Changing Education through earlier Differentiation for Better Specialisation

An essay for a new structure of medical education

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Imagine! The hopeful surgical resident who cannot handle a scalpel. Imagine! The hopeful intensivist-in-training who does not understand basic physiology. Imagine! The hopeful GP-in-training not knowing the most common cause of a red skin lesion. These are not imaginary situations, they are quite realistic possibilities. After six years of studying medicine it is possible to be a novice in some of the basic skills required for your future specialisation. 

I propose a new system where this will be less of a problem. In this hypothetical system only the first year of the bachelor is a shared trunk teaching the basics of medicine. In the second year you will take elective courses related to the future specialisms you are interested in, with nothing being set in stone yet. This will include internships to get acquainted with the reality of the specialisms in the field. In the third year of the bachelor you select a differentiation. You will be able to choose first line, surgical or internal medicine. Everybody gets the same Bachelor of Medicine. Then for the master you have longer internships which are related to the differentiation you chose. At the end of these you receive a Master of First Line Medicine, a Master of Surgery or a Master of Internal Medicine.

I hope that through reading this article you are challenged to look at the current structure of medical education globally. I am not hoping to change the system overnight, since the current system is producing a lot of extremely skilled doctors. I put forward this hypothetical alternative as a device to critically look at the situation now and see if small changes could be made to help both medical students in addition to the quality of the healthcare system. 

Jack of all trades, master of none
The goal of studying medicine is to become a specialist, be it a thoracic surgeon or a GP, and not to be a specialist in every single specialty that exists in the world of medicine. This would be unrealistic and chasing this folly would not lead to become a better doctor. Every specialty requires its own skill set. A surgeon needs to develop finesse, spatial thinking and anatomical knowledge. A rheumatologist needs to be good at pattern recognition and understanding complicated biological processes. 

Let us take the aspiring surgeon as an example. They will not hold a scalpel in the entire bachelor and in the master only under very specific circumstances. Other similar skill sets are nowhere in the world a regular part of the curriculum from the earliest phase. They are expected to develop these skills only after they have already taken the oath or in their own time. I point to our sister vocation of dentistry as an example of how I would see surgical education. From the first year our fellow medical professionals start developing practical skills on dummies and continue doing so to the end of their education. This makes them more than capable to perform the art of dentistry as soon as they graduate. 

Teaching the correct skill set to the correct person before an (aspiring) doctor enters the clinic is not only good for the level of skill of the doctor it is also better for the patient. Imagine being a patient and outside the door you hear two doctors whispering: “This is the first time I’ve done this, are you sure it will be fine?” How much confidence would that inspire in you? Similar things happen in every teaching centre and I think with proper preparation you can more confidently start practicing skills on real patients.

One too many, one too few
Is there a shortage of aspiring medical students? No. Is there a shortage of GPs? Yes, a big one. Is there a shortage of neurosurgeons? A big no. A significant amount of medical students have a dream of becoming an oncologist who works on the cure for cancer or of becoming a world-renowned surgeon. While most medical students are extremely capable and ambitious, not everybody has the skill set befitting their dream specialty. However, in the current theory-centred curriculum (which is logical in university-level education) you will only find his out very late in your education. On the national level the surplus of hopefuls of certain specialisms can be avoided by making selections earlier in the curriculum. If you are horribly incompetent with a scalpel and suturing needle then you should probably not become a surgeon. Testing the relevant competencies before aspiring doctors start their career  will prevent a great deal of hardship for the hopeless hopefuls. Therefore, setting quotas on the amount of students differentiated to specialised internal medicine or surgical medicine you will prevent a lot of disappointment later on (when it is too late). An additional benefit is that the average quality of each group per specialism will probably go up because of the more relevant skill sets. 

Can I have one of those career orientations?
While discussing my proposal with colleagues the first thing most people say is that it is a bad idea. The argument they give for this is that most people have no idea what specialism they wanted that early in their education. They have a good point there but I think this is a problem which would be quite easy to solve. By organising earlier internships the day-to-day work becomes clear and students get acquainted with the skill set required per specialism. In the current curriculum of Groningen a great step in right direction has already been taken in the form of profiling education. I do think this programme can be improved by making it a monthly or bimonthly required undertaking so many more specialisms can be experienced. This puts these students more in touch with the real day-to-day work of a specialism, but it also shows them which skills are actually required for that specialism. Nothing is more frustrating than to build your CV to become a neurologist only to find out in your fifth year that you do not like what a day’s work looks like for a neurologist. Then you are left with a CV great for a neurologist but not for what you really enjoy. 

Conclusion
Being able to develop the correct skills earlier in your education will make it easier to perform well and more confidently at the onset of your career. Selecting those with correct skills will also make it easier to get the right people in the right places which will increase the quality of the healthcare system as a whole. However changes are needed so that people can orient earlier which specialism they want to enter into, something which the UMCG is already working on through profiling education. While I do not expect an overnight change since some of the changes I have proposed are a little radical, I do hope that you will keep thinking critically about your education and collaborate in creating a  better learning landscape for all.