There is no exact moment when beetles, different animals from knowledge and skills, entered formal curricula. We hypothesize that two main developments played a role.
First, the focus on the safety and care of the patient. A focus on the lay rather than the professional has been with us for a century, in Dewey for general education [6], and in Osler for medicine passim [7]. From the 1970s [8] onwards, there have been increasing calls for humanized medicine, with its emphasis on the patient as well as the disease [9]. A major impetus in the UK was the response to the tragedy at Bristol Royal Infirmary, where there were serious problems in paediatric cardiac surgery. Kennedy spoke of the need to ‘broaden the notion of competence’, to include such things as communication, team-work and the like [10]. Human factors and patient-centredness became important aspects of healthcare [11, 12].
Second, the movement toward outcome-based education, and consequently the burgeoning use of the OSCE approach offered itself explicitly as an objective way of assessing competence [13,14,15,16,17]. Insights from educational sciences were used as an inspiration and ‘a detailed analysis of the characteristics and qualifications of the modern physician was deemed necessary, in terms of skills, personality traits, social and economic problems, and responsibility as a citizen’ [13]. Taking guidance from ‘functions required for the practice of medicine in a specified setting’, doors opened for new and previously unexplored themes in medical education. The famous CanMeds roles can be seen as an offshoot of this development, as they are in part a response to changes that patients and society required from doctors. Among the CanMeds roles we find ‘professional’, ‘communicator’, and ‘collaborator’ [18].
In grappling with CanMeds roles, many strange guests entered the formal curriculum: integrity, professionalism, empathy, reflection, a caring attitude, and so on. These new concepts had to comply with some of the demands of their new home: beetles were immediately clearly defined to be measurable and assessable—as is customary in systems under scrutiny of accreditation bodies. This demand for conceptual clarity was quickly satisfied, transforming a beetle-like empathy into an ‘achievement’ or ‘performance’, a set of behaviours that can be taught and demonstrated, and therefore assessed and measured. However, the attempt to find a uniform definition hinges on the assumption that when we are using the same word, we mean the same thing.
Beetles were added to the curriculum to make medicine more human, which is an endeavour we applaud. But the cost has been to reduce them to knowledge and behaviours. When empathy becomes a skill or a performance, it ceases to be empathy. The moment reflection becomes a tick-box exercise, it ceases to be authentic reflection [19]. This paper explores the problems we encounter in dealing with beetles in medical education, and how to move forward. So first, we will focus on the complexity of beetles.