What's in the Scope of Medicine?

Physicians are privileged among healthcare practitioners in that medicine's scope, both functionally and legally, is essentially unbounded from a professional standpoint. While other healthcare professions are limited somewhat in what's considered their area of expertise, particularly from a legal perspective, physicians generally are not, with some obvious exceptions (dental work, for example).

Unfortunately, this also leaves unbounded the amount of information or expertise that could be considered worthwhile for a physician to learn. Any medical student past their first semester will have experienced this, sitting through more than a few lectures where some emphasized pieces of information appear to be relevant to the eventual practice of maybe 1% of the class only. Even as a future generalist, I can think of quite a bit that I've learned over the past 4 years that I will likely never have to use in clinical practice, even if some of my classmates will.

Physicians are also starting to explore areas outside of what is typically considered clinical medicine. For example, as the profession rightly acknowledges the high impact of social factors on health, medicine is slowly expanding to include, well, virtually anything. Everything from urban infrastructure, to primary education, to environmental regulations, to immigration, to energy policy touches on human health in significant ways. We have some teaching about these factors in medical school, but not overly in-depth, nor do we have time to touch on everything in society conceivably impacting health.

While I love learning about these "other" parts of healthcare outside of standard clinical medicine and finding ways to incorporate them into practice, it's unrealistic to expect me or anyone else to be masters of even a fraction of this material. This begs the question - what is essential for all physicians to know, and what is not? I don't believe we have answered this question particularly well and I believe it needs a good answer.

Physicians are fortunate to be able to push or around through the barriers that constrain other healthcare professionals from doing novel work outside their scope, because our scope is so ill-defined, and it leads to a lot of innovation within our healthcare system. That ability to innovate is worth preserving. The downside is that as we allow physicians to be just about anything these days, we've started structuring our medical education system to push physicians to be everything. This is neither realistic nor optimal.

At some point, we need to introduce more flexibility into our medical education to match the flexibility we expect from our practicing physicians. That means developing a core base of competency that is relevant to virtually everyone at that stage of training which is emphasized heavily, but then making much of what we currently teach non-mandatory. To compensate, more selective, elective, and extra-curricular education should be incorporated. Admittedly, this takes a degree of coordination medical schools and residency programs have not proven to be too adept at handling in the past. However, as medicine grows ever-wider, medical educators will have to start recognizing the limits of what can be taught and start seriously considering what should be taught, even if that means eliminating useful elements from what is currently part of the mandatory curriculum.