QUEST FOR COMPETENCE IN MEDICINE: Tasks and Hurdles for Asia

和信治癌中心醫院黃達夫教授於2012年四月廿二日以錄影演說在International Conference for Medical Education in East Asia發表。

追求醫學競爭力：亞洲的任務和障礙

黃達夫 (台灣醫學院評鑑委員會主任委員)

Medical Education 

The essence of medical education is fundamentally an effort to convert a student from knowing very little about medicine and the respect for life to someone who can understand what medicine is about, how to value life and to begin her/his quest for competence as she progresses in life. Therefore medical education has a clear purpose and that is to confer on and equip that person of interest with the ability to pursue her/his life in the art of healing with ultimate satisfaction. The process of education should be therefore a continuum of learning. The testing and licensing of a physician’s competence is merely a necessity and a social obligation, not an authorization that s/he is mature and harmless.

Definition of Competence 

What is competence in medicine? Its definition is a simple yet at the same time a complex one. It connotes the ability to heal, to care for the sick and to help solve other health-related problems for the patient. A physician is considered competent when s/he is professionally knowledgeable, skillful, dutiful and altruistic [1]. To seek competence, a physician-in-the-making as well as a senior physician should be, in her/his pursuit, engage in endless, relentless and ever expanding effort toward perfection. The search for professional perfection has no endpoint. It is, indeed, a process of transformation. Humility is a necessary companion. It is a conserving activity of goodness, beauty and truth in the effort of preserving life and human dignity [2,3]. Competence implies observation of ethical behavior.

Can competence be measured? The answer is yes. Can it be tested? The answer is a difficult one. One can test for the minimum of competence. One is, however, at a loss to find a metric for higher achievement. Competence is, however, perceivable by the discerning observers. 

The Quest for Competence 

As implied above, the quest for competence is endless and far-reaching. It entails a profound self-derived and intensely motivated desire to learn as a pre-requisite from the standpoint of the learner. Both the academic and working environment as a counterpart has to be free, attractive, warm and highly conducive to the learners who wish to learn. Mentors or role models should be abundant among the faculty whose eagerness to teach is matched by the motivation of the learners as a team of educational activity. The exchanges between learners and faculty should ideally be without boundary. General and in-depth knowledge and skill should be abundantly available on campus at all times. Educational funds should be in step with the richness of learning. Such conditions or requirements may sound idealistic and daunting for an educational institution. The more requirements the institution possesses, the less hindrance there will be in the combined quest for excellence.

The Learner and the Environment 

What then is the driving force for competence? As the quest for competence is lifelong and the environment may be there for choosing, the driving force must come from within the learners themselves. Therefore, the attributes of the learners will determine how successful the result will be. “Input determines the output” [4]. The center of the quest for competence lies in the learners and the environment that supports them. In a diverse society with infinite opportunities ahead, the search for a good match between the learner and her/his environment is paramount. Right person finding the right place of learning and working can lead to infinite pleasure and happiness.

No doubt in my own mind that the environment for learning and working occupies equal importance for the quest for competence. I have observed many masters who originate from an excellent match when learners’ strong desire to excel is amply supported by the environment in the direction of their pursuit. Dr. Jim Yong Kim is apropos a testimony of the best interaction. Let us examine President Obama’s nomination of Jim Yong Kim to lead the World Bank closely. Dr. Kim is a magna cum laude graduate of Brown University, MD of Harvard Medical School, a PhD of Harvard Anthropology, a McArthur fellow, a co-founder of Partners-In-Health with Dr. Paul Farmer and finally the President of Dartmouth College. It is indeed a great example of an exceptional learner growing through a series of great institutions, resulting in a much-deserved reward for his single-minded hard work for the welfare of the world. 

The Spectrum of Competence 

Competence can have a very wide spectrum. Competence in medicine can be shown in clinical science, in research, in public policy, in administration, in the teaching of medicine . . . In the world of today, medicine touches our lives in infinite directions. Educational institutions should be open to all possible directions of pursuit coming from their students. The properly monitored bottom-up restructuring of curriculum is necessary. Such restructuring ensures a mechanism of continuous reform of education to meet the demands of the ever-changing world and of student-centeredness.

Thus, competence not only denotes the quality of product in medical education, that is, the graduates, it also implies even greater needs for competence demanded of the medical schools as an institution that provides diverse education demanded by this progressive world.

Tasks and Hurdles facing Asia 

In Asia today, while the call throughout the region is 1) to raise the standards of our health of our citizens, 2) to upgrade the quality of graduates from the medical school and 3) to ensure that the health centers and hospitals are capable of providing safe and effective care to the public, the call rather should aim more strongly and directly toward the schools that prepare the human capital for its society. At the turn of the 20th century, we saw a glimpse of such effort in Peking Union Medical College (PUMC) founded in 1906 with funds later coming from the Rockefeller Foundation and led by a group of able educators, for example, William Welch of the Johns Hopkins University and his former student, Simon Flexner, of the Rockefeller Institute [5]. Within a short time, a world-class institution was quickly evident. Due to the societal unrest shortly after its founding, including the World War II and the civil war in China, the initial faculty and students had faded away. In recent years, we see the effort of rebuilding the school.

The medical schools in Asia in the recent 20-30 years have made remarkable progress and have risen to meet the demand of our growing economies. The wealth has also provided better support for both the educational institutions and funds for health care. However, these academic institutions tend to focus on meeting the societal service demands, but less able and willing to provide education that can exert long-term sustainability and self-renewal. These hurdles do not just come from the outside political or social environment. They more importantly come from within the educational institutions themselves. The recognition that these institutions should concentrate on building a diverse faculty whose devotion should not only be to the quality of service but also to producing graduates whose later responsibilities are multi-fold and divergent. Currently the majority of schools with their health centers behave as mere stations of service. They in general have forgotten their major role to the society is not the expansion of clinical services but the production of future quality health workforce. They have disappointedly turned into financial and service institutions, not institutions of learning whose primary purpose is to produce leaders and human capital that aim to promote the ultimate health of their respective society [6].

Conclusion 

Asia has been successful as a region of rapid economic growth. The urgent task now is to concentrate on making its economic growth sustainable. Asia eventually should not be the center of inexpensive labor. The institutions of learning should always be the center of this necessary transformation. Medical education above all should be a leading component of this process of transformation. The leading medical schools and their health centers in Asia should move away from just focusing on service work for the present but should defiantly and more arduously head toward their primary mission of learning, of providing their respective society competent leaders and workforce in medicine responsible for the health of future society.

References:

1.     Robert Coles and Randy Testa, A Life in Medicine: A Literary Anthology, New York: New Press, 2002

2.     Neil Postman. Teaching as a Conserving Activity, Delacorte Press, 1979

3.     Howard Gardner, Truth, Beauty and Goodness Reframed, Perseus Book Group, 2011

4.     E. A. Stead. We Produced No Single Product, 1978, Editors: Wagner, G. S. et al, citing from Stead’s essay published in Medical Times, 94: 1001-1004, 1966

5.     Mary Brown Bullock, An American Transplant: The Rockefeller Foundation and the Peking Union Medical College, Berkeley University of California Press, 1980

6.     Kenneth Ludmerer. Time to Heal: Oxford University Press, 1999