Everything alone: Is medical education chasing a harmful myth in its effort to embrace societal need?

In this era of competency-based medical education, various frameworks have been developed to detail the many expectations we have of health care providers. The Canadian model, CanMEDS, 1 adopted or adapted by many countries, describes the ideal characteristics of a physician using seven distinct roles, which are currently undergoing revision. 2 The accompanying popularised symbol of a simple flower, with Medical Expert in the centre surrounded by six intrinsic competency petals, stands in stark contrast to the many layers of traits, skills, attitudes and ideologies within. While the intrinsic roles can be interpreted as reminders that physicians are expected to have knowledge and skills in many domains, they can also take on other meaning as evidenced by an early study of the symbolism in CanMEDS, which compared the flower to armour that protects the core Medical Expert role from the scrutiny of the public. 3 Rather than protecting the core , an alternative perspective is that the intrinsic Roles have begun to obscure the Medical Expert Role as societal needs and values evolve. 2 In fact, the medical profession is being called to reflect an ever-increasing list of values that, while undeniably important, may not be sustainable for any one individual. In other words, as new discourses emerge that direct medical education to strengthen physician competencies in health advocacy, cultural competence, planetary health, social justice and accountability, among other things, we must question whether development of pre-existing core medical expert competencies begin to get taken for granted.

and skills in many domains, they can also take on other meaning as evidenced by an early study of the symbolism in CanMEDS, which compared the flower to armour that protects the core Medical Expert role from the scrutiny of the public. 3ther than protecting the core, an alternative perspective is that the intrinsic Roles have begun to obscure the Medical Expert Role as societal needs and values evolve. 2 In fact, the medical profession is being called to reflect an ever-increasing list of values that, while undeniably important, may not be sustainable for any one individual.
In other words, as new discourses emerge that direct medical education to strengthen physician competencies in health advocacy, cultural competence, planetary health, social justice and accountability, among other things, we must question whether development of pre-existing core medical expert competencies begin to get taken for granted.
The medical profession is being called to reflect an ever-increasing list of values that, while undeniably important, may not be sustainable for any one individual.
Nearly a decade ago, the 2015 CanMEDS framework was met with criticism for being encumbered by countless competencies and sub-competencies. 4Since then, scholars' predictions that teaching and assessment activities would become unsustainable are being realised, 5 yet the model (and others like it) continues to increase in complexity. 2 In this issue of Medical Education alone, there are papers reporting on explorations of how medical students help with climate disasters 6 and how they act to resist social injustice, 7 two of countless activities that take up considerable energy above and beyond what is expected of core medical training.Indeed, XXX et al. 6 situate their study within a recent mandate for medical curricula to be socially accountable. 7s the pressures placed on our students and health care providers continue to accumulate and as health care continues to increase in complexity, perhaps it is time to finally confront the idea that the physician who can do everything is an idealised mythical concept.Perhaps it is time to more fully embrace that health care is a team activity and properly confronts the idea that the heavy emphasis we place on the breadth of competencies required by each health care provider reinforces a long-held tradition of emphasising independence. 8The self-regulated nature of the profession 9 is mirrored by scholars encouraging individuals to self-regulate, self-assess to identify knowledge gaps, condition one's self to embrace a growth-mindset and engage in self-monitoring and self-direction to close those performance gaps-seemingly, everything alone.
The self-regulated nature of the profession 9 is mirrored by scholars encouraging individuals to self-regulate, self-assess to identify knowledge gaps, condition one's self to a growth-mindset and engage in self-monitoring and self-direction to close those performance gaps-seemingly, everything alone.
"Grounded in Greek mythology, the iconic lone physician embodies the noble ideals of superior knowledge, self-sacrifice, compassion, accessibility, ethical judgment, and equal treatment for all.This myth … is reinforced by our biomedical paradigm, social expectations of healing, health care funding, and legal culpability for malpractice." "For individuals who choose medicine as a career, the myth promises physicians a sense of control: over one's practice, over one's schedule, and over one's patient care decisions.This sense of control, illusory as it may be, often overshadows our awareness of the myth's dark side." 10 p.169Such emphasis is commonplace in the context of the Medical Expert Role given that, with few notable exceptions, 11 clinical reasoning continues to be treated as the realm of the lone, mysterious expert diagnostician.We continue to perpetuate that myth through recommendations to self-detect and self-correct diagnostic errors despite little to no supporting evidence for such recommendations. 12Conversely, the values represented by concepts like shared decision making, collective competence and team-based care continue to be met with resistance. 8lf-detect and self-correct diagnostic errors despite little to no supporting evidence for such recommendations.
To be clear, I am not suggesting that we go back to a time when poor communication skill, interpersonal conflict, and so on were simply accepted as the quirks of some physicians.Rather, I am drawing attention to the risks of conflating the profession's need to address a wide array of societal issues with individuals' capacity to be everything alone by juxtaposing modern tendencies to add ever more to our curricula with long-term tendencies to emphasise the self in medical culture.As medical curricula take on mandates for their programme to be socially accountable, it is easy to translate that into a proliferation of social accountability competencies and learning objectives that get imposed on each student 7 to the point that even selfless acts become targets for competency-based education and assessment.For example, consider the study alluded to above, conducted in the context of students volunteering to assist with medical aid and cleanup in response to a flooding disaster. 13No official statement came from the institution as to whether or how students should engage, leading many to volunteer in secret, which is incredibly altruistic by any definition.While the study yielded many insights into factors that contribute to prosocial behaviour, I was intrigued by the way the study was contextualised as a way, in part, to develop the underutilised resource of medical students to support a coordinated disaster response.The study honoured the students' sacrifices, fears and bravery, but that those three words that offer apt descriptors make it surprising to me that disaster response could so readily become part of the formal curriculum, diverting students from core aspects of their training to meet a programme's mandate to be socially accountable.

It is often difficult to separate out what programmes (or the profession) must do from what each individual student or professional
should be expected to do, but if we are not careful in specifying how values are evolving, we run the risk of serving a harmful myth rather than societal need.Neither the profession nor society will benefit if medical education curricula become so inflated that we lose sight of core expectations and the reality that no one can be everything.We must pay attention to designing health care and education systems, policies, procedures and processes that facilitate the prioritisation of important medical values while dismantling the myth of the lone and all-capable individual physician.
And education systems, policies, procedures and processes that facilitate the prioritisation of important medical values while dismantling the myth of the lone and all-capable individual physician.