Education of Health Professionals: Global Lessons & Challenges Lincoln Chen, MD CMB 8th International Medical Education Leadership Forum Canadian College of Physicians & Surgeons October 21, 2015 Fairmont Hotel, Vancouver

Presentation Flexner Century: Lessons Emerging Forces Global Connections & Challenges Canada: inter-professional leadership China: postgrad training systems

Welch-Rose and Goldmark Flexner Report 1910 Welch-Rose and Goldmark

Supply of health workforce Demand for health workforce Systems Approach Provision Needs Demand Supply Supply of health workforce Demand for health workforce Provision Education System Health System Demand

Interdependence in Education Transformative Learning Education System Structure Institutional Design Stewardship Accreditation Collaboration Financing Instructional Design Criteria admission Competencies Channels Career Process Context Global-Local Outcomes Interdependence in Education Transformative Learning

Science based Problem based Systems based Three Generations of Reform Science based Problem based Systems based 1900 2000+ Scientific curriculum Problem-based learning Competency driven: Global-local Instruction University based Academic  centers  Academic Health-Educ Systems Institution

Commission Recommendations Instructional Design Competencies-roles Transformative learning for team work (Canada) IT revolution in learning Ethical professionalism Institutional Design Health-education systems (China) Academic health systems Collaboration-partnerships

Vietnam

Bangladesh

India

Lesson: Power of Knowledge Knowledge Professional Producer Researcher – scientist Agents Service professionals Clinicians-specialists Primary care Population health Reproducer Faculty – students Based Policy-maker, manager

Lesson: Brighter-Darker Sides Knowledge broker Service provider Technology Quality assurance Team leader Advancing Health Darker Monopoly knowledge Financial self-interests Professional chauvinism Over-specialization Urban preference Inequities in health

Emerging Global Forces

epidemiologic transitions Global Forces Demographic epidemiologic transitions Global change Educated patients Co-production Biosciences ICT Private markets Social justice

  Life Expectancy (2013) 81.4 75.4 Health Financing (2013) Health expenditure % GDP 11 6 Government % of total health expenditure 70 56 Government % of total gov’t expenditure 18 13 Per capita health expenditure (US PPP$) 4,800 650 Health Professionals (Canada 2010, China 2011) Physicians (No.) 0.07 2.0 Nurses and midwives (No.) 0.30 2.2 Physicians density (per 1000 popn) 2.1 1.5 Nurses-midwives density (per 1000 popn) 9.5 1.7 Nurse-physician ratio 4.6 1.1

University of Alberta Medical School

Transformative Learning for Leadership Level Objectives Outcome Informative Information Skills Experts Formative Socialization Values Professionals Transformative Leadership attributes Change agents

Norman Bethune Shanghai Medical College

China Health Systems Output-Outcomes Health Status Financial Protection Patient Satisfaction

Health Insurance Coverage (China-USA 2000-2013)

Symptoms Diagnosis Patient Satisfaction Weak professionalism 73% hosps reported violence against doctors 9,831 major disturbances in 2006 Double (17,243) disturbances by 2010 Diagnosis Mistrust doctors-patients Weak professionalism Vicious circle – low-level equilibrium trap http://www.bmj.com.ezp-prod1.hul.harvard.edu/content/345/bmj.e5730.full.pdf+html

Patient Dissatisfaction

Hospital System Imbalances Top hospital 5% but care for 36% patients 66% hosp (Grade I) treat only 5% patients Source: China Ministry of Health; Technomic Asia Analysis

Overcrowded Hospitals Vicious Circle Limited time Financial incentives Drugs & testing Poor communications 3-yr residency Lack primary care 5-yr schooling Students Supply Demand No Accreditation No Certification Professionals No Jobs Overcrowded Hospitals Curriculum mismatch No quality control Faculty-student ratio Education Health Low satisfaction Distrust Violence Patient Flow Not top students Status Salary Career Workload 6-in-1

Doctors by Education

Fragmented Circle Education Health Supply Demand Professionals Primary care Village - Township Assistant Doctors Da Zhuan & Zhong Zhuan Village Doctors Supply Demand Professionals 5+3 Big Hospitals Cities Education Health Weak Referral

Doctor-Patient Circle Family want Doctors Patients Prescribe Cultural Feedback Loop Unnecessary IVs Expensive drugs Equipment for testing

Virtuous Circle Supply Demand Tertiary hospitals Professionals 3-yr residency Primary care 5-yr schooling Students Supply Demand Tertiary hospitals Professionals Graduates=Jobs Quality standards Accreditation Certification Competency-based curriculum Referral system Satisfaction Both Patients & Professionals What we want Status Salary Career Workload 1-in-1 Top students

Health Services = People Business Flexner Century Global forces Transformative leadership for team work Virtuous circle education-health systems Patients and Professional Satisfaction! http://www.bmj.com.ezp-prod1.hul.harvard.edu/content/345/bmj.e5730.full.pdf+html