The End of Tinkering: International Academic Group Explores Transformational Needs in Health Professional Education.

As a non-clinician, I often wonder: were I one, what I would think of my chosen life work upon learning about two of the medical industry's most astonishing data points. The first is that among the various factors contributing to the health of people and communities, clinical care accounts for just 10% to 15%.[1] Put differently, one's choice to work as a clinician leaves 85% to 90% of the influences on health off the table. These influences are the determinants of health such as economic status, education, housing, environment, and life choices.

An integrative health and medicine practitioner might take solace that prioritizing clinical engagement with patients on bettering lifestyle choices affirmatively shifts the balance. One hits some of the notes that can push the 10% to 15% upward compared to the drug-and-procedure orientation of reactive clinical treatment. Still, even a non-clinician activist can wonder if one may have based one's career decisions on a lousy differential diagnosis. Clinical practice is not the most powerful pressure point if health creation is the goal.

The second data point regards the collective policy response to this evidence. The broad array of preventive and proactive interventions suggested by these determinants together receive, in the United States, just 9% of “health expenditures.”[2] We are not putting our money where our evidence is. In our focus on clinical medicine we are, it appears, barking up the wrong—if much better watered and fertilized—tree.

The good if yet rough-cut news is that some top academic leaders internationally are beginning to 'fess up and face up to this discordance between evidence and action. They are boring into the tough questions regarding the necessary role of education if health creation's integrative terrain is to flourish. The over-bearing shadow of misaligned economics presses in on the dialogue.

This column focuses on activities of the Global Forum on Innovation in Health Professional Education convened by the US National Academy of Medicine (NAM), formerly the Institute of Medicine. The initiative, now in its fourth year, is a unique interprofessional convening of leaders of virtually every national North American health professional educational organization. Included also are a smattering of academics from Africa, Europe, Asia, and South America. The Global Forum's work is to identify how professional education must change to meet needs after what might be called the Flexner century.

One of the Global Forum's founding texts was a Lancet report from 2010. The release date—100 years after the seminal Flexner Report—was intentional. Whatever its virtues, the intended and unintended consequences of the Flexner model enthroned reductionism and reactivity as doctrines, hospitals as palaces, and medical specialists as gods. Flexner opened massive channels of resource allotment that eroded public health via the just-described Grand Canyon between evidence and practice.

Entitled Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Independent World,[3] the report took a 180-degree turn. The international team of authors described an emerging era that is global, multicultural, team-focused, beset by chronic more often than acute concerns, rapidly changing, and necessarily focused on equity. Rather than inhabiting a separate ivory tower, academics must get their hands dirty in the rough-and-tumble of their communities. They must directly engage with cost and delivery needs, with community and public health.

A table in the report eloquently captures the shift in desired outcomes. Flexner's 1910 recommendations promoted a type of learning that was “informative” and created “experts.” The coming era demands learning that is “transformative.” The end product: health professionals who are “change agents” (Table).

Table

Levels of Learning

Type of Learning	Objectives	Outcome
Informative	Information, skills	Experts
Formative	Socialization, values	Professionals
Transformative	Leadership attributes	Change agents

Reprinted from: Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010 Dec 4;376(9756):1923-58. Copyright 2010, with permission from Elsevier.

The April 2015 workshop in Washington, DC, “Envisioning the Future of Health Professional Education,” was the Global Forum's seventh 3-day session since its kickoff in 2012. A NAM goal with each of its dozens of forums is relationship building. By now, these 60 leaders of national academic organizations representing medicine, nursing, public health, veterinary medicine, pharmacy, sociology, psychology, complementary and integrative health, and a dozen other fields had developed a rich camaraderie. I've participated continuously as a representative of a consortium of integrative health and medicine councils of colleges (the Academic Consortium for Complementary and Alternative Health Care [ACCAHC]). Passions run high. Discussions sometimes show a liveliness approaching that of the British House of Commons, though with a focus on collaboration rather than polarization.

The 3-day session began on this sober note: “I've spent 40 years tinkering with health professions education, and the tinkering has done nothing.”[4] The speaker was Malcolm Cox, MD, an incoming Global Forum co-chair. Prior to his retirement in 2014, Cox served as Chief Academic Affiliations Officer for the United States' Veteran's Health Administration. Cox's self-deprecating reflection set the tone for a deep planning dive into a future session that will focus entirely on educating health professionals on the social determinants of health. Cox continued, “We need a transformation. And transformational change requires death… and rebirth.” He paused. “That is not an easy way to put things.”

Co-chair Susan Scrimshaw, PhD, president of The Sage Colleges, later chimed in with her own urgency: “We are preparing people literally for a system that does not exist. What people are doing may not be preparing them for the system of today.” Then she directly echoed Cox: “We can't just reform and tinker around the edges. We need to break some boxes. We need to break the box of the curriculum.”[5]

The lyrics from the 1970 Elton John–Bernie Taupin song about burning down the Mission if we're going to stay alive wafted up. Widespread adoption of directions subsequently described would do that. All are available via the NAM website.[6] This is a brief sampling.

Brazilian policy leader Francisco de Campos described how, despite an imbalanced investment in high-tech medicine that serves just 20% of his population, Brazil's effort to offer primary health services to the other 80% comes via 44 000 community health teams.[7] Each has a physician, nurses, and a dentist and is powered by 6 community health workers (CHWs). The perceived value of CHWs to communities is now such that “the community health workers' lobby is almost as strong as physicians.”

The University of New Mexico's Arthur Kaufman, MD, presented a program to engage social determinants modeled on Brazil's and on the widespread investment in agricultural extension programs in the United States: “Why not ‘health extension agents’ in every community?”[8] Via a partnership with a managed care organization that funds Health Extension Rural Offices (HEROs), CHWs directly engage community members on health and cost impacting issues such as utilities, employment, childcare, employment, education, food, and housing. HERO is rooted in fundamental community organizing. As in Brazil, the CHWs at the center of this health-creating scheme are individuals empowered via their respect as community leaders rather than via medical status. Flexner's expertise hierarchy is upended. Might, as Kaufman later suggested and Cox reiterated, one step toward transformation be to require all hospitals and health systems, as federally funded health centers are in the United States, to have at least 50% of their boards and advisory committees reflect the constituencies they serve?

Transformative ideas continued to roll out. One modeled development of a “new competency” that breaks the ivory box: “We learn about the cardiovascular system but not the system in which we work.”[9] This East Carolina University program forges ties with health systems. Each student engages a community project and graduates with a certificate in public health. A segment led by a veterinary medicine leader argued for the One Health Initiative orientation that “links human, animal and environmental health.”[10] And if health rather than reactivity is desired, mustn't professionals be tuned to skills managing their personal determinants? In a discussion section, presenter Elizabeth Goldblatt, PhD, from ACCAHC, urged her fellow members to devote an entire NAM workshop to how to enhance “self-care, resilience, health, and well-being in health professional education.”

Closing keynoter Laura Madana Valladares, PhD, from Mexico's Instituto Nacional de la Salud Publica, rattled the cages again: “We need change that goes beyond the Lancet recommendations.”[11] The message in the Elton John–Bernie Taupin lyrics drifted back: “We need to reinvent our health professions educational system. We need a radical change.”

Cox, the co-chair, opened the workshop's final day with a reflection: “The older I get, the more I am interested in the power of money.”[12] Despite apparent consensus for transformation, a pervasive impotence flows through these leaders as surely as resources under Flexner ripped open the chasm between evidence and the practice of health creation. The vast majority of academic and payment resources remain controlled by hospitals and tertiary care. Money, the most powerful social determinant, is, not surprisingly, the overbearing determinant to academic change, wiring curricular boxes shut even as evidence urges their demolition. More than once, Global Forum members spoke to the need to directly invite the elephant of economics to plop its considerable behind into the room. If the Global Forum does not do so, change agency will be little more than tinkering—if radically minded—around the edges.