Carry on learning, doctor

June 29, 2001

NHS training is facing a radical shake-up. Claire Sanders talks to the man responsible for much of it

Five floors above the busy streets of south London sits a man who could seriously affect your health. Graeme Catto is not only dean of the Guy's, King's and St Thomas's hospitals' medical and dental school - the biggest in the United Kingdom - but also chairman of the education committee of the General Medical Council.

He has been in London for nearly a year, having moved down in October from Scotland, where he was vice-principal at the University of Aberdeen and chief scientist at the Scottish Health Department. King's graduation photos line his walls - as well pictures of the Scottish Highlands and Robert Gordon College in Aberdeen, where he is chairman.

The world of medical education is fast moving. Not only is it undergoing the biggest expansion in a generation, but the way medicine is taught, regulated and practised is also being reformed. The GMC is slimming down its council, bringing in more lay membership and setting in motion a process of revalidation for doctors. This involves continual assessment throughout their lives.

The education committee is the only statutory committee of the GMC and is under the authority of the Privy Council. It is responsible in law for promoting high standards and coordinating all stages of medical education - both undergraduate and postgraduate. It can shut courses that are not up to scratch and determine the knowledge and skills required to qualify as a doctor. The committee is about to issue new guidance on medical education, building on the major reforms begun with the publication of the report Tomorrow's Doctors in 1993.

What, in Catto's view, makes a good doctor? "It is important to stress that education is a continuum," he says, sounding for a minute like one of the GMC's many guidances on the subject, before swerving off-line. "But this is not the case. Even the GMC's own guidance does not offer continuity of advice. There is guidance up until the senior house officer (SHO) training period and then nothing. Postgraduate education is not as well coordinated as it should be."

Back in 1993, Tomorrow's Doctors heralded a new era. Gone was the stress on knowledge learnt parrot-fashion and divided into neat chunks. It was replaced by an integrated, problem-solving approach, requiring students to look at the whole body not just its parts. Students were taught to look at patients' place in a family and in society. It required doctors to work in teams, to have early contact with patients and, above all, to understand that medical school was just the beginning of their education.

"The knowledge base is constantly changing," Catto says. "Doctors have to keep on learning until the day they retire."

The draft guidance does not change the aims of Tomorrow's Doctors but does recommend that the principles of professional practice set out in the GMC guidance Good Medical Practice in 1998 must be at the heart of undergraduate medical education. It recommends that medical curriculums should "encourage a questioning and self-critical approach to medical practice and foster the intellectual skills required for further personal and professional development" and that "the burden of factual information on students must be kept to an essential minimum".

But Catto sounds a note of caution. "We need doctors who can communicate well with both patients and colleagues. But it is no good producing barmaids - sympathetic listeners who know nothing."

Working in teams is constantly stressed in the guidance. Health secretary Alan Milburn has more than once referred to the "tribalism" in the National Health Service, with the different health professions working against rather than with each other. Catto himself refers to "Spanish practices" and the need for greater collaboration. When the NHS plan was published last year, it was billed as the last chance to save the NHS and called for a common foundation programme, even a core curriculum, as a way of teaching that would bring the professions together.

"There were fears that we would be pushed down a rather crude path with everyone forced to sit some sort of common programme," Catto says. "What is happening is more imaginative. Students are being taught to work in teams where they can play to their strengths. And where it is sensible to teach people together, such as on ethics courses, then that happens."

He says that moving the education of nurses into universities has helped "move mountains". "It has brought about better coordination. Not every university will teach nurses and doctors and other health professions, but there are a number that do and teaching links are being set up across the country."

But what of continuity? Catto would like to set up a sub-committee of the education committee to oversee what he calls the middle years. This would cover the final year of the undergraduate programme, the pre-registration house officer (PRHO) year and the SHO training period.

"There is no continuum across this period," he says. "Universities are responsible for students in their final year up to the end of the PRHO year. Then, although SHOs are taught by clinical academics, universities find themselves involved but bypassed."

The NHS plan proposed setting up a Medical Education Standards Board to replace the separate bodies for general practice and hospital specialities and to provide "a coherent, robust and accountable approach" to postgraduate medical education. A consultation document on this is expected shortly.

"It is crucial to offer doctors proper training and career paths in this period. There is a lost tribe of SHOs out there, shunted into dead-end posts and unable to gain promotion because they cannot get the right training," he says.

A critical report from the King's Fund called Racism in Medicine , published last week, highlights how difficult it is for black and Asian doctors to gain promotion, particularly in popular specialities. "We need to reform the whole training system at this stage," Catto says. "We also need to reform the system by which overseas doctors gain registration to bring it in to line with the training system offered to all doctors."

The British Medical Association has also called for a thorough review of this area. "There is a new commitment to reform postgraduate medical education and a determination to get it right," Catto says. Despite this determination, Catto suffers from what he calls "guilt".

"I studied in the 1960s and never worried about money," he says. "I did not get a full grant but I did not have to pay fees. The cost now is alarming."

Guy's, King's and St Thomas's has set up an access scheme for its medical school, designed to attract disadvantaged pupils from south London. Catto says: "We offer financial support as well. I do not see how we could run such a scheme without supporting the students financially."

The scheme will also take pupils who lack the A-level grades, but who have the potential to succeed. "We must get away from this stress on As at A level. We must not allow the system to ossify," Catto says.

The changes introduced as a result of Tomorrow's Doctors nearly ten years ago have taken time. It will be a few years before these doctors start to make a difference and many more before the expansion in medical numbers and reforms being planned have an impact.

Only then will it be clear just how Catto has affected our health.

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