35
Medical Education PLANNING A NEW MEDICAL SCHOOL* H. ORISHEJOLOMI THOMAS C.B.E., C.O.N., Hon. D.Sc., M.B. Birm., F.R.C.S. DEAN AND HEAD OF THE DEPARTMENT OF UNIVERSITY OF LAGOS MEDICAL
SURGERY, SCHOOL, LAGOS, NIGERIA
A PROJECT as complex as the foundation of a new medical school requires adequate planning, but too many medical schools have been on the drawing boards for far too long. Meetings of planning committees, begun in attenuated by the passage of years. We become earnest, must not allow our desire to build the best medical school to delay forever our realisation of a good one.
There are three main objectives in planning a new medical school: (1) the establishment of an educational institution for training personnel of all grades to ensure that the health of the community is maintained; (2) the establishment of a centre for research and for training research workers; and (3) the provision of hospital care of the highest quality by teams of specially trained men and women.
But, in addition to these often recapitulated and obvious there are many others. They are seldom because they are taken for granted as corollaries of the main ones. One such is the feeling of conscious " health-confidence " created in a community by the establishment of a medical school. The people become convinced that because there is a medical school in their midst their health is assured. Serious surgical emergencies, ranging from head injuries to a ruptured appendix, will be dealt with promptly; epidemics and pestilences will be kept at bay; the water can be drunk without fear of dysentery; and mosquito bites may still raise a blister but will certainly not raise the fear of yellow fever.
objectives, mentioned,
Some of us in the developing areas of the world who are fortunate in having medical schools recognise that the services associated with them have facilitated the economic development of our countries. By assuring them that their health, and more important still, the health of their wives and children are in good hands, technical experts and skilled personnel have been attracted to start much needed industries and train local men to work with them. High salaries in themselves are no longer sufficient incentives-the health of families must also be assured. These facts seem to have escaped those who argue that the provision of medical schools and teaching hospitals is a drain on the economy of a new nation. TRAINING OF SKILLED PERSONNEL FOR COMMUNITY HEALTH
We know that
how highly developed a to provide doctors to there is still need country becomes, ensure the health of the population and to restore to fitness those that fall sick. A paradox of the present century is that the affluent society demands an increasing measure of medical service, so that countries with a high living standard find the ratio of 1 doctor to 2000 persons no longer adequate and prefer to see a ratio of 1 doctor to less than 1000. Consequently, rich or poor, in every country, the question that arises is not whether new medical schools are required, but how many medical *
no
matter
An address delivered at the Third World Conference Education, New Delhi, India, Nov. 20-25, 1966.
on
Medical
schools the country can afford and effectively utilise. It has been postulated that for every 2-5 m. of population, there should be one medical school designed to yield up to 100 qualified doctors a year. But I do not think one should regard this as more than a rough guide. A more definite projection would be to determine the number of physicians required for a given number of population, bearing in mind the economic circumstance of the country. If we accept 1 physician to 1000 of the population as the optimum for the more developed countries, then it is perhaps realistic, though not ideal, to estimate for 1 physician to every 10,000 of the population in a developing country. This should be regarded as an initial minimum; for, as the country’s economy develops, so the healthservice demands of the community will grow and the doctor/population ratio improve. The demand for medical schools is world-wide. But one of the tragic anomalies of our time is that the countries which need medical schools most are the least able to afford them. _
CRITERIA FOR A NEW MEDICAL SCHOOL
If the new medical school is to function efficiently, there must first of all be a student-body capable of benefiting from the education that is to be offered by the medical school. The education must be at university level: on this there For the standard at which we can be no compromise. aim to maintain health must be at the same high level, whether in a highly developed society or in a country still very low down on the ladder of economic development. The students we admit to our medical schools must be adequately prepared in the basic sciences of biology, chemistry, physics, and mathematics to be able to acquire some of the knowledge piling up in bewildering complexity in the medical sciences. To make allowance for or admit persons with a lower standard of education is to make difficulties not only for the students themselves, but also for the faculty, and, later, for the community. Experience in many developing countries confirms this. Secondly, there must be a good faculty. Since able medical teachers are difficult to find, the temptation is great for a young school to manage with anyone it can lay its hands on, and to hope that as time passes and the school becomes known good teachers will join its faculty. This is a delusion. Such a school is likely to build up a disreputation rather than a reputation. Efforts must be made even before the foundation is laid to make contact with established medical schools to seek assistance with recruitment of academic staff. Here we must not allow the bounds of nationalism to restrict us. If we cannot get suitably qualified teachers of our own nationality, then we must accept (and gladly) experienced teachers from other countries, provided, of course, that we understand the need for and take steps to implement the training of our own teachers. Indeed, the two exercises should proceed simultaneously-that is, the appointment at the start of some teachers from abroad, and the training of nationals. The training should be carried out in the new medical school itself and in medical schools abroad, so that as soon as possible these young men and women can participate in the work of the medical school. Thirdly, the cost of the school must be estimated as accurately as possible. In the enthusiasm of planning, cost is often played down, but while planning is going on, costs all over the world tend to increase rather than decrease. The longer planning takes, the more expensive the buildings are when they come to be started. In
36
budgeting, two costs must be borne in mind: capital costs for building and for equipment of a more permanent nature; and recurrent costs to provide salary for staff, transportation for them and their families, and replacement of expendable material. An initial capital outlay of not less than E2 m. and provision of EO-5 m. annually should be made for a medical school designed for 500 students altogether and about 100 members of academic staff. These figures will need to be adjusted according to the local cost of labour and material. Allowing for the inevitable wastage of 10%, such a school should provide the community with no less than 90 doctors every year. For the medical school to function, a complementary teaching hospital must be planned at the same time. Both the capital and recurrent costs of the teaching hospital will be higher than those of the medical school. For instance, a hospital planned to qualify 90 to 100 medical students yearly may cost E3 m. to build and as much as EO-9 m. a year to run. A hospital of this sort should accommodate up to 900 patients. For the economically prosperous nations, these are not large sums, but for the poorer nations, they represent a goodly proportion of their income. The commitment is justified, however, when we recall that these institutions train not only doctors but also nurses, technologists, radiographers, and a host of paramedical personnel, as well as providing high-level healthcare for the community. Square-footage, the height of the buildings, the size of rooms, and the rest of the minutiae which form the
physical part of the school are matters that properly belong to the province of the architect, the engineer, and the surveyor. Architects are not doctors nor are they medical teachers. It is for the doctors and medical teachers who will use the buildings to be quite explicit as to their requirements and to have a written record kept of discussions and decisions reached with their architects, engineers, and surveyors. The financial aspect must also be borne in mind constantly, not least the fact that every time the architect alters a drawing a charge is made and the figure soon mounts up. Unless care is exercised, the major part of the budget can be easily expended on drawings and other consultant services before the site is even cleared for construction to begin. Multidiscipline laboratories enable a unit laboratory to be used for the teaching of up to four subjects by a proper arrangement of the timetable. This is the most efficient method of space utilisation that I know of, and all those who employ it are enthusiastic about it. Not only space but also money for construction is saved-an observation which never fails to repair any breach between planning committees and academic bodies. Our fourth criterion is the provision of an adequate number of technological staff-that cadre of " middlemen " in a medical school and teaching hospital which comprises the laboratory technologist, the instrument engineer, the electronicist, and a lot more. Without them, neither medical school nor teaching hospital can function, no matter how promising the students or how competent the faculty members. Here again, this group of people may be difficult to come by, because their services are in great demand everywhere. Therefore, initial staffing may be from abroad, although training of indigenous staff must be started immediately. The reason I bring in a fifth criterion is to allay the fear sometimes expressed by people who have little knowledge of developing countries-the fear that the population are
sophisticated enough hospital, the fear that
not
to use
the
cervices of a modern
so-called
witch-doctor or medicine-man is still more acceptable to most of the people. Traditional healers do play a role in developing countries, yet anyone visiting a hospital in any of these areas will soon realise that all hospitals and even dispensaries enjoy an overwhelming popularity and that the people greatly appreciate the services they give. NEW,
the
OR ADAPTATION OF THE
OLD ??
Sequentially, the next question that faces the planners is: should there be a new medical school or should an already existing hospital be adapted for use as a medical school ? If the estimated cost for it can be readily met, then a new medical school should be built. If this is not possible, then rather than plan and wait and postpone indefinitely, there is every reason to recommend the adaptation of a suitable hospital. Having said that, I must qualify it by adding that experience has sometimes shown that the cost of modification of an old building can be almost as expensive as building a new one. Wooden buildings may be inelegant, but need not be, and though perhaps unedifying to our ego, their use can mean reaching a target several years ahead of budgetary delay. There is no fixed way to start. I have mentioned some of the alternatives. There are others. I am convinced that what is important is that having decided that a medical school is necessary, and having satisfied some of the criteria, one should go ahead as rapidly as possible to produce one. An example of what can be done is to be seen in the University of Lagos Medical School in Nigeria where, starting with what was built as a good general hospital of 350-bed capacity, it was possible to establish the departments of basic medical sciences and to start clinical training several years before it could have been possible otherwise. ADMINISTRATORS AND TEACHERS
While we all have the greatest regard for the democratic processes of committees, boards, and councils, I think it is important that in establishing a new medical school a single person must be charged with the final responsibility. In their traditional role of checking and balancing and begetting subcommittees and working parties, committees and boards can frustrate, distract, and retard. Admittedly at such times committees show themselves in their most disagreeable phase. But, properly briefed and taken into confidence, especially when carried along on a wave of enthusiasm by the dean or chairman, committees can be a welcome source of experience and an invaluable support. For these reasons the dean or chairman of the planning committee should possess the attributes of a pioneer-a capacity for hard work and a relentless drive, an ability to initiate and follow through, a sense of timing, an understanding of people and a resilience of mind that knows when to give in or to dig in, a thickness of skin that ignores minor criticisms, and, withal, sufficient humility to admit that he may be wrong in some of his ideas. Above all, he must have implicit belief in the necessity, desirability, and importance of his assignment-the founding of a new medical school. One of the first tasks confronting the dean is to seek out suitable persons to head various departments, but it is not necessary to find a head for each department before a medical school can start. In fact, if scarcity of staff is so great, it may be impossible to do any more than keep a year ahead of the students. For example, if students are
37
due to study surgery a year hence, then a professor for the department should be found in the year immediately preceding. The professor and head of department will then have at least twelve months in hand in which to plan and to look for members of staff who will help run the department. To start off, however, there should be someone in charge of the department of anatomy and another person in charge of a combined department of physiology, biochemistry, and pharmacology. Unless suitably quali-
fied persons are available there should be one chairman of department for all three. Too early fragmentation is expensive and can easily lead to a lack of balance in teaching. In many developing countries, a teacher with enough experience to head a department in the basic medical sciences may be impossible to find. In that case, one has to look abroad. The person chosen should be imaginative and possess an aptitude for adaptation and improvisation. Much more is required of him than the ability merely to transport the academic habits and methods of his home-country to another country. TYPE OF TEACHER
The type of teacher
should look for is the man who is prepared to experiment and seek for better ways of teaching in medicine. The great increase in the amount of information in the basic medical sciences and in all the different specialties of clinical medicine calls for changes in the method of their presentation which are in keeping with recent ideas in the use of audio-visual equipment. Furthermore, teachers and practitioners who received their medical education in Europe or America have become increasingly aware that their concepts of the practice of medicine are sometimes not applicable without modification to the needs of developing countries. Because of this, teachers in medical schools in the new countries should be prepared to find out what it is that they have to emphasise to their students in order to make them useful doctors for the community. Sometimes in response to requests for loan of teachers from abroad, an offer is made of an older man, the superannuated or retired professor. Let no one question the usefulness of this category of staff. Such a man can bring to his work a rich experience of medical education. What is unbut often is a expected, possessed by him, forward-looking and agile mind prepared to try out revolutionary ideas in medical education. It is as though these ideas, bottledup for many years by the combined intransigence of colleagues at home, had only been waiting for just such a challenging environment to come bubbling forth. Any medical school that has the good fortune to find such a man must make every effort to get and retain him. one
CONCLUSIONS
Some of the challenge to the new medical school concerns clinical teachers, the training of auxiliaries, research, and the life of the medical student. Fortunately, the shortage of clinical teachers is not anything like as acute as it is in the preclinical sciences. But a postgraduate qualification, even when coupled with experience of consultant practice, does not necessarily fit a man to become a lecturer or a professor in a university medical school. Experience of the methodology of teaching and understanding of the process of learning are no longer just desirable assets but are basic necessities for the modern medical teacher. Because of this, the prospective teacher in medicine should spend a period of one or two years preparing for his professional work as a teacher. Among
other things, he must familiarise himself with various methods of audio-visual communications, and be able with preclinical colleagues to devise efficient methods of integrated teaching. We have to admit that, even up to the present in many medical schools, the education of students continues to be largely a byproduct of our major interest as clinicians or laboratory investigators. Their very low doctor/population ratio makes it obvious that many countries will not meet the demands for medical services in a decade or even in a generation. Because of past experience in the use of assistant medical officers, many countries are unwilling to revive the experiment. This is understandable; I think we all agree that health services anywhere should be of the highest standard possible. But in areas where doctors are so few some means must be found to train persons who will assist the doctor in his work. The alternative is a doctor or no doctor at all. A university medical school can barely exist by teaching alone; it needs research to spark off and maintain its vitality. No school can continue to attract top-grade teachers and students who show promise unless it establishes some reputation for original work. Serious attempts should be made to provide space and equipment for research, no matter how modest, from the very inception of the school. But is it the function of the new medical school to reach out for the frontiers of knowledge ? Should it not content itself with more down-to-earth investigation ? Should not its search for new knowledge be confined to looking for answers posed by immediate problems ? There is need, I venture to suggest, without curbing academic freedom, for some sense of direction to be given to research. Research projects need careful working out, and those who plan them must take into consideration the needs of the medical school and the obligations it owes to the whole community. University life, whether in the sciences or arts, ought to be a stimulating experience. The study of medicine offers in addition an opportunity for rich human experience, an opportunity to understand persons as individuals, to learn at first hand of their sufferings, delusions, hopes, and aspirations. Surely it should be one of the highest ideals of a medical teacher to assist the student in his appreciation of these aspects of life-but not by leading him on to observe these reactions in his patients with the complete detachment of the scientist watching a chemical reaction in a test-tube nor yet with an emotional involvement that could distort his judgment for carrying out His teacher’s experience is necessary correct decisions. to guide him to a true understanding that he is fortunate and privileged to be taught the means of assisting a fellow human being in his time of suffering and need. I have lately1 tried to point out that as teachers we have in some respects accepted too readily some European academic traditions. One of them in particular-the aloofness of teachers from students-I know has greatly militated against informal meetings and conversations with our students. It is my belief that there should be closer contact between teacher and taught, so that communication and understanding between them should be easier. This should take place inside and outside the lecture-room and laboratories. In all developing countries, doctors, by their unique relation with men, women, and children, parents and families, employers and employed, 1.
Thomas, H. O. Presidential Address at Fifth Annual Conference of Association of Medical Schools in Africa, Ibadan, April, 1966.
38 trusted and taken into confidence in many personal If the medical student of today is to counsel as the doctor of tomorrow, we must realise what wisely tremendous responsibility may rest on his shoulders for peace and orderly development or for discord, disruption, and misery. With this realisation, can we be satisfied to remain just formal teachers of medical sciences to our students ? Is it not time for some of the art and humanity of medicine to be re-incorporated into our teaching and precepts ? Nowhere is the opportunity for doing this greater than in the new medical school, unfettered by tradition, and as yet unretarded by frustration. If medical schools in developing countries succeed in giving their students a sense of greater responsibility for their fellow men and women that goes beyond efficiency in wards, laboratory, or operating-theatre, then the older
are
Cleanliness, of
course,
came
first and
practical nursing
second. We could have qualified as domestic supervisors, because we had then to do so much domestic work ourselves. We believed that doctors wanted the wards and beds clean and tidy; but they do not demand it of us now, and they accept that the most popular place for toddlers’ books and toys is the floor. For two short periods each day the wards are clean and tidy, however, and everything is in its proper place. Not so in the mothers’ unit; the nursing staff, and in particular the domestic staff, found this very irksome to begin with. In a hospital it is considered a crime to stand and stare, unless at a patient. Nurses were critical of mothers sitting around enjoying the luxury of boredom, they felt they should have been doing something constructive, knitting or sewing, for example. Thus, nursing attitudes which have their origin in the medical schools of Europe and America, their teachers and students, both those who have become and those still past made nurses unhappy about accepting mothers to become doctors, and the very wide circle of men and gladly, because they were deprived of the nursing care of the child, forced to accept a lower standard of tidiness in women with whom they come into contact, may possibly wish to re-examine the matter of good human relations. the mothers’ unit, and were often, though busy themselves, faced by the inactivity of the mothers. For on these relations the survival of mankind depends more now in the twentieth than in any preceding century. Waiting for the first mother I felt rather like a new hotel
matters.
keeper, apprehensive and anxious
to please. Nevertheless, I I was. This mother be like one-but treated expect on and she spoke to most of her time the bed, reclining spent none of the staff unless it was to order something. The child was not bathed, neither was her cot made, and when the family left it was without saying goodbye to the nurse in charge. Nevertheless, I called the trained nurses together and was unwise enough to ask for written comments about their relations with all the mothers we admitted. Alas, the comments were unprintable, and I deemed it wiser not to ask for comments again (though I still get them). The next visitor won a grudging approval; she was a nursing mother whose baby had an intussusception. She came in with a writing-case and got her correspondence up to date for the first time in two years. This mother was ideal in that she obeyed the unwritten rules. She deprived us of nothing: we had the nursing care of the child for the first twelve hours, she was always occupied, and she was so tidy she even stripped her bed and the cot before leaving. We needed her because the next group of mothers turned the place into a slum. After they had lived in for three days, the orderly came to me with tight lips announcing she had removed eight unrinsed milk bottles, the waste bucket was overspilling on the floor, the occupants were using the butter dish as an extra ash tray and eating butter out of its paper, the milk saucepan was burned, and the floor was very dirty because the cleaner could never get in to clean-a terrible tale. I was driven to say that we were supposed to create a home-like atmosphere, and if this was how they lived at home we must accept it. Nursing and domestic staff expected me to discipline the mothers as I do them. I was as reluctant then, as I am now, to express concern for anything except the care of the child. The first round the consultant did with these mothers was memorable. I should have sent a runner before us to ask them to be in their rooms, but I did not, so we entered the day room which was transformed. The air was blue with smoke, the television was switched on, the children were crawling on the floor among toys, bricks, and cups, and each mother listened avidly to the doctor’s talk to the other. These mothers were bored, and used to take it in turns to go to the canteen for coffee. One used to sit in the waitingspace looking into the car park as though from prison. Mother and child are not enough for each other, and now we advise them to mix with the other children in our wards as soon as possible. Since our association with the child in the unit is often a painful one, I hope it improves our image for the child to see us with other children.
did
Special Articles MOTHERS IN HOSPITAL* The Nurse’s
Viewpoint
B. D. MORGAN S.R.N. SISTER-IN-CHARGE, CHILDREN’S UNIT,
WARWICK HOSPITAL
THE criticism is often levelled at nurses that, although they may be good with patients, their relations with visitors leaves much to be desired. They are taught how to treat visitors in one sentence: " Be kind and understanding towards them. " The general idea was that this meant avoiding them whenever possible. I remember visiting-time as a period when one hid away in bathrooms and sluices-now one cannot hide; the visitors are everywhere, even in those places of retreat. At 6.30 P.M., when the visitors leave, the nurses enjoy one brief period of peace, when the ward belongs to them. When it was planned to take away this hour of peace by admitting three mothers, there was a great outcry in this hospital. It was inevitable that we should take a little time to adjust to the presence of mothers sleeping, on the ward. I am going to mention some of our problems-they may seem very petty now but they were troublesome at the time. In our defence, I will first refer to past teaching. Many senior nurses in children’s wards will have trained when visiting was not considered good for the child. We were taught mainly of godliness and cleanliness, and they ruled our lives. Godliness was interpreted as nursing and caring for the child as a whole, not sharing the care with the mother. (The health visitor coped with the mother and child, but the hospital nurse did not.) The first instinct of a nurse may still be take the child from the mother, perhaps to undress him, while his mother stands helplessly watching. However inexperienced the nurse, she used to be considered more capable than the mother. *
Based on an address given to the Midland Association on May 13.
Regional Pædiatric
not
to