- Email: [email protected]
PREREGISTRATION YEAR
417
patients and their families. A number of medical schools have- recently made considerable progress in this direction by introducing practical instruction in the work of the family doctor 2 ; but perhaps it is still not fully recognised that it is mainly in the homes of the people that the student appreciates the great possibilities-and the enormous difficultiesof prevention. In the relationship of the family doctor with his patient he watches the ideal of J. A. RYLE brought to life : clinical medicine applied to man in his environment. As a clinician the general practitioner undertakes many teaching functions in his daily work, and a period of apprenticeship which brings the
taught
to
student into direct touch with the home is the finest introduction to the practice of preventive and social medicine.
Annotations CAREERS IN MEDICINE -IIEDICAL students are often vague about their plans for the future. At times exam-worn and lecture-weary, at times rebellious against too much organisation of their affairs, they have little opportunity or even inclination to sit down and think about those remote days that lie beyond the final examination. A few decide in favour of one specialty or another (including general practice) at an early stage, but the majority adopt the wise course of waiting and seeing ; for each successive item of the curriculum may hold promise of an attractive career. It may be midwifery above all else one month, and neurosurgery the next. Apart from a general inclination towards medicine or surgery, the clinical student may emerge from the hurly-burly with little notion of what he wants to do. In the wards, outpatient departments, and elsewhere in the hospital he can learn something of the day-to-day work of each member of the in assimilating facts staff, but he is often too
already
PREREGISTRATION YEAR THE belief that our young doctors are being thrust into responsibility too soon after qualification was accepted in the Medical Act passed by Parliament in 1950. The educational clauses of the Act provide for a compulsory period of house-appointments after qualification ; and the period has now been fixed as 12 months and the appointed day as Jan. 1, 1953.:’2 From then on all doctors, newly qualified in the United Kingdom, must " spend a year in approved " hospital jobs before they are fully registered by the General Medical Council. The year is to be divided into 6 months’ medicine and 6 months’ surgery, or, as an alternative to either of these, The approval of hospitals and 6 months’ midwifery. institutions for this purpose has been the responsibility of the universities and the bodies granting qualifying diplomas (" the licensing bodies "). They have now advised the G.M.C. of their selection, and the council is preparing a list (to be published shortly) of the hospitals approved and the appointments available in them. The new graduate who has no suitable job in mind can choose from the list and apply for an advertised house-appointment wherever he wishes. As soon as he has been accepted, he will be granted provisional registration. At the end of the year the licensing body will give him a certificate to say that he has been employed in the prescribed way and that his work has been satisfactory ; and he will then be entitled to full registration. Though there is no statutory obligation for deans to find jobs for their students, it is clear that they are In discussion with the anxious to do all they can. licensing bodies and the hospital authorities, they have been examining the scheme and preparing to help graduates to find the right jobs without delay. It is important that there should be as short a gap as possible between qualification and startingwork ; for the new doctor will not be able to fill in any odd weeks with as he has locum work in hospital or general done in the past. The steps that will probably be taken include the acceptance of applications from students who have not yet sat their final examination (a practice already followed in some teaching hospitals) ; the speeding-up of appointments by the formation of regional bureaux to handle all applications ; and the adjustment of time-tables to reduce the waiting period. The preparatory work has also included estimation of the balance between posts available and numbers qualifying. It
1952, i, 495.
1. Careers in Medicine. Edited by P. O. WILLIAMS, M.R.C.P. London: Hodder & Stoughton. 1952. Pp. 265. 15s. 2. See Lancet, July 26, 1952, p. 176.
occupied
give the matter much thought or to retain any lasting impressions. Moreover his ideas of a career in this specialty or that are often based on memories of outstanding teachers or brilliant clinicians, and he may not realise what days of comparative drudgery have preceded His knowledge of general such spectacular eminence. be small and his practice may experience less-a serious deficiency that is now being put right in many medical to
schools.
He is well advised, then, to do
no more
than
speculate. The best time for him to make definite plans is probably the year after his qualification-the preregistration year as it will shortly be. As he goes through his first houseappointments, he can examine more closely the impressions he has formed and turn them into personal judgments. But he cannot cover much ground in a year or so, and three or four house-appointments may leave him still undecided. Some may say that he has had ample time for reflection, and that he must be an uncommonly indecisiveyoung man ; but he should not be criticised for hesitating at this vital point. If he inclines to hospital work, the keen competition for junior appointments gives him good reason to delay no longer ; and should he have military service to do, it would be an advantage to acquire some experience of a specialty before joining the Forces, if he is to have a chance of continuing this work during his service. At all events, he may be pressed into
a hasty move, and, if he sees no opening in general medicine or surgery, he may care to inquire further about other branches of medicine. He may turn to his teachers for advice, or talk to others engaged in the work he is considering ; or he may (from now on) look at a
2. Ibid,
book which has just been published1 and which gives him the sort of practical information he needs. Dr. Peter W’illiams has made a collection of essays, signed by names of undoubted authority and dealing with every kind of medical work. Nothing has been overlooked-from general practice (described by Dr. G. 0. Barber) through all the divisions of medicine and surgery to the less-frequented background of medical statistics (by Prof. A. Bradford Hill). There is even a short article on the medical historian by Mr. V. Zachary Cope (though he is unable to recommend this attractive occupation as a full-time career). Most contributors have probably emphasised the particular satisfactions that they themselves find in their work ; but the snags have certainly not been neglected. As well as these personal assess’ ments the formal facts of each career are given in detail, and there are appendices summarising the courses and regulations for the various postgraduate diplomas, and giving the scales of pay for consultants and specialists in training under the National Health Service. This book answers the very questions that our perplexed young doctor is asking. He (and anyone else looking for information and guidance about a career in medicine) can turn confidently to it for help.
practice
418 that there will be enough jobs to go round ; for, we do not yet know what proportion of hospitals will be approved, the majority of newly qualified men and women already do at least one or two house-jobs as It may indeed prove hard to fill a matter of course. those posts which, for one reason or another, are considered unsuitable. Here a more experienced and fully registered man could be appointed with advantage. More people spending more time in resident hospital work will do much to ease the situation where housesurgeons and house-physicians are at present hard to get. that when similar legislation Moreover, it is comes into force in Eire on Jan. 1, a number of new Irish graduates will be unable to find suitable jobs at home.3 Many of them will no doubt come to this country to obtain the experience required for full registration.
seems
though
expected
4
PRECLINICAL SUBJECTS: A WIDER APPROACH MANY deans believe that the education of a boy should be as wide and general as possible before he enters a medical school. This view has been accepted at most universities and by the headmasters of most schools, but circumstances have combined to hinder its practical application. The parents of the prospective medical student feel that if he studies science while he is at school, he will gain an advantage which may mean the saving of a year in the medical curriculum ; the students themselves feel that they must choose to be on the science side of the school if they are eventually to do medicine ; and the masters believe that a place is more likely to be given to a student who has shown ability in scientific subjects. Scholarships and county and other awards often encourage this move towards science at the earliest possible moment. The result has been that a large number of applicants for places in the medical schools have taken chemistry, physics, and biology in their matriculation or examination ; they have specialised in these subjects from then on, taking them in their higher school certificate to obtain exemption from the 1st M.B. Thus from the age of thirteen or so their interest and time have been largely devoted to chemistry, physics, and biology. Many students are keen on science and may develop into fir,t-class scientists, but this alone is an inadequate recommendation. There is, of course, a place for pure scientists in medicine, but the general practitioner needs a far wider interest in men and affairs than is usually found in the pure scientist. The student of medicine will he concerned with science for the rest of his life, and if ht- lias failed to acquire a knowledge and liking for other aspects of learning he will have suffered an irreparable loss. Many of the regulations for admission to medical schools and for the 1st M.B. examination positively discourage a broader outlook, and in an attempt to improve matters the University of London has devised a new plan for preclinical education. The new regulations aim at two things : to make it impossible to gain exemption from the 1st M.B. examination at school : and to ensure a fuller integration of the preclinical courses. The regulations abolish the 1st and 2nd M.B. examinations and replace them by a preclinical examination. Thi-- preclinical examination will be divided into two parts—the urst to be taken one year after entering the medical school and the second eighteen mouths later. The original scheme was designed to include biology with elementary human anatomy, physics with elementary physiology, and chemistry with organic and elementary biochemistry :but the regulations published so far do not go into any great detail. They only say : The papers will include questions- on elementary anatomy and physiology." and, for part 11. " The papers will include questions on the application of biology and medical science." On these points at least. it’ seeing that no radical change will be involved. Rut
matriculation-exemption
"
physics to
3.
Ibid, 1952, i, 882.
manv of the London medical schools have decided to their preclinical programmes in the light of the new regulations, and in the Students’ Guide on other pages of this issue several deans refer to what is being done in this way. It will still be possible to enter some of the London medical schools under the old regulation... and therefore to gain exemption from the 1st M.B. and to pass straight on to anatomy and physiology with the saving of one year. At those schools which have adopted the new regulations, the passing of an examination which would formerly have given exemption from the 1st M.B. examination will not, of course, be a bar to entry, but it will save no time. The second. part of the preclinical examination differs from the old 2nd M.B. examination in certain important ways. Firstly, instead of a single examination in physiology and biochemistry, this examination has been divided into two parts ; and secondly, the pharmacology examination has been allotted extra time, and unless the student attains a certain standard in pharmacology he is not referred in this subject but failed in the whole examination. In biochemistry too, a candidate may fail the whole examination or be referred at the discretion of the examiners. A full estimate of the new London regulations must be deferred until we have seen them in operation ; but it does seem, on paper at least, that the preclinical student may have his hands even fuller than before. Certainly his task is none the easier, as many would like to see for nothing has been omitted from the syllabus. On the other hand, he will enter the medical school after an education from which one of the main incentives to early specialisation has been removed. He will be encouraged to give more time to history, literature, and languages while at school-a diversion that will undoubtedly make him a happier and better doctor in the end. But less restriction to his school work may bring a more immediate benefit ; he may turn from his excursion into other subjects with a facility for grappling with the mass of scientific knowledge that will soon press upon him.
modify
it,
greater
STUDENT SELECTION THE number of students in our universities has just about doubled since before the war, and there seems little reason to expect a falling off in the next few years. The question of how best to choose from the tremendous number who apply for admission is as pressing as ever. and indeed Mr. F. W. Warburton, PH.D., who has just written a useful survey of the subject,1 points out that what may have been regarded at first as a temporary post-war problem must now be considered a permanent responsibility. From his examination of existing method!of selection Warburton concludes that much more research is needed to measure the -efficiency of these methods. Higher school certificate results, headmaster ? reports, the information given in the application form. and the personal interview are commonly taken a8 reliable guides to the quality of an but he would like to see more evidence of their value as judged by the subsequent performance of the undergraduate. He also suggests that " new methods such as mental tests and group interviews should be tried out on borderline candidates." On another page of this issue Dr. J. T. Aitken and Dr. M. L. Johnson describe their experiences in choosing medical students at University College, London. They found that an entrance examination (consisting cf intelligence tests and an essay) gave little indication of the performance of students in later examinations. They then decided to givethree interviews to each candidate who survived the initial pruning (a difficult business in itself) :: two individual interviews to assess intelligent and personality respectively; and a group interview.
applicant ;
1. The Selection of University Students. 1952. Manchester University Press.
By F. W. WARBURTON Pp. 46. 4s. 6d.
patients and their families. A number of medical schools have- recently made considerable progress in this direction by introducing practical instruction in the work of the family doctor 2 ; but perhaps it is still not fully recognised that it is mainly in the homes of the people that the student appreciates the great possibilities-and the enormous difficultiesof prevention. In the relationship of the family doctor with his patient he watches the ideal of J. A. RYLE brought to life : clinical medicine applied to man in his environment. As a clinician the general practitioner undertakes many teaching functions in his daily work, and a period of apprenticeship which brings the
taught
to
student into direct touch with the home is the finest introduction to the practice of preventive and social medicine.
Annotations CAREERS IN MEDICINE -IIEDICAL students are often vague about their plans for the future. At times exam-worn and lecture-weary, at times rebellious against too much organisation of their affairs, they have little opportunity or even inclination to sit down and think about those remote days that lie beyond the final examination. A few decide in favour of one specialty or another (including general practice) at an early stage, but the majority adopt the wise course of waiting and seeing ; for each successive item of the curriculum may hold promise of an attractive career. It may be midwifery above all else one month, and neurosurgery the next. Apart from a general inclination towards medicine or surgery, the clinical student may emerge from the hurly-burly with little notion of what he wants to do. In the wards, outpatient departments, and elsewhere in the hospital he can learn something of the day-to-day work of each member of the in assimilating facts staff, but he is often too
already
PREREGISTRATION YEAR THE belief that our young doctors are being thrust into responsibility too soon after qualification was accepted in the Medical Act passed by Parliament in 1950. The educational clauses of the Act provide for a compulsory period of house-appointments after qualification ; and the period has now been fixed as 12 months and the appointed day as Jan. 1, 1953.:’2 From then on all doctors, newly qualified in the United Kingdom, must " spend a year in approved " hospital jobs before they are fully registered by the General Medical Council. The year is to be divided into 6 months’ medicine and 6 months’ surgery, or, as an alternative to either of these, The approval of hospitals and 6 months’ midwifery. institutions for this purpose has been the responsibility of the universities and the bodies granting qualifying diplomas (" the licensing bodies "). They have now advised the G.M.C. of their selection, and the council is preparing a list (to be published shortly) of the hospitals approved and the appointments available in them. The new graduate who has no suitable job in mind can choose from the list and apply for an advertised house-appointment wherever he wishes. As soon as he has been accepted, he will be granted provisional registration. At the end of the year the licensing body will give him a certificate to say that he has been employed in the prescribed way and that his work has been satisfactory ; and he will then be entitled to full registration. Though there is no statutory obligation for deans to find jobs for their students, it is clear that they are In discussion with the anxious to do all they can. licensing bodies and the hospital authorities, they have been examining the scheme and preparing to help graduates to find the right jobs without delay. It is important that there should be as short a gap as possible between qualification and startingwork ; for the new doctor will not be able to fill in any odd weeks with as he has locum work in hospital or general done in the past. The steps that will probably be taken include the acceptance of applications from students who have not yet sat their final examination (a practice already followed in some teaching hospitals) ; the speeding-up of appointments by the formation of regional bureaux to handle all applications ; and the adjustment of time-tables to reduce the waiting period. The preparatory work has also included estimation of the balance between posts available and numbers qualifying. It
1952, i, 495.
1. Careers in Medicine. Edited by P. O. WILLIAMS, M.R.C.P. London: Hodder & Stoughton. 1952. Pp. 265. 15s. 2. See Lancet, July 26, 1952, p. 176.
occupied
give the matter much thought or to retain any lasting impressions. Moreover his ideas of a career in this specialty or that are often based on memories of outstanding teachers or brilliant clinicians, and he may not realise what days of comparative drudgery have preceded His knowledge of general such spectacular eminence. be small and his practice may experience less-a serious deficiency that is now being put right in many medical to
schools.
He is well advised, then, to do
no more
than
speculate. The best time for him to make definite plans is probably the year after his qualification-the preregistration year as it will shortly be. As he goes through his first houseappointments, he can examine more closely the impressions he has formed and turn them into personal judgments. But he cannot cover much ground in a year or so, and three or four house-appointments may leave him still undecided. Some may say that he has had ample time for reflection, and that he must be an uncommonly indecisiveyoung man ; but he should not be criticised for hesitating at this vital point. If he inclines to hospital work, the keen competition for junior appointments gives him good reason to delay no longer ; and should he have military service to do, it would be an advantage to acquire some experience of a specialty before joining the Forces, if he is to have a chance of continuing this work during his service. At all events, he may be pressed into
a hasty move, and, if he sees no opening in general medicine or surgery, he may care to inquire further about other branches of medicine. He may turn to his teachers for advice, or talk to others engaged in the work he is considering ; or he may (from now on) look at a
2. Ibid,
book which has just been published1 and which gives him the sort of practical information he needs. Dr. Peter W’illiams has made a collection of essays, signed by names of undoubted authority and dealing with every kind of medical work. Nothing has been overlooked-from general practice (described by Dr. G. 0. Barber) through all the divisions of medicine and surgery to the less-frequented background of medical statistics (by Prof. A. Bradford Hill). There is even a short article on the medical historian by Mr. V. Zachary Cope (though he is unable to recommend this attractive occupation as a full-time career). Most contributors have probably emphasised the particular satisfactions that they themselves find in their work ; but the snags have certainly not been neglected. As well as these personal assess’ ments the formal facts of each career are given in detail, and there are appendices summarising the courses and regulations for the various postgraduate diplomas, and giving the scales of pay for consultants and specialists in training under the National Health Service. This book answers the very questions that our perplexed young doctor is asking. He (and anyone else looking for information and guidance about a career in medicine) can turn confidently to it for help.
practice
418 that there will be enough jobs to go round ; for, we do not yet know what proportion of hospitals will be approved, the majority of newly qualified men and women already do at least one or two house-jobs as It may indeed prove hard to fill a matter of course. those posts which, for one reason or another, are considered unsuitable. Here a more experienced and fully registered man could be appointed with advantage. More people spending more time in resident hospital work will do much to ease the situation where housesurgeons and house-physicians are at present hard to get. that when similar legislation Moreover, it is comes into force in Eire on Jan. 1, a number of new Irish graduates will be unable to find suitable jobs at home.3 Many of them will no doubt come to this country to obtain the experience required for full registration.
seems
though
expected
4
PRECLINICAL SUBJECTS: A WIDER APPROACH MANY deans believe that the education of a boy should be as wide and general as possible before he enters a medical school. This view has been accepted at most universities and by the headmasters of most schools, but circumstances have combined to hinder its practical application. The parents of the prospective medical student feel that if he studies science while he is at school, he will gain an advantage which may mean the saving of a year in the medical curriculum ; the students themselves feel that they must choose to be on the science side of the school if they are eventually to do medicine ; and the masters believe that a place is more likely to be given to a student who has shown ability in scientific subjects. Scholarships and county and other awards often encourage this move towards science at the earliest possible moment. The result has been that a large number of applicants for places in the medical schools have taken chemistry, physics, and biology in their matriculation or examination ; they have specialised in these subjects from then on, taking them in their higher school certificate to obtain exemption from the 1st M.B. Thus from the age of thirteen or so their interest and time have been largely devoted to chemistry, physics, and biology. Many students are keen on science and may develop into fir,t-class scientists, but this alone is an inadequate recommendation. There is, of course, a place for pure scientists in medicine, but the general practitioner needs a far wider interest in men and affairs than is usually found in the pure scientist. The student of medicine will he concerned with science for the rest of his life, and if ht- lias failed to acquire a knowledge and liking for other aspects of learning he will have suffered an irreparable loss. Many of the regulations for admission to medical schools and for the 1st M.B. examination positively discourage a broader outlook, and in an attempt to improve matters the University of London has devised a new plan for preclinical education. The new regulations aim at two things : to make it impossible to gain exemption from the 1st M.B. examination at school : and to ensure a fuller integration of the preclinical courses. The regulations abolish the 1st and 2nd M.B. examinations and replace them by a preclinical examination. Thi-- preclinical examination will be divided into two parts—the urst to be taken one year after entering the medical school and the second eighteen mouths later. The original scheme was designed to include biology with elementary human anatomy, physics with elementary physiology, and chemistry with organic and elementary biochemistry :but the regulations published so far do not go into any great detail. They only say : The papers will include questions- on elementary anatomy and physiology." and, for part 11. " The papers will include questions on the application of biology and medical science." On these points at least. it’ seeing that no radical change will be involved. Rut
matriculation-exemption
"
physics to
3.
Ibid, 1952, i, 882.
manv of the London medical schools have decided to their preclinical programmes in the light of the new regulations, and in the Students’ Guide on other pages of this issue several deans refer to what is being done in this way. It will still be possible to enter some of the London medical schools under the old regulation... and therefore to gain exemption from the 1st M.B. and to pass straight on to anatomy and physiology with the saving of one year. At those schools which have adopted the new regulations, the passing of an examination which would formerly have given exemption from the 1st M.B. examination will not, of course, be a bar to entry, but it will save no time. The second. part of the preclinical examination differs from the old 2nd M.B. examination in certain important ways. Firstly, instead of a single examination in physiology and biochemistry, this examination has been divided into two parts ; and secondly, the pharmacology examination has been allotted extra time, and unless the student attains a certain standard in pharmacology he is not referred in this subject but failed in the whole examination. In biochemistry too, a candidate may fail the whole examination or be referred at the discretion of the examiners. A full estimate of the new London regulations must be deferred until we have seen them in operation ; but it does seem, on paper at least, that the preclinical student may have his hands even fuller than before. Certainly his task is none the easier, as many would like to see for nothing has been omitted from the syllabus. On the other hand, he will enter the medical school after an education from which one of the main incentives to early specialisation has been removed. He will be encouraged to give more time to history, literature, and languages while at school-a diversion that will undoubtedly make him a happier and better doctor in the end. But less restriction to his school work may bring a more immediate benefit ; he may turn from his excursion into other subjects with a facility for grappling with the mass of scientific knowledge that will soon press upon him.
modify
it,
greater
STUDENT SELECTION THE number of students in our universities has just about doubled since before the war, and there seems little reason to expect a falling off in the next few years. The question of how best to choose from the tremendous number who apply for admission is as pressing as ever. and indeed Mr. F. W. Warburton, PH.D., who has just written a useful survey of the subject,1 points out that what may have been regarded at first as a temporary post-war problem must now be considered a permanent responsibility. From his examination of existing method!of selection Warburton concludes that much more research is needed to measure the -efficiency of these methods. Higher school certificate results, headmaster ? reports, the information given in the application form. and the personal interview are commonly taken a8 reliable guides to the quality of an but he would like to see more evidence of their value as judged by the subsequent performance of the undergraduate. He also suggests that " new methods such as mental tests and group interviews should be tried out on borderline candidates." On another page of this issue Dr. J. T. Aitken and Dr. M. L. Johnson describe their experiences in choosing medical students at University College, London. They found that an entrance examination (consisting cf intelligence tests and an essay) gave little indication of the performance of students in later examinations. They then decided to givethree interviews to each candidate who survived the initial pruning (a difficult business in itself) :: two individual interviews to assess intelligent and personality respectively; and a group interview.
applicant ;
1. The Selection of University Students. 1952. Manchester University Press.
By F. W. WARBURTON Pp. 46. 4s. 6d.