“The uncertainty of life”

“This is the root of magic and science, life’s response to uncertainties”¹

Compiling this issue reminded me of the dilemma raised by Klamen et al [2]. They warned against the headlong rush, and time involved, in moving clinical curricula to ‘competencies, milestones, and core entrustable professional activities’; an endeavour they claimed, ‘history suggests will collapse under its own weight’[2]. Is this because we are ignoring a reality? Life is uncertain. Medicine can never be a pure science. Be it ‘humanities’ or ‘magic’, there is a dimension of learning within patient care we risk failing to capture.

Much time is spent defining and assessing measurable behavioural outcomes. Yet, as Appleby et al point out in this issue, learning about spirituality within a patient/doctor interaction fits poorly into the UK Royal College of General Practitioners (GPs) curriculum’s competencies. This leads, they claim, to GPs ill prepared to integrate spirituality into practice. But can spirituality be fitted into a competency-based framework or is it part of the curriculum we are failing to reach?

Despite the move from behavioural to constructivist-based learning, are we being slow to accept that learning is NOT linear? Durning et al [3] rightly argue for non-linearity within medical education assessment. We face two stark facts. Firstly, that assessment drives learning. Secondly, that doctors face a future of increasing uncertainty and risk in health care. As Appleby et al suggest, we need broader philosophical frameworks supported by transformational learning. The current linearity of our curricula and assessments needs addressing.

Does redefining ‘competence’ more broadly as ‘capability’ help? Tate et al in this issue emphasise the importance of primary care as an excellent platform for supervised transformational learning. They offer an expanded view of capability through using the supervised opportunities of general practice to ‘heighten sensitivity to context, develop divergent thinking and assess zones of professional practice.’ Helping learners move beyond defined competencies to identify and respond to novelty may enable them to capture some of the ‘magic’ of human interactions.

Nor can observed learned behaviour reflect what is goes on in the learner’s mind.

Johnstone et al, in our Three Papers series, explore the potential, as yet poorly explored, of supporting learners to develop their professional identities. They highlight primary care pedagogy as an environment where learners can be enabled to understand the complexity of feeling within themselves not only when interacting with patients but in addressing their own personal life events. Helping them adjust and realign their different identities, and feel valued as human beings, is of paramount importance.

All these papers highlight the complexity of capturing the non-linear, difficult to define and assess, parameters of medical education. They are right to challenge. The, as yet poorly explored, potential of learning in generalist primary care about the relative uncertainties of life offers a way forward. Perhaps we do need to openly accept that ‘magic’ alongside ‘science’ is at the root of life’s uncertainties. Perhaps Eisley’s words help our understanding. ‘Magic runs to the beginnings of life because life is a gift and uncertain.’[1] We owe it to our patients and future doctors to champion the educational opportunities in primary care to capture some of the ‘magic’, broaden our philosophical frameworks and become more non-linear in our approach.