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The society as educator
PUBLIC
HEALTH
The Journal of The Society of Medical Officers of Health Vol. 83 . . . . . . . . .
November 1968 i
]
;
Hill[ i
Hill
Hill
i
I
No. 1 ii
ii
ii i
~
-
[
The Society as Educator MANY of those who are active in the Society's affairs must have taken great pleasure in reading paragraph 96 of the Sheldon Report on Child Welfare Centres which, after paragraphs discussing the appropriate post-graduate training for medical officers in the Child Health Service of the future, referred to the Society's six-week courses in developmental paediatrics and commented that with some expansio n theywould form a "satisfactory basis for postgraduate education in child health." The recognition was well earned, for a great deal of hard work by a great many people h/ts gone into the development of the courses. That they will be expanded and continued is certain and there are no signs of complacency in those responsible for them. However, they are only part of tlle Society's total educational activities, and their recognition by the Sheldon Committee, together with other recent developments, makes it opportune to do a little stock-taking. Clinical medicine has in the past hundred years progressed from the known to the less-known. There are few new diseases which have come into being during that period. The story has been rather that vague composite clinical pictures have been defined and analysed so that what was formerly considered to be a single syndrome has been shown to be a family of similar and often-though not always directly related--pathological entities. Apart from the special effects of the introduction of the antibiotics, diagnosis and treatment, medicine, surgery and pathology, have been principally concerned with developing and extending old principles and practices. Virtually all that is new has grown progressively out of the old, even when it has succeeded in turning the old upside down. In this kind of development the traditional apparatus of research and education has functioned satisfactorily, even though some of the methods of education have been shown to need an overhaul, and the division between those who are principally teachers and those who are principally field workers has been not unreasonable. The various disciphnes within public health, however, have had a very different task. In the middle of the nineteenth century the first public health doctors went out to explore the unknown with no body of systematized knowledge to
2
PUBLIC
HEALTH
V O L . 83 N O . I
help them. They found, defined and endeavoured to solve problems which had not previously been recognized. A body of knowledge came into being and made possible the setting up of training schools for a degree c3r diploma in public health. But the application of this knowledge to the problems brought some of them close to final solfition and radically changed the shape of others. Moreover, aS each problem was solved or changed, in a society which was itself chan~ng, new problems were discovered or spontaneously arose. The result of this has been that by the time that it was possible to formalize teaching in any branch of the subject that teaching was already obsolescent. In fact, the majority of the people.who had the knowledge necessary to teach in the context of the time were the more advanced, original and progressive among the field workers. It was consequently inevitable that the organization of the field workers must concern itself with teaching and in the years since World War 1I the Society has shown itself ready to accept that responsibility. We are not suggesting that all or even the greater part of post-graduate education for public health doctors must be in-bred. There are many people in the clinical field, in the laboratories and in disciplines outside medicine, from whom the public health doctor has much to learn. But education must be closely related to the needs of the people who are going to be educated.!'and it is only the doctors working in public health who know what they need and how their education should be oriented and presented. The classical mistake was made in the field of child health. The doctors in the field child health service were concerned primai'ily with the healthy child in his social setting, though to do their job they needed to know something about the illnesses of children. The paediatricians were the experts in the care of sick children and had little contact with healthy ones. The idea that there should be a Diploma in Child Health was eminently sound and the Royal College of Physicians deserves credit for instituting it. Unfortunately, under the College's aegis the Diploma was, naturally, paediatricaIly oriented and it has proved in practice to be a diploma in "mid-level" clinical paediatrics, of no great value to those who acquire it and certainly not something which has lived up to its name. The R.C.P. is in process of re-casting it as something which will give proper emphasis to developmental and social paediatrics and we hope that in its new form it will come much nearer to achieving what is intended. The early attempts of the Society to arrange courses included occasions on which a university institute or department was invited to. provide a short course. There was no lack of willingness in the universities, but it soon became clear that this method would not work literally', it Was impeded by the gap in understanding of need to which we have already referred. And so the pattern began to develop by the Society, a university department and the health department of the city in which the university was situated went into informal partnership to organise a course. Who played what part and to-what extent has varied
T H E S O C I E T Y AS E D U C A T O R
3
from time to time and from place to place, but the pattern is certainly practical and ~ !~':, we believe, continue to be followed in many courses. We nave referred to "the Society". In practice, the Society's central organization has been under considerable pressure and could not have hoped to manage a complete educational programme: The organizational burden has been principally shouldered by the groupswith the Cot.tory Borough, County DistricL Infectious: Diseases, Maternity and Child Welfare, Mental Health and School Health principally involved; The ~oclety s central organization has dealt with tile practical work of handling applications and fees: The rest of 'the task has lain with the groups and they have all found willing volunteers to undertake it. In our view it is right that the grqups should nave the j o b r - a n d the 'credit which comes from it--in so far as courses of "refresher" type are concerned. This is certainly the best way of making sure that the content of the course is accurately adjusted to current special needs and it is good for the health and vigour of the Society that it~ members should be involved in this way. We would go further and suggest that recent experiments by branches in arrangingshort oneday or week-end local courses and seminars should be encouraged to go further. When, however, one comes to consider courses.lasting formore than a couple m" weeks or so, the groups and branches cannot be expected to handle the organization by themselves and in basic courses, like the six-week one, the disciplines of more than one group maybe involved. There must be an improved central mechanism for the purpose, but the Society Cannot do. this entirely from its own .resources, That is why we welcome.the exditing newsthat the Nuflfield.Provincial Hospitals.Trusthas approved a: grant to •the Society of £7500 over three years, to help its postgraduate training Programme in developmental paediatrics: This comes just at the time when.the, need .for extension of the programme is becoming important and urgent and .will 'make a cardinal difference to the prospect. This n e e d not, a s w e have already.indicated, restrict the educational work of the groups and branches and. it may to some extent make that work easier. However it. is certainly:necessary for. the ?three: 'groups directly. :interested in developmental paediatrics-~Maternity a n d C h i l d Welfare; Mental Health: and School .Health--to p0ol-their, knowledge and. experience i n devising the new programme. There are ' a g o o d many specific questions which need to,be asked: and a few o f t h e m m a y be referred t o here. Has the six-week.course,, in its naturM coneentration.on the child's early.Years, taken too little notice o f the school years, which .are also years of development? Can one CourSe of six weeks; adequately cover, the whole .:range, or.~iS-there:a oneed for. a similar fairly-lotig:course for doctors in the scho01..healthservice? How.far is it possible to devise purposeful programmesof field work to supplement the theoretical training of such courses ? Whatabout thebringing in. of doctors outside the public heatfll service?Up
4
PUBLIC
HEALTH
V O L . 83 N O . 1
to now it has appeared virtually impossible to produce courses, either long or short, which attract G.P.s. As regards long courses, this may well be due to the many factors which prevent G.P.s from sparing sufficient time and it may be that the impending changes in G.P.s' conditions will make things easier. But it would seem that even short week-end courses fail to attract the two branches equally. We suspect that some of these courses in the "child health field which have been devised with tile G.P. principally in mind have been somewhat below the level which best suits keen public health doctors. What about the attitude of the Local Authorities ? Some send their M.O.s to courses in substantial numbers while others do do only rarely a n d reluctantly. It may be that the less wi!ling authorities l already have adequate in-service programmes of their own, or that their M.O.s already know everything. W e suspect that a more cogent reason is that they are lo0king more closely at their budgets than at the practical efficiency of their services. M a n y authorities, as a matter of policy, send to courses only their whole-time M.O.s. In the days when part-time M.O.s were fewand, usually;, temporary Jttiis might be justified; at present, when more and more permanent part-tinae]M.O.s form the backbone of the service the case against their receiving training can no longer stand. The ideal would be that basic training Courses should become mandatory, in the. same way as the E.S.N. :ascertainment course., This is not to be expected till the number of basic courses is increased and tliey have demonstrated their quality without question. We believe that both these desiderata will be brought nearer b y thedevelopments which should com~ from the Nuffield grant. Meanwhile we would comment that it is require6 that health visitors, district nurses and midwives m u s t take refresher courses at certain minimmn interval~ Are medical officers of less value to their employers ? There is one argumen. against requiring L.A.s~to send their medical staff to refresher courses at least every three or five years. It is that M.O.s employed by the authorities which are atpresent generous might find that the "maximum,' interval became also the minimum interval, so that they h a d fewer opportunities than they do at present. Though there is substance in this, we are reluctant to accept it as final. Eve n if it did happen, might not the loss to some M.O.s be counterbalanced by the gain to others, so that the service as a whole benefited ? We are conscious that this is a time of change and that the pessimists see the public health service as being on the r o a d to extinction. We accept that it will undergo change; but in some form it must survive if the health of the people is to be maintained. I t will be the more sure to survive if it fits itself to meet the newand challenging needs. The Society willhave great deal o n its hands in the next ten years, but we believe that what-it does in the educational field is at least as important as any of its other tasks. It has done well in the past and its experience and accumulated expertise in this field areunique, It can do even better in. the future--better t h a n fits own past achievements and better, too, than any other organization at present in the field or likely to enter it.
HEALTH
The Journal of The Society of Medical Officers of Health Vol. 83 . . . . . . . . .
November 1968 i
]
;
Hill[ i
Hill
Hill
i
I
No. 1 ii
ii
ii i
~
-
[
The Society as Educator MANY of those who are active in the Society's affairs must have taken great pleasure in reading paragraph 96 of the Sheldon Report on Child Welfare Centres which, after paragraphs discussing the appropriate post-graduate training for medical officers in the Child Health Service of the future, referred to the Society's six-week courses in developmental paediatrics and commented that with some expansio n theywould form a "satisfactory basis for postgraduate education in child health." The recognition was well earned, for a great deal of hard work by a great many people h/ts gone into the development of the courses. That they will be expanded and continued is certain and there are no signs of complacency in those responsible for them. However, they are only part of tlle Society's total educational activities, and their recognition by the Sheldon Committee, together with other recent developments, makes it opportune to do a little stock-taking. Clinical medicine has in the past hundred years progressed from the known to the less-known. There are few new diseases which have come into being during that period. The story has been rather that vague composite clinical pictures have been defined and analysed so that what was formerly considered to be a single syndrome has been shown to be a family of similar and often-though not always directly related--pathological entities. Apart from the special effects of the introduction of the antibiotics, diagnosis and treatment, medicine, surgery and pathology, have been principally concerned with developing and extending old principles and practices. Virtually all that is new has grown progressively out of the old, even when it has succeeded in turning the old upside down. In this kind of development the traditional apparatus of research and education has functioned satisfactorily, even though some of the methods of education have been shown to need an overhaul, and the division between those who are principally teachers and those who are principally field workers has been not unreasonable. The various disciphnes within public health, however, have had a very different task. In the middle of the nineteenth century the first public health doctors went out to explore the unknown with no body of systematized knowledge to
2
PUBLIC
HEALTH
V O L . 83 N O . I
help them. They found, defined and endeavoured to solve problems which had not previously been recognized. A body of knowledge came into being and made possible the setting up of training schools for a degree c3r diploma in public health. But the application of this knowledge to the problems brought some of them close to final solfition and radically changed the shape of others. Moreover, aS each problem was solved or changed, in a society which was itself chan~ng, new problems were discovered or spontaneously arose. The result of this has been that by the time that it was possible to formalize teaching in any branch of the subject that teaching was already obsolescent. In fact, the majority of the people.who had the knowledge necessary to teach in the context of the time were the more advanced, original and progressive among the field workers. It was consequently inevitable that the organization of the field workers must concern itself with teaching and in the years since World War 1I the Society has shown itself ready to accept that responsibility. We are not suggesting that all or even the greater part of post-graduate education for public health doctors must be in-bred. There are many people in the clinical field, in the laboratories and in disciplines outside medicine, from whom the public health doctor has much to learn. But education must be closely related to the needs of the people who are going to be educated.!'and it is only the doctors working in public health who know what they need and how their education should be oriented and presented. The classical mistake was made in the field of child health. The doctors in the field child health service were concerned primai'ily with the healthy child in his social setting, though to do their job they needed to know something about the illnesses of children. The paediatricians were the experts in the care of sick children and had little contact with healthy ones. The idea that there should be a Diploma in Child Health was eminently sound and the Royal College of Physicians deserves credit for instituting it. Unfortunately, under the College's aegis the Diploma was, naturally, paediatricaIly oriented and it has proved in practice to be a diploma in "mid-level" clinical paediatrics, of no great value to those who acquire it and certainly not something which has lived up to its name. The R.C.P. is in process of re-casting it as something which will give proper emphasis to developmental and social paediatrics and we hope that in its new form it will come much nearer to achieving what is intended. The early attempts of the Society to arrange courses included occasions on which a university institute or department was invited to. provide a short course. There was no lack of willingness in the universities, but it soon became clear that this method would not work literally', it Was impeded by the gap in understanding of need to which we have already referred. And so the pattern began to develop by the Society, a university department and the health department of the city in which the university was situated went into informal partnership to organise a course. Who played what part and to-what extent has varied
T H E S O C I E T Y AS E D U C A T O R
3
from time to time and from place to place, but the pattern is certainly practical and ~ !~':, we believe, continue to be followed in many courses. We nave referred to "the Society". In practice, the Society's central organization has been under considerable pressure and could not have hoped to manage a complete educational programme: The organizational burden has been principally shouldered by the groupswith the Cot.tory Borough, County DistricL Infectious: Diseases, Maternity and Child Welfare, Mental Health and School Health principally involved; The ~oclety s central organization has dealt with tile practical work of handling applications and fees: The rest of 'the task has lain with the groups and they have all found willing volunteers to undertake it. In our view it is right that the grqups should nave the j o b r - a n d the 'credit which comes from it--in so far as courses of "refresher" type are concerned. This is certainly the best way of making sure that the content of the course is accurately adjusted to current special needs and it is good for the health and vigour of the Society that it~ members should be involved in this way. We would go further and suggest that recent experiments by branches in arrangingshort oneday or week-end local courses and seminars should be encouraged to go further. When, however, one comes to consider courses.lasting formore than a couple m" weeks or so, the groups and branches cannot be expected to handle the organization by themselves and in basic courses, like the six-week one, the disciplines of more than one group maybe involved. There must be an improved central mechanism for the purpose, but the Society Cannot do. this entirely from its own .resources, That is why we welcome.the exditing newsthat the Nuflfield.Provincial Hospitals.Trusthas approved a: grant to •the Society of £7500 over three years, to help its postgraduate training Programme in developmental paediatrics: This comes just at the time when.the, need .for extension of the programme is becoming important and urgent and .will 'make a cardinal difference to the prospect. This n e e d not, a s w e have already.indicated, restrict the educational work of the groups and branches and. it may to some extent make that work easier. However it. is certainly:necessary for. the ?three: 'groups directly. :interested in developmental paediatrics-~Maternity a n d C h i l d Welfare; Mental Health: and School .Health--to p0ol-their, knowledge and. experience i n devising the new programme. There are ' a g o o d many specific questions which need to,be asked: and a few o f t h e m m a y be referred t o here. Has the six-week.course,, in its naturM coneentration.on the child's early.Years, taken too little notice o f the school years, which .are also years of development? Can one CourSe of six weeks; adequately cover, the whole .:range, or.~iS-there:a oneed for. a similar fairly-lotig:course for doctors in the scho01..healthservice? How.far is it possible to devise purposeful programmesof field work to supplement the theoretical training of such courses ? Whatabout thebringing in. of doctors outside the public heatfll service?Up
4
PUBLIC
HEALTH
V O L . 83 N O . 1
to now it has appeared virtually impossible to produce courses, either long or short, which attract G.P.s. As regards long courses, this may well be due to the many factors which prevent G.P.s from sparing sufficient time and it may be that the impending changes in G.P.s' conditions will make things easier. But it would seem that even short week-end courses fail to attract the two branches equally. We suspect that some of these courses in the "child health field which have been devised with tile G.P. principally in mind have been somewhat below the level which best suits keen public health doctors. What about the attitude of the Local Authorities ? Some send their M.O.s to courses in substantial numbers while others do do only rarely a n d reluctantly. It may be that the less wi!ling authorities l already have adequate in-service programmes of their own, or that their M.O.s already know everything. W e suspect that a more cogent reason is that they are lo0king more closely at their budgets than at the practical efficiency of their services. M a n y authorities, as a matter of policy, send to courses only their whole-time M.O.s. In the days when part-time M.O.s were fewand, usually;, temporary Jttiis might be justified; at present, when more and more permanent part-tinae]M.O.s form the backbone of the service the case against their receiving training can no longer stand. The ideal would be that basic training Courses should become mandatory, in the. same way as the E.S.N. :ascertainment course., This is not to be expected till the number of basic courses is increased and tliey have demonstrated their quality without question. We believe that both these desiderata will be brought nearer b y thedevelopments which should com~ from the Nuffield grant. Meanwhile we would comment that it is require6 that health visitors, district nurses and midwives m u s t take refresher courses at certain minimmn interval~ Are medical officers of less value to their employers ? There is one argumen. against requiring L.A.s~to send their medical staff to refresher courses at least every three or five years. It is that M.O.s employed by the authorities which are atpresent generous might find that the "maximum,' interval became also the minimum interval, so that they h a d fewer opportunities than they do at present. Though there is substance in this, we are reluctant to accept it as final. Eve n if it did happen, might not the loss to some M.O.s be counterbalanced by the gain to others, so that the service as a whole benefited ? We are conscious that this is a time of change and that the pessimists see the public health service as being on the r o a d to extinction. We accept that it will undergo change; but in some form it must survive if the health of the people is to be maintained. I t will be the more sure to survive if it fits itself to meet the newand challenging needs. The Society willhave great deal o n its hands in the next ten years, but we believe that what-it does in the educational field is at least as important as any of its other tasks. It has done well in the past and its experience and accumulated expertise in this field areunique, It can do even better in. the future--better t h a n fits own past achievements and better, too, than any other organization at present in the field or likely to enter it.