Health of future doctors depends on reforms

November 21, 1997

Medical education must evolve and changes being planned and implemented are no cause for despondency, says Stephen Tomlinson

RECENT articles in The Times Higher Education Supplement, particularly the editorial on October 24, may have given the impression that changes in medical education now being implemented are a response to short-term problems of recruitment and funding.

They are not - they are planned changes that have been introduced to improve the quality of education, to broaden access, to encourage inquiry and research, to assimilate major advances in medical science, to respond to changing patterns of disease and disability in our population and to changes in medical practice and the delivery of health care.

The impetus for change was provided by the General Medical Council's guidance in Tomorrow's Doctors, published in 1993, which emphasised the need to concentrate on the understanding of essential principles rather than simply acquiring increasing quantities of information to be regurgitated in examinations.

The council also emphasised the importance of behavioural and social science in addition to biomedical science and highlighted the importance of attitudes, skills and competencies as well as knowledge.

Doctors spend much of their time finding out about patients' problems, trying to understand them and making a diagnosis. It is hardly surprising therefore that problem-solving exercises play an important role in new curricula.

Nevertheless, it would be mistaken to believe that the essential features of a good medical education described by Abraham Flexner earlier this century have been forgotten.

Safe (and effective) medicine is founded on a sound understanding of biomedical science based on up-to-date laboratory and clinical research; research informs teaching and clinical practice within a strong biomedical and clinicalfaculty.

According to Flexner (and many others), a close association between the medical school, a multi-faculty and a clinical environment (be it in hospital or community) is important.

Moreover, the opportunity to mix with and be influenced by students in other health care professions and with undergraduates in other disciplines is, in our view, of increasing importance for the future doctor. In line with thisphilosophy, plans to integrate medical schools in London with multi-faculty institutions are now well advanced.

There is no evidence whatsoever that bright young people are deterred from a career in medicine. Rather, the quality and number of applicants for medical schools remains high, while there is a cap on the numbers that can be admitted.

However, more than 70 per cent of medical students do come from socio-economic groups 1 and 2 and the majority of students make the decision to enter medicine in their teens.

It is clear that the country needs more doctors and we are expecting that the Medical Workforce Standing Advisory Committee will recommend a significant increase in intakes to medical schools in its next report, to be published shortly. It seems sensible therefore to explore additional pathways to entering the medical course by further widening access to graduates and mature students.

Courses for such individuals would be no less rigorous than those already in place. The GMC's education committee, as well as the funding councils and ourselves as professionals, would see to that.

Finally, we believe that a medical education should take place in a research-active environment. Some students will become researchers themselves, but all will need to understand research method and develop skills in critically evaluating research-derived evidence to inform their clinical practice. An essential task of an academic medical centre is to undertake clinical research to learn how to apply results of basic research to the care of patients.

This does not mean that all members of faculty will have a lead role in research; some will make their contribution in education and some in clinical innovation, clinical leadership and clinical practice, but within a research environment. The concentration of all medically related research within institutions without patients or medical students would ultimately benefit neither research, education nor the care of patients.

The changes that are now taking place are challenging and exciting - they are certainly not a cause for gloom and despondency. Far from being a response to short-term funding problems, implementation in many medical schools is at risk as a consequence of recent and proposed severe financial cuts. This is particularly regrettable when it is widely recognised that medical education cannot and must not stand still and when change is being strongly encouraged and supported by the GMC, the National Health Service and Chief Medical Officer, the funding councils, universities and medical schools and medical students themselves.

Stephen Tomlinson is dean of medicine at the University of Manchester and an executive secretary of the Council of Heads of Medical Schools.

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