- Email: [email protected]
TEACHER TRAINING FOR MEDICAL SCHOOLS IN AFRICA
570 The third course is concerned with the varieties of " simulated experience ", widely used by general-practitioner teachers and others in the United Kingdom, North America, and Australia, for some years. The fourth course deals with " micro " teaching, the learning of single behaviours identified as deficient in course members by an analysis of the prerecorded audiotapes of real-life surgery consultations. A broader-based introductory course is also available. The importance of the sharing with students of defined learning objectives is emphasised throughout. Some 400 doctors have attended these courses, including some faithful Dutch with a few Australians, New Zealanders, Canadians, and Americans. We have yet to have as a course member a doctor who is not a general practitioner. The present extended Nuffield course for teachers, conducted by the Royal College of General Practitioners, is attempting to produce apostles who will spread the practical gospel in their own regions.
The book, The Future General Practitioner, created for the Royal College of General Practitioners, has been of value in that it provides a job definition of general practice, with derived educational goals, and a framework for thought, discussion, and experiment which seems to be required elsewhere in medicine. For we, in general practice, are assisting to create general practitioners to practise in Britain within the National Health Service. This is the ethos of our training programmes. The Royal College of General Practitioners has been and is a source of ideas and inspiration, but the endpoint of training is to produce competent N.H.S. principals and not merely to satisfy
College requirements. A
REFERENCES
Byrne, P. S., Long, B. E. Learning to Care—Person to Person. London, 1973. 2. Freeman, J., Byrne, P. S. The Assessment of Postgraduate Train1.
ing in General Practice. Society for Research into Higher Education, London, 1973.
TEACHER TRAINING FOR MEDICAL SCHOOLS IN AFRICA*
J.-J. GUILBERT Chief Medical Officer, Educational Planning, World Health Organisation, Geneva
Though the problem
areas of medical education in Africa have been defined and steps have been taken to attack them, notably by preparing teaching staff as agents of change and by opening teacher-training centres, progress cannot be otherwise than slow.
Sum ary
QUIET REVOLUTION
The history of a book on person-to-person teaching illustrates a difficulty contained in all multidisciplinary endeavours: the question of language. We know that jargon is the term applied to the language of one discipline by members of another. The general practitioner and the educationist have each large professional vocabularies, each a form of professional shorthand by which members of that profession may the more easily communicate with one another. Those who are learning a new profession, that of teaching, must learn its language, unless of course they wish to appear as petulant amateurs bleating of jargon ". It is not necessary that they use the language on all occasions. It is necessary that professional terms be explained on many occasions. But courses and books alone do not make teachers. One may learn " about " this new profession, but one has to learn " to do ", to teach. Practical experience of teaching is required, while ready means of feedback must be open to the teacher on his own performance as well as on that of the student. To do this effectively, resources not at present available are needed. In the few places where significant research into medical education is being prosecuted and published, the staff have little time to monitor the progress of the new teachers who have only been launched, "
trained. The new regional postgraduate machinery has much to do in this direction, but it has not yet acquired either the necessary experience or the resources. Much
not
of the quiet revolution in the production of teachers in general practice is unknown even within the profession itself. A monograph2 on the assessment of postgraduate training in general practice describes methodology of a much wider application than the title might suggest. In medicine generally, in our universities as a whole, teachers are like Topsy, they just grow. In general practice, however small a beginning, there is discernible the start of the making of teachers. Who knows-we may even reach the stage where all our medical educators read, and even contribute to, the British Journal of Medical Education.
THERE is certainly no plethora of studies on the development of medical education in Africa between 1962 and 1972. Despite the modest amount written, the literature contains references to : adaptation of curricula; influence of colonialism; lack of health personnel ; outflow of personnel; need for more medical schools; need for African teachers; external aid; need for health planning and coordination of personnel; the role of the physician and educational objectives; the importance of preventive medicine; the integrated approach; active learning methods; and teacher training. Referring to the necessary changes in African medical education, authors stress the importance of preparing teachers for their new tasks. Such a change of attitude will most certainly excite active, if not violent, resistance. If our medical schools are to look to the future they must be prepared to take "
critical look at their present status " 1 "... the call for an increased supply of teachers and researchers though still distant is rapidly approaching and will surely overtake and overwhelm us unless we prepare ourselves to offset this eventuality."2 Huttonhad if changes are to be made in already indicated that medical education " it is the orientation of the faculty of medicine as a whole, rather than having this or that in the curriculum, which is important". a
*
Excerpts from
a dissertation written in partial fulfilment of requirefor the degree of Doctor of Philosophy, University of Southern California, Los Angeles.
ments
571 THE PROBLEM AREAS
The
problem
areas
that
can
be found in
policy
statements of W.H.O. are: Lack of adaptation of curricula to local conditions. "
Introduction of the health team concept Relative value of external assistance
Concerning lack of qualified health personnel, I a content analysis, used selected key words to identify significant statements indicating the Statements for that area were selected when such words as the following were found: shortage, absence, wanting, lack, needs. The W.H.O. Executive Board defined " needs " thus: "byneeds’ is meant the gap between the trained personnel available and those reasonably required now and at certain target dates in the future ".44 W.H.O. indicates that the quantitative problem is a priority for newly independent African nations: "there is therefore urgency for these countries to make provision for the training of their own personnel ... they need to4 be self-sufficient in personnel as soon as possible ".* Similar statements, year after year, seem to indicate that such a problem " remains " urgent : " the shortage of qualified personnel constitutes one of the greatest obstacles to a raising of the standard of living of African populations ". "To train men is, in the last analysis, the major problem of African nations."" The situation is getting worse rather than better owing to the popula-
problem.
growth."6
"The most important (obstacle to development) (is) the lack of qualified personnel in almost all fields and especially in that of public health."7 As can easily be forecast, it would be unreasonable to expect that within such a short period as ten years, this type of problem could be solved: " the major stumbling block in improving the level of health (remains) the extreme shortage of health
staff".8 This monotonous refrain may be heard for many more years and was restated as lately as 1971: " Extreme shortage of health personnel is one of the major obstacles to the development of effective health services ". The education and training of medical and allied health personnel have, in fact, been given consideration in successive general programmes of work for specific periods proposed by the Executive Board and approved by the World Health Assembly, and thus continuity in the World Health Organisation’s efforts has been ensured. THE PROPOSED SOLUTION
Problem
an
effort
Advised solutions
areas
to
find
policies
Lack of adaptation of curricula Systematic approach to educational to local conditions planning and national health planning Influence of colonialism
on
curriculum Lack of qualified personnel
Africanisation of staff Local training Increased intake of students
Building of new medical schools Outflow of health personnel
Preparation of Teaching Staff as Agents of Change Selection of significant statements was based on words such as preparation and training ofteachers. Training of Teachers "The University must find solutions adapted to the needs and demands particular to development. It is a matter of pedagogy and of efficiency of the teaching process, and it is up to those in higher education to provide this adaptation and prepare future teachers for this new type of teaching."5 The Executive Board outlined this preparation in 1963.4 " As to the preparation of teachers of medical and allied subjects, even in very recently opened training establishments selected students might be assigned to junior posts as demonstrators and instructors, thus preparing them for future training for more responsible posts and adding to the teaching potential of the institution. There might be added to the conditions for fellowships for postgraduate training abroad the requirement that the fellow be given practice in tutoring or class teaching in his subject." In 1965 the expert committee on professional and technical education of medical and auxiliary personnel recommended that " W.H.O. should assist in the establishment of an international centre or centres for training medical teachers in educational sciences ".10 In 1968 the regional director began to give more precise details: " The need for teaching staff specially trained to function on new lines ... and for training an initial nucleus of professors prepared to work in a new context ".s " Deans in particular would need special training to enable them to tackle new tasks with a new approach" 11 The teaching staff would have to be given appropriate training in teaching theory and methods, the definition of educational objectives, and evaluation techniques. Under future arrangements for the appointment of medical teachers in Africa, training in teaching methodology should be made compulsory.8 In 1971 the regional committee passed a resolution 12 inviting the regional director " to use every available means to accelerate the teacher-training programme in Africa and intensify activities concerning applied research in the field of educational methodology and technology for the training of teaching personnel in Africa " 13
Finally, the Director-General, in his address to the 27th Assembly in 1971, declared: " The training of teachers is more than the mere acquisition of specialised knowledge; the study of pedagogy and behavioural sciences should be an integral part of their preparation." THE
or
Health-team concept Improvement of teacher training Local training, more schools Better planning of health services Study of its causes
Self-reliance Africanisation Coordination of external assistance
Thus, for lack of qualified personnel, one of the solutions was " improvement of teacher training ".
have, through
Policies advised by W.H.O. in remedies and solutions are :
Training of health planners Systematic approach to national health planning Multidisciplinary approach in education
Influence of colonialism " on curriculum. Lack of qualified health personnel. Outflow of health personnel. Need for planning of the health services and coordination of activities of different categories of health personnel. Relative value of external assistance.
tion
Need for planning of health services and coordination of activities of personnel
IMPLEMENTATION
To what extent have been implemented?
some
of the
proposed solutions
Opening of Regional Teacher-training Centres To ensure that training in educational science becomes available at local level and pursuing the underlying concept that " first-line teachers should preferably be trained in their own country, in their own cultural setting, in their own language and with funds of their own country-or, at least, as near as
572
possible to the schools where they will teach ", W.H.O. planned a comprehensive, coordinated long-term programme for teachers of medical and allied health
sciences. A memorandum of agreement was signed in 1970 * to the effect that future full-time members of the regional teacher-training centre would be trained to become the
directors of such centres. The future staff of the national centres would then be trained in the regional centres. The sites of two regional teacher-training centres in Africa were selected by the regional office in accordance with certam criteria elaborated and adopted by a group of W.H.O. consultants.14 The English-language regional teacher-training centre is Makerere University, Kampala, Uganda, and the French-language one is the University Centre for Health Sciences, Yaounde, Cameroon. In June, 1972, one fellow from Makerere University received his master’s degree after a one-year course at the Inter-Regional Teacher Training Centre.* Another fellow from the same University and a fellow from U.C.H.S. (Cameroon) started a one-year course in June, 1972. To encourage the development of national teachertraining centres two inter-regional seminars were held (in 1971 and 1972) for top-level administrators for schools of health personnel where regional or national teachertraining centres may be established. " A second project was a planned conference on medical education" which was not implemented before March,
1966.15 A third major project
was the meeting of professors of public health ". Its aim was to " define suitable methods for improving the teaching of public health ". Following the advice expressed at a meeting of deans in 1970, the title was changed to " meeting of professors of health sciences " and its aim became " to draw up an integrated
programme of medical studies and propose methods of implementation of such a programme ". It met every two years (1968, 1970, 1972) and, in an effort to promote pre-
ventive medicine, participants included not only publichealth specialists but also clinicians and specialists in basic sciences, and it served to integrate preventive medicine into the new curricula being developed in Africa. In an effort to encourage collaboration among medical schools of the region, meetings of deans were arranged by W.H.O. under an inter-country project and meetings were also held every two years. The first meeting emphasised the need to adapt curricula of medical schools to African requirements, advocating the setting up of curriculum committees, cooperation in research and in the production of teaching materials, and exchange of staff; it also stressed the need to train specialists and to start by making a precise and detailed inventory of the existing possibilities for higher training of specialists; it advocated the creation of multi-professional training centres and favoured the concept of the health team. The second meeting aimed at defining measures to help medical schools to participate in the preparation of national health plans, and in defining the orientation of the work to be undertaken by each medical school. The third meeting had its emphasis on management problems of medical schools in the region. Another significant inter-country project was " staff exchanges between medical schools of the African region " to " facilitate exchange visits of teachers between the different medical schools in the region for temporary teaching, to conduct examinations or to give advice in various specialised fields ". The idea of the regional office was munications between teachers, leading *
With the
improve comespecially to the
to
University of Illinois.
gradual disappearance of artificial divisions between English and French speaking teachers; to utilise fully the small number of teachers available in the region; to train future staff by using the specific facilities of each centre for the benefit of all; and to understand better the common problems facing African medical teachers. There was an appreciable increase in exchanges: 1972 Year
1968
1969
1970
1971
(first six months,
No. of exchanges..
7
8
8
14
10
In reviewing this project at a deans’ meeting in 1972, it felt that there was a lack of participation by Frenchspeaking institutions and a concentration of exchanges amongst a small number of English-speaking schools (four English-speaking schools had taken up 66% of W.H.O. The allocated assistance in the exercise 1970-72). budget was not fully used, possibly because of insufficient knowledge of the existence of the project and the way it
was
operates. In 1969 another inter-country project was created to supply medical schools with educational material, textbooks, and laboratory equipment. In four years it distributed almost 100,000 dollars ($98,637) worth of
equipment. To assist in establishing and developing departments, institutes, and schools of public health which will train staff necessary for the extension of health services, a special inter-country project was established and became operational in 1972 with one staff member, who had received additional training specifically for that purpose, assigned to Yaounde (Cameroon). Finally, a last inter-country project will be mentioned: in 1968 it was planned to organise workshops in medical education in Africa to enable medical-school teachers to study teaching methods and acquaint themselves with new educational techniques.
W.H.O. Teacher-training Workshops For the implementation of most of W.H.O. policies in the area of education and training, " the existing teachers must be trained in new educational techniques ". In 1966 the regional director reported 16 that " (two participants from the African region) attended the interconference on effective teaching methods of medical education held in Geneva in November 1965 ". In 1969 the regional director indicated 17 that two meetings were organised in 1968 in an effort to assist African teachers to formulate " a methodology for the preparation of curricula based on educational goals adapted to the future responsibilities of the staff ". " Two consultants directed a workshop on teaching methods in medical education in Brazzaville [in] December 1969 for W.H.O. staff members. Other workshops of this kind, considered essential in ensuring consistent development of education programmes in the Region, will be repeated in the next few years with participation by nationals." 18 English-speaking national teachers were trained in new educational methods at a workshop on medical education methodology held in Kampala in October 1970; French-speaking nationals were trained,at a similar workshop in Dakar in 1971." 12 In 1972 two workshops on medical education methodology were held in the African region, in Accra and Yaounde. In 1973 one was held in Abidjan. Between 1969 and 1972, over 100 professors teaching in allAfrican medical schools participated in short-term courses in a systematic approach to educational planning.:9-:
regional
"
573 These workshops have made it possible to create conditions which are expected to foster significant changes in teaching
practices. CONCLUSION
African medical educators are confronted with a great challenge. A systematic approach tends to replace very gradually traditional methods of the As this orientation involves drastic recent past. of attitudes among the faculty which are changes at present in control, one must consider that changes will come slowly-very slowly-and that it cannot be otherwise. What is important is that changes introduced by teacher-training are in the right direction. REFERENCES 1. 2. 3.
4. 5.
6. 7.
8.
Ngu, V. A. West Afr. med. J. 1964, 13, 219. Kibukamusoke, J. W. East Afr. med. J. 1970, 47, 126. Hutton, P. W. Lancet, 1963, ii, 135. 16th World Health Assembly Official Records no. 127. Geneva, 1963. Quenum, A. Place et Role de l’Université dans le Dévelopment des Nations Africaines. Rentrée solennelle des Facultés, Université de Dakar, Dakar, 1965. Quenum, A. The Planning of Medical Education and Health Staff Training in Africa. W.H.O. Regional Office for Africa, 1968. Quenum, A. Some Problems in the Education and Training of Medical and Health Personnel in Africa. Lecture, Faculty of Hygiene and Epidemiology of Charles University, Prague, 1968. Quenum, A. Why Should We Innovate in Medical Education in Africa? W.H.O. Regional Office for Africa, press release, March,
1970. 9. 24th World Health Assembly Official Records no. 193. Geneva, 1971. 10. Techn. rep. Ser. Wld Hlth Org. 1966, no. 337, p. 26. 11. Quenum, A. Adapting Medical Education to African Conditions. W.H.O. Regional Office for Africa, 1968. 12. 21st Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1971. 13. Handbook of Resolutions and Decisions of the Regional Committee for Africa (1951-71), Brazzaville, 1971. W.H.O. Regional Office for Africa. 14. Fulop, T. W.H.O. Comprehensive and Coordinated Long-Term Training Programme for Teachers of Medical and Allied Health Sciences. Geneva, 1972. W.H.O., ET/SG/72. 15. Report on Seminar on Medical Education in Africa, Yaoundé, 1966. W.H.O. Regional Office for Africa. 16. 16th Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1966. 17. 19th Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1969. 18. 20th Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1970. 19. Report on Meeting of Professors of Public Health, Brazzaville, 1968. W.H.O. Regional Office for Africa. 20. Towards a Philosophy of Health Work in the African Region. AFRO Technical Papers no. 1, Brazzaville, 1970. 21. The Place of Public Health Education in Programmes for the Training of Health Team Personnel. AFRO Technical Papers no. 3, Brazzaville, 1971.
EDUCATIONAL ASSISTANTS C. E. ENGEL
Department of Audio Visual Communication, British Medical Association and British Life Assurance Trust for Health Education, London WC1H 9JP
Sum ary
Certain needs of medical education
might be met through a team approach by which clinical teachers, in particular, can save time and effort in the planning, implementation, and assessment
of education.
This could be achieved
through the help of educational consultants whose relationship to the teachers, as well as their responsibilities and training, are here discussed. INTRODUCTION "
In every
department of human knowledge
men are
asking
guidance in the solution of
a world-old problem-how to train the mind and heart and hands of the young. The past and the present are in the melting pot-the moulds are ready, and all await with eagerness the result of the casting, and none with greater eagerness than our own profession. For we are in a quandary. Naturally conservative, we are bewildered by the rapidity of a forced progress and change. There is a new outlook in every department not alone in the fundamentals of science and in methods of practice, but in the relations of the profession to the public and to the State. The actual care of the sick, once our sole duty, is now
supplemented by
such
a
activities, social, scientific, ever-increasing number of our do with patients as such.... The
host of other
and administrative, that
an
members have nothing to truth is, we have outrun an education system framed in simpler days and for simpler conditions. The pressure comes hard enough upon the teacher, but far harder upon the taught, who suffer in a hundred different ways." - WILLIAM OSLER, Lancet, 1913, ii, 1047.
Few would wish to dispute that these views are still relevant some sixty years later. Many would contend that the needs for a new approach to medical education are even more pressing today. A growing and constantly changing complex of knowledge and skills has to be transmitted to an increasing number of students. This applies not only to undergraduate education but also to postgraduate and continuing medical education. These needs are not likely to be met unless the individual is prepared to accept full responsibility for his own studies. However, active, independent learning is not likely to be fostered by courses of lectures, but rather by carefully planned opportunities for individual study and participation in small-group activities. Indeed, Millerhas argued that this is the only effective method for teaching .large numbers of students. The implications of individual and small-group learning were considered by a W.H.O. Study Group,2 and its conclusions clearly point to an even greater involvement of the teacher than in the past. As in the practice of medicine, the teacher’s main role is here concerned with the diagnosis of educational needs, with the planning of learning activities, the monitoring of the student’s progress and the provision of remedial learning opportunities, as well as the assessment of the student’s overall achievements.3 While the teacher adopts the functions of a manager, consultant, and counsellor, he will have to devote additional time to discussions with his colleagues to ensure a comprehensive integrated programme of work for his students. In Britain the University Grants Committee has acknowledged that effective teaching in higher education constitutes a considerable responsibility for the academic, that explicit recognition must be accorded, and that he must be given time to devote to these activities.4 However, the medical teacher is also for the care of patients; and research responsible work, as well as administrative commitments, will occupy a further proportion of his time. Where, as in Britain, medical education is closely interwoven with a national health service, many teachers are likely to be faced with additional committee duties. A realistic allocation of time for educational activities would thus require a sizable expansion of the clinical staff in undergraduate and postgraduate teaching institutions. As the necessary financial resources are not likely to be available in the foreseeable future,
The book, The Future General Practitioner, created for the Royal College of General Practitioners, has been of value in that it provides a job definition of general practice, with derived educational goals, and a framework for thought, discussion, and experiment which seems to be required elsewhere in medicine. For we, in general practice, are assisting to create general practitioners to practise in Britain within the National Health Service. This is the ethos of our training programmes. The Royal College of General Practitioners has been and is a source of ideas and inspiration, but the endpoint of training is to produce competent N.H.S. principals and not merely to satisfy
College requirements. A
REFERENCES
Byrne, P. S., Long, B. E. Learning to Care—Person to Person. London, 1973. 2. Freeman, J., Byrne, P. S. The Assessment of Postgraduate Train1.
ing in General Practice. Society for Research into Higher Education, London, 1973.
TEACHER TRAINING FOR MEDICAL SCHOOLS IN AFRICA*
J.-J. GUILBERT Chief Medical Officer, Educational Planning, World Health Organisation, Geneva
Though the problem
areas of medical education in Africa have been defined and steps have been taken to attack them, notably by preparing teaching staff as agents of change and by opening teacher-training centres, progress cannot be otherwise than slow.
Sum ary
QUIET REVOLUTION
The history of a book on person-to-person teaching illustrates a difficulty contained in all multidisciplinary endeavours: the question of language. We know that jargon is the term applied to the language of one discipline by members of another. The general practitioner and the educationist have each large professional vocabularies, each a form of professional shorthand by which members of that profession may the more easily communicate with one another. Those who are learning a new profession, that of teaching, must learn its language, unless of course they wish to appear as petulant amateurs bleating of jargon ". It is not necessary that they use the language on all occasions. It is necessary that professional terms be explained on many occasions. But courses and books alone do not make teachers. One may learn " about " this new profession, but one has to learn " to do ", to teach. Practical experience of teaching is required, while ready means of feedback must be open to the teacher on his own performance as well as on that of the student. To do this effectively, resources not at present available are needed. In the few places where significant research into medical education is being prosecuted and published, the staff have little time to monitor the progress of the new teachers who have only been launched, "
trained. The new regional postgraduate machinery has much to do in this direction, but it has not yet acquired either the necessary experience or the resources. Much
not
of the quiet revolution in the production of teachers in general practice is unknown even within the profession itself. A monograph2 on the assessment of postgraduate training in general practice describes methodology of a much wider application than the title might suggest. In medicine generally, in our universities as a whole, teachers are like Topsy, they just grow. In general practice, however small a beginning, there is discernible the start of the making of teachers. Who knows-we may even reach the stage where all our medical educators read, and even contribute to, the British Journal of Medical Education.
THERE is certainly no plethora of studies on the development of medical education in Africa between 1962 and 1972. Despite the modest amount written, the literature contains references to : adaptation of curricula; influence of colonialism; lack of health personnel ; outflow of personnel; need for more medical schools; need for African teachers; external aid; need for health planning and coordination of personnel; the role of the physician and educational objectives; the importance of preventive medicine; the integrated approach; active learning methods; and teacher training. Referring to the necessary changes in African medical education, authors stress the importance of preparing teachers for their new tasks. Such a change of attitude will most certainly excite active, if not violent, resistance. If our medical schools are to look to the future they must be prepared to take "
critical look at their present status " 1 "... the call for an increased supply of teachers and researchers though still distant is rapidly approaching and will surely overtake and overwhelm us unless we prepare ourselves to offset this eventuality."2 Huttonhad if changes are to be made in already indicated that medical education " it is the orientation of the faculty of medicine as a whole, rather than having this or that in the curriculum, which is important". a
*
Excerpts from
a dissertation written in partial fulfilment of requirefor the degree of Doctor of Philosophy, University of Southern California, Los Angeles.
ments
571 THE PROBLEM AREAS
The
problem
areas
that
can
be found in
policy
statements of W.H.O. are: Lack of adaptation of curricula to local conditions. "
Introduction of the health team concept Relative value of external assistance
Concerning lack of qualified health personnel, I a content analysis, used selected key words to identify significant statements indicating the Statements for that area were selected when such words as the following were found: shortage, absence, wanting, lack, needs. The W.H.O. Executive Board defined " needs " thus: "byneeds’ is meant the gap between the trained personnel available and those reasonably required now and at certain target dates in the future ".44 W.H.O. indicates that the quantitative problem is a priority for newly independent African nations: "there is therefore urgency for these countries to make provision for the training of their own personnel ... they need to4 be self-sufficient in personnel as soon as possible ".* Similar statements, year after year, seem to indicate that such a problem " remains " urgent : " the shortage of qualified personnel constitutes one of the greatest obstacles to a raising of the standard of living of African populations ". "To train men is, in the last analysis, the major problem of African nations."" The situation is getting worse rather than better owing to the popula-
problem.
growth."6
"The most important (obstacle to development) (is) the lack of qualified personnel in almost all fields and especially in that of public health."7 As can easily be forecast, it would be unreasonable to expect that within such a short period as ten years, this type of problem could be solved: " the major stumbling block in improving the level of health (remains) the extreme shortage of health
staff".8 This monotonous refrain may be heard for many more years and was restated as lately as 1971: " Extreme shortage of health personnel is one of the major obstacles to the development of effective health services ". The education and training of medical and allied health personnel have, in fact, been given consideration in successive general programmes of work for specific periods proposed by the Executive Board and approved by the World Health Assembly, and thus continuity in the World Health Organisation’s efforts has been ensured. THE PROPOSED SOLUTION
Problem
an
effort
Advised solutions
areas
to
find
policies
Lack of adaptation of curricula Systematic approach to educational to local conditions planning and national health planning Influence of colonialism
on
curriculum Lack of qualified personnel
Africanisation of staff Local training Increased intake of students
Building of new medical schools Outflow of health personnel
Preparation of Teaching Staff as Agents of Change Selection of significant statements was based on words such as preparation and training ofteachers. Training of Teachers "The University must find solutions adapted to the needs and demands particular to development. It is a matter of pedagogy and of efficiency of the teaching process, and it is up to those in higher education to provide this adaptation and prepare future teachers for this new type of teaching."5 The Executive Board outlined this preparation in 1963.4 " As to the preparation of teachers of medical and allied subjects, even in very recently opened training establishments selected students might be assigned to junior posts as demonstrators and instructors, thus preparing them for future training for more responsible posts and adding to the teaching potential of the institution. There might be added to the conditions for fellowships for postgraduate training abroad the requirement that the fellow be given practice in tutoring or class teaching in his subject." In 1965 the expert committee on professional and technical education of medical and auxiliary personnel recommended that " W.H.O. should assist in the establishment of an international centre or centres for training medical teachers in educational sciences ".10 In 1968 the regional director began to give more precise details: " The need for teaching staff specially trained to function on new lines ... and for training an initial nucleus of professors prepared to work in a new context ".s " Deans in particular would need special training to enable them to tackle new tasks with a new approach" 11 The teaching staff would have to be given appropriate training in teaching theory and methods, the definition of educational objectives, and evaluation techniques. Under future arrangements for the appointment of medical teachers in Africa, training in teaching methodology should be made compulsory.8 In 1971 the regional committee passed a resolution 12 inviting the regional director " to use every available means to accelerate the teacher-training programme in Africa and intensify activities concerning applied research in the field of educational methodology and technology for the training of teaching personnel in Africa " 13
Finally, the Director-General, in his address to the 27th Assembly in 1971, declared: " The training of teachers is more than the mere acquisition of specialised knowledge; the study of pedagogy and behavioural sciences should be an integral part of their preparation." THE
or
Health-team concept Improvement of teacher training Local training, more schools Better planning of health services Study of its causes
Self-reliance Africanisation Coordination of external assistance
Thus, for lack of qualified personnel, one of the solutions was " improvement of teacher training ".
have, through
Policies advised by W.H.O. in remedies and solutions are :
Training of health planners Systematic approach to national health planning Multidisciplinary approach in education
Influence of colonialism " on curriculum. Lack of qualified health personnel. Outflow of health personnel. Need for planning of the health services and coordination of activities of different categories of health personnel. Relative value of external assistance.
tion
Need for planning of health services and coordination of activities of personnel
IMPLEMENTATION
To what extent have been implemented?
some
of the
proposed solutions
Opening of Regional Teacher-training Centres To ensure that training in educational science becomes available at local level and pursuing the underlying concept that " first-line teachers should preferably be trained in their own country, in their own cultural setting, in their own language and with funds of their own country-or, at least, as near as
572
possible to the schools where they will teach ", W.H.O. planned a comprehensive, coordinated long-term programme for teachers of medical and allied health
sciences. A memorandum of agreement was signed in 1970 * to the effect that future full-time members of the regional teacher-training centre would be trained to become the
directors of such centres. The future staff of the national centres would then be trained in the regional centres. The sites of two regional teacher-training centres in Africa were selected by the regional office in accordance with certam criteria elaborated and adopted by a group of W.H.O. consultants.14 The English-language regional teacher-training centre is Makerere University, Kampala, Uganda, and the French-language one is the University Centre for Health Sciences, Yaounde, Cameroon. In June, 1972, one fellow from Makerere University received his master’s degree after a one-year course at the Inter-Regional Teacher Training Centre.* Another fellow from the same University and a fellow from U.C.H.S. (Cameroon) started a one-year course in June, 1972. To encourage the development of national teachertraining centres two inter-regional seminars were held (in 1971 and 1972) for top-level administrators for schools of health personnel where regional or national teachertraining centres may be established. " A second project was a planned conference on medical education" which was not implemented before March,
1966.15 A third major project
was the meeting of professors of public health ". Its aim was to " define suitable methods for improving the teaching of public health ". Following the advice expressed at a meeting of deans in 1970, the title was changed to " meeting of professors of health sciences " and its aim became " to draw up an integrated
programme of medical studies and propose methods of implementation of such a programme ". It met every two years (1968, 1970, 1972) and, in an effort to promote pre-
ventive medicine, participants included not only publichealth specialists but also clinicians and specialists in basic sciences, and it served to integrate preventive medicine into the new curricula being developed in Africa. In an effort to encourage collaboration among medical schools of the region, meetings of deans were arranged by W.H.O. under an inter-country project and meetings were also held every two years. The first meeting emphasised the need to adapt curricula of medical schools to African requirements, advocating the setting up of curriculum committees, cooperation in research and in the production of teaching materials, and exchange of staff; it also stressed the need to train specialists and to start by making a precise and detailed inventory of the existing possibilities for higher training of specialists; it advocated the creation of multi-professional training centres and favoured the concept of the health team. The second meeting aimed at defining measures to help medical schools to participate in the preparation of national health plans, and in defining the orientation of the work to be undertaken by each medical school. The third meeting had its emphasis on management problems of medical schools in the region. Another significant inter-country project was " staff exchanges between medical schools of the African region " to " facilitate exchange visits of teachers between the different medical schools in the region for temporary teaching, to conduct examinations or to give advice in various specialised fields ". The idea of the regional office was munications between teachers, leading *
With the
improve comespecially to the
to
University of Illinois.
gradual disappearance of artificial divisions between English and French speaking teachers; to utilise fully the small number of teachers available in the region; to train future staff by using the specific facilities of each centre for the benefit of all; and to understand better the common problems facing African medical teachers. There was an appreciable increase in exchanges: 1972 Year
1968
1969
1970
1971
(first six months,
No. of exchanges..
7
8
8
14
10
In reviewing this project at a deans’ meeting in 1972, it felt that there was a lack of participation by Frenchspeaking institutions and a concentration of exchanges amongst a small number of English-speaking schools (four English-speaking schools had taken up 66% of W.H.O. The allocated assistance in the exercise 1970-72). budget was not fully used, possibly because of insufficient knowledge of the existence of the project and the way it
was
operates. In 1969 another inter-country project was created to supply medical schools with educational material, textbooks, and laboratory equipment. In four years it distributed almost 100,000 dollars ($98,637) worth of
equipment. To assist in establishing and developing departments, institutes, and schools of public health which will train staff necessary for the extension of health services, a special inter-country project was established and became operational in 1972 with one staff member, who had received additional training specifically for that purpose, assigned to Yaounde (Cameroon). Finally, a last inter-country project will be mentioned: in 1968 it was planned to organise workshops in medical education in Africa to enable medical-school teachers to study teaching methods and acquaint themselves with new educational techniques.
W.H.O. Teacher-training Workshops For the implementation of most of W.H.O. policies in the area of education and training, " the existing teachers must be trained in new educational techniques ". In 1966 the regional director reported 16 that " (two participants from the African region) attended the interconference on effective teaching methods of medical education held in Geneva in November 1965 ". In 1969 the regional director indicated 17 that two meetings were organised in 1968 in an effort to assist African teachers to formulate " a methodology for the preparation of curricula based on educational goals adapted to the future responsibilities of the staff ". " Two consultants directed a workshop on teaching methods in medical education in Brazzaville [in] December 1969 for W.H.O. staff members. Other workshops of this kind, considered essential in ensuring consistent development of education programmes in the Region, will be repeated in the next few years with participation by nationals." 18 English-speaking national teachers were trained in new educational methods at a workshop on medical education methodology held in Kampala in October 1970; French-speaking nationals were trained,at a similar workshop in Dakar in 1971." 12 In 1972 two workshops on medical education methodology were held in the African region, in Accra and Yaounde. In 1973 one was held in Abidjan. Between 1969 and 1972, over 100 professors teaching in allAfrican medical schools participated in short-term courses in a systematic approach to educational planning.:9-:
regional
"
573 These workshops have made it possible to create conditions which are expected to foster significant changes in teaching
practices. CONCLUSION
African medical educators are confronted with a great challenge. A systematic approach tends to replace very gradually traditional methods of the As this orientation involves drastic recent past. of attitudes among the faculty which are changes at present in control, one must consider that changes will come slowly-very slowly-and that it cannot be otherwise. What is important is that changes introduced by teacher-training are in the right direction. REFERENCES 1. 2. 3.
4. 5.
6. 7.
8.
Ngu, V. A. West Afr. med. J. 1964, 13, 219. Kibukamusoke, J. W. East Afr. med. J. 1970, 47, 126. Hutton, P. W. Lancet, 1963, ii, 135. 16th World Health Assembly Official Records no. 127. Geneva, 1963. Quenum, A. Place et Role de l’Université dans le Dévelopment des Nations Africaines. Rentrée solennelle des Facultés, Université de Dakar, Dakar, 1965. Quenum, A. The Planning of Medical Education and Health Staff Training in Africa. W.H.O. Regional Office for Africa, 1968. Quenum, A. Some Problems in the Education and Training of Medical and Health Personnel in Africa. Lecture, Faculty of Hygiene and Epidemiology of Charles University, Prague, 1968. Quenum, A. Why Should We Innovate in Medical Education in Africa? W.H.O. Regional Office for Africa, press release, March,
1970. 9. 24th World Health Assembly Official Records no. 193. Geneva, 1971. 10. Techn. rep. Ser. Wld Hlth Org. 1966, no. 337, p. 26. 11. Quenum, A. Adapting Medical Education to African Conditions. W.H.O. Regional Office for Africa, 1968. 12. 21st Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1971. 13. Handbook of Resolutions and Decisions of the Regional Committee for Africa (1951-71), Brazzaville, 1971. W.H.O. Regional Office for Africa. 14. Fulop, T. W.H.O. Comprehensive and Coordinated Long-Term Training Programme for Teachers of Medical and Allied Health Sciences. Geneva, 1972. W.H.O., ET/SG/72. 15. Report on Seminar on Medical Education in Africa, Yaoundé, 1966. W.H.O. Regional Office for Africa. 16. 16th Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1966. 17. 19th Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1969. 18. 20th Annual Report of Regional Director to Regional Committee for Africa. W.H.O. Regional Office for Africa, 1970. 19. Report on Meeting of Professors of Public Health, Brazzaville, 1968. W.H.O. Regional Office for Africa. 20. Towards a Philosophy of Health Work in the African Region. AFRO Technical Papers no. 1, Brazzaville, 1970. 21. The Place of Public Health Education in Programmes for the Training of Health Team Personnel. AFRO Technical Papers no. 3, Brazzaville, 1971.
EDUCATIONAL ASSISTANTS C. E. ENGEL
Department of Audio Visual Communication, British Medical Association and British Life Assurance Trust for Health Education, London WC1H 9JP
Sum ary
Certain needs of medical education
might be met through a team approach by which clinical teachers, in particular, can save time and effort in the planning, implementation, and assessment
of education.
This could be achieved
through the help of educational consultants whose relationship to the teachers, as well as their responsibilities and training, are here discussed. INTRODUCTION "
In every
department of human knowledge
men are
asking
guidance in the solution of
a world-old problem-how to train the mind and heart and hands of the young. The past and the present are in the melting pot-the moulds are ready, and all await with eagerness the result of the casting, and none with greater eagerness than our own profession. For we are in a quandary. Naturally conservative, we are bewildered by the rapidity of a forced progress and change. There is a new outlook in every department not alone in the fundamentals of science and in methods of practice, but in the relations of the profession to the public and to the State. The actual care of the sick, once our sole duty, is now
supplemented by
such
a
activities, social, scientific, ever-increasing number of our do with patients as such.... The
host of other
and administrative, that
an
members have nothing to truth is, we have outrun an education system framed in simpler days and for simpler conditions. The pressure comes hard enough upon the teacher, but far harder upon the taught, who suffer in a hundred different ways." - WILLIAM OSLER, Lancet, 1913, ii, 1047.
Few would wish to dispute that these views are still relevant some sixty years later. Many would contend that the needs for a new approach to medical education are even more pressing today. A growing and constantly changing complex of knowledge and skills has to be transmitted to an increasing number of students. This applies not only to undergraduate education but also to postgraduate and continuing medical education. These needs are not likely to be met unless the individual is prepared to accept full responsibility for his own studies. However, active, independent learning is not likely to be fostered by courses of lectures, but rather by carefully planned opportunities for individual study and participation in small-group activities. Indeed, Millerhas argued that this is the only effective method for teaching .large numbers of students. The implications of individual and small-group learning were considered by a W.H.O. Study Group,2 and its conclusions clearly point to an even greater involvement of the teacher than in the past. As in the practice of medicine, the teacher’s main role is here concerned with the diagnosis of educational needs, with the planning of learning activities, the monitoring of the student’s progress and the provision of remedial learning opportunities, as well as the assessment of the student’s overall achievements.3 While the teacher adopts the functions of a manager, consultant, and counsellor, he will have to devote additional time to discussions with his colleagues to ensure a comprehensive integrated programme of work for his students. In Britain the University Grants Committee has acknowledged that effective teaching in higher education constitutes a considerable responsibility for the academic, that explicit recognition must be accorded, and that he must be given time to devote to these activities.4 However, the medical teacher is also for the care of patients; and research responsible work, as well as administrative commitments, will occupy a further proportion of his time. Where, as in Britain, medical education is closely interwoven with a national health service, many teachers are likely to be faced with additional committee duties. A realistic allocation of time for educational activities would thus require a sizable expansion of the clinical staff in undergraduate and postgraduate teaching institutions. As the necessary financial resources are not likely to be available in the foreseeable future,