CHANGE MEDICAL EDUCATION
The contribution of the Italian Network for Global Health Education
Are medical schools able to educate health professionals who can give an answer to the health needs of people and the communities they will work for? How do medical schools answer to the challenges in a time of globalization and complexity? How do they deal with the issue of social responsibility and social justice? The Italian Network for Global Health Education (INGHE) believes that these questions should be taken into consideration and it expresses in this paper its contribution to the debate regarding medical education.
In summary, in the opinion of the INGHE:
- Every action and decision taken in the medical field is not ethically neutral. Medicine implies intrinsic ethical aspects and it should be studied and taught starting from these ethical components.
- The paradigm of complexity, which is typical of our time, provokes the recognition of the intrinsic limits of every human practice, including medicine. It is necessary to create moments of dialogue and debate between fields of knowledge, disciplines and professions.
- Within the matrix of education, it is necessary to promote the development of critical thinking and to encourage ethical choices. This is possible by stimulating moral reflection with the contribution of different disciplines. Educational experiences outside universities, in the places where people live and work, could be important in this direction.
- It is important to reduce overspecialization in order to give space to a “new generalism” whereby a wider approach can consider health and disease inside peoples’ life continuum.
- It is necessary to make a call to social responsibility for current and future health professionals. Social responsibility should inform and influence crisis situations, social injustice, exclusion caused by globalization. This responsibility isn’t decided “a priori”/ from the beginning; it should be actively sought on a personal level and in debates with every person who wants to give their contribution.
From global health to medical and health professionals’ education
The Italian Network for Global Health Education (INGHE) is a national network formed by academic institutions, scientific societies, non-governmental organizations, associations, groups and individuals engaged in teaching global health, at universities and in civil society. The establishment of INGHE was the outcome of a process that started in 2007, stimulated by the European project, “Equal opportunities for health” and the active participation of medical students in Italy. Similarly, the Secretariat of the Italian Medical Students (SISM) has been an important active part of INGHE since the beginning.
INGHE is concerned about the actual organization of medical schools and aims to open a national debate on medical education, global health education and “health education” in a wider sense. As members of INGHE we believe that teaching global health means introducing a new way to think and act concerning health while “aiming to produce change in the community and in the whole society, and bringing evidence into practice, thus reducing the know-do gap”. This is the reason why INGHE, which began its work considering only medical education, recognises the necessity to take into consideration educational paths of the diverse professions involved in the safeguarding and promotion of health.
According to INGHE it is necessary a reform not only medical schools, but also educational paradigms.
Medicine as an ethical practice
Medical education’s reform should start from the awareness that to think about medicine only as a science or a scientific activity is a substantial mistake. Medicine, as a practice, implies actions that express different meanings and purposes. Ethical aspects should be considered part of it. Every decision and action taken in this field is not neutral, and it is not possible to disregard ethical considerations. This means that medicine should be studied and taught starting from an ethical perspective.
This approach should not be limited to reflections around doctor-patient relationships, but it should be extended also, for example, to relationships between medicine and other fields of knowledge. This could help to identify deficiencies and weak points where it is necessary to work. The real question is: are current medical schools able to educate future health workers to have sufficient ethical and scientific knowledge needed to inform citizens and professionals while considering the complex systems in which they live every day?
For a new generalism
In a time characterized by the exponential increase of scientific and technical knowledge, academic curricula are becoming systems of rote learning in order to pass exams. Moreover, the request of hyper-specialization provokes an educational blackmail that obliges graduates to continue studies waiting for a place in residency. In Italy this time between graduation and residency is in limbo, a state of uncertainty.
As knowledge becomes ever more hyper-specialized and fragmented, doctors risk transforming themselves into competent technicians. This reductionist organization, based on superficial factual knowledge, is the consequence of the fracture between science and ethical acts, typical of positivist culture. A fragmented knowledge base is not able to produce future health professionals who are able to answers health’s needs of people and communities they are going to serve.
Hyper-specialization provokes a growing estrangement of doctors from places of people’s everyday life. Medical education takes place mostly inside lecture halls and hospitals, impeding future doctors’ from an awareness of factors that influence health in different social contexts. Ageing and the increase of non-communicable diseases require a wider approach, which should give centrality to aspects of prevention, health promotion, primary health care and health and social care integration . For this reason, we believe that it is important to reduce hyper-specialization to give space to a new generalism that considers health and disease inside people’s life continuum .
The necessity of wise choices
The vertiginous increase of diagnostic and therapeutic possibilities and the social construction of the power of medicine have fed an ingenuous trust in the ability of medical professions to free man from pain, suffering and death. The growing pressure of bio-medical and pharmaceutical industries contributes to a progressive medicalization of every aspect of human life (i.e. the phenomenon of disease mongering , and a consequent induction of false needs).
Expectations of people who access health services are growing, as well as health expenditure, and there is an increasing inappropriateness of services. The context of economic crisis and the partial shortage of resources warrant wise choices for the allocation of expenses. It is important that these choices go in the direction of equity and universal access to health care. A utilitarian approach that exclusively follows economic criteria needs to be rejected. Starting from education, it is important to reflect upon the concept of limits, and upon the necessity of wise and ethically founded choices, oriented to avoid squandering and fighting against both corruption and conflicts of interest.
Doctors’ social responsibility
There are growing scientific evidence  of the unequal distribution of diseases between and within countries, in relation to social divisions (described with different kinds of indicators of socio-economic positions). Health inequities are related to social determinants of health; in order to reduce them, it is important to act on all the factors (not simply biologic ones) that could influence an individual or a community’s health. This does not have to give medicine an excessive task. It is necessary to call future doctors to a responsibility beyond the doctor-patient relationship, and moves towards a responsibility that encompasses considerations of the greater society .
Health professionals are able to recognise and scientifically prove the real consequences of political and economic systems on peoples’ lives and health. Therefore, they cannot remain neutral in front of these inequities.
With this in mind, doctors and future health professionals should enter into dialogue with different sectors of society and with disciplines that work for the common good. This is not a technical or facultative aspect, but rather an ethical imperative.
Change medical education: a social matter
These are only a few examples that show the necessity to insert wider knowledge and ethical reflections within medical education . In other words, medical education should provide the instruments to develop critical thinking and to face the complexities of reality, and promote experiences that encourage free and responsible answers to challenges and problems of a globalised world.
These challenges and problems, touchable and visible among the poor and excluded, provoke the need to recognise the limits of every human act related to one’s own person, role or education. That’s why every act, grounded on a real and critical choice and ethical values, should recognise the importance of collaboration among different professions and disciplines. Reflections and practical experiences related with the concept of solidarity, responsibility, justice, equity, limits, and cooperative thinking should be considered an important part of medical education.
It is essential to involve medical students so that they can become active protagonists of their education. It is important to give value to other discipline’s points of view, so that they can help to analyse the context of crises, not only economic but also cultural, ethical and anthropological, in which medical faculties (and the whole academic world) are involved. This in a necessity related with the limits of medicine, limits that are more evident in complex systems where health professionals are called to work.
Now is the moment to create the basis for a new pedagogy of health and this is a cultural, organizational, ethical, civil and professional endeavour. Thus, not only future workers, but first and foremost citizens, for a society where equity and social justice should become fully-fledged instruments of health.