'A wicked problem': does medical education produce better doctors?

‘What is a wicked problem?’ I naively asked Lambert Schuwirth as we discussed his thought-provoking question: ‘Does medical education produce better doctors?’ ‘Problems which are difficult or impossible to solve, because of incomplete, contradictory, and changing requirements’, was the answer. Health care and human nature, both entwined in social complexity, are prime examples. Solving one aspect of a problem may reveal and create others. Training health professionals to deal with this is challenging. Schuwirth and van der Vleuten outline six complexities to grapple with. They argue for more rigorous, multi-faceted research using triangulation to help unravel the complex task of producing doctors for rapidly changing twenty-first century health care.

Have we been taking a too simplistic approach? I am grateful to Roger Jones, editor of the British Journal of General Practice, for his guest editorial. We both aim to raise the quality of the medical education research papers we receive for publication and move beyond the seemingly linear approach, i.e. ‘we have introduced a new teaching innovation and students liked it.’ More cross institution collaboration, more focus on improvement, not just innovation, and more robust evaluation of impact on behaviour change and improved health-care outcomes are all essential. Not easy. Arguably though, just as with climate change (another wicked problem), the crisis is already upon us, yet we remain slow to act. The global challenge of a clinical workforce unable to meet twenty-first century healthcare needs has arrived. I bemoan, once again, our tardy response to the 2010 Lancet report [1] and the slow transition of learning into the primary care context.

This issue highlights two ways for the journal to move forward. First, through increasingly strong inclusion of the student voice. Letters from medical students offer their perspective, from their experience as consumers, on our articles. We ask for a clear new message of interest to our readers and justification of their views from the literature. This helps open our eyes to the complexity of the learner experience and human nature; thus, helping move beyond linear interpretation of research findings. We aim to engage students early in medical education research. The article from Santoni et al., UK National Student Social Prescribing Champions, shows how pivotal students can be in introducing change. We also publish advice from Reid, a recently qualified doctor, offering tips for Foundation doctors entering their rotation in general practice; a challenging transition.

Santoni et al. believe ‘general practice can play an integral role in shaping values and beliefs amongst tomorrow’s doctors.’ The second way forward is to build on this and champion cultural shift. Caroll and O’Reilly highlight, from their Northern Ireland perspective, the importance of placing GP trainees in underprivileged areas. They echo the experience from Deep End practices in Glasgow published last year [2]. The importance of directly engaging students face to face with the narrative of marginalised patients with tri-morbidity (physical and mental health problems and substance abuse) is evaluated by Player et al.

Culture can shift. Cunningham et al. describe the move over time of continuous professional development into small interprofessional group learning. While Shah introduces the concept of enabling the learner to reflect from outside rather than within the discussion. Traditional beliefs though can be hard to change as Harrison et al. highlight. They identified a resistant view among some UK GP trainers that trainees must learn, not teach. This denies the opportunity for students and trainees to interact; a contrast to their experience in hospitals. There is an urgent need to normalise the role of the GP trainee as a teacher.

So, can medical education produce better doctors? A question easy to ask but difficult to answer. I leave that for further debate. The social complexity of medical education is without question challenging but open to different strategic approaches to research;- a task to face as we move into 2020.

Happy New Year.

Disclosure statement

No potential conflict of interest was reported by the author.