CHANGES IN MEDICAL EDUCATION

1. CHANGES IN MEDICAL EDUCATION A Surgeon's Perspective R. S. Williams Senior Visiting General Surgeon Modbury Public Hospital Adelaide South Australia

2. 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

3. 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

4. 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?

5. 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”

6. 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.

7. 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 Adelaide Medical School preclinical years 1-3

8. 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? !965

9. “ Core Curriculum” • Anatomy should be core curriculum • Students must demonstrate competency before progressing • Anatomy “electives” promoted

10. 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?

11. 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?

12. 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

13. Basic science teaching Concerns expressed by • RACS • Royal College Pathologists Australasia • Australian Med Students Society • Many individual clinicians via conferences, journals and media

14. 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”

15. Flinders University Graduate Medical School • Anatomy taught in first year, but can fail anatomy and still pass overall • Anatomy “elective” in second year optional • Butgraduate entry; most have already studied basic sciences including anatomy

16. 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?

17. 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

18. 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

19. “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

20. 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 ?

21. 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!

22. 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?

23. 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

24. 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”

25. 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

26. 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!

27. 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.

28. 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