By Prof D. Cristina Stefan MD, MMED, FCP, CMO, MsC, PhD, MBA, Adjunct Associate Professor SingHealth Duke-NUS Global Health Institute (SDGHI), Duke-NUS Medical School, Singapore.

Not long ago, in December 2019, I attended a conference on innovation in Cluj-Napoca, a Romanian city well-known for its nation-leading medical school. Listening to many reputable speakers and being stimulated by many engaging interactions, I found myself reflecting on the future of the education of the next generation of doctors in Eastern Europe and elsewhere in the world.

I remembered having attended in Africa, in January of the same year, the conference of the Western College of Surgeons which took place in Senegal, where more than 800 participants from across the continent shared their views, expertise and results of their research. Among many specialist sessions, the one on the education of the next generation of doctors in Africa enjoyed a special interest.

There were ardent debates around curriculum, student’s assessments, logbooks and harmonisation of the medical curriculum across the continent. Professors expressed various interesting views, with some of them reporting a relative low motivation and enthusiasm of the new generation of students, who estimated that medical curricula did not adequately prepare them for the future of medical practice. Far from discarding that opinion as just another fashionable attitude adopted by students to avoid being left out of their peer groups, I believe that any medical school that wants to continue to offer value needs to build its curriculum with an eye on future developments in the profession.

This approach to teaching medicine is required indeed more stringently, as the pace of change in medical knowledge and technology in health care is accelerating. While no one could foresee exactly what the future has in store for our profession, some determinants of the work environment of the future doctors are quite probable.

Even more so than today, the future doctor will have instant access to professional information, mostly on portable devices. The search will be facilitated by expert software and structured around the particulars of a case, thus offering a reliable framework for diagnosis or treatment. Artificial intelligence will make this kind of task much more efficient.

While the contact with the patient will remain central during clinical training, numerous simulation digital programs and simulation robots will ensure that the student is adequately primed for its interaction with the reality of sick people.
Continuous medical education programs and recertification tests will make extensive use of artificial and augmented reality.
Spending time on simulators is already a prerequisite to participating in operations and it will become widespread. Surgery will gradually move to using exclusively minimally invasive techniques and more complex interventions will be performed via robots by highly skilled surgeons. A large number of procedures will be performed as day surgeries, with patients monitored at home, if needed, via sensors transmitting to a central monitoring room.

Doctors will practice in an environment where antibiotics are less effective than today, and some very aggressive pathogens, resistant to antimicrobials, will require innovative ways to contain them. Viral epidemics will become more frequent, triggering a new technological wave in producing vaccines and antivirals.

The use of imaging like CT, MRI, echography, endoscopy of all kinds, laparoscopy, enhanced by digital software, will be widespread and some imaging techniques will be often used during consultations. Images will be easily relayed to other specialists for instant opinion. Communication between professionals will be frequent, facilitated by broadband transmission lines, mobile devices and electronic health records of patients.

Therapies will be more individualised, with assistance from a larger pharmacologic arsenal, expert programs and gene profiling of patients (also of malignant tumours, or viral or bacterial pathogens). The patients themselves will become more and more involved in designing their treatments, after personally seeking information on patient-oriented internet sites and after being extensively counselled on the benefits and disadvantages or complications of the chosen therapy.

The globalisation, the rapid technological change, the cultural clashes, the evolution of mores in society, the continuous re-skilling demanded by the workplace and other as yet unknown challenges will take their psychological toll on many people and the demand for psychotherapy will increase substantially in the future.

With the implementation of plans for permanent human presence on the Moon and possibly on Mars, space medicine will see a much more important role.

Questions about the adequacy of the medical curricula are fully justified by the above. Will the typical teaching of anatomy, semiology, pathology, listening to the chest and heart sounds, reading a full blood count and so on remain unchanged on the pages of the books of the young generation of students? Most probably it will still be there in the future, but it will not be enough anymore.

Doctors would need a better understanding of genetics, genomics, transcriptomics, proteomics and metabolomics, in order to master the future diagnostic and therapeutic methods, derived from such science. A deeper understanding of immunology will be necessary. They would need to grasp the basics of radiation and ultrasound physics and of digital image processing. They would need to understand the elements of programming, the principles of big data processing, the essence of machine learning and to be able to evaluate the benefits and the limits of using artificial intelligence in their field. They would have to wade deeper into the knowledge of psychology and psychotherapy.

Being trained as an oncologist, I am also wondering about the training curriculum of my future colleagues. At the moment oncologists are working in a reactive mode, where the patient sees them once the disease manifested itself already and the aim of therapy is to destroy the tumoural tissue hoping that it will not grow back. Survival is defined statistically as remission lasting more than 5 years. The relatively modest successes we register in treating cancers need to be measured also in the context of a predicted massive increase of the incidence of the malignant disease, if the present trend continues unchecked.

A completely new paradigm needs to be adopted in cancer control, where factors of risk, be they hereditary or environmental, are identified and eliminated or mitigated long before the control of cell multiplication is damaged. A splendid example of this kind of approach is the use of anti-HPV vaccine to eliminate the risk of cervical cancer and of other, less frequent tumours related to HPV infection. Other ways of preventing cancer will be provided by our better understanding of the mechanisms by which DNA mutations appear and escape repair in the process of cell multiplication. Immune cells equipped to identify and destroy malignant cells need to be better studied and ways to support their activity should be found. Early diagnosis, which holds a better promise of cure, will be improved by evaluating the individual’s genetic predisposition to cancer and by finding new markers of the early stages of the disease.

The oncologist of tomorrow will also benefit from the modern communication possibilities. International tumour boards will be organised more frequently, in particular for the benefit of patients from low- and mid-income countries. Telepathology will be a common way of diagnosing problematic tumours, daily interactions, especially in low-resource areas. Matching patients with clinical trials will be just a matter of downloading an app and uploading the patient’s file.

Healthcare practitioners are embracing a new wave of innovation and new technology and those from old schools have a lot of work to do in embracing the new. Does the same apply for the doctors and nurses serving billions of people who live in low and low-mid income countries? Do medical school curricula need to be adapted to the specifics of these environments?

My opinion is that the references to new and validated methods of diagnostic and treatment should definitely remain in the curricula, even if they are yet out of reach for practitioners. Many of them will gradually make their way in the practice of present medical students in lower income countries. The rapid accumulation of knowledge in the healthcare field requires that no one is left behind, as they risk not being able to be brought up to speed.

Apart from that, the resilience and ingenuity of doctors and nurses practicing in lower income areas should not be under-estimated. Telehealth, for example, slowly becomes more and more present in the clinics. It is increasingly common to have midwives in remote areas in Africa using smartphones while communicating imaging of ultrasounds or intrapartum foetal monitoring to doctors in the nearest hospitals, for advice. The introduction of electronic health records on a larger scale would facilitate the communication about patients and decision making in conjunction with senior doctors from regional or even academic hospitals. The innovations sprouting spontaneously in such settings deserve closer attention as some of them might prove valuable additions to future textbooks.

Finally, medical students should not have to complain about the content of curricula. In fact, they should be co-opted in the curriculum building process from the beginning and thereafter be asked at regular intervals to reassess the content of what is being taught, to ensure its relevance and actuality.