Graduates join student doctor revolution

February 6, 1998


SHE IS 54 years of age, physically active and has rarely had a day's illness in her life. But, as she confides to a friend at the local gymnasium, she has recently discovered a lump in her breast and is desperately worried. What should she do? Could it be cancer?

The group of medical students look at the television screen on which the woman is explaining the problem to her friend.

In a voice-over, the narrator poses a series of other questions: is a lump in the breast normal or abnormal? What is the breast made up of and how is this related to its function?

The woman is anxious in case the lump is cancerous, but what is cancer? Which cells does cancer affect in the breast?

The queries pour out, challenging the students to tackle an issue they will often meet in general practice in a new, holistic way.

Instead of learning separately about the physiology of the breast in a lecture on anatomy, the nature of cancer in a lesson on cellular biology and how cancer is treated at another, the students are presented with a clinical problem they have to solve.

This is the new doctor training programme at the University of Sydney, which admits good graduates rather than the traditional school-leaver.

Three times a week students meet a tutor in problem-based learning tutorials. They also attend four to five lectures and two clinical science sessions, all related to the same problem. Up to 20 hours are left free on the weekly timetable for learning alone.

A similar course also began last year at the University of Queensland.

A slow revolution in medical training has spread to half the nation's ten medical schools over 20 years from the University of Newcastle.

Ann Sefton, associate dean in charge of curriculum development at Sydney's faculty of medicine, said: "People have almost forgotten that Newcastle was the first."

"Although it did not decide to admit only graduates, they were the first to change the system by which students got into medicine and the way they learned thereafter."

Sydney's medical faculty decided to switch to graduate entry in 1991 but it took another six years of planning to complete the radical redesign of the curriculum. The first class of 143 graduates was admitted last year - out of more than 400 applicants from across Australia.

Graduates have to sit a common entry test, have very good academic records in their first degree, and undergo a lengthy interview.

Those enrolled are an older and more varied group than the bright school-leavers with their high scores in mathematics and science who used to be admitted.

While a majority have a science or health sciences degree, there are graduates in the arts, economics, physics, pharmacy, plus an optometrist and even a couple of engineers.

They will spend four years in medical school, instead of the six a school-leaver must complete.

At Flinders University, which introduced graduate entry for the first time in Australia in 1996, students have the option of spending their entire third year working alongside a general practitioner in the country.

They meet visiting specialists in rural hospitals and use video-conferencing facilities to take part in tutorials run from Adelaide.

David Prideaux, head of the office of education in the school of medicine, said: "Graduate entry has created a climate for innovation and change. It has enabled us to adopt a different mode of teaching and to bring an integrated curriculum into line with the sort of realities that will confront medical practice in future."

While Melbourne's faculty of medicine decided to make similarly sweeping changes to its course, it also agreed that only a third of this year's intake will be graduates.

Richard Larkins, who has just taken over as dean, said this was because Melbourne feared that if its best students had to wait three years and then compete with others to gain admittance, some might switch to another medical school.

"We hope that by combining graduates and school-leavers we will get the best of both worlds," Professor Larkins said. But he adds that as well as using school results to select students, they will also face a psychometric test, thus, "broadening the base".

Professor Larkins said that there are other problems with graduate entry than a possible loss of school-leavers to competing faculties.

A six-year course, for example, would be clearly inequitable and uncompetitive. Yet a packed four-year course provided little opportunity for students to explore areas in depth or "support oneself with part-time employment and continue with interests outside medicine".

Nevertheless, both groups will face an integrated curriculum: instead of individual subjects such as biochemistry, anatomy or physiology, they will study a series of vertical streams throughout the course with subjects such as the scientific basis of medicine, health and society, clinical skills and professional attitudes and development.

For the school-leaver group, the faculty decided to incorporate a year between the fifth and eighth semesters where they will select from a range of options, all including a minimum of one-third research but some comprising all research.

Professor Larkins said that this will allow students to explore an area of interest in depth and to develop the rigours of research methodology.

Australia's first bachelor of medicine degree was awarded at Melbourne University in 1862. The bachelor of surgery was added in 1879. Now the bachelors has been scrapped but the students who complete the new year of medical science will receive a degree at that point.

"This will allow a potential exit with a qualification and dignity for those who decide at this point that medicine is not for them," Professor Larkins said.

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