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Clinical education: context is everything

There are times I wish I was a cartoonist and this is among them. How else can we easily portray the mad dash of medicine into the subspecialty stratosphere? This trend leaves behind too few to sort out the messy collision between the human experience of illness and the complexity of modern medical care that occurs where we mostly live – in the community. The debates I see in medical schools, at the operational level, are often not about what sort of doctors our societies will need in the next decade or so and how we will achieve them. Rather, the focus is on the problem of having insufficient curriculum time to represent the fullness of an emerging subspecialty and how and where to fit it into the existing curriculum. On top of this, generalism as an endpoint is often demeaned. The result is a situation in which we do not have enough doctors with the right skills in the right places, accompanied by an alarming lack of interest amongst students in following generalist careers. Something somewhere has to give. The needs of populations are changing: complex comprehensive care is needed more and more; multiple chronic conditions dominate, and rural areas, in particular, are increasingly underserved by doctors. We need doctors in rural and underserved areas. We also need generalists, not just family doctors, but general internists, paediatricans and surgeons too. We just don’t seem to be able, or perhaps willing, to train generalists anymore, at least not in the numbers we need. These pressures have led to a number of developments which include increasing the intake of students into medicine, the creation of rural schools or campuses and reforms of postgraduate specialty training. Reacting to need often happens in advance of any research results to guide that reaction, but there are a number of educational initiatives that have been established long enough to begin to produce useful research. This issue of the journal contains two reports that focus on learning environments. The first, from Australia, examines the experiences of students learning core clinical medicine in an integrated, community-based, rural environment and compares these experiences to those of their peers, who are following traditional discipline rotations in a tertiary care centre.