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Education or training: medicine's learning agenda

BMJ 1997; 314 doi: (Published 29 March 1997) Cite this as: BMJ 1997;314:983
  1. ZoË-Jane Playdon,
  2. DanË Goodsman
  1. education adviser to the South Thames Department of Postgraduate Medicine and Dentistry
  2. education adviser to the United Medical and Dental Schools of Guy's and St Thomas's, London

    Although the process of professionalisation for doctors is called medical education its rhetoric is that of training. To professionals from mainstream education this presents a paradox as we recognise a critical distinction between training and education.

    We identify training as a learning process which deals with known outcomes. It is exemplified in the production line and production management, and its central concern is that the same product should be produced identically each time. So it deals in repetitive skills and uniform performances which are expressed as standards or criteria which must be followed exactly. Medicine deals with some areas where uniformity of this kind is desirable–for example, taking blood. But, clearly, these protocols are not the whole of medicine.

    For that we must turn to education. Education is a learning process which deals with unknown outcomes, with circumstances which require a complex synthesis of knowledge, skills, and experience to solve problems which are often one off problems. There are no simple answers to ethically based questions such as “Should this 3 year old child have a bone marrow transplant?” Education, on the other hand, refers its questions and actions to principles and values, rather than merely standards and criteria. In a clinical setting a major means of communicating these is the activity which we identify as “the professional conversation,” the ongoing interchanges about patients, principles, and procedures through which doctors learn and update their clinical practice. Further, where training takes responsibility for the workplace only, education recognises that it must deal with the whole person, that personal and professional life are intertwined. So, instead of requiring people to follow only instructions, the philosophy of education is to empower learners to take control of and responsibility for their own learning and at the same time to be personally accountable.

    In real terms this distinction manifests itself in the statement that education contains training but that training cannot contain education. This is particularly important in considering the different power bases of training and education. Training and its sponsor, management, is concerned to control individuals. Whenever we hear the question “How can we make people…?” we know that we are in a purely training environment and we expect that the next words we will hear are “And if they won't do it we can [exert some punitive measure or another]”. And if students are not literally killed then their hope, enthusiasm, and self worth will be.

    In the wider world education is a morally charged activity. Ethically, therefore, it is crucial that the location of power should be constantly under question, that the learners should be empowered to take responsibility for their own learning, that they should be given the support and guidance that they need to move into new areas of experience while retaining autonomy. In education, as in medicine, a moral imperative is “to help or at least not to harm.”

    If the practice of medicine is considered to require only a training, in which personnel are instructed in uniform procedures to be applied on a production line basis, then a doctor will be no more than a competent technician. In this scenario doctors would be replaceable by much less expensive practitioners. If, however, medicine considers itself often to be working without predictable outcomes, in situations where depth and breadth of experience accompany a constant reference to ethical principles, then it may rightfully identify itself as a profession. In that case, though, it must accept the accompanying responsibility: professionalism in education, with its rigorous ethical questioning of how the learner's interests are being served and concomitant high levels of accountability and empowerment for its students and its teachers.

    Such a scenario would draw on the benefits of both training and education to bring new opportunities and a new sense of professionalism to medicine. Increasing “protocolisation” of appropriate procedures could allow the nurse practitioner grade to be expanded. This would allow career grade doctors to begin to incorporate an additional professionalism, in education, in management, or in research. Second careers in these areas, already in existence for medical directors and educational deans, would become more common as senior doctors took on these new responsibilities.

    The choice, of course, lies with medicine itself. As professional advisers we can recommend only a course of action, not impose it. But then, as every doctor knows, ignoring professional advice can be fatal.

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