“If you want to change the system, start from education” - with these words medical education pioneer professor Fedde Scheele steered Lithuanian Junior Doctors’ Association toward extensive research - from Flexner’s report to competency based medical education (CBME) and entrustable professional activities (EPAs). Inspired by the CanMEDS framework and the idea of patient-oriented healthcare, a movement called LitMEDS took its first steps, striving to shift physician training in Lithuania toward CBME with emphasis on social accountability, non-technical skills and innovation in the field of medicine.
As NGOs we saw our role as advocates aiming to convince two medical universities and key decision makers of the importance of CBME and #LitMEDS in general. After some time, necessary legislation has successfully passed and financial sources for the CBME project have been found. Only then were we confronted with the real struggles in this quest for paradigm shift. Despite publicly displayed eagerness to change the whole education system and collaborate with junior doctors, we were quickly excluded from financially or otherwise important decision making. During that time, it dawned on us - comprehensive vision for medical education was and still is no one’s priority because of a problem as old as the world itself. For certain stakeholders’ substantial changes in the system means giving up the power and stability that comes with the status quo. I cannot help but remember an old saying that the only person who likes change is a wet baby. Nonetheless, this whole experience gave us a new direction - for CBME to prosper, our main goal had to become the creation of a fundamental vision that would address the remaining problems in medical education.
First, responsibility for medical education lies within two highly competitive universities, Ministry of Healthcare, Ministry of Education, Science and Sport and, though not officially, university hospitals. Insufficient communication between these stakeholders and the lack of accountability creates a faulty network with questionable transparency. For example, residency tuition fee has been steadily increasing for a few years now, therefore universities are getting more national funding. Yet the exact flow of these funds is unknown to this day.
Another problem arises from medical universities having an absolute autonomy in some key aspects of physician training. For example, the number of undergraduate students accepted into university is increasing - although there is a limit on how many medical students receive funding from the Ministry of Healthcare, universities can admit as many students as they like if they are willing to pay for their education themselves. However, after six years of undergraduate studies all students compete for the limited amount of residency spots. Due to this, some residents leave Lithuania while others end up paying huge tuition - as a country we are quite unique in this aspect. Moreover, due to the lack of human and clinical resources in hospitals the increase in student quantity causes difficulties to get enough clinical cases or feedback from the mentoring physician.
Some of the problems are seen in the context of university hospitals, mainly because they do not have to cover resident’s salary or educational costs - everything comes through national funding. Therefore, it should not be surprising that a resident is seen as more of an employee than a trainee that is best suited for the most tedious tasks. In some cases, residents are strongly discouraged from leaving university hospitals to go practice in the regional hospitals because of their significant help with the workload at university hospitals. Though it should be mentioned that even if resident mobility would be sufficient, education quality assurance systems are not in place. If we look even closer, responsible ministries do not enforce quality standards for residency programs in general or arrange extensive evaluations of these programs.
However, the most concerning aspect is the way we’re learning to see ourselves as medical professionals and human beings. While evidence of significant risk of burnout, mood and anxiety disorders and even suicide is devastating amongst healthcare workers, neither undergraduate nor postgraduate curriculum contains topics such as well-being, stress resilience or how to minimize the risk of burnout. It becomes even more important in the face of psychological abuse - not even two years ago Lithuanian doctors finally revealed what has been happening behind hospitals’ closed doors. In addition, according to the survey conducted by Lithuanian medical students’ association a few years ago, 34 percent of medical students had had suicidal thoughts. This clearly shows that interventions in postgraduate studies in some cases could be long overdue - our responsibility to young doctors as members of the medical community begins from their first day at the university. We believe that being able to take care of our well-being should be the most important learning outcome - it has been long established that only then can we provide the best care for our future patients.
Although challenges ahead of us are humbling and discouraging at times, we can see that Lithuania is on the verge of critical changes in the field of medical education. However, I cannot help but feel a bit scared seeing how popular it is to believe, that all it takes to bring fundamental changes is for our generation to grow up and replace the ones who make decisions now. Unfortunately, it is not that simple - only through taking the responsibility now and looking for ways to empower and enable young people, real changes can be achieved in the medical education and health care system as a whole. □