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POSTGRADUATE MEDICAL EDUCATION
367
Medical Education POSTGRADUATE MEDICAL EDUCATION Conference Convened by the Nuffield Provincial Hospitals Trust A PRIvATE conference was held at Christ Church, Oxford, on Dec. 16 and 17 under the chairmanship of the Regius Professor of Medicine, Sir GEORGE PICKERING. Its members were drawn from the Ministry of Health, the University Grants Committee, the universities, the Royal Colleges and the College of General Practitioners, and the
British Postgraduate Medical Federation, as well as boards of governors of teaching hospitals, regional hospital boards, and consultants in the provinces. The Questions
Facing
the Conference
opening the conference, the Chairman posed three questions: 1. Is postgraduate medical education important ?
In basic
Assuming the answer to this to be " Yes ", are the arrangements adequate at the moment ? 3. If the arrangements are not adequate, can better provision be made, and what should be done now, both immediately to improve the position, and to stimulate action for a thorough review of the situation ? 2.
It seemed
him that the answers were self-evident. medical education was important, and Postgraduate more so because of the advance becoming increasingly of medical knowledge as a whole. It was above all important to the development and improvement of health services. Yet its demands had received little attention in the United Kingdom-possibly because the long overdue scrutiny of the needs of undergraduate education may have tended to overshadow the equally pressing question of postgraduate training. He suggested that the conference might apply itself mainly to the problem of men and women holding training posts in hospitals, leaving on one side detailed consideration of training for general practice. This did not imply that the latter was unimportant, but merely that the objectives of the conference should be limited. Relatively more attention had been given to the question in the United States of America. Despite the fact that there was no national hospital system there, there was at least agreement as to the minimum requirements of postgraduate training posts. In this country, with its National Health Service, no minimum requirements were laid to
down. The Elements of Agreement The feeling was unanimous that something could and should be done now to improve the arrangements. To focus attention on what appeared to be the common grounds of agreement, the Chairman developed an outline of what it seemed desirable to do. The following represents this outline, as modified and agreed in the subsequent
discussion. SOME ELEMENTARY
There ance
importseem
so
simple. 1. The arrangements for
United
Kingdom
are
2. Arrangements should be made to enable all doctors have postgraduate education, not only while they occupy training posts in hospital and elsewhere but as a continuing discipline throughout their careers. to
3. With the pace of advancement of medical and scientific knowledge, postgraduate education will be even more important in the future.
4. As a continuing process, postgraduate education should therefore: (a) supplement undergraduate education ; (b) continue even after service in training posts is ended; and (c) include arrangements to allow not only trainees but doctors from all branches of the medical profession to have access to reference libraries and to clinical discussion groups. 5. Postgraduate education has been to date largely the concern of the institutes of the British Postgraduate Medical Federation in London and to a limited extent the teaching hospitals. The greatest emphasis, however, has been on training future teachers and those who will become consultants. 6. It is of urgent and immediate concern for both the present and the future of the health services that the pattern of, and facilities for, education in the hospitals of the regional boards should be radically improved. A few outstandingly good regional hospitals have shown that this can be done within their existing arrangements. 7. All posts ranging from preregistration appointments to those of senior registrar should be recognised as training posts. 8. Organised training facilities for doctors not yet permanently established in specialties, or general or other practice, will be insufficient to meet requirements of the future unless accompanied by better arrangements for the
continuing exchange of knowledge, particularly between specialists and general practitioners. This is not formal education in the ordinary sense, but requires the provision of opportunities for discussion at clinicopathological conferences, other clinical demonstrations and ward rounds, consultation in the diagnostic departments, reference facilities, and some assistance in undertaking special inquiries, whether of a statistical or laboratory nature. This is in addition to the periodic refresher courses which are already provided for general practitioners and need further expansion. REQUIREMENTS
The basic Regional Postgraduate Training Unit should be the district hospital or hospital group
CONSIDERATIONS
certain elementary points, whose may easily escape attention because they are
island, to the Commonwealth, and to other countries whence graduates come to the United Kingdom-because the excellence of the education available to graduates at all levels in our hospitals will inevitably influence the present and future quality of the National Health Service; because we have an obligation to contribute generously to the training of graduates for Commonwealth countries; and because the good name of this country depends to some extent on how far we exert ourselves to ensure that the young doctors sent here from abroad are provided with a solid foundation for their professional work.
postgraduate education in the important-to the people of this
a. All consultants should recognise their responsibility in the training of junior staff, regarding this as one of the most important aspects of their work. b. It is important to promote an educational atmosphere in the regional hospital unit. Senior staff and junior
368
staff should have time over and above service commitments to devote to education, and this should be borne in mind in the review of hospital staffing to be carried out following the Platt report. c. In each of these hospitals or hospital groups a consultant should be nominated by the Regional Committee for Postgraduate Education (see below), as clinical tutor, for teaching arrangements and the general responsible " care " of those under training. He should have administrative support and adequate secretarial assistance. d. The clinical tutor should also be the person responsible, in consultation with general practitioners in the area, for organising opportunities for them to participate in clinical discussions and in clinicopathological conferences. They should, of course, have access to the library and to the diagnostic departments for consultation. e. Certain physical facilities are necessary for the unit:
i. Seminar ii. Library
room.
(in
which there should be
a
part-time
librarian). iii. Clinical tutor’s room. iv. Laboratories adjacent to the wards in which trainees can perform tests on their patients. v. Married quarters for junior hospital staff, to allow them to move from hospital to hospital. vi. Lunch room, as a focal point where hospital medical staff can meet and be joined by general practitioners.
The immediate objectives should be to provide nos. i, ii, and iii; the rest should follow as soon as practicable. f. Certain criteria should be developed to create standards to which all such units should aspire. These will relate to: i. Standard of supervision. ii. Quantity and variety of clinical material. iii. Standard of records. iv. Postmortem service. v. X-ray and pathological services. vi. Laboratory facilities. vii. Seminars, clinicopathological conferences, &c.
Postgraduate medical education should be organised in regional scheme, in which the units are the basic elements, but there must be an association with the regional university a. There should be a postgraduate dean and/or director, appointed by the medical faculty of the university concerned, on whom the success or otherwise of this scheme will very much depend. He should have proper a
office accommodation and secretarial assistance. Such a person or persons’ main responsibilities will be: i. The interrelationship between the region and the
university. ii. Arrangements for teaching in the region. iii. Advising on careers. iv. Advising and placing of overseas graduates. v. The integration of general practitioners into these
postgraduate
arrangements.
b. There should be a strong Regional Committee for Postgraduate Education, the convenor of which should be the postgraduate dean, and on which will be represented: the university, the regional hospital board, the Royal Colleges, and the College of General Practitioners. Its main tasks will be the coordination of services and division of responsibilities between the various authorities, including eventually the arrangements for rotating junior staffs as necessary in a regional training scheme. It will also be responsible for appointing the clinical tutors at the Regional Postgraduate Training Units.
FINANCE
The financial responsibility might follow basically the responsibilities between educational and National Health Service commitments. Thus the university should be responsible for the appointment and payment of the dean and his secretary, and for honoraria to the clinical tutors. The regional hospital board should meet the expenses incurred in such a scheme by regional board staff. URGENT
MORE
NEED
DEFINITE
FOR
FORMULATION OF
PRINCIPLES
AND
POLICY
depend largely on local initiabe some central formulation of principles and of policy for postgraduate medical education. This is a matter of urgency, and to achieve it, some official body should be established as soon as possible, representing the University Grants Committee (and universities), the General Medical Council, the Departments of Health, the Royal Colleges, the Royal Corporations, and the College of General Practitioners. Such a body should consider the desirability or otherwise of central arrangements for supervision and designation of training and qualifying posts. Immediate action will
tive, but there ought
to
Epilogue The conference was generally agreed about what needed to be done, but it did not discuss in detail how it was to be done. Nevertheless, it was clear that certain regionalboard hospitals have already begun to develop educational facilities along the lines proposed. Others are in a position to begin once they have fully appreciated the need. For those who have begun, for those who could begin, and for others who might begin, the success of the programme will depend greatly on the support given by the universities and regional boards. The conference thought that detailed suggestions for financial and other aid to the scheme were ultra vires. However, the vast amount of common ground and of good will for the general objectives outlined left no doubt that a modest investment of support would yield a handsome dividend in terms of quality of medical service at home and improved relations abroad.
SUPPORT FROM NUFFIELD TRUST E250,OOO set aside for Postgraduate Training AFTER considering the report on the conference described above, the governing trustees of the Nuffield Provincial Hospitals Trust have decided to reserve 6250,000 to finance regional and area schemes for postgraduate training in the provinces. Such projects should seek to apply the principle enunciated in the outline arrangements which the conference agreed were needed, and which seemed the most practical means of improving the situation with regard to postgraduate training and education of doctors in the health services in the United
Kingdom. therefore looking forward to receiving from interested bodies for grants over applications limited periods to initiate suitable schemes. The trustees will be specially concerned to see that the appropriate university and regional hospital authorities are both wholeheartedly behind any approach to the Trust, and whether there is evidence of an appreciation of the urgency, as well as of local interest and self-help by way of financial support. The
trustees are
Medical Education POSTGRADUATE MEDICAL EDUCATION Conference Convened by the Nuffield Provincial Hospitals Trust A PRIvATE conference was held at Christ Church, Oxford, on Dec. 16 and 17 under the chairmanship of the Regius Professor of Medicine, Sir GEORGE PICKERING. Its members were drawn from the Ministry of Health, the University Grants Committee, the universities, the Royal Colleges and the College of General Practitioners, and the
British Postgraduate Medical Federation, as well as boards of governors of teaching hospitals, regional hospital boards, and consultants in the provinces. The Questions
Facing
the Conference
opening the conference, the Chairman posed three questions: 1. Is postgraduate medical education important ?
In basic
Assuming the answer to this to be " Yes ", are the arrangements adequate at the moment ? 3. If the arrangements are not adequate, can better provision be made, and what should be done now, both immediately to improve the position, and to stimulate action for a thorough review of the situation ? 2.
It seemed
him that the answers were self-evident. medical education was important, and Postgraduate more so because of the advance becoming increasingly of medical knowledge as a whole. It was above all important to the development and improvement of health services. Yet its demands had received little attention in the United Kingdom-possibly because the long overdue scrutiny of the needs of undergraduate education may have tended to overshadow the equally pressing question of postgraduate training. He suggested that the conference might apply itself mainly to the problem of men and women holding training posts in hospitals, leaving on one side detailed consideration of training for general practice. This did not imply that the latter was unimportant, but merely that the objectives of the conference should be limited. Relatively more attention had been given to the question in the United States of America. Despite the fact that there was no national hospital system there, there was at least agreement as to the minimum requirements of postgraduate training posts. In this country, with its National Health Service, no minimum requirements were laid to
down. The Elements of Agreement The feeling was unanimous that something could and should be done now to improve the arrangements. To focus attention on what appeared to be the common grounds of agreement, the Chairman developed an outline of what it seemed desirable to do. The following represents this outline, as modified and agreed in the subsequent
discussion. SOME ELEMENTARY
There ance
importseem
so
simple. 1. The arrangements for
United
Kingdom
are
2. Arrangements should be made to enable all doctors have postgraduate education, not only while they occupy training posts in hospital and elsewhere but as a continuing discipline throughout their careers. to
3. With the pace of advancement of medical and scientific knowledge, postgraduate education will be even more important in the future.
4. As a continuing process, postgraduate education should therefore: (a) supplement undergraduate education ; (b) continue even after service in training posts is ended; and (c) include arrangements to allow not only trainees but doctors from all branches of the medical profession to have access to reference libraries and to clinical discussion groups. 5. Postgraduate education has been to date largely the concern of the institutes of the British Postgraduate Medical Federation in London and to a limited extent the teaching hospitals. The greatest emphasis, however, has been on training future teachers and those who will become consultants. 6. It is of urgent and immediate concern for both the present and the future of the health services that the pattern of, and facilities for, education in the hospitals of the regional boards should be radically improved. A few outstandingly good regional hospitals have shown that this can be done within their existing arrangements. 7. All posts ranging from preregistration appointments to those of senior registrar should be recognised as training posts. 8. Organised training facilities for doctors not yet permanently established in specialties, or general or other practice, will be insufficient to meet requirements of the future unless accompanied by better arrangements for the
continuing exchange of knowledge, particularly between specialists and general practitioners. This is not formal education in the ordinary sense, but requires the provision of opportunities for discussion at clinicopathological conferences, other clinical demonstrations and ward rounds, consultation in the diagnostic departments, reference facilities, and some assistance in undertaking special inquiries, whether of a statistical or laboratory nature. This is in addition to the periodic refresher courses which are already provided for general practitioners and need further expansion. REQUIREMENTS
The basic Regional Postgraduate Training Unit should be the district hospital or hospital group
CONSIDERATIONS
certain elementary points, whose may easily escape attention because they are
island, to the Commonwealth, and to other countries whence graduates come to the United Kingdom-because the excellence of the education available to graduates at all levels in our hospitals will inevitably influence the present and future quality of the National Health Service; because we have an obligation to contribute generously to the training of graduates for Commonwealth countries; and because the good name of this country depends to some extent on how far we exert ourselves to ensure that the young doctors sent here from abroad are provided with a solid foundation for their professional work.
postgraduate education in the important-to the people of this
a. All consultants should recognise their responsibility in the training of junior staff, regarding this as one of the most important aspects of their work. b. It is important to promote an educational atmosphere in the regional hospital unit. Senior staff and junior
368
staff should have time over and above service commitments to devote to education, and this should be borne in mind in the review of hospital staffing to be carried out following the Platt report. c. In each of these hospitals or hospital groups a consultant should be nominated by the Regional Committee for Postgraduate Education (see below), as clinical tutor, for teaching arrangements and the general responsible " care " of those under training. He should have administrative support and adequate secretarial assistance. d. The clinical tutor should also be the person responsible, in consultation with general practitioners in the area, for organising opportunities for them to participate in clinical discussions and in clinicopathological conferences. They should, of course, have access to the library and to the diagnostic departments for consultation. e. Certain physical facilities are necessary for the unit:
i. Seminar ii. Library
room.
(in
which there should be
a
part-time
librarian). iii. Clinical tutor’s room. iv. Laboratories adjacent to the wards in which trainees can perform tests on their patients. v. Married quarters for junior hospital staff, to allow them to move from hospital to hospital. vi. Lunch room, as a focal point where hospital medical staff can meet and be joined by general practitioners.
The immediate objectives should be to provide nos. i, ii, and iii; the rest should follow as soon as practicable. f. Certain criteria should be developed to create standards to which all such units should aspire. These will relate to: i. Standard of supervision. ii. Quantity and variety of clinical material. iii. Standard of records. iv. Postmortem service. v. X-ray and pathological services. vi. Laboratory facilities. vii. Seminars, clinicopathological conferences, &c.
Postgraduate medical education should be organised in regional scheme, in which the units are the basic elements, but there must be an association with the regional university a. There should be a postgraduate dean and/or director, appointed by the medical faculty of the university concerned, on whom the success or otherwise of this scheme will very much depend. He should have proper a
office accommodation and secretarial assistance. Such a person or persons’ main responsibilities will be: i. The interrelationship between the region and the
university. ii. Arrangements for teaching in the region. iii. Advising on careers. iv. Advising and placing of overseas graduates. v. The integration of general practitioners into these
postgraduate
arrangements.
b. There should be a strong Regional Committee for Postgraduate Education, the convenor of which should be the postgraduate dean, and on which will be represented: the university, the regional hospital board, the Royal Colleges, and the College of General Practitioners. Its main tasks will be the coordination of services and division of responsibilities between the various authorities, including eventually the arrangements for rotating junior staffs as necessary in a regional training scheme. It will also be responsible for appointing the clinical tutors at the Regional Postgraduate Training Units.
FINANCE
The financial responsibility might follow basically the responsibilities between educational and National Health Service commitments. Thus the university should be responsible for the appointment and payment of the dean and his secretary, and for honoraria to the clinical tutors. The regional hospital board should meet the expenses incurred in such a scheme by regional board staff. URGENT
MORE
NEED
DEFINITE
FOR
FORMULATION OF
PRINCIPLES
AND
POLICY
depend largely on local initiabe some central formulation of principles and of policy for postgraduate medical education. This is a matter of urgency, and to achieve it, some official body should be established as soon as possible, representing the University Grants Committee (and universities), the General Medical Council, the Departments of Health, the Royal Colleges, the Royal Corporations, and the College of General Practitioners. Such a body should consider the desirability or otherwise of central arrangements for supervision and designation of training and qualifying posts. Immediate action will
tive, but there ought
to
Epilogue The conference was generally agreed about what needed to be done, but it did not discuss in detail how it was to be done. Nevertheless, it was clear that certain regionalboard hospitals have already begun to develop educational facilities along the lines proposed. Others are in a position to begin once they have fully appreciated the need. For those who have begun, for those who could begin, and for others who might begin, the success of the programme will depend greatly on the support given by the universities and regional boards. The conference thought that detailed suggestions for financial and other aid to the scheme were ultra vires. However, the vast amount of common ground and of good will for the general objectives outlined left no doubt that a modest investment of support would yield a handsome dividend in terms of quality of medical service at home and improved relations abroad.
SUPPORT FROM NUFFIELD TRUST E250,OOO set aside for Postgraduate Training AFTER considering the report on the conference described above, the governing trustees of the Nuffield Provincial Hospitals Trust have decided to reserve 6250,000 to finance regional and area schemes for postgraduate training in the provinces. Such projects should seek to apply the principle enunciated in the outline arrangements which the conference agreed were needed, and which seemed the most practical means of improving the situation with regard to postgraduate training and education of doctors in the health services in the United
Kingdom. therefore looking forward to receiving from interested bodies for grants over applications limited periods to initiate suitable schemes. The trustees will be specially concerned to see that the appropriate university and regional hospital authorities are both wholeheartedly behind any approach to the Trust, and whether there is evidence of an appreciation of the urgency, as well as of local interest and self-help by way of financial support. The
trustees are