Deepest cut for medicine

October 24, 1997

THIS summer Glasgow University received an "excellent" rating for its medical course from the Scottish Higher Education Funding Council. The grading was on the basis of the faculty's efforts to introduce an entirely new type of medical education, beginning with last year's first-year intake.

Aberdeen and Dundee, also with vast curricular changes, did similarly well. Trailing behind, with only a "highly satisfactory", were Edinburgh and St And-rews, both judged not to have been sufficiently innovative.

The changes in medical education were initiated by the General Medical Council in its 1993 document Tomorrow's Doctors. The new medical curriculum has been portrayed as the salvation of modern medicine. But as a final-year medical student at Glasgow, studying in the traditional curriculum, I have several problems with the replacement. Most importantly, it fails to give students an adequate scientific education, and the reduction of science content is actually celebrated.

Far from being a step forward, I feel this is a step back from the gains of scientific medical education over the past century. The new curriculum, through which the lack of confidence in science is being institutionalised, is a very large threat to medical progress and thus ultimately to patient care.

Earlier this year I took part in a medical students' debate, arguing against the proposition: "This house believes the new curriculum is an improvement on the old." One of my opponents was a favourite lecturer, whose brilliant, concise course ensured there were students prepared to sit on the steps of the theatre to hear him speak. He would stride into our anatomy labs, academic gown exchanged for grubby white coat, and, in precise tones, he would guide us through the intricacies of dissection with an enthusiasm sometimes difficult to face at 9am but always infectious.

This kind of teaching exemplified the best of the old curriculum. A lot was expected of students and, generally, the high standards of teaching and stimulating character of it meant that students rose to the challenge. Of course I do not remember it all word for word but I do remember many concepts, and parts that I found particularly interesting (the anatomy of the knee joint has always stuck in my mind) and, perhaps more importantly, I remember his excitement.

So what was he arguing for? Glasgow has been one of the keenest followers of the GMC's instructions. Last October, first-year students entered an undergraduate curriculum that had been transformed completely.

Lectures are no more. "Didactic" is a dirty word. Instead, new students undertake "problem-based" learning, working in small groups. No teaching occurs, God forbid, only "facilitating". And, in fact, the contribution of basic medical sciences (anatomy, biochemistry, physiology) has been vastly reduced, to a "core" of "relevant" knowledge, integrated with clinical studies.

The old medical curriculum certainly had its problems. However, there were some principles that the old curriculum did uphold, most importantly the centrality of science and research in medicine.

At its best, the old model of medical education had at its heart the ideal of the doctor as scientist. The idea that students should be taught by practising clinicians and scientists reflected the eagerness of the profession to enthusestudents about the importance of science.

Current thinking that didacticism (ie teaching) itself is aproblem, exposes a real failure of nerve on the part of academic medicine. And this will result in a failure to give students the challenges and stimulation they deserve at university level.

The old division between clinical and pre-clinical studies underlined the idea that doctors, whatever else they were, should primarily be scientists. We spent two years learning about the healthy functions of the human body before laying eyes (let alone hands) on a patient. The aim of the curriculum was to give students a systematic grasp of medical science, a necessary tool both in the day-to-day work of the doctor and in the realm of research.

The new emphasis is all on "relevance". Students will learn a "core" of scientific knowledge, on a need-to-know basis, through the problem-based learning technique. This, I believe, betrays a very superficial understanding of scientific thought.

Learning a circumscribed core of information in bite-sized chunks as applied to clinical problems does not teach you to be a scientist. Scientific education is about the confidence and ability to grasp and manipulate abstract concepts and patterns through which reality can be understood. Without this level of abstraction it is impossible to grasp what is and is not relevant, except superficially.

This is a technical training, not a scientific education, and this is simply not adequate for a profession that gains much of its respect and authority from science.

It is telling that communication skills are now a central facet of medical education, almost as though the practice of medicine is being reduced to "breaking bad news". This represents a profound lowering of horizons for the possibilities of medical progress.

Liz Frayn is a medical student at the University of Glasgow.

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