changes in medical education
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CHANGES IN MEDICAL EDUCATION. A Surgeon's Perspective. R. S. Williams Senior Visiting General Surgeon Modbury Public Hospital Adelaide South Australia. My background. Graduated 1971 Adelaide Medical School General surgeon FRACS , FRCS (Eng)1979 - PowerPoint PPT PresentationTRANSCRIPT
R. S. Williams Senior Visiting General Surgeon Modbury Public Hospital Adelaide South Australia
My background
Graduated 1971 Adelaide Medical School General surgeon FRACS , FRCS (Eng)1979 Teaching students since 1970’s; Royal
Adelaide and Modbury Public Hospital, S.A. Currently teach 4th and 6th year students from
Adelaide Med School
My view of current undergrad. medical education Hard sciences and academic excellence
gradually devalued Clinical students keen & enthusiastic but
struggle Eventually most will overcome deficiencies in
undergraduate education, but is this right? Proud traditions of Adelaide Medical School
( founded 1885) under threat
Changes in medical education since 1990 Problem Based Learning adopted late
1990’s My impression since; anatomy and other basic sciences
neglected social and behavioural sciences promoted.
Is this what the community needs? What was so wrong with previous
curriculum?
Changes in medical education Communication skills “holy grail”
Students’ basic scientific knowledge ‘?’ now
inadequate for clinical medicine
Clinical tutors and postgraduate Colleges “plug the gaps”
Communication , interactive skills and teamwork
Rightly emphasized in modern medical curriculum
Possibly too little training in past
But…. Scientific training must always receive highest
priority.
Adelaide Medical School preclinical years 1-3
1965 40 contact hours /week
Emphasis
• Didactic teaching - physics - chemistry - anatomy - histology embryology - physiology - biochemistry “Medicine and the
humanities”
2005
25 contact hours/week
Emphasis
• Problem orientated, self-directed learning
- Social sciences - interaction and communication skill - some anatomy and histology, no embryology
Human Anatomy ; the basis of Medicine
1960’s
progressive dissection of cadaver during 18 months , regular viva’s and final exam.
600-700 hours 2000 onwards
self-directed study of prosections
100 hours
Is anatomical knowledge adequately
tested?
“ Core Curriculum”
Anatomy should be core curriculum
Students must demonstrate competency before progressing
Anatomy “electives” promoted
Problems in medical education
Pendulum Effect
• 1960’s arguably too much detailed basic sciences
• 2000’s Too Little
80% reduction in anatomy, histology, embryology teaching, and reductions in physiology, biochemistry
Where should the pendulum be?
Basic science teaching “ 3 R’s ” analogy
1980’s and 1990’s basic language and math skills downgraded in schools
Deterioration in literacy and numeracy Will we have to learn this lesson in medical training?
Compounding the problems
Teaching in clinical years relies on goodwill of
clinicians who may not wish to, or be best qualified to teach basic medical science
Reductions in working hours for junior
doctors limits clinical experience and stimulus to add to knowledge
Basic science teaching
Concerns expressed by RACS Royal College
Pathologists Australasia
Australian Med Students Society
Many individual clinicians via conferences, journals and media
RACS Anatomy Working Party 2004• “ crisis in the teaching of anatomy in medical
schools”
• “soft subjects jeopardising anatomy”
• “the current problem-based learning model has been a failure in teaching basic sciences”
• “RACS will have to fill the gaps”
Flinders University Graduate Medical School
Anatomy taught in first year, but can fail anatomy and still pass overall
Anatomy “elective” in second year optional
But graduate entry; most have already studied basic sciences including anatomy
Changes in medical education The concept that less training in anatomy and
other basic sciences produces better doctors is counter-intuitive
Is there any evidence that radical curriculum changes have been necessary or produce better doctors?
What do Adelaide students say?
•“ not prepared for PBL in first year” • “thrown in at deep end”
•“not enough didactic teaching” • “not enough lectures and demonstrations of anatomy”•“ too much self-directed learning”• “not sure where I am, if I know enough.”•“can’t access tutors easily
Justifications for new medical curriculae“Doctors have been poor communicators”
Address this but not at expense of scientific knowledge
“Medical knowledge expanding exponentially” All the more reason for have thorough grounding in basics “Medical practice in future will be based on public health / preventative
medicine” = IVORY TOWER stuff For the conceivable future we will have an ageing population needing medical and surgical treatment
“Dumbing down” of medicine Medical education post 1990’s;
less theory, less basic sciences, lower standards
Nursing education since 1990’s;
more theory, more basic sciences, higher standards
Other issues in medical education
Adelaide Med school 2004 ;
70% female, 30% local Flinders graduate school similar ratios Workforce projections ? based on outdated
models Changing work ethic (male and female ) Future medical workforce ?
Other issues. . .
Adelaide Med School’s non graded pass/fail system (rationale; discourage competition between students working in groups)
Analogy with primary and secondary schools discouraging competition ;
It didn’t work!
Competition and excellence
non-graded pass/ fail = failure to reward merit
does this foster mediocrity?• How do we identify excellent students?• Does it prepare students for medicine or life in
general?• Good students don’t like it ; lazy students love it!• Has this approach already failed in pre- university
education?
Medical Student Selection
TER, UMAT, Interview Academically gifted students missing out Selection interviews reward verbal and
communication skills. Is this assessment reliable at age 17? (also, females better at this age.)
Evidence of coaching for UMAT & interview What effect on quality of future graduates? Majority of future doctors female = serious workforce implications
other thoughts. . . Is the move away from didactic teaching of
basic sciences aimed at reducing costs and staffing in medical schools?
Allow me a moment of paranoia ! Are there wider agendas? e,g, deskilling in hard sciences reduces status of medical doctors -- become “health care
workers”
Current Medical EducationSome good things! Students keen, enthusiastic, well presented Communicate and engage well with staff and
patients Work well in teams Recognize deficiencies and seek help and
direction from clinical teachers to improve in these areas
Aware of need for balanced lifestyle
What can medical schools do? Change selection process; stop “dumbing down!” Make sure basic medical science knowledge is
properly taught and assessed. ( esp. anatomy)
Intersperse PBL with more didactic teaching
If persist with PBL, consider change to graduate entry
Listen to concerns of students and clinicians and act on them!
Rescuing medical education conclusions (At least in Adelaide) current pre-clinical
medical education inadequate in basic sciences
Urgent review of medical student selection needed
Urgent review of anatomy teaching needed.
Students struggling , need more didactic teaching
“Softer” sciences should not dominate curriculae
Views of senior clinicians and students must be heeded.
Rescuing Medical Education
My thanks to the organizing committee for asking me to contribute.
I hope this meeting leads to reform in medical education !
R.S. Williams , Sydney February 2005