Stephen Leeder: Education tiers

TO have worked in a medical school where clinical care is fully integrated into an academic program of research and education is a rare privilege.

This was true of McMaster University Medical Centre in Canada where I worked briefly in the late 1970s. It was the dawn of clinical epidemiology with its questioning and critical appraisal of clinical evidence and of cross-disciplinary research as well as astounding innovations in medical education that liberated the students to think and solve clinical problems and absorb the freedom implicit in the environment of clinical and basic science research.

Since then, many medical schools have revised their curricula to embrace a more intellectually active and critical approach to learning, with problem-based learning, interaction and self-direction.

Although these approaches attract some criticism most medical schools have adapted so students can make the best use of questioning, scientific education, which sits comfortably with integrated research and teaching.

In a recent article, published in Science Translational Medicine, US medical academics say the revolution in medical education, especially in the clinical years that followed the prophetic intervention of Abraham Flexner in 1908, has proved to be durable.

The authors argue that a common questioning approach to both clinical care and research could be achieved by having more research workers in the clinical environment. Clinician-researchers who split their time between the ward and the laboratory would find clinical problems in need of research and would likewise seize opportunities to apply what their research revealed to clinical care.

Research is by nature highly competitive — there are no second prizes for important discoveries — and this competition could drive excellence in both clinical care and research.

The authors’ view of the common intellectual approach between research and clinical problem solving was their central argument. Hence, they look warily at the development, since 2002, of 16 new medical schools in the US.

The authors used National Institutes of Health (NIH) funding figures to show that the new medical schools either did not prioritise NIH-funded research or had been unable to secure the increasingly scare NIH dollars. Their paper includes some comparisons of NIH research funding for medical schools which are staggering — mean funding ranging from $11 million to $800 000. “It is not surprising that many of the new medical schools do not, or cannot, support basic, translational, or clinical research”, the authors write.

They conclude that the education offered by these new schools is inferior to that of the older schools because it is less imbued with the atmosphere of concurrent research, constituting what they fear is a lower tier of educational quality.

Yet, in the absence of outcome markers of what constitutes a good medical education, we run the risk of simply projecting our personal ideas of what is good and bad onto these institutions.

There are many elephants in the room in this debate, perhaps the largest being the development of communication skills by students that have nothing much to do with how many NIH grants their tutors hold.

I also wonder where medical education for our sorely-needed cadres of generalists — in medicine and surgery, in hospital and community — fits.

Although customer satisfaction is but one dimension of good education, I found during my tenure of the office of the dean at the University of Sydney Medical School that students consistently ranked their educational experience in teaching hospitals inversely to their research activity — the smaller the hospital the more they liked it. At smaller hospitals, tutors were more personable, caring, less likely to teach by humiliation, less likely to delegate their tutorials to interns and less likely not to show up without explanation than at the more academic hospitals.

So while ideas about the common intellectual features of solving clinical problems and doing research stand firm, extrapolating this to say that new medical schools light on research offer inferior education is a stretch.

The US authors end by suggesting that a more equitable distribution of research funds might see a larger share going to the newer, less resourced schools. And yes, come the next ice age hell may freeze over.

There are risks in Australia of two-tiered medical education, but more likely due to the rise of fee-paying students and the unintended consequences of high enrolments of self-funded students from overseas.

The charity of clinical teachers is sorely tested by knowing that half the students they are tutoring will never work in Australia and are charged high fees largely to support underfunded universities. This is not xenophobic nonsense: the consequences are huge.

So long as our Prime Minister and his government believe the economy is the most important thing in our society, these divisive practices will remain essential to the survival of tertiary education in Australia.

Medical education will become the domain of the rich and then we will have tiers all right — and tears as well.

Professor Stephen Leeder is emeritus professor at the Menzies Centre for Health Policy at the University of Sydney. Find him on Twitter: @stephenleeder

Jane McCredie is on leave.