Factors affecting the outcomes of medical education

1. Factors affecting the outcomesof medical education Dr E.G.Cleary Assoc Dean for Curriculum University of Adelaide University of Adelaide Medical School

2. The issues that have to be addressed by an Assoc. Dean for Curriculum (and the Curriculum Committee) in meeting today’s (and tomorrow’s) needs from medical education Alternative Title University of Adelaide Medical School

3. Graduate Sydney Univ. Medicine 1955 6 Years RPAH - physician training MD Sydney (physiology) 30 years research in basic science 30 Consultant Physician (OPD) RAH 40 years “teaching” pathophysiology 32 years in medical education Undergoing my 5th curriculum “revision” My Background = Prejudices declared? University of Adelaide Medical School

4. I agree, there is a crisis in medical education! But I disagree with some proposed diagnoses, and especially with some proposed treatments. As with so many patients today, the aetiology of the problem is multifactorial and simple uni-dimensional “solutions” do not address the real issues. First, we need to define our models and introduce some ideas from modern research on how people learn. Lets go back to the ‘patient’ University of Adelaide Medical School

5. Curriculum models Layer cake model of Flexner (1910) v Integrated spirals of active learning Basic Concepts University of Adelaide Medical School

6. Flexnerian Model? • Clinical Practice • Clinical Training • Paraclinical disciplines • Basic Sciences University of Adelaide Medical School

7. Adelaide Medical School Model ClinicalPractice Scientific Basis of Medicine Medical Personal and Professional Development Vertical and horizontal integration, contextual - basic science is still being learned in later years and clinical work is introduced from beginning The experience should be engaging and enjoyable! University of Adelaide Medical School

8. Learning and Teaching models Traditional: didactic, staff driven, rote learning v Modern: contextual, self-directed, ‘adult’ learning University of Adelaide Medical School

9. Assessment: Intermittent ‘cram-dump’ Model • fact-rich, • mostly rote, • intermittent • learning with view to ‘cram-dump’ University of Adelaide Medical School

10. Assessment: Continuing Accumulative Model • On-going • Formative and summative • Cumulative • Directed to test learning for understanding University of Adelaide Medical School

11. Preparing students for practice 10-12+ years ON Need to envision future practice requirements Competent undifferentiated practitioner Ready for internship Knowledge, skills and practice, attitudes Personal and professional development Ethical, ‘equipped’ for life-long learning and self-care Minimal competence assured Need to address causes of ‘adverse events’ in practice Aware of own competence level, seeks help if unsure Defining our objectives of Med Educn University of Adelaide Medical School

12. Knowledge is increasing exponentially Predicting, and training for, future needs Students are different Pressures on Staff and Medical Schools Teaching poorly valued in Universities Time and service pressures in Hospitals Administrative and fiscal pressures Pressure groups and Media Some major issues to be addressed University of Adelaide Medical School

13. Ageing of population Social and Economic determinants of health Changing burden of disease (prevention and management) Health inequalities Changing governance and service delivery Population health focus Emphasis on primary health care (prevention, health promotion, health information, functioning in a multi-disciplinary team) Dr M Rice Chair of Clinical Senate’s wish-list University of Adelaide Medical School

14. Secondary schools ‘driven’ by TER Forced-fed, rote-learning style imprinted Principals: “We no longer teach students, we ‘teach curriculum’” Reinforced now by training programs for selection to Medical School Television and computer games Visual learners ‘ER’ type TV programs influence student ‘entering view’ of medicine ‘Get-a-life’ affects students too! - further aggravated by: Rising HECS, fee-paying students, living costs High proportion of students work during term (up to 25 h/wk) Challenges to assessment are an increasing burden for academic staff Living away from home and international students - mentoring need Students are ‘different’ University of Adelaide Medical School

15. Promotion mainly through publications Teaching is undervalued, so teachers are diverted Funds for teaching are being constantly squeezed Reductions in government funding Medical Faculties viewed as funding source - “socialization” Pressures to take more fee-paying students Universities have the centre-focussed ‘business model’ SA Medical Schools are overrun with out-of-state students We are not training enough students to meet present needs Clinical staff ‘resent’ teaching students who will go elsewhere Pressures from within University University of Adelaide Medical School

16. Patient related: Bed numbers are being reduced to contain costs Narrow spectrum of patients - age, diseases, trauma, very ill Duration of stay is much reduced (3.5 - 4 days average stay v 14-21 days av.) Effect of ODA surgery and overnight admissions Patients are too ill and too busy to talk with (so many) students Emphasis on patients rights, expectations, demands (this is good, but different) Staff related: Increasing service load and bureaucratic burden on staff Management do not value teaching Advent of speciality units and reduction in general med/surg units Effects of ‘cost shifting’ between Commonwealth and State Governments Changes in ‘teaching hospitals’ limit learning opportunities University of Adelaide Medical School

17. Relative increase in number of students per patient Lack of time to teach as before No time, or incentive, to engage in staff development Results in inability to teach students clinical skills Major reduction in clinical student-assessment activities No time to supervise ‘long-cases’ for students Lack of time to provide feedback to students Reluctance to fail students Effects of changes in teaching hospitals on staff University of Adelaide Medical School

18. Consequences Seems to generate false assumptions about ‘prior knowledge’ students are bringing to wards at year 4 This leads to increased expectations/demands on earlier teaching - ? a form of ‘blame shifting’, and often to denigration of students Diminishes relationships between staff and students Questions? Are major tertiary, acute-care (teaching?) hospitals still appropropriate places in which to train medical students? What mix of primary care training should be included in the medical course and how can this be staffed and funded? Effects of changes in teaching hospitals on staff -2 University of Adelaide Medical School

19. Factors related to general practice Rural training schemes Workforce issues Private hospitals Medical Boards AMC Governments and Depts of Health Other factors University of Adelaide Medical School

20. Need for more dialogue and to accept good intentions of parties Understanding of issues and less ill-informed criticism - feeds media ‘confrontation frenzy’ Willingness of medical community to provide effective, modern, focussed, teaching and learning opportunities Willingness to undertake staff development in teaching Concerted approaches to help Governments to understand the problems and to implement solutions Actively engage in educating administrators regarding the urgent need for change in their approach to training of THEIR future medical and health science staff members We must educate community attitudes with informed inputs Some possible solutions University of Adelaide Medical School

21. We all agree: There IS a crisis in medical education! This is a multi-factorial problem - unidimensional solutions will do little to produce the outcomes required in the future Modern curricula are being adapted to predictable future needs It is our experience that students from our new curriculum know AND CAN USE more of their basic science learning in clinical years than those from our older didactic curricula There are critical shortages of clinical learning opportunities There are overwhelming pressures on clinical staff to divert them from providing adequate training for medical students We need a combination of critical analysis and creativity. Our political and administrative “masters” must engage! Take Home Messages University of Adelaide Medical School