- Email: [email protected]
REFORM OF THE CURRICULUM
511
period of five years’ study
before a medical qualification could be obtained and aimed at methods which would make of the road to qualification a continuous period of study as little broken up by examinations as possible, thus affording the students more time and opportunity for self-
THE LANCET LONDON:
SATURDAY, AUGUST 31,
1935
REFORM OF THE CURRICULUM A CONSPECTUS of the courses in medical education which present themselves to the student at the various universities and colleges before a medical degree or diploma can be obtained is published in these columns every year ; and every year the Students’ Number of THE LANCET is on the surface much like its predecessor, as on the surface it may resemble its successor. But the progressive nature of the educational curriculum can be grasped in a moment if issues which have appeared at considerable intervals are looked at with the comparing eye, and it is likely that in the near future there will be changes to record, whose effect will be immediately perceived. But, judging by the past, such changes may take place before their results appear in any conspectus. For several years, and latterly with increasing attention, the medical curriculum has been closely examined by persons with proper equipment and authority to report upon it. In 1933 the General Medical Council adopted some wise recommendations in regard to professional examinations in response to a generally expressed opinion from many of the educational centres that the absence of due continuity and sequence in medical study caused the results of examinations to give an unfair view of the work of the candidates. In the same year the Council of the British Medical Association appointed a committee on Medical Education with the reference to consider and report upon the premedical studies ; the content of the curriculum and its arrangements ; the nature of examinations or other tests to be satisfied ; and lastly on the question whether post-graduate educational experience should be required prior to registration. This was a valuable report, contemplating no stereotyped system of medical education but seeking to raise the scientific status and educational equipment of entrants to the profession. The course designed was coordinated so as to avoid separate blocks of study, and a feature of the scheme was the insistence on a period of practical work after the main part of the final examination had been passed, before full licence to practise was granted. There was no suggestion for lengthening the curriculum.1 Next, in the spring of this year there appeared the report, the result of a joint conference between representatives of the universities of London; Oxford, and Cambridge, of the English Royal Colleges, and of the Society of Apothecaries, and in many directions the same conclusions were arrived at. The conference recommended no changea which would prolong the present minimum
The conference was impressed by proportion of failures in examinations in anatomy and physiology, but it looked to alterations in modes of teaching rather than to any lowering of the standard to mitigate this trouble. In respect of post-graduate clinical experience the conference held that a medical student after passing the final examination should spend at least six months as a resident medical officer in an approved hospital before entering upon private practice, and thought that in the near future a sufficient number of posts for the purpose would be available.2 Thirdly, in June of this year there appeared the report of the Special Committee of the General Medical Council on the revision of the medical curriculum. This was an admirably clear analysis of the existing course, agreeing with the main recommendations which had already been expressed not only in the two reports alluded to above, but, and with reiteration, in the columns of the British M edical Journal and The Lancet. The document confirmed the accuracy of much of the criticism, but included the cheering expression that by comparison with the standards of qualification prevailing in other countries the British system was good, while its development could be best advanced by reshaping it. Admitting that the General Medical Council has no power to make any requirements subsequent to the passing of qualifying examinations, the report of the Council registered the opinion that there were no grounds for3 lengthening the present period of the curriculum. All three reports are the outcome of a general impression, to which frequent voice has been given, that the curriculm requires reshaping, as is allowed in the report of the G.M.C. The student is compelled to acquire for examination purposes matter that is of little practical service to him-while we allow that all knowledge has value ; the thread of continuity is not sufficiently maintained between the preclinical and clinical instruction; the multiplicity of examinations consequently bears hardly upon the student, while as the standard of preliminary education, speaking generally, is not high, for many students the tests become unduly difficult. The three reports have appeared in substance in the medical press so that there is education. the high
now a
perfect opportunity of understanding
supervision, respects always the autonomy of the qualifying bodies. It would seem that it is at the beginning and at the end of the course that the real changes may be expected, though action must be influenced by the necessity for obtaining the 2
Brit. Med. Jour., Suppt., 1934, i., 192.
the
experts think of it. The issue remainswiththeG.M.C., the standardising authority, which, though it has the responsibility of control and
situation and what
THE LANCET, 1935, i., 1161, and 1185-88. 3 Ibid., 1935, i., 1393, and 1403-07.
512 consent of the different centres concerned ; and this may be a delicate matter when the standard of preliminary education is at issue. Registration of medical students is not mentioned in any of the Medical Acts and we understand can only be enforced by the G.M.C. if Parliamentary power or general consent of the qualifying bodies is obtained ; yet for many reasons registration should be made compulsory. At the end of the curriculum the student having passed the necessary tests for admission to the Register should be given more opportunity to acquire practical knowledge. This common
is stated or implied in all the reports but there is no recommendation dealing expressly with the matter which is common to them all. As a corollary we publish this week the results of a limited investigation into the material prospects of certain newly qualified persons. The wish is to give a picture of how a group of entrants belonging to an early period of qualification have been able to use their training, as now given, to make good in the world.. The results of the investigation thus have a pertinent bearing on any reforms in the curriculum now contemplated.
SPECIAL ARTICLES THE PRESENT-DAY OPENINGS OF MEDICAL PRACTICE "Good heavens, gentlemen, what is to become of " was Mr. Abernethy’s remark a hundred you all years ago to the students of St. Bartholomew’s Hospital on the first day of a new session. And last month in his presidential address to the national health insurance section at the Royal Sanitary Institute health congress at Bournemouth, Mr. F. J. Webb pointed out the difficulties facing the presentday graduate in medicine. Competition, he said, was being steadily increased from two sourcesnamely, the overcrowding of the profession by the large number of students annually qualifying, and, secondly, the encroachment of the public health services upon the territory of the family doctor through municipal hospitals, infant welfare centres, The latter influence, and tuberculosis clinics. however hardly it may bear upon the general practitioner, does not, of course, necessarily reduce the graduate’s prospects of employment ; it may merely1 shift its centre of gravity. In his promoter’s address to Edinburgh medical graduates, delivered about the same time, Prof. R. W. Johnstone also expressed some anxiety about the increasing number of medical students and the greater number of graduates likely to come upon the Register in the next few years. Our export trade, he reminded his hearers, is not what it was ; the Dominions are producing doctors of their own in increasing numbers (" not Scottish doctors, it is true, but still doctors "). But he was confident that the so-called law of supply and demand would rectify matters, although too keen competition might introduce into professional life a commercial spirit destructive of its best traditions. The first five years of practice would almost certainly be lean years financially ; but, as his old chief used to say to him, there is nothing makes a man work like an empty stomach. Prof. Johnstone pointed his remarks by giving an account of an inquiry he had made into the careers of Edinburgh graduates who had been at least 25 years in practice. His information was derived largely from the Medical Directory. Of 1445 men and women whose record he analysed he regarded 3 per cent. as having achieved distinguished success, 31 per cent. considerable success, and 55 per cent. a fair degree of success-refusing however to give away the basis of his classification. Of these 1445 men and women about 80 per cent. went into general practice, 13 per cent. into the regular imperial services (Army two-thirds), and just over 6 per cent. became 1 See THE LANCET,
July 27th, 1935, p. 215.
whole-time medical
officers (62 M.O.H.’s, 30 asylum superintendents). The proportion taking higher degrees since graduation were in percentages :M.D., 30 ; one or more of the higher diplomas, 26 ; fellowships of the royal colleges, 16. Of the 100 women 60 had married. With such problems as these in mind it appeared to the Editor of THE LANCET that it would be of considerable value and interest to prospective candi. dates for a medical degree, if a special inquiry were made into the experience of a large sample of medical men and women who had graduated in a more recent year. For this purpose the graduates of 1930 were selected, and approached by means of a questionnaire. METHOD OF INVESTIGATION
In the year 1930, 1490 men and women registered their names with the General Medical Council. Of this total it was found possible to identify 1477 in the Medical Register of 1935, and to each of these the questionnaire here reproduced (the entries, of course, are imaginary) was directed. This questionnaire was sent out in the middle of June and the replies .received up to the middle of August have been included in the analysis discussed in the succeeding sections. It must be noted that of these 1477 graduates there were 1163 resident (according to their registered addresses) in Great Britain and the Irish Free State, and 314 who had migrated (or returned) to other parts of the world142 to India, 39 to South Africa, 31 to Australia and New Zealand, 15 to Canada, and the remainder in twos or threes to countries spread throughout the world. The time interval which had to be allowed between dispatch of the questionnaire and the analysis of the replies was insufficient to allow all the possible replies to be received from abroad,
although actually nearly or
colonial stamps
were
100
replies bearing foreign
received.
THE RESPONSE
The total number of replies (excluding 39 returned "present address unknown") amounted to 651, or 44 per cent. of the maximum. A response of nearly one-half must be regarded with satisfaction, since many inquiries by questionnaire fail to secure replies from more than 10 per cent. of those addressed. This relatively large response is without doubt due to two factors-namely, the exclusion of any clue to the identity of the correspondent and the careful simplification of the queries included on the form. Whether the 44 per cent. of the graduates who replied may fairly be regarded as a representative sample of the total addressed is an important question, but one to which it is impossible to give a certain answer. There might well be a tendency for those who have been successful in their profession to be more eager to
period of five years’ study
before a medical qualification could be obtained and aimed at methods which would make of the road to qualification a continuous period of study as little broken up by examinations as possible, thus affording the students more time and opportunity for self-
THE LANCET LONDON:
SATURDAY, AUGUST 31,
1935
REFORM OF THE CURRICULUM A CONSPECTUS of the courses in medical education which present themselves to the student at the various universities and colleges before a medical degree or diploma can be obtained is published in these columns every year ; and every year the Students’ Number of THE LANCET is on the surface much like its predecessor, as on the surface it may resemble its successor. But the progressive nature of the educational curriculum can be grasped in a moment if issues which have appeared at considerable intervals are looked at with the comparing eye, and it is likely that in the near future there will be changes to record, whose effect will be immediately perceived. But, judging by the past, such changes may take place before their results appear in any conspectus. For several years, and latterly with increasing attention, the medical curriculum has been closely examined by persons with proper equipment and authority to report upon it. In 1933 the General Medical Council adopted some wise recommendations in regard to professional examinations in response to a generally expressed opinion from many of the educational centres that the absence of due continuity and sequence in medical study caused the results of examinations to give an unfair view of the work of the candidates. In the same year the Council of the British Medical Association appointed a committee on Medical Education with the reference to consider and report upon the premedical studies ; the content of the curriculum and its arrangements ; the nature of examinations or other tests to be satisfied ; and lastly on the question whether post-graduate educational experience should be required prior to registration. This was a valuable report, contemplating no stereotyped system of medical education but seeking to raise the scientific status and educational equipment of entrants to the profession. The course designed was coordinated so as to avoid separate blocks of study, and a feature of the scheme was the insistence on a period of practical work after the main part of the final examination had been passed, before full licence to practise was granted. There was no suggestion for lengthening the curriculum.1 Next, in the spring of this year there appeared the report, the result of a joint conference between representatives of the universities of London; Oxford, and Cambridge, of the English Royal Colleges, and of the Society of Apothecaries, and in many directions the same conclusions were arrived at. The conference recommended no changea which would prolong the present minimum
The conference was impressed by proportion of failures in examinations in anatomy and physiology, but it looked to alterations in modes of teaching rather than to any lowering of the standard to mitigate this trouble. In respect of post-graduate clinical experience the conference held that a medical student after passing the final examination should spend at least six months as a resident medical officer in an approved hospital before entering upon private practice, and thought that in the near future a sufficient number of posts for the purpose would be available.2 Thirdly, in June of this year there appeared the report of the Special Committee of the General Medical Council on the revision of the medical curriculum. This was an admirably clear analysis of the existing course, agreeing with the main recommendations which had already been expressed not only in the two reports alluded to above, but, and with reiteration, in the columns of the British M edical Journal and The Lancet. The document confirmed the accuracy of much of the criticism, but included the cheering expression that by comparison with the standards of qualification prevailing in other countries the British system was good, while its development could be best advanced by reshaping it. Admitting that the General Medical Council has no power to make any requirements subsequent to the passing of qualifying examinations, the report of the Council registered the opinion that there were no grounds for3 lengthening the present period of the curriculum. All three reports are the outcome of a general impression, to which frequent voice has been given, that the curriculm requires reshaping, as is allowed in the report of the G.M.C. The student is compelled to acquire for examination purposes matter that is of little practical service to him-while we allow that all knowledge has value ; the thread of continuity is not sufficiently maintained between the preclinical and clinical instruction; the multiplicity of examinations consequently bears hardly upon the student, while as the standard of preliminary education, speaking generally, is not high, for many students the tests become unduly difficult. The three reports have appeared in substance in the medical press so that there is education. the high
now a
perfect opportunity of understanding
supervision, respects always the autonomy of the qualifying bodies. It would seem that it is at the beginning and at the end of the course that the real changes may be expected, though action must be influenced by the necessity for obtaining the 2
Brit. Med. Jour., Suppt., 1934, i., 192.
the
experts think of it. The issue remainswiththeG.M.C., the standardising authority, which, though it has the responsibility of control and
situation and what
THE LANCET, 1935, i., 1161, and 1185-88. 3 Ibid., 1935, i., 1393, and 1403-07.
512 consent of the different centres concerned ; and this may be a delicate matter when the standard of preliminary education is at issue. Registration of medical students is not mentioned in any of the Medical Acts and we understand can only be enforced by the G.M.C. if Parliamentary power or general consent of the qualifying bodies is obtained ; yet for many reasons registration should be made compulsory. At the end of the curriculum the student having passed the necessary tests for admission to the Register should be given more opportunity to acquire practical knowledge. This common
is stated or implied in all the reports but there is no recommendation dealing expressly with the matter which is common to them all. As a corollary we publish this week the results of a limited investigation into the material prospects of certain newly qualified persons. The wish is to give a picture of how a group of entrants belonging to an early period of qualification have been able to use their training, as now given, to make good in the world.. The results of the investigation thus have a pertinent bearing on any reforms in the curriculum now contemplated.
SPECIAL ARTICLES THE PRESENT-DAY OPENINGS OF MEDICAL PRACTICE "Good heavens, gentlemen, what is to become of " was Mr. Abernethy’s remark a hundred you all years ago to the students of St. Bartholomew’s Hospital on the first day of a new session. And last month in his presidential address to the national health insurance section at the Royal Sanitary Institute health congress at Bournemouth, Mr. F. J. Webb pointed out the difficulties facing the presentday graduate in medicine. Competition, he said, was being steadily increased from two sourcesnamely, the overcrowding of the profession by the large number of students annually qualifying, and, secondly, the encroachment of the public health services upon the territory of the family doctor through municipal hospitals, infant welfare centres, The latter influence, and tuberculosis clinics. however hardly it may bear upon the general practitioner, does not, of course, necessarily reduce the graduate’s prospects of employment ; it may merely1 shift its centre of gravity. In his promoter’s address to Edinburgh medical graduates, delivered about the same time, Prof. R. W. Johnstone also expressed some anxiety about the increasing number of medical students and the greater number of graduates likely to come upon the Register in the next few years. Our export trade, he reminded his hearers, is not what it was ; the Dominions are producing doctors of their own in increasing numbers (" not Scottish doctors, it is true, but still doctors "). But he was confident that the so-called law of supply and demand would rectify matters, although too keen competition might introduce into professional life a commercial spirit destructive of its best traditions. The first five years of practice would almost certainly be lean years financially ; but, as his old chief used to say to him, there is nothing makes a man work like an empty stomach. Prof. Johnstone pointed his remarks by giving an account of an inquiry he had made into the careers of Edinburgh graduates who had been at least 25 years in practice. His information was derived largely from the Medical Directory. Of 1445 men and women whose record he analysed he regarded 3 per cent. as having achieved distinguished success, 31 per cent. considerable success, and 55 per cent. a fair degree of success-refusing however to give away the basis of his classification. Of these 1445 men and women about 80 per cent. went into general practice, 13 per cent. into the regular imperial services (Army two-thirds), and just over 6 per cent. became 1 See THE LANCET,
July 27th, 1935, p. 215.
whole-time medical
officers (62 M.O.H.’s, 30 asylum superintendents). The proportion taking higher degrees since graduation were in percentages :M.D., 30 ; one or more of the higher diplomas, 26 ; fellowships of the royal colleges, 16. Of the 100 women 60 had married. With such problems as these in mind it appeared to the Editor of THE LANCET that it would be of considerable value and interest to prospective candi. dates for a medical degree, if a special inquiry were made into the experience of a large sample of medical men and women who had graduated in a more recent year. For this purpose the graduates of 1930 were selected, and approached by means of a questionnaire. METHOD OF INVESTIGATION
In the year 1930, 1490 men and women registered their names with the General Medical Council. Of this total it was found possible to identify 1477 in the Medical Register of 1935, and to each of these the questionnaire here reproduced (the entries, of course, are imaginary) was directed. This questionnaire was sent out in the middle of June and the replies .received up to the middle of August have been included in the analysis discussed in the succeeding sections. It must be noted that of these 1477 graduates there were 1163 resident (according to their registered addresses) in Great Britain and the Irish Free State, and 314 who had migrated (or returned) to other parts of the world142 to India, 39 to South Africa, 31 to Australia and New Zealand, 15 to Canada, and the remainder in twos or threes to countries spread throughout the world. The time interval which had to be allowed between dispatch of the questionnaire and the analysis of the replies was insufficient to allow all the possible replies to be received from abroad,
although actually nearly or
colonial stamps
were
100
replies bearing foreign
received.
THE RESPONSE
The total number of replies (excluding 39 returned "present address unknown") amounted to 651, or 44 per cent. of the maximum. A response of nearly one-half must be regarded with satisfaction, since many inquiries by questionnaire fail to secure replies from more than 10 per cent. of those addressed. This relatively large response is without doubt due to two factors-namely, the exclusion of any clue to the identity of the correspondent and the careful simplification of the queries included on the form. Whether the 44 per cent. of the graduates who replied may fairly be regarded as a representative sample of the total addressed is an important question, but one to which it is impossible to give a certain answer. There might well be a tendency for those who have been successful in their profession to be more eager to