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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.
There are clearly problems with the current medical curricula, certainly from this practising clinician’s view there is woefully inadequate clinical teaching time and face-to-face student-patient interaction. What used to be several months of general medicine and surgery is now crammed into a few weeks. A lot less allocated time is further blighted by too many students trying to see too few patients.
The second aspect of Prof Leeder’s article highlights the problem of when someone is “purchasing a product” they expect that the transaction will be completed, ie, if you are a full fee paying student you expect that at the end, a degree in medicine will come your way. This places a pressure on medical schools to pass students who might otherwise not meet the previous exacting standards of an Australian medical degree. Universities offering degrees to overseas students would soon go broke if the product failed to deliver !
Short of a substantial increase in funding to our unis and medical schools by government, not likely ever, then I cant see a solution to the above problems. The grads who come to work for me are highly intelligent, well motivated and fortunately, for the most part, fast learners who are seriously short changed in their clinical training and exposure. For me PBLs dont cut it and never really have.
There are complex issues related to the quality and funding of undergraduate medical education and the selection and entry requirements for medical students. It is time the profession had an open debate on these issues instead of leaving them to academia. For example, the current emphasis on Grade Point Average for entry into graduate medical courses severely disadvantages those who have undertaken science degrees, in which high marks are very difficult to obtain and are considerably dependent on group activites such as laboratory work and presentations. Another point is that most medical schools reserve their full fee places for overseas students who use this as a pathway to internship and then permanent residency in Australia, yet there is no legisltive reason why such places could not be offered to Australian citizens. Medical schools also continue to rely on the goodwill of VMOs and staff specialists, as ell as junior medical staff, in providing undergraduate clinical teaching. To use the current terminology, such approaches are not sustainable.
Agreed Mark.
The two major topics Prof Leeder addressed above: the alignment of medical education with primary research and the apparently unwelcome concentration of that research within established institutions and the PBL programs (also imported from North America in the 1990s) deserve wider review.
A forced dilution of scarce NH&MRC medical research money to more institutions in Australia does not to me (at least superficially) sound like a recipe quality outcomes given the huge recurrent costs of maintaining said establishments. e.g.the CSIRO predicament. Hell freezing over Prof. is a valid prediction.
It is also clear to me, who has had two children who graduated after the introducion PBLs (largely supervised by non-medical educators with no idea whatsoever of clinical integration) and who also is a practicing laboratory pathologist dealing on a daily basis with the signficant gaps in basic knowlege evident in recent graduates that problems do exist in undergraduate medicine. PBLs are very much cheaper tools for the Unis to operate however, unless integrated into a broader educational fabric do end up being nothing but ”Readers Dïgest” medicine; “This is Dick’s liver go figure!” so to speak. I have also been an Assoc Sen Lecturer preparing PBLs! The conseqences of 4 year PBL loaded courses are graduates with highly concentrated areas of knowledge but with huge gaps where often they don’t even know what they don’t know. My real world experience is that the reviewers mentioned above have suffered from a degree of starry eyed postive bias.
More than ever medical students need to understand how evidence is generated and how to examine it critically. They need to see role models questioning and improving clinical practice by rigorous resarch and develop familiarity with the roles of a range of disciplines in this process.
Not sure whether its so important that clinician-researchers are involved at a medical school level. Most students don’t seem to give a toss about much other than passing exams. The real need for researchers that look after patients and clinicians that do research is in the hospitals where junior doctors are trained (of course this does have the spill-over effect onto the students anyway).