scholarly treatments of important, penetrating questions about potential future directions in academic medicine, based on the application of an explicit method or structured approach (that should be described in the manuscript), and followed by a cogent analysis of consequences and implications. Authors may wish to explore what can be done to prepare for various future scenarios, contemplate what kinds of strategies are likely to broaden, rather than restrict, the range of options for future stakeholders in academic medicine, and consider limitations and biases to thinking about the future.
And so, although predicting the future is a risky business – fraught with uncertainty, unknowables, and unanswerables – we do know that in a relatively short period of time, today’s students will become tomorrow’s doctors and scientists. As such, they will administer to patients treatments that have not yet been discovered based on heretofore inaccessible understandings and classifications of disease, in a health care environment that surely will undergo significant change. And they will address questions and problems unknown today with methods and technologies that have yet to be developed. One important way we can prepare them for whatever may occur is to arm them with the results of scholarly considerations of future scenarios. The more we stimulate our imaginations to consider a broad range of ideas about the future, the more prepared we will be to recognize and seize new opportunities – even unexpected ones – and the more effective we will be in advancing education, research, and patient care.
Steven L. Kanter, MD
2 Ringland G. Scenario Planning. 2nd ed. West Sussex, England: Wiley, 2006.
4 Paul JH. Schoemaker, PJH. Scenario planning: A tool for strategic thinking. Sloan Management Review. 1995 (Winter): 25–40.
5 Sorensen, RA. Thought Experiments. New York: Oxford U. Press, 1992.