Despite repeated and increasingly vociferous calls for reform, making substantive changes to the healthcare system and health professions is incredibly hard. This isn’t a particularly novel or daring conclusion. Part of that comes from the fact that those changes are high stakes and involve a great deal of personal discomfort. I would even argue that an underappreciated barrier to making more radical reform comes from a feeling that accepting that the current system is broken in some way invalidates the hard work that millions of physicians, nurses, pharmacists, etc. have put in toward their training, and more generally, the care they deliver. To voice a belief that things may need to change at their core can cause fear, hurt, and identity crises that limit personal behavior and policy change in the health professions. In an effort to circumvent the emotionally raw nature of these feelings, I offer the following extended metaphor:
Imagine that you are the new president of a multi-divisional manufacturing corporation that specializes in making vehicles. Your company makes planes, helicopters, vans, trucks, buses, sports cars… you name it. You consider yourself to be one of the greatest corporations in history, even if your products tend to be more pricy than your competitors. Now, all your market analysts have told you that there is a great need for cargo planes. The U.S. government has said that there is a historical, current, and worsening lack of cargo planes in the market. There are even advocacy organizations saying that consumers are being hurt by a lack of cargo planes. It seems obvious that your company should be making as many cargo planes as it can in the near future to meet that need. So as the new president, you announce to the whole company from VPs, to engineers, to line works, to the cafeteria workers that we must make more cargo planes! Everyone agrees this is the way to go and commits themselves to the cause.
Now, one year later, you are looking at the results of your initiatives and have found that you have made almost no change to meet the need for cargo planes. Instead, you are making predominantly the same amount of buses, sports cars, and trucks with perhaps a nominal increase in the overall number of cargo planes. In fact, in many cases, the number of cargo planes have only increased by slapping wings on several buses and shoving as many boxes as you can into a few 400 Horse Power sports cars. The planes you are making are immediately being overused due to the incredible needs of the market and constantly breaking down based on excessive wear and tear. Some of the solutions you have seen even boggle the mind in their lack of rationality. One of your executives suggested the helicopters just act more like planes. This was inefficient and a stopgap at best. Another decided to pay extra for trucks to complete cargo plane routes in order to incentivize their conversion from the former to the latter. That decision resulted in several of your trucks trying to haul cargo from New York to London with an ensuing catastrophic loss of the vehicles in the North Atlantic. Very few of our trucks have turned into planes long term. What happened?
As president, you decided to get to the bottom of the problem.
First, you spoke to the VP of distribution who added the wings to the buses to find out why she did that. She explained that we had too many buses and too few cargo planes to sell, even after you told the factories to change production.
Next, you went to the cargo plane factory foreman. He relayed that he was doing the best he could to make cargo planes, but that all of his machines and workers were trained and designed to make buses and no one had given him new designs or materials to work with. Some of the materials even came pre-cut into bus shapes and it was almost impossible to adapt them to other needs.
With this new information, you realized the problem must be more upstream in the supply chain and went to meet with the VPs of Purchasing and Design. Together they informed you that they wanted to make cargo planes just as you asked, but they had to keep using the “highest grade” bus materials to make the cargo planes since they were sure that had always worked best in the past and the engineers did not want to make an “inferior product.”
Now in desperation, you decided to meet with your suppliers to see if you could just order the right materials for cargo planes and force everyone else in the company to adapt that way. Unfortunately, the sales representative informs you that since high-grade bus materials are considered the best, thanks to the importance placed on them by your company, she had not bothered to support the creation, refinement, and stockpiling of anything else.
Head in hands, you decide to explore ways to better attach wings to buses.
So, what am I getting at here?
If you clicked on any of the links above, it should become increasingly obvious that we have built a similarly unresponsive system that is not designed toward our stated professional goals. Our health professions education systems, especially medical education with its high reliance on test scores, are producing exactly what they are designed to produce. Whether this is a result of conscious choice, unconscious bias, or unwillingness to change, the fact is that as long as we hold to old models, old training approaches, and old ways of defining merit, we will forever produce the same old product.
As one of those “old products,” it hurts me to say that the system in which I was selected, trained, promoted, and indoctrinated is fatally flawed. The system lacks supporting evidence that its current design is anything but unfair and biased against certain groups. Furthermore, little to none of the factors we use to select or assess our learners are correlated with eventual workplace performance.
What is abundantly clear is that we are not meeting the growing need for primary care doctors, other physicians, and scientists from under-represented backgrounds, or physicians with the cultural competency necessary to care for the current or future U.S. population. Reevaluation and reform at the most basic level across the multiple stages of the health professions educational pipeline is needed if we are to significantly change our future workforce. If we are unable or unwilling to do so, we will need to be honest with ourselves and our patients that we are content to find the best ways to attach wings to buses for the foreseeable future.