Analysis in Brief | The global health workforce is in a skills shortage crisis. Distance learning, as applied to clinical disciplines, can upgrade and expand the existing workforce without causing an acute human resource deficit.
- The global population is expanding, but skilled healthcare workers are not being produced at a sufficient rate to meet the needs
- Technological improvements have rendered the classroom superfluous to knowledge sharing, demonstrating a need for medical schools to commit to distance learning formats
- Distance learning offers financial and competence-based training advantages over the current format and can be linked with sustainable development goals (SDG)
In 2014, the World Health Organisation (WHO) released their follow up report A Universal Truth: No Health Without a Workforce to the 2000 and 2006 conference reports on the human resources in healthcare. Detailed in their report was that, as of 2010, there were 9.2 million doctors and 17 million nurses globally. The WHO estimated that, in 2014, there would be a 7.2 million deficit in skilled healthcare workers globally, which would increase to 12.9 million by 2035. How can 26.2 million doctors and nurses effectively execute their mandate of looking after 7.5 billion people?
The problem as applied to medical schools and curriculum reform
The reasons for this deficit vary, including length of training time – in some cases up to 14 years, low number of graduates, costs involved, limited training space and highly selective criteria involved in recruiting students for training. These factors work together to create a situation where global population growth exceeds the rate that skilled healthcare professionals are produced.
As suggested by the WHO, the deficit shows no signs of slowing down. In 1910, on the back of the Flexner Report to the Carnegie Foundation, there was a call to review medical curriculum development, producing the model of post-graduate medical training that we see today: two years of basic science training followed by two years of clinical training. In 2010, the Carnegie Foundation made the call for another review, suggesting the new curriculum should achieve four basic outcomes:
Standardisation and Individualisation – standardise learning outcomes through competence-based assessments while keeping the learning process open to allow students the flexibility to explore their own interests, simultaneous to their fundamental studies.
Integration – integrate the formal knowledge of both basic clinical and social sciences and allow for clinical immersion at an early stage in the training process; secondly, engage learners in a comprehensive learning experience where they follow cases from beginning to end, learning about different practitioner roles and functions; thirdly, focus on inter-professional education and teamwork.
Habits of inquiry and improvement – allow students to engage other students in problem solving, clinical participation, quality assurance and clinical governance; also, develop skills in self-directed habitual learning and self-improvement.
Identity formation – promote professionalism by focusing on ethics, mentoring, collaborative working and self-reflection.
Another good reason for reform is that healthcare is driven by evidence based medicine, and the industry is subject to rapid and massive change. Healthcare professionals are expected to remain current, and continuing professional development is the preferred framework to achieve this. Technological developments have also caused a shift in how information is accessed by individuals. With the advent of the internet and smart devices, the classroom has become a space of little relevance to the process of knowledge exchange. There is mounting evidence that shows didactic lecturing is an inefficient education technique, with evidence pointing to self-directed learning techniques being more effective.
Work-based learning and the professional learning community
One of the reasons why medical or clinical education has been slow to adopt to distance learning is the belief that clinical training depends on physical demonstration and mentoring as a core mode of knowledge exchange. This occurs in the form of bedside teaching at academic hospitals, where students are engaged in clinical care under the direct tutelage of a clinical facilitator, and through knowledge dissemination in lecture halls within medical schools, biomedical laboratories and patient simulations laboratories. These are driving factors in the restrictions of students accepted into clinical training programmes; there is simply not enough physical space for everybody.
Professional learning communities (PLCs) may provide an alternative. PLCs are collections of individuals who share and critically engage their practice in on-going, collaborative, learner-oriented, growth-promoting way. These learning communities are based in the workplace and are committed to the ethos of self-directed growth. Traditionally, medical schools are tied to training hospitals that are comprised of PLCs, where the staff trains the students that work there. Allowing these staff members the opportunity to formally engage in professional training for themselves through joint workplace/university partnering programmes formally brings the PLC into universities and can be accomplished through the university providing the theoretical training requirements while the workplace provides the practical component. This is how traditional clinical training already works.
This system of joint workplace/university partnering programmes could hold the key for upgrading the existing workforce without depleting it. Programmes could be created that allow Doctor of Medicine (MD) or Bachelors of Medicine and Surgery (MBBCh) students to work in their clinical discipline while they continue their studies. In this way, the skills of the workforce are upgraded, as a whole, without reducing the number of working practitioners at any stage of the process.
The benefits of joint workplace/university programmes
This system has numerous other benefits. Practitioners produced under this system will have improved expertise of basic clinical and social sciences, as well as practical experience from working with patients. They would have a better understanding of the healthcare system, having been a part of the patient experience from intake through to discharge. The patient’s experience will also be aided exponentially by the practitioners’ insights into the roles of other practitioners and an understanding of how the process works for the patient.
Developing a work-based MD programme allows universities the opportunities to meet the recommendations of the Carnegie report and remove the limits on the number of students trained to become doctors. By focusing this programme around students that are already trained and working in clinical fields, there is an increased likelihood that pass rates will improve. The possibility of competent practitioners will also increase.
Students who do not make it into medical school through traditional routes may rather choose to focus on a clinical programme initially and then pursue their studies further, and many may prefer this to the traditional route. This creates a revolving door situation, where there would continuously be students coming into mid-level clinical disciplines and being trained in upper-level clinical disciplines. There is a possibility that many of these students would return to their initial field to continue working as doctors, for example, a physiotherapist may return as a sports medicine physician or orthopaedic surgeon.
There are also financial benefits to this system. In South Africa, there is a crisis in student debt as university fees increase and government funding decreases. In 2016, protests within the country against the cost of education and the duration of study were widely publicised under the banner “#FeesMustFall”. By creating a system that allows students to progress their careers in a distance learning format, students are able to continue working full time while studying, creating less debt as they would have steady incomes to pay their university fees. Another option is to develop a scheme where fees are covered by workplaces in the form of scholarships. This further increases the workforce by ensuring that the practitioner has employment upon graduation. The financial benefits are not limited to just students. Increased student numbers mean increased funding for universities, growing revenues to upgrade their facilities and attract better quality educators and researchers.
Work-based training and the developing world
The benefits of this system have implications on the developing world. The developing world has less access to resources and, in many situations, has significantly less human resources (HR) available than the developed world and is hard hit by the skills shortage. In 2006, the WHO estimated that 57 countries had a critical shortage of skilled healthcare practitioners, 36 of those were located in Sub-Saharan Africa. Skills migration is also of concern as it further dilutes the workforce within the developing world.
A core principle of SDGs, as developed by the UN, is that the developed world should be involved in resource sharing with the developing world. The UN proposes that the developed world’s intellectual property regarding sustainability be shared with the developing world at a reasonable cost or for free. The goal is to assist the developing world in upgrading and catching up to the developed world. Universities from the developed world, as well as those in the developing world, should partner with governments within the developing world to assist in solving the acute and chronic deficit in skilled HR. Work-based distance learning programmes offer a platform through which this could be achieved. These programmes could be set up in a manner that is principally akin to the SDGs and could work towards achieving not only the goals of the Carnegie Foundation but also the goals of sustainability.