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Curriculum Renewal: A Challenge for Specialty Medicine

We're doing well but likely to change

Richard Reznick
Richard Reznick
The University of Toronto is embarking on a process of undergraduate curriculum renewal. By all measures, we are doing well. We had a very successful accreditation in 2004. Our scores on national licensing exams are amongst the best in the country. Our graduates are getting into the best residency programs. Our decanal team is strong and committed. However, like all good organizations dedicated to continuous quality improvement, it is unlikely that the renewal process will culminate in minor tweaking. Rather, it appears that we may be headed for some profound changes. Not all will applaud these changes, which to a large extent will be driven by our internal perceptions of our social responsibility. While this may be a laudable driver of change, it will no doubt provoke and highlight some inevitable tensions that will shape the debate around what our medical school will ultimately focus on and what type of physician "product" we hope to produce.

Who will make the best doctors?

It is likely that the first question we will have to tackle is our admission policies. Currently we admit an amazing group of young talented individuals, often from very different and eclectic backgrounds. Many have a wealth of premedical school experiences, and many enter medical school at a relatively advanced age compared to other countries. By definition our system admits almost all of its entrants after a bachelor degree, and an increasing number with graduate degrees. This frames a question for our school that with residency becoming longer and longer and with specialty fellowships becoming the rule rather than the exception, one has to question the relative societal merits of graduating older vs. younger physicians. Another point to consider is the issue of gender. The majority of our class is women and if the trends continue as they have over the last decade, within a short few years men could represent fewer than 25% of our class. With respect to the issue of gender imbalance, it is laudable that we have redressed the issue of too few women in medicine. However, in the long run there may well be a debate with respect to gender. On one polar extreme will be those of the opinion that gender should play no role in admissions to medical school. That is to say, the best candidates, as measured by the criteria we set, should be admitted. On the other polar extreme will be those who argue that maintaining a reasonable gender balance is important for our school, for the profession and for society.

A response to generalism

To a larger extent the current process is responding to the call for a more generalist approach to medical education. This movement, which had its strongest moments in the 90s, still persists today. Its persistence is fueled by continuing shortage of primary care specialists and the perception that we have over-focused on the tertiary and quaternary care agenda. At U of T this was manifest in a "generalist care curriculum enhancement task force" that authored a report which was highly critical of our own attitudes and approaches to the issues embraced in the generalist agenda. (www.facmed.utoronto.ca/programs/md/generalist.htm) While we all agree that the shortage of family doctors across Canada is of concern, one has to question if this issue should dominate as we contemplate changes for our future. We currently train more family physicians than any other medical school in the country, and yet unlike many other medical schools, one could argue that given our research and specialty infrastructure, we should be narrowing our focus on the complex, with the comfort that other schools across the country have as their principal mission the education of the generalist physicians. We are suffering from some confusion of just what the generalist construct is. It currently means different things to different groups such as the production of primary care physicians, or the need for a more holistic approach to the care of patients, or the concern over attitudes of specialists towards family physicians. While we can easily empathize with many of these concerns, it can be argued that the issue of physician "generalism" may be somewhat of a passing fad as many of the functions of the generalist physician of today may be assumed in the future by other health professionals, arguably at less cost to the health system.

Will there be a Department of Surgery in fifty years?

Perhaps even more contentious will be the allocation of curricular weeks by department. Indeed, holding on to one's aliquot, particularly of clerkship time, promotes almost religious zeal amongst departmental leaders. As surgeons, we feel strongly that we are in a unique position to teach about surgery.

Further, we believe strongly that we can teach general skills about looking after sick patients that will be of great value to our undergraduate studentship. The last wave of curricular change resulted in an element of specialist disenfranchisement when systems based teaching, for which specialists felt a fair degree of ownership, was replaced by more PBL teaching and more generic courses that are taught by a wide spectrum of physicians and non-physicians. Specialists are therefore, to some degree, poised to react to any suggestions that there be further erosion of curricular time to their specialty.

But perhaps we have this all wrong! Perhaps we need to be thinking more futuristically and speculating what medical care will be like in 30, 40 and 50 years from now. Will we still be doing surgery as we know it? Or will surgery be some sort of amalgam of traditional surgery, interventional radiology, image guided therapy and the procedural aspect of medical sub-specialties? In this light should time be given longitudinally across specialties in a more generic sense? There may well be some merit to this concept. However, currently our affiliations, budget, reward systems and allegiances align strongly on with our departmental structures, and trying to break down these structures may yield more negatives than positives.

Finally, with respect to surgery, I would strongly suggest that our department and its faculty want to be highly invested in the undergraduate curriculum. Early exposure to junior medical students is critical if we are to continue to attract the best and the brightest to surgery. If we don't interact with them, serving as their advisors, teachers and role models, we will see a diminution in the popularity of surgery as a specialty. Just as important we have a lot to teach our future colleagues. We have an array of skills that are critical to impart to our students. We know more about trauma, critical illness, cancer, cardiovascular physiology, wound healing, and nutrition than most. There is a closeness to our relationships with patients that is unrivaled in most other domains of medicine. Last, but certainly not least, a surgeon's job is the most exciting and gratifying of any of the medical professions. We need to pass on this excitement to our students.

The ultimate great debate

Finally, the debate which will be framed to a large extent around the issue of social responsibility will pit the "soft stuff" against the "hard core". To be sure, as physicians we have to be mindful of the many social issues which dominate our society. We have to be mindful of just how privileged we are to be living and working where we do. When compared to billions around the world, our riches are extraordinary. We must understand that the afflictions of hunger, poverty, torture, war, and abuse are overwhelming and deserve our attention. The question will be, as we fashion a new curriculum, whether these issues should gain further expression in our curriculum, and if so, at the expense of what. For instance, should these issues divert curricular time away from the field of transplantation, because in comparison to the number of individuals who will have transplants, the numbers affected by the above-mentioned afflictions are staggeringly imbalanced. Yet, the University of Toronto has special expertise in transplantation and can deliver an outstanding education in this area. Similarly, should we devote a large element of curricular time to having our students in the community and in our patients' homes? If so, should this be at the expense of a rotation in the ICU, the ER or a tertiary care facility in-patient ward? Obviously the two extremes need not be mutually exclusive, but there are going to have to be trade-offs. Ultimately we cannot be all things to all students. And to a large extent, our future curriculum should be dictated by our vision and mission. The University of Toronto has an embarrassment of riches, talent beyond belief, an extraordinary research infrastructure and some of the best professors in the world. It would be my opinion that we should aspire to graduating all of our medical students with special expertise. That may be graduating with an MD/PhD and heading for a career in research. It may be aiming for a career as a leader in family medicine. It may be aspiring to be a clinician-educator who will help define the educational processes of the future. It may be dedicated to pursuing a career in public health policy. It could be developing a thirst for a surgical career working primarily in countries less fortunate than Canada. It is my view that above all our goal should be for all of our graduates to have the skills, the potential and the desire to do something special, something unique. We owe this to our heritage. We owe this to our magnificent faculty. And, above all, we owe this to the extraordinary students we accept each year into our first year medical class.

Richard K. Reznick
R.S. McLaughlin Professor and Chair

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