Future proofing medical education: The case for a confrontationally oriented and hidden curriculum informed restructuring of professional preparation

‘Future proofing’ medical education requires a future-focused, advocacy infused, context sensitive and grounded in a reconceptualization of what it means to train physicians as ‘future professionals’. In considering these challenges, we must reimagine how we, as a community, wrestle with a fundamental issue facing medicine as a profession—medicine's future as a profession—including how to best re-engineer and recalibrate the work of education as a practice of professional preparation in service to this fragile yet critically important social status. Over the past quarter century, the emergence of a professionalism movement within medicine has generated a plethora of definitions, metrics, codes, charters, competencies and curricula intended to imbue professionalism—whether that be framed as a virtue, a behaviour or as an identity.1 More recently, programmes2 have been deployed to remediate professionalism shortcomings for what the culture of medicine insists are its ‘one or two bad apples’ and with a parallel focus—be that trainees, faculty or practitioners—on the individual. Even calls to address system factors typically frame those constellational elements in terms of their impact on the individual. One consequence of this rapidly institutionalised view of professionalism has been to routinely—even ritualistically—conceptualise ‘new professionalism issues’, professional identity formation being one example, as a property of individual social actors with little or no recognition that identity also is a collective issue, and thus medicine's own identity and its future as a profession should be being worthy of both our time and our imaginations. This lacuna also contains a small measure of irony since early calls within both within sociology3 and medicine4 largely focused on threats to medicine writ large than individual members. The problem with such a truncated focus is that it ignores both the complexities of professionalism5 as well as the complexities of a rapidly evolving health care system within which both professional preparation takes place and within which medicine must function as a profession. Today's health care contains an ever-expanding bevy of new health occupations along with new ways of paying for and organising medical work. Even billion-dollar companies (e.g., Google and Amazon) not traditionally seen as having a health care profile are now aggressively pivoting into the health care marketplace. Insurers (as payers) have acquired health delivery systems, with new systems spawning new residency programmes and medical schools—and with all players having their own vested interests—and accompanying visions—of what it means to practice medicine and in what or whose interests. Training programmes, whatever the level (undergraduate/UME, graduate/GME and continuing/CPD), need to recognise these complexities as they prepare future physicians—as professionals—to act both on behalf of patients, but also on behalf of their profession—as a profession. Among other things, this means that medical schools and residency programmes must re-imagine themselves not just sites of professional preparation (e.g., places where professionalism is taught and enacted), but as organisational entities that themselves express and embody professionalism as they engage in the work of preparing future professionals.6 In short, medical schools need to see professionalism as being reflected in the way they organise the work of delivering medical education. All of which brings us to a more genuinely systems view of professionalism as we begin to imagine the expression of professionalism as extending beyond the individual to the various constituencies that make up the House of Medicine, including its various membership groups (specialty based and otherwise) and thus how these entities act and interact as expressions of professionalism. Whatever the particulars, when we talk about professionalism we are talking about the fundamental logic of professionalism—with logic ‘… a socially constructed, historically developed pattern of beliefs and rules that shape the organising principles of an institution …’7 and professionalism a way or organising work in contrast to the logics of the market and of bureaucratic managerialism.3 This also means what when we practice and teach professionalism, we do so by explicitly ad strategically recognising the presence of countervailing logics within the practice of both medicine and professional preparation.8 In addition, we need to be mindful of potential differences between stated purpose versus the purpose-in-action and thus the presence of a hidden curriculum within professional preparation—a restructuring that prepares both training environments and its inhabitants to both advance the public service mission of the profession as well as to recognise and resist countervailing logics. Not to do so raises the potential for medicine to suffer from identity expropriation/degradation as other logics, such as those of the market and managerialism continue to infiltrate and replace key elements in how health care professionals themselves organise and make sense of their work. Medical education has not been cognizant enough of this theft/infiltration/expropriation and as such needs to be more proactively strategic in helping the next generation of physicians recognise and counter the presence of these often invisible and countervailing forces in how they are reshaping the structure and practice of medical work—all of which constitute a particular threat where a compliance follow-the-rules version of what it means to be a professional blurs the potential of both members and the profession to critical examine ‘whose rules’ and thus to better understand ‘to what end and benefit’ these rules might operate. Ultimately, ‘to future proof’ both medical education and professional preparation means to thus ensure an educational system that speaks to the service of medicine as a profession—which means attending to professionalism as something more than just an individual-level phenomenon. Otherwise, we may usher in an era in which we educate future practitioners rather than future professionals.9