Key competencies
Even though we have not undertaken any formal analysis of the students' reflections, we interpret their descriptions of these two examples as evidence of ability to engage in systems thinking and critical thinking. According to UNESCO, these are two key competencies needed to realise the SDGs (4). System thinking is the ability to identify and understand interconnections, to analyse complex systems and, not least, to deal with uncertainty. In a health service context, this could involve analysing interconnections between illness/health and the context of the issue at hand, including economic and social conditions. Having critical thinking skills means to be able to question norms, practices, procedures and opinions. This includes reflecting on one's own values, opinions and actions, and being able to participate in discussions on sustainability. Critical thinking is considered crucially important, since doctors very often need to relate to uncertainty and ambivalence in situations that have no predictable outcome, nor a 'single best solution'. Critical reflection requires a student (and later clinician) to be able to explore the underlying premises of the problem they are facing. This may imply that although tiredness is not a diagnosis, it might still be appropriate to write a sick note. Is there anything in the specific situation (e.g. in light of the doctor's knowledge of the patient's history and social situation) that should be given weight? Skills in system thinking and critical thinking include the ability to express doubt about the validity of arguments, facts and current arrangements. Moreover, these skills are crucial in order to develop independence as a professional practitioner and for personal growth.
In practical life, the student – and later doctor – must reflect on these matters and based on them decide what is the best possible action to take with regard to this patient in particular. As shown by the examples above, this will not always be what the patient asks for or hopes for. Quite the opposite, it will often mean refraining from ordering tests and examinations or deciding against initiating a drug-based treatment. In the situation, the patient may of course easily perceive this as a rejection – that they are not 'being taken seriously'. Our preliminary interpretation of the findings from our little study (see the box) also indicate that the students found it difficult to relate to the patients in such situations. How should they communicate their reflections and their decision so as to get the patient on board? How could they bring the patient to understand that this was not a rejection, but a professionally based overall assessment that was in the best interest of the patient as well as that of others? We need to teach the students that such communication is in fact possible, and that it must be based on trust. As they gradually gain experience, and continuity in their doctor-patient relationships, this will gradually become easier and eventually be seen as a natural element of a GP's life. The contract GP scheme is in itself a contribution to a sustainable health service, where increasing continuity contributes to use of fewer resources, which has also been shown to lead to better health outcomes (5).
The contract GP scheme is in itself a contribution to a sustainable health service, where increasing continuity contributes to use of fewer resources, which has also been shown to lead to better health outcomes
Finally, we would like to highlight two issues that these examples illustrate. The first is how training programmes can ensure that the students are taught to include sustainability in their clinical decisions. The RETHOS regulations do not mention this explicitly, but section 16a says: 'The candidate has detailed knowledge about fundamental factors that promote good health and prevent illness at the individual and societal level, including the importance of environmental factors, vaccines, infection control and labour force participation' (6). Section 2 says: 'The training shall ensure that the candidate safeguards the welfare of the individual patient, while also taking the needs of society and global priorities into account'. We believe that the regulations should be amended with a clarification of the responsibility of the educational institutions to develop their students' competence in dealing with challenges associated with sustainability.