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Many birds with one stone: opportunities in distributed education

2010; Wiley; Volume: 44; Issue: 3 Linguagem: Inglês

10.1111/j.1365-2923.2009.03609.x

1365-2923

Bob Woollard,

Healthcare Systems and Technology

The paper 'Socially responsible medical education: innovations and challenges in a minority setting'1 in this issue represents an inherently commendable undertaking that appears to be moving towards success. However, its significance extends far beyond the realm of distributed and community-engaged scholarship. It is a report of an important innovation in medical education through the development of a community-engaged campus that collaborates across political, social, institutional and community boundaries. It is grounded in the historical development of the concept of the 'social accountability of medical schools'2 and focuses on serving an ethno-linguistic minority, the health status of which is at negative variance from that of the population as a whole. It represents a singular form of 'distributed medical education' connected equally well across universities, medical schools and communities. Although distributed education is a piece of the puzzle, it is evident that the initiative is best presented as a remarkable achievement in collaborative development and ongoing delivery across an array of 'solitudes'. Thus, to have achieved engagement and joint effort across academic institutions, political boundaries, community and institutional divides, ethno-cultural and language differences is the real story here and the experience has implications for a number of jurisdictions around the world. It is a worthy example of the 'scholarship of engagement'3 and, indeed, the power of community engagement to assist in the development of highly relevant institutional and curricular innovations. Distributed education is best presented as a remarkable achievement in collaborative development and ongoing delivery across an array of 'solitudes' The current worldwide trend towards distributed models of medical education is undoubtedly based on a number of influences, including a desire to draw from and serve distributed populations, the fostering of primary care and community-focused education, the political influence of regional representatives in policy-making bodies, the evolution of self-directed and learner-focused pedagogy, and the rapid revolution and deployment of telecommunications and information technologies that place whole libraries within reach of learners and connect them efficiently with teachers, wherever they may be. In the wealthier nations an added factor concerns the pedagogic saturation of traditional, large, tertiary teaching hospitals and is compounded by reductions in the numbers of hospital beds, advances in procedural technology and the early discharge of sicker patients into the community. This 'perfect storm' of converging factors has led to a dramatic change in the distribution (both geographic and social) of medical education in the 21st century. The old saw that 'necessity is the mother of invention' seems to hold true, even in the sometimes arcane and always complex world of medical education. Although distributed education is not itself entirely new, the particular combinations of change exemplified by the report in this issue of Medical Education are. This is worthy of careful scrutiny. The old saw that 'necessity is the mother of invention' seems to hold true even in the sometimes arcane and always complex world of medical education The relative 'success' of each institutional innovation must perforce rest with the stated intent and effective evaluation particular to that institution. However, the profession has long taken a more collective responsibility in this area through a complex array of systems for accreditation, licensing and inter-jurisdictional recognition. This has always been imperfect, but has seemed to serve the various publics well, except, importantly, for its almost universal failure to achieve an equitable distribution of the doctors so trained. A major impetus for distributed education in many jurisdictions is precisely this shameful mal-distribution of health human resources.4 For the past decade and more, this has been a focus of major concern at the World Health Organization and has culminated in its most recent World Health Report 2008 Primary Care: Now More than Ever.5 Whether or not this global call to arms and the specific initiative reported in this edition of Medical Education are successful in fostering more equitable human resource distribution, there are many other potential impacts worthy of note. A major impetus for distributed education in many jurisdictions is precisely this shameful mal-distribution of health human resources One is the concern expressed almost half a century ago by Kerr White that we are simply teaching students using the wrong patients. His seminal study6 of the health behaviours and concerns of 1000 people in an average month was repeated and refined by Green et al. in 20017 and is worth pondering here. The vast majority of medical schools in the 20th and early 21st centuries have focused their teaching almost exclusively on the one in a thousand patients who reach the teaching hospital, not the 217 who visit doctors' surgeries and certainly not the 750 who may represent 'teachable moments' for health promotion and disease prevention. Might the shifts we are seeing in distributed education be the solution to a problem that has plagued us for more than a century? Although an article of this length cannot hope to explore all of the other opportunities inherent in the changing face of 21st century medical education, we might take the paper 'Socially responsible medical education: innovations and challenges in a minority setting' to represent a springboard for a number of observations: effective community engagement is a powerful tool for shaping the curriculum and other scholarly work to the needs of the community that is served by the medical school; distributed sites of existing schools may represent an edge phenomenon, like the edges of oceans, where creativity is more likely to occur; distributed sites at the interface of cultures and languages may represent very ripe venues for the learning of cross-cultural competencies;8 the framework of the social accountability of medical schools9 can provide a useful framework for advancing both the nature and distribution of practitioners to better address the priority health needs of society; current pressures and trends towards interprofessional education10 are very challenging to deliver in large institutions and communities but are required as a matter of course in distributed sites because necessity dictated by constrained resources leads to the production of effective role models, and as global pressures for task shifting11 attempt to adapt health resources to evolving needs, distributed health care training sites are places where delivery, reflection and evaluation capacity are likely to become foci for innovation. Distributed sites of existing schools may represent an 'edge phenomenon', like the edges of oceans, where creativity is more likely to occur While these and other opportunities arise in the context of changes in medical education, it is worth considering that the profession, in an increasingly global age, has a collective responsibility to be even more thoughtful in creating effective practitioners for the 21st century. Our existing institutions of quality assurance and peer review need to be challenged towards a global consensus on how best to realise the potential that resides in the medical schools of the world.12 The paper under discussion here is a useful marker along that path. The profession, in an increasingly global age, has a collective responsibility to be even more thoughtful in creating effective practitioners for the 21st century One final observation concerns the suggestion that increasing experience with distributed education may have an even more profound influence on the epistemology of medical schools and universities themselves. The latter have developed their peer review, evaluation and career advancement systems based on their specific geographic locations and, frequently, a model of three realms of achievement: research, teaching and service. This has presented real challenges as teachers and the teaching became far less geographically focused and the scholarship of distributed academics more challenging to squeeze through the traditional descriptive sieve of the work of a scholar. Although there is some value in taking this simple view of the roles of the scholar, Boyer8 and others have helpfully described a taxonomy for scholarship far more in keeping with the 21st century: the scholarship of teaching includes transmitting, transforming and extending knowledge; the scholarship of discovery refers to the pursuit of inquiry and investigation in search of new knowledge; the scholarship of integration consists of making connections across disciplines and, through this synthesis, advancing what we know; the scholarship of application asks how knowledge can be practically applied in a dynamic process whereby new understandings emerge from the act of applying knowledge through an ongoing cycle of theory–practice–theory, and the scholarship of engagement connects any of the above dimensions of scholarship to the understanding and solving of pressing social, civic and ethical problems. Without putting too fine a point on it, it seems to be readily apparent that universities must maintain the rigour that has served society well for over half a millennium, but must change the definitions of that rigour as they enter a 21st century calling for a more engaged academy. Properly managed, this transition will benefit both the academy and the societies they serve. Medical schools and, in particular, the initiative represented in the paper 'Socially responsible medical education: innovations and challenges in a minority setting' should be on the leading edge of this transition.