MEDICAL EDUCATION

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Points of View MEDICAL EDUCATION

JAMES PARKHOUSE Department of Anæsthetics, University of Manchester THE setting up of an inquiry into the functions of the General Medical Council gives us an obvious opportunity to think about the administration of medical education in the broadest possible way. There are signs that the retention-fee issue is just one indication of a widespread discontent with the present organisation of the medical profession and its educational affairs. Some of the causes of this were obviously clear to Lord Todd and his commissioners; the prolonged delay in formulating an official response in any way worthy of the significant efforts of the Royal Commission has done additional harm. Several interested organisations have taken independent initiative in suggesting changes. The reception, naturally, has varied. The General Medical Council made proposals regarding specialist certification and the setting up of specialty boards; these appeared unacceptable at the time and were quietly shelved. The Department of Health put forward suggestions concerning the responsibilities of the consultant grade, very relevant to education, which were more noisily considered to be unacceptable. The Royal Commission on Medical Education, with Lord Todd as chairman, proposed a non-consultant career grade which was very loudly regarded as dubious. The Royal Colleges and Faculties are now making recommendations for training which may be expected to display varying degrees of palatability ; and meanwhile the deans, undergraduate and postgraduate, discuss the curriculum and the pre-

registration

year.

Ferment is a great improvement upon apathy. It is essential to the health of our system to have these separate groups, with different and sometimes opposite points of view, each arguing its case and maintaining its right to be heard. They must all, in my view, retain their distinct identities. But it is a hopeless basis for planning and future development to have a succession of uncoordinated, unilateral proposals which, on grounds which are by no means clear, are

38. Wld Med. 1970, 5, 80. 39. Dimock, E. M.D. thesis, University of Cambridge, 1936. 40.’Cleave, T. L. Br. med. J. 1941, i, 461. 41. Cleave, T. L. ibid. 1972, ii, 409. 42. Aries, V., Crowther, J. S., Drasar, B. S., Hill, M. J., Williams, R. E. O. Gut, 1969, 10, 334. 43. Hill, M. J., Crowther, J. S., Drasar, B. S., Hawksworth, G., Aries, V., Williams, R. E. O. Lancet, 1971, i, 95. 44. Burkitt, D. P. Cancer, 1971, 28, 3. 45. Trowell, H. C. Eur. J. clin. Biol. Res. 1972, 17, 345. 46. Trowell, H. C. Atherosclerosis, 1972, 16, 138. 47. Mathur, K. S., Khan, M. A., Sharma, R. D. Br. med. J. 1968, i, 30. 48. Shurpalekar, K. S., Doraiswamy, T. R., Sundaravalli, O. E., Rao, M. N. Nature, 1971, 232, 555. 49. Schowengerdt, C. G., Hedges, G. R., Yaw, P. B., Altemeier, W. A. Archs Surg. 1969, 98, 500. 50. Antonis, A., Bersohn, I. Am. J. clin. Nutr. 1962, 11, 142.

either dropped or rather surprisingly implemented. Few people really know what is going on, and nobody knows why. I believe that what is said here applies equally to undergraduate and to postgraduate education, since, with varying degrees of emphasis, all parties to the debate must concern themselves with all stages. The distinction, in fact, is irrelevant. The question is not whether the universities and the General Medical Council should be involved at the postgraduate stage, or whether the Colleges and the Department of Health should have an audible view on undergraduate teaching, but how best to create a system in which medical education can be planned and implemented as a whole, not forgetting the supreme importance of continuing

education and retraining. This means a reconciliation of the interests of all who are involved-the most important interests, not so far mentioned and easily forgotten, being those of the patient and the

practitioner. All this points inescapably to the need for a policymaking body, in which all the relevant voices can be heard and from which, as a result of debate, research, and deliberation, clear legislative decisions can emerge. Proposals and suggestions from the constituent bodies should be submitted to this council, or legislative assembly, and its ultimate law-making decisions should be binding upon all concerned. In this respect the legislative assembly that I envisage would need to take over and make effective the work of the Council for Postgraduate Medical Education, which, in the opinion of most people, has so far proved disappointing. It would also need to supersede the closed and inappropriately simplistic relationship of " Man proposes but God disposes " between the faculties of medicine and the General Medical Council in respect of the undergraduate phase of education. It would be a complex body, requiring active committees and working groups, research facilities, and perhaps more than one office even for England. It should not be financed directly by the Department of Health or any other single interested party. Given the right relationship with the Colleges, it could give us the best possible approach to an Academy of Medicine. The question of B.M.A. representation would inevitably arise, but in my opinion the more important principle would be to accept an element of lay membership and to take adequate note, through some appropriate means, of the views and experiences of students, specialist trainees, clinical teachers, and those particularly concerned with the vital relationship between training and health manpower

requirements. At the executive level, I am convinced of the advantages of a regional, university-based system. Putting into effect a plan or, if the description is more apt, implementing a set of rules which govern medical education, once they have been made, is a matter of caring for individuals. In the undergraduate

have the established basis for an effective The lack of anything comparable after graduation is the outstanding defect of our present arrangements. The graduate trainee should have a frame of reference; he should know who is responsible

schools system.

we

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planning and supervising his training

and to He may take clinical appointments outside his home region, or even outside the country, but this should from the administrative point of view be no more than an extension of the student elective, clinical attachment, No and preregistration arrangements of today. national body, sitting only in London, can achieve the necessary intimacy with individual men and women. The machinery for guidance and supervision would in any case be hopelessly expensive for either the General Medical Council or the Colleges. The appointment of College and Faculty tutors and regional advisers is a recognition of the need for decentralisation, but it is inadequate in itself and has the defect in principle that trainees do not immutably " belong " to specialties and their self-appointed representatives. The need, again, is for strong regional medical education committees which can stand in clear relationship to the central legislative assembly and function as its executive arms.

for

whom, in return, he is accountable.

Within each region the ultimate responsibility for medical education should lie as firmly with the university at the postgraduate level and in the field of continuing education as it does at the earlier stages. This would need, of course, every bit of the money that the General Medical Council and the Colleges manifestly do not have, but this money should come in large measure from the Department of Health, through its new regional authorities. Lord Todd’s Commission told an important part of the truth in saying that the National Health Service, like any good employer, should provide for the training of its future employees. The other part of the truth, as has been said of legal education, is that " it was, and is, the essence of a learned profession that apprenticeship, while indispensable, is not sufficient ". The traditions of clinical teaching and apprenticeship in this country are priceless, but more is needed, both academically and administratively. Already the initiative in arranging and conducting organised courses of various kinds for graduate trainees comes almost invariably from individual professors, and the resulting burden of work falls heavily upon them and their academic colleagues. Regional training schemes must develop in the best possible educational way, in which specialisation is altogether too important to be left entirely to the specialists. Having said something of legislative and executive functions, there remains the question of the judicature, and in the present context I am thinking, first of all, not of the judgment of misconduct, but of education. The assessment of the student’s progress, throughout his training, should rest, as it now does for the undergraduate and the preregistration house-officer, with the faculty of medicine. Here should lie the responsibility both for ensuring that acceptable courses and experience are available and for certifying that they have been satisfactorily completed in individual cases. For the purposes of registration, either general or specialist, this certification could perhaps as well be made to a legislative assembly as to a General Medical Council. Possibly even the disciplinary function of the General Medical Council could

become the responsibility of a suitably formed committee of the legislative assembly. Inspection of the credentials of overseas doctors wishing to practise in this country is likely to become an increasingly important function, especially in relation to the specialist registration arrangements of other countries. How best to do this, if need be putting the interests of the public before those of the profession and its specialised sectors, is to my mind a second-stage decision which lies beyond the proper formulation of a concept of " specialist " for this country. So I come back, very inconclusively, to the functions of the General Medical Council, and to some of the contents of the Todd Report. There is a great chance at this moment to create a single and logical administrative framework for the whole of medical education, from high school to retirement. The most important need in my opinion, for both practical and political reasons, is to establish an effective legislative assembly to which we all know that we can look with confidence for clearly defined and flexible policy decisions at the highest level. If this turns out to be nothing less than a totally reconstituted General Medical Council, so much the better-except that we shall still have to decide how to pay for it.

Round the World United States FINANCIAL TROUBLES

It is not only the more conservatively oriented American Medical Association which is in financial trouble. At the opposite end of the spectrum is the American Public Health Association, holding firmly to the concept that Federally financed compulsory national health insurance is the answer. But while its membership has been rising slowly its expenses have been mounting faster, and its greatest increase in membership has been from the lower income levels. So it has had to cut back, cut out some committees, and close offices; but it has not changed its policies. Between the extreme views all sorts of conflicting voices are to be heard; and Dr. John Knowles, now President of the Rockefeller Foundation, has pointed out that if there is going to be better health in this country there has got to be considerable change in areas not primarily of medical concern-less unemployment, higher pay-rates for the unskilled, more job opportunities, better housing, less discrimination, injustice, and pollution, and improvement of our cities. These are all areas which, as he says, we have neglected in favour of high-cost technological development. (It has been calculated that treating patients with acute attacks of pulmonary oedema in the expensive intensive-care units with all the gadgets and care offers no obvious benefit to the prospects of the individual patient, but enormously increases his hospital bill.) Dr. Knowles also warns that many of our hospitals have been built and maintained by communities many of whose members have devoted to them not only financial support but an infinity of time and labour. If these voluntary institutions are handed over to the Government and to bureaucracy, how much will be gained and how much lost ? By the way, has this been calculated in

Britain ?