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Education v. The Curriculum
LEADING ARTICLES
THE LANCET LONDON
30
Education
v.
AUGUST
1958
The Curriculum
EARLIER this year TANNER1 outlined a reorientation of preclinical studies which would, in his view, make them more appropriate than they now are to the practice of medicine, at present largely concerned with applied human biology. At that time we forecast2 small likelihood of such ideas being translated into action in British schools. The powers of resistance to change include the fear of giving up what was once good, in favour of the new and unproven; and in the federation of departments which makes a medical school, that fear can easily be exploited by any unit which suspects that its own interests can best be served by adherence to the " status quo. But we added, if all the older schools are tied to their dead past the same cannot be said of new schools, such as that of Western Australia "; and we are very glad, therefore, that Prof. DAVID SINCLAIR has written the article on p. 430 describing the curriculum which, it has been agreed, shall at the moment be used in Perth. The planning of the early years suggests that the aim accords to some extent with that of TANNER. The actual programme, however, also reflects many local and, it is to be hoped, temporary obstacles. One of these at present means that the first year is spent in isolated study of " premedical " subjects. The second year, on the other hand, will consist of a coordinated in human biology, with at its end a single examination which should act as a stimulus to the student to integrate his studies of anatomy and physiology. Dissection of the whole body will be required and will be carried out under the pressure of the traditional viva system until the professional examination in topographical anatomy at the end of the second term of the third year. A term later the student will take one " examination in biochemistry and another in physiology and the general principles of pathology (with one question on psychology) ". We hope that before long circumstances will allow these two examinations to be fused, so that the student may be encouraged to link the general principles of pathology with physiology, psychology, and biochemistry (and even anatomy)-as obviously he must. SINCLAIR points out that although the plan he describes has been agreed to by all his colleagues some of them would place a different emphasis on the description. This no doubt would apply to the clinical part of the curriculum, in which no mention is made of that exceptionally important though technical part of medical education-the introduction to clinical method. The arrangement of the clinical years is, however, of such simplicity that at least it cannot be criticised for being
’
Lancet, 1958, i, 1185.
diffuse. A first year in the wards (during the first half of which the course and examinations in pathology will be completed) should give the student that advantage of long-continued practice in clinical method which has been such a good feature of the traditional British training. A second year consisting of four months’ obstetrics and gynaecology, four months’ paediatrics, and four months’ experience of specialties (with a carefully coordinated course in preventive medicine) indicates that the University of Western Australia is at the outset keen to achieve that sense of proportion, in regard to specialisation in undergraduate education, which characterises the best American schools. A final year " relatively free from formal classes " in which the student may gain experience and integrate his knowledge is, of course, something to which almost every British school is vainly trying to return. As HALE HAM3 has said, " The curriculum is the course through which the student travels; it is a definition of limitations as well as opportunity ". It closely resembles a railway guide which shows the expected times of arrival and departure, occasionally explains the local reasons for the route taken, and briefly indicates the It does main features of interest in each not state the degree of efficiency of the organisation, nor reveal its standards or those of its employees. Sometimes its avowal of close concern with the problems of the individual should not be taken too literally. Unfortunately in many medical schools in this country there are railway-guide teachers who still think of medical education primarily in terms of the curriculum. Unless a suggested improvement or reorientation is expressed in time-table form it seems to them to be hopelessly vague and diffuse-yet it cannot be translated into such form except by themselves in collaboration with their colleagues. Thus, old curricula remain, annually becoming structurally more. "concrete" but functionally less successful: and some schools wait on, in agitated depression, for ready-made " concrete plans which will never come. For this reason, we said2 two break the mould of the existing curriculum it may be necessary to start in Britain a new medical school ". As one means of solving our problems SCOTT4 " pleaded for restoration of the art of great teaching " to its proper place. But the " great " teachers were largely engaged in teaching what was known, while we are now equally concerned with teaching the best attitude to what is not yet kriown. " He teaches best," said ALAN GREGG in 1953,5 who shows his students how to learn: not what to think in 1953, but how to think and how to learn to think in that long stretch of days (ahead) till, let us say, the year 2000." We agree, however, with ScoTT and with WILSON6 that there is a great need for " teachers who take their responsibility as teachers as seriously as they take their research work or their clinical duties ". We are particularly impressed, therefore, with
stopping-place.
course
1. Tanner, J. M. 2. ibid. p. 1213.
447
"
...
Ham, T. An Experiment in Medical Education at Western Reserve University; p. 13. New York, 1954. 4. Scott, J. H. Lancet, 1958, i, 1334. 5. Gregg, A. For Future Doctors; p. 50. Chicago, 1957. 6. Wilson, R. R. Lancet, July 5, 1958, p. 45.
3. Hale
448
the principles which, as SINCLAIR records, were kept in mind during the planning of the Perth curriculum. " A series of weekly lunch-time meetings was instituted among the professors, and it is proposed to continue this most valuable practice indefinitely." " The second was that the details of time-table principle arrangements or teaching methods must never obscure the all-important attitudes of both teachers and taught towards the process of becoming a doctor." This augurs well for the future of Perth. Meanwhile, in this country, our best hope seems to lie in the Association for the Study of Medical Education,7 which will hold its first conferenceon Sept. 25 and 26. If it can draw together all the interested teachers from all disciplines and all schools, it will not only provide them with mutual strength and encouragement but will also enable them to work together to increase our knowledge of education. The stimulus to progress thereby generated cannot be ignored: it can produce that factual evidence of present weakness, and of the results of change, which alone will convince the faint-hearted, and the too easily satisfied, that change has to be made.
doctor in India will find himself dealing with a different set of problems in different circumstances and in a different culture from his colleague, say, in Africa or British Guiana-and therein lies the difficulty of teaching the subject thousands of miles from where the students will finally work. It is a good idea, too, to ask tropical
practitioners on furlough to help: home-leave is still, happily, on the grand scale, and many of them would be pleased to share their experiences and earn a little extra monev. J
Dr. WRIGHT treads on emotionally insecure ground when he suggests that new countries should scale down the training of students to methods they can afford; but, as he points out, what is sauce for the British goose is not necessarily sauce for the tropical gander, and medical practice will improve by adaptation to local circumstances. Dr. WILLIAMS thought it wrong for developing countries to put emphasis on large Western-style institutions ; and we believe that Western experts do a disservice if they encourage such Governments to start costly ventures of uncertain value. Likewise, as Dr. JOHN B. GRANT has insisted,11 the undergraduate medical curriculum in the tropics should be devised, not to reflect curricula in the U.S.A. or the United Kingdom, Tropical Practice but to train an " undifferentiated physician ", comMEDICINE in tropical climates has always been a petent to undertake general practice in his own challenging affair, and its enormous problems have community. Obscure investigations, all-day operations, attracted outstanding men. Now that the perils of complicated treatments may be out of perspective monsoon and insect have to some extent receded, when the average age of death is in the thirties and doctors in the tropics are looking at matters which had infant mortality is twenty times as great as in Britain, previously been masked by the daily drama and, perhaps, This is not to say that research has no place in the by the traditional approach to scientific medicine. From tropics, but it should be devoted to the vast her wide experience, Dr. CICELY WILLIAMS9 believes unsolved problems of epidemiology and nutrition that training in paediatrics for the tropics is not as good and to the relationship of disease to the wide cultural as it should be-and we agreed Now, in this issue, differences throughout the world. Many Western Dr. JOHN WRIGHT puts forward some good ideas for riddles might be solved if we knew the answers to overcoming present deficiencies and for helping the the sort of questions that abound here. Why is appentropical neophyte. With increasing specialisation and dicitis so rare in some primitive rural communities?1 complexity in Western medicine, training needs for the Why is disseminated sclerosis almost never seen in home front " and for the tropics are always diverging. India ? Why is syphilis so widespread in the tropics, The doctor in veldt or jungle has no second opinion, and yet affection of the central nervous system so rare? If to " pass the buck" may involve a long journey by the difference is due to autotherapy " from attacks of bullock cart and an expense that the patient’s family malaria, does the pattern hold for malaria-immune hill cannot afford. The doctor’s daily tasks may include areas ?Facts emerging from careful work in the tropics drawing a tooth, removing a uterus, taking an X-ray (if could radically alter ways of life in many other countries. he is lucky enough to have a machine), and fitting a new How should the doctor fit into this changing pattern half-shaft to the hospital van-cum-ambulance. Medicine of tropical practice ? Hitherto, effort has centred round of this calibre demands high skill and considerable isolated overworked Government or mission hospitals, mental stability. and it is tempting to follow a more thorough version of this his for meeting challenge, this plan. But large-scale curative and preventive Among proposals Dr. WRIGHT’S most interesting suggestion is a year’s measures, though very necessary, are of slight value internship " in a teaching hospital at the place where when unsupported by coordinated development projects a doctor intends to work. This seems such good sense touching many aspects of life-economic, eugenic. that we wonder why it was not introduced long ago: educational, technical, domestic, and (many would add there are still too few suitable institutions, of course, and religious. Such plans are proceeding in India on a herou the small number of doctors has made the: scale,12 and the experience they are providing will beof perhaps " waste " of a year impossible. But tropical medicine is’ the utmost interest to all who work in deprived countries not just a specialty, it is a complex of specialties; and the: In this scene, the greater medical profession includes 7. ibid. 1958, i, 1261. experts in many social and technical subiects, and the "
"
"
.
"
8. ibid. Aug. 2, 1958, p. 273. 9. Williams, C. D. ibid, 1958, 10. ibid. p. 951.
i, 863. 919
"
11 See ibid, p. 1009. 12. ibid. 1956, i, 491.
THE LANCET LONDON
30
Education
v.
AUGUST
1958
The Curriculum
EARLIER this year TANNER1 outlined a reorientation of preclinical studies which would, in his view, make them more appropriate than they now are to the practice of medicine, at present largely concerned with applied human biology. At that time we forecast2 small likelihood of such ideas being translated into action in British schools. The powers of resistance to change include the fear of giving up what was once good, in favour of the new and unproven; and in the federation of departments which makes a medical school, that fear can easily be exploited by any unit which suspects that its own interests can best be served by adherence to the " status quo. But we added, if all the older schools are tied to their dead past the same cannot be said of new schools, such as that of Western Australia "; and we are very glad, therefore, that Prof. DAVID SINCLAIR has written the article on p. 430 describing the curriculum which, it has been agreed, shall at the moment be used in Perth. The planning of the early years suggests that the aim accords to some extent with that of TANNER. The actual programme, however, also reflects many local and, it is to be hoped, temporary obstacles. One of these at present means that the first year is spent in isolated study of " premedical " subjects. The second year, on the other hand, will consist of a coordinated in human biology, with at its end a single examination which should act as a stimulus to the student to integrate his studies of anatomy and physiology. Dissection of the whole body will be required and will be carried out under the pressure of the traditional viva system until the professional examination in topographical anatomy at the end of the second term of the third year. A term later the student will take one " examination in biochemistry and another in physiology and the general principles of pathology (with one question on psychology) ". We hope that before long circumstances will allow these two examinations to be fused, so that the student may be encouraged to link the general principles of pathology with physiology, psychology, and biochemistry (and even anatomy)-as obviously he must. SINCLAIR points out that although the plan he describes has been agreed to by all his colleagues some of them would place a different emphasis on the description. This no doubt would apply to the clinical part of the curriculum, in which no mention is made of that exceptionally important though technical part of medical education-the introduction to clinical method. The arrangement of the clinical years is, however, of such simplicity that at least it cannot be criticised for being
’
Lancet, 1958, i, 1185.
diffuse. A first year in the wards (during the first half of which the course and examinations in pathology will be completed) should give the student that advantage of long-continued practice in clinical method which has been such a good feature of the traditional British training. A second year consisting of four months’ obstetrics and gynaecology, four months’ paediatrics, and four months’ experience of specialties (with a carefully coordinated course in preventive medicine) indicates that the University of Western Australia is at the outset keen to achieve that sense of proportion, in regard to specialisation in undergraduate education, which characterises the best American schools. A final year " relatively free from formal classes " in which the student may gain experience and integrate his knowledge is, of course, something to which almost every British school is vainly trying to return. As HALE HAM3 has said, " The curriculum is the course through which the student travels; it is a definition of limitations as well as opportunity ". It closely resembles a railway guide which shows the expected times of arrival and departure, occasionally explains the local reasons for the route taken, and briefly indicates the It does main features of interest in each not state the degree of efficiency of the organisation, nor reveal its standards or those of its employees. Sometimes its avowal of close concern with the problems of the individual should not be taken too literally. Unfortunately in many medical schools in this country there are railway-guide teachers who still think of medical education primarily in terms of the curriculum. Unless a suggested improvement or reorientation is expressed in time-table form it seems to them to be hopelessly vague and diffuse-yet it cannot be translated into such form except by themselves in collaboration with their colleagues. Thus, old curricula remain, annually becoming structurally more. "concrete" but functionally less successful: and some schools wait on, in agitated depression, for ready-made " concrete plans which will never come. For this reason, we said2 two break the mould of the existing curriculum it may be necessary to start in Britain a new medical school ". As one means of solving our problems SCOTT4 " pleaded for restoration of the art of great teaching " to its proper place. But the " great " teachers were largely engaged in teaching what was known, while we are now equally concerned with teaching the best attitude to what is not yet kriown. " He teaches best," said ALAN GREGG in 1953,5 who shows his students how to learn: not what to think in 1953, but how to think and how to learn to think in that long stretch of days (ahead) till, let us say, the year 2000." We agree, however, with ScoTT and with WILSON6 that there is a great need for " teachers who take their responsibility as teachers as seriously as they take their research work or their clinical duties ". We are particularly impressed, therefore, with
stopping-place.
course
1. Tanner, J. M. 2. ibid. p. 1213.
447
"
...
Ham, T. An Experiment in Medical Education at Western Reserve University; p. 13. New York, 1954. 4. Scott, J. H. Lancet, 1958, i, 1334. 5. Gregg, A. For Future Doctors; p. 50. Chicago, 1957. 6. Wilson, R. R. Lancet, July 5, 1958, p. 45.
3. Hale
448
the principles which, as SINCLAIR records, were kept in mind during the planning of the Perth curriculum. " A series of weekly lunch-time meetings was instituted among the professors, and it is proposed to continue this most valuable practice indefinitely." " The second was that the details of time-table principle arrangements or teaching methods must never obscure the all-important attitudes of both teachers and taught towards the process of becoming a doctor." This augurs well for the future of Perth. Meanwhile, in this country, our best hope seems to lie in the Association for the Study of Medical Education,7 which will hold its first conferenceon Sept. 25 and 26. If it can draw together all the interested teachers from all disciplines and all schools, it will not only provide them with mutual strength and encouragement but will also enable them to work together to increase our knowledge of education. The stimulus to progress thereby generated cannot be ignored: it can produce that factual evidence of present weakness, and of the results of change, which alone will convince the faint-hearted, and the too easily satisfied, that change has to be made.
doctor in India will find himself dealing with a different set of problems in different circumstances and in a different culture from his colleague, say, in Africa or British Guiana-and therein lies the difficulty of teaching the subject thousands of miles from where the students will finally work. It is a good idea, too, to ask tropical
practitioners on furlough to help: home-leave is still, happily, on the grand scale, and many of them would be pleased to share their experiences and earn a little extra monev. J
Dr. WRIGHT treads on emotionally insecure ground when he suggests that new countries should scale down the training of students to methods they can afford; but, as he points out, what is sauce for the British goose is not necessarily sauce for the tropical gander, and medical practice will improve by adaptation to local circumstances. Dr. WILLIAMS thought it wrong for developing countries to put emphasis on large Western-style institutions ; and we believe that Western experts do a disservice if they encourage such Governments to start costly ventures of uncertain value. Likewise, as Dr. JOHN B. GRANT has insisted,11 the undergraduate medical curriculum in the tropics should be devised, not to reflect curricula in the U.S.A. or the United Kingdom, Tropical Practice but to train an " undifferentiated physician ", comMEDICINE in tropical climates has always been a petent to undertake general practice in his own challenging affair, and its enormous problems have community. Obscure investigations, all-day operations, attracted outstanding men. Now that the perils of complicated treatments may be out of perspective monsoon and insect have to some extent receded, when the average age of death is in the thirties and doctors in the tropics are looking at matters which had infant mortality is twenty times as great as in Britain, previously been masked by the daily drama and, perhaps, This is not to say that research has no place in the by the traditional approach to scientific medicine. From tropics, but it should be devoted to the vast her wide experience, Dr. CICELY WILLIAMS9 believes unsolved problems of epidemiology and nutrition that training in paediatrics for the tropics is not as good and to the relationship of disease to the wide cultural as it should be-and we agreed Now, in this issue, differences throughout the world. Many Western Dr. JOHN WRIGHT puts forward some good ideas for riddles might be solved if we knew the answers to overcoming present deficiencies and for helping the the sort of questions that abound here. Why is appentropical neophyte. With increasing specialisation and dicitis so rare in some primitive rural communities?1 complexity in Western medicine, training needs for the Why is disseminated sclerosis almost never seen in home front " and for the tropics are always diverging. India ? Why is syphilis so widespread in the tropics, The doctor in veldt or jungle has no second opinion, and yet affection of the central nervous system so rare? If to " pass the buck" may involve a long journey by the difference is due to autotherapy " from attacks of bullock cart and an expense that the patient’s family malaria, does the pattern hold for malaria-immune hill cannot afford. The doctor’s daily tasks may include areas ?Facts emerging from careful work in the tropics drawing a tooth, removing a uterus, taking an X-ray (if could radically alter ways of life in many other countries. he is lucky enough to have a machine), and fitting a new How should the doctor fit into this changing pattern half-shaft to the hospital van-cum-ambulance. Medicine of tropical practice ? Hitherto, effort has centred round of this calibre demands high skill and considerable isolated overworked Government or mission hospitals, mental stability. and it is tempting to follow a more thorough version of this his for meeting challenge, this plan. But large-scale curative and preventive Among proposals Dr. WRIGHT’S most interesting suggestion is a year’s measures, though very necessary, are of slight value internship " in a teaching hospital at the place where when unsupported by coordinated development projects a doctor intends to work. This seems such good sense touching many aspects of life-economic, eugenic. that we wonder why it was not introduced long ago: educational, technical, domestic, and (many would add there are still too few suitable institutions, of course, and religious. Such plans are proceeding in India on a herou the small number of doctors has made the: scale,12 and the experience they are providing will beof perhaps " waste " of a year impossible. But tropical medicine is’ the utmost interest to all who work in deprived countries not just a specialty, it is a complex of specialties; and the: In this scene, the greater medical profession includes 7. ibid. 1958, i, 1261. experts in many social and technical subiects, and the "
"
"
.
"
8. ibid. Aug. 2, 1958, p. 273. 9. Williams, C. D. ibid, 1958, 10. ibid. p. 951.
i, 863. 919
"
11 See ibid, p. 1009. 12. ibid. 1956, i, 491.