In the 2013 Question of the Year, the editor of this journal asked the simple yet provoking questions “What is a doctor? What is a nurse?”1 By asking these questions, the editor hoped to explore several underlying ideas: What do transformations in the health care delivery system mean about the present and future functions, descriptions, training, and ultimately identity of doctors, nurses, and interprofessional teams? Big, philosophical issues, to be summarized in no more than 750 words. It yielded reference to the distinctions between the two professions,2,3 to very personal accounts showing what the gestalt of nursing is,4,5 and to the interprofessional nature of future health care delivery.6 The authors of these reactions did not explicitly provide a historical perspective. To examine such a perspective, my purpose in this commentary is to explore the question What is a 21st-century doctor? My focus is on the significance of the medical degree within the continuum of medical training.
A Brief History of the Medical Degree
Ask anyone in the street to pick one profession on earth that stands out for its well-defined status, and the medical doctor will soon be mentioned. Societies have had professionals caring for the health of citizens as long as mankind has existed.7 Over time, healing became the prerogative of certified professionals. As early as in 2000 BC Babylonian society,8 documented rights and obligations began to signify the social contract between a medical professional community with distinct knowledge and skills and the society’s collective citizens. Medical doctors, initially modeled after Asclepius and Hippocrates, became university-educated professionals, and in the 19th century, theoretical university study combined with practical experience as an apprentice became a certification requirement for the medical doctor.7,9 In virtually all countries, certification is now grounded in national legislation. The degree of medical doctor, awarded by a university, and the right to practice the medical profession, granted by registration as a medical practitioner, mark a rite of passage into the professional community. The medical degree seems solidly rooted in society.
However, the professional world of health care has dramatically changed in the 20th century. Abraham Flexner, reporting a century ago about the state of U.S. and European medical education,10 did not yet mention internships or any hospital training after graduation. This reflected the prevailing practice of relying on undergraduate medical education as sufficient preparation for lifelong medical practice.9 At that time, Dutch medical diplomas were signed not only by university authorities but also by the city mayor, certifying service to the local community for many years. Additional postgraduate specialty training was an exception, only later becoming the norm for medical graduates. In the 21st century the medical degree, while still significant in its legal status, has become an intermediate station in a long educational trajectory, rather than an end point. In addition, its status has become much less clear, and we might wonder whether we are approaching the end of the MD status as we have known it for many decades. Six questions should make us rethink this status.
Rethinking the Status of the Medical Degree
What is the core knowledge that medical doctors should possess?
If one thing should enable us to define what a doctor is, it may be his or her knowledge and skills. However, the core medical knowledge—that is, the universally relevant, canonical knowledge that all medical practitioners are expected to possess11—has become less clear than it used to be.
The content of undergraduate medical education is variable across schools, countries, and time. The confined length of degree programs limits the continuous wish to add to the medical degree requirements, and curriculum developers face increasing difficulty determining required content for the degree. The medical practitioners holding no more than a medical degree who used to serve as a reference for curriculum planners half a century ago hardly exist anymore in the industrialized world. The contents of most medical curricula are determined by specialists who do not necessarily oversee the breadth of the medical degree. As justified pressures on medical curricula grow to add general training in communication skills, research skills, professionalism, and other nondisciplinary areas, the space for basic and clinical knowledge decreases while the body of knowledge increases. Clinicians and basic scientists also diverge in opinion about what should be included in the medical course.12,13
Many schools have turned to problem-based learning, not only to stimulate motivation and enhance learning but also to instill a habit of solving problems rather than memorizing facts.14 The ubiquitous access to information for everyone in the 21st century has also changed our epistemology—that is, our philosophy around knowledge. Doctors have lost the knowledge monopoly in their own domain. It has been predicted that medical schools will shift their effort from training students to memorize information to training them to efficiently deal with a ubiquitously accessible knowledge cloud containing up-to-date medical information, both from the scientific literature and from individual patient records.15 This urges us to rethink the nature of the canonical knowledge every doctor should possess by heart. It is undisputed that there is such knowledge, but it is hard to say what that required knowledge is. For example, the most recent edition of the Dutch National Framework of undergraduate objectives16 shows only general descriptions, replacing previously detailed listings of topics. International standards of undergraduate education only mention broad categories of content, process, educational environment, and outcomes of medical education. They tend to serve as a lever for medical school change and reform rather than a requirement for program content.17 Recommendations for assessment are typically limited to general categories, such as “Normal and abnormal human behavior,” “Molecular, cellular, biochemical, and physiological mechanisms that maintain the body’s homeostasis,” and “Evaluate health problems and advise patients taking into account physical, psychological, social, and cultural factors”;18 details are left for local decision making. While a call for fixed standards is widely heard,19 clear benchmarks for the content of the medical degree program seem to disappear. National exams can uphold standards for a while, but should be derived from agreed-on content20 rather than prescribing it.
What signifies the medical degree within the continuum of medical training?
In the industrialized world, there is no distinction between doctors with and without specialized training. We left that era behind decades ago, as virtually all doctors now specialize. Rather than an end point of training, the medical degree has become not much more than a ticket to start specialized training.
Interestingly, specialty training has recently shifted its focus from specialized knowledge and skill only, to include general medical competencies. Recent frameworks for competencies of medical specialists, such as the Canadian CanMEDS framework21 with pervasive impact on postgraduate training worldwide, predominantly stress general qualities pertaining to all postgraduate medical education programs. If specialized training focuses on general competencies, then what sets the general medical degree apart? Their separation seems to disappear.
Indeed, the interest for developing a continuum of medical education across undergraduate and postgraduate phases increases.22–25 For example, the British medical education system has created foundation years,26 and the Dutch a transitional year,27 to bridge undergraduate and postgraduate training and to lower the costs of the lengthy training of medical practitioners.28 Some pediatrics programs in the United States have begun developing training that extends across the continuum.29 The shift in focus from objectives for undergraduate training to objectives for the continuum is logical. Specialist work has, in fact, become the only benchmark for clinical practice, not the undergraduate medical degree.
Is the trajectory to highly specialized medical practice too long?
The current training of medical practitioners is about twice as long as it was a century ago. If the historical trend of doubling the training time within a century is extrapolated, by 2100, physicians-in-training may be en route to retirement before they are fully licensed. Some have suggested that specialists are too old, too smart, and too expensive when they finish training,30 and shortening undergraduate training is now being discussed.31,32 By not having the opportunity to take full responsibility for medical practice, medical trainees may be wasting time at an age when they are supposedly at the top of their physical and mental abilities. Training requires time and money, and any commercial firm would more carefully balance the resources spent on investments versus the quality of their products.
It is difficult to say how much effort is spent in medical education on the acquisition of knowledge and skills that are not used in later practice or that can be acquired more easily after licensing.33 Some highly specialized medical occupations might require considerably less education if the educational trajectory were more focused. Is it really necessary to have a long undergraduate medical education, postgraduate residencies first in internal medicine and then in cardiology, and subsequently a fellowship in interventional cardiology, to predominantly do routine interventional cardiology procedures all day? What is the reason that training for an ophthalmologist is twice the length of that for a dentist? What medical knowledge is really needed as a background for specialized practice?
To what extent is medical practice still the prerogative of medical doctors?
Doctors and earlier healers have always relied on the assistance of other practitioners. In their legitimate privilege to act medically, doctors were assisted by either nonphysician health care providers, specifically nursing personnel, or by trainees of their own profession. The diversity of nonphysician health care providers has increased in the past decades. The privilege to act medically, granted by legislation and by insurance reimbursement, is gradually being shared with professionals without an MD degree, such as midwives, nurse practitioners, physician assistants, and many more. This urges us to rethink what sets the medical doctor apart from other skilled health care workers.
How must international medical graduates be recognized?
The Netherlands recently introduced requirements for international medical graduates (IMGs), derived from standards of the U.S. Educational Commission for Foreign Medical Graduates,34 and saw a dramatic decrease in the number of accepted IMGs. Failure to meet MD diploma-level requirements by experienced foreign medical specialists is a major obstacle to licensure in a new country, second only to difficulties meeting language and cultural standards.35 This leaves one wondering how important these general requirements are for a skillful specialist. It would be much easier if experienced specialists could be acknowledged for all relevant specialty-specific knowledge and skills, without first meeting the knowledge and skills requirements of an undergraduate medical degree in their new country.
Is the medical profession becoming an occupation?
Societal change in Western countries impacts professional identity in medicine. Duty hours restrictions in residency training (48 per week in EU countries, 80 in the United States) may be justified by arguments of patient safety and protection of residents.36 A more likely explanation of this culture change may be the fundamental wish of citizens to get more out of life beyond having just one full-time professional identity, which is reflected in increased desire to work part-time as a doctor37 while excelling in multiple domains. New generations want to multitask. While many physicians do combine clinical work with research, education, and other duties, being a doctor seems to become more and more an occupation conducted in specified hours, rather than a full-time identity.38 Professional identity formation has recently been stressed as an important aim to be restored in medical education.19 This call for reform may well be a reaction upon an actual decrease of the traditional identity concept of the medical doctor.
Is It Time to Rethink the Medical Degree?
The undergraduate medical degree, bestowed on the medical doctor and linked to a license to practice, may have enjoyed its longest life as a universally recognized and clear label of healers in society. While students will keep enrolling in medical schools, we might need to redefine what exactly they are trained for. That single magical moment of licensing that grants the autonomous privilege to practice medicine seems a ritual of the past rather than having much practical significance for the future.
So then, what is the university-trained “medical doctor”? This is not a trivial question. If we cannot define what a medical doctor is, then the identity of millions of professionals is unclear. Flight attendants calling, “Is there a doctor present?” hope to keep receiving responses from qualified medical personnel. It would be highly disruptive if we stopped having a uniform profession called “medical doctor” encompassing all specialties.
There is no easy answer to the questions posed, but one way to redefine the medical degree is to not just list knowledge, skills, attitudes, and competencies but to actually analyze what tasks we want graduates to be able to do. A portfolio of mastered and well-documented core entrustable professional activities for entering residency (rather than for independent practice), such as those recently presented by the Association of American Medical Colleges,39 could be an approach to this redefinition. When carefully formulated, these may privilege learners, even within an educational trajectory, to start bearing specific critical health care responsibilities, and help build their identity as medical practitioners. This may be close to what medical professionals have always been expected to do for patients throughout history, with or without the medical degree.
Acknowledgments: The author is grateful for the discussion of this topic during the 2013 meetings of the International Network of Clinician Educators and of the South East Faculty of Clinical Educators Symposium, and to Dr. Carrie Chen from the University of California, San Francisco, for her language suggestions on an earlier version of this text.
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