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The training of undergraduates in the public health approach
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THE T R A I N I N G OF U N D E R G R A D U A T E S PUBLIC HEALTH A P P R O A C H By M 1 C H A E L D. W A R R E N,
IN THE
M.D., D.t'.IL, D.I.11.
Senior Lecturer ht Preventive and Social Medichte, London School o f ttygiene and Tropical Medichte It is common experience that there are peculiar difficulties in effectively teaching undergraduate medical students "'The Public Health Approach". One reason for this is the prevalent atlitudc among medical students, and among their teachers, that "public health" knowledge is at best tangential and at worst irrelevant to the practice of medicine. Furthermore, the speciality of public health is seen as one of low caste among the specialties (Coker, et aL, 1959). For the present we must accept that the m'kiority of our students begin their study of medicine with starry-eyed and unrealistic ideas of the quality and quanlily of the work of a doctor. This is no new phenomenon. Many distinguished doctors now specializing in public health ~tnd/or preventive and social medicine decided on their choice of specialty as a result of alterations in their attitudes following experiences after graduation (Fulmer, 1964). For some this alteration in attitude followed experience with the health problems of developing countries; for others service in the Armed forces brought renlization of the contribution that the principles of preventive and social medicine can make to the health of people. The challenge to us is to develop the right attitudes, lmbits, and skills in the undergraduate medical students. OBJECTIVES
The objectives of our teaching must be clearly defined. We have to avoid the grandiloquent expressions of intent, such as "teaching comprehensive medical care", as these are tao vague to challenge the siudent and they imply unacceptable and arrogant criticism of our clinical colleagues. The student must understand the purpose of our teaching, must perceive intermediate goals of achievement along the course, and must believe that all the work required of him is an essential part of what he wanted to accomplish by coming to the medical school. The objectives of our teaching to undergraduates may be summarized under three headings which follow the pattern of the statement of objectives of medical education made by the Association of American Medical Colleges (Miller, 1961). These are:
1. To acquire certaht detailed knowledge of (a) the manner in which the environment, living habits, and social forces affect pebple, both favourably and unfavourably; (b) the techniques and resources available both to the individual and to the community for the prevention of disease and the maintenance of health; (c) the social, cultural, and administrative settings in which medical practice is carried on.
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All this is the basic content of our specialty. 2. To ('-I) (b) (c)
contrihute to the fi~rmat/on o f habits o f continuing self-education, self-criticism, and self-appraisal; thoroughness and accun~cy in carrying out all work; consideration and perceptive,less in the handling of patients.
3. To help the .~'tudent to achieve basic skills ht: (a) eliciting an accurate and adequate history; (19) interpreting findings; (c) gaining lhe conlidence of palients and their relatives; (d) working as a member ot" a learn; (e) balancing his concern for the individual by concern for the community and its hcallh problcms.
C O N T I I NT O ]" TI!F, TIiA Cll IN G The content of the tcaching ol" departmcnts of prcvcnlive a~K] social medicine h'is been discussed clsewhcrc (e.g. Grundy, Mackintosh, 1957; McKeown, 1957, "tnd W,uTen, 1961). llro'~dly speaking, the sulzjects and related subjec,ts that must be presented, although not necessarily by members of the department of prevcnlive and social medicine, :ire Statistics Epidcm iology Human growth and development Medical sociology Social mcdicine Prcventive medicine ldcally Ihc content of the statistics teaching should include most of the knowledge cncoz,npassed by Sir Austin Bradford Hill's famous textbook. Epidemiology must be taught as a basic scientilic discipline of prevenlive and social medicine. The teaching will present the major health problems of the community, discuss the range of normality, the aetiology of disease, the identification of vulnerable groups in the commtmity, methods of clinical trials, field surveys and the examination of the operation of health services. More emphasis wants to be placed on the teaching of the structural, physiological, and psychological changes associated with human growth and development from conception to death. The content of Medical Sociology iS perhaps not so f a m i l i a r ~ a t least under this title. Susser (1964) and Susser and Watson (1962) have detailed and discussed much of the substance that this part of the course should contain. The committee considering the syllabus for the School of Medicine and Human Biology (Malleson, 1963) have also set out the areas of knowledge to be presented. The aspects of the subject that should be covered include the develop-
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ment of the social services in relation to medicine; the structure of families; demographic studies; social determinants of behaviour; social obligations, duties, relationships and expectations as influenced by sex, age, marital, educational and occupational status and cultural background; ecological concepts; the social causes and consequences of physical and psychological illness; the role of the doctor in society; medicine as a social institution and the study of systems of medic:" ~? including the planning, organization and evaluation of medical, healti .velfare services. These latter aspects of the subject I would include as p .... of social medicine. Preventive medicine is concerned with primary prevention (e.g. control of environmental hazards; immunization and chemo-prophylaxis) with the presymptomatic screening of population groups (e.g. see Burns and Warren, 1965), and the aftercare, including rehabilitation and resettlement, of patients (Warren, 1960). METHODS
OF
TEAGHING
Our objectives are ambitious. The knowledge we want to present is extensive. How can all this be accomplished within the present medical course? The answer lies partly in our methods of teaching and partly in integrating much of our teaching into the mainstream of the School's teaching. Statistics and the principles of epidemiology can be taught by lectures and tutorials followed by practical classes. I would like to see statistics taught at school. I am sure it is as satisfactory a subject for the teaching of logic as is geometry; and has the considerable advantage of relevance to life as it is lived today. However, until " O " level maths, is changed to arithmetic, algebra, and statistics, we shall have to continue teaching even elementary statistics at medical schools. Statistics must be taught early, because an understanding of statistics is necessary for handling biological data, comprehending epidemiology and some aspects of medical sociology and evaluating the worth of new and even old treatments. At the Royal Free Hospital School of Medicine I was associated with an experiment to teach a group of ist M.B. (Biology, Physics, and Chemistry) students some elements of statistics. We found that at this stage we could hold their interest, that the students retained a reasonable amount of the teaching, and that a discussion of the major causes of death and illness in various countries added a very acceptable flavour to their studies. Because many students have completed their pre-medical studies before entering a medical school, the statistics course should be in the first term of pre-clinical teaching (anatomy, pyhsiology, etc.). This, I understand, is now done at the Royal Free Hospital School and the application of statistics is emphasized in various practical classes in physiology and pharmacology.
Epidemiology and medical sociology Epidemiology, medical sociology, and human growth and development should be taught as part of the pre-clinical group of subjects, as well as during
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the clinical course. The leaching of these subjects will be partly by lectures, by practical exercises in epidemiological problems, by group discussions (which are particularly valuable for the teaching of medical sociology), and by visits and family attachment schemes. During the pre-clinieal year~, visits should be paid to child welfare sessions, day nurseries, and old people's clubs and communal homes, so that growth, development, and ageing can be observed; at the same time these visits can be used to introduce the student to health problems outside the hospital setting. For example, a visit may be made to a day nursery in order to compare children of different ages. Following such a visit a discussion can be held under the guidance of the medical sociologist about the problems of day nurseries, illegitimacy and/or employed mothers of pre-school children. In this way, time is saved and our objectives of increasing the sensitivity of the students and the comprehensiveness of their understanding of a situation, are approached.
Family attachment schemes Family attachment schemes are used in some American and British medical schools. I have had limited experience of ~ e s e schemes (Horder, Lovell, Marvin, and Warren, 1962) and I feel that this is a valuable method of teaching. The student is introduced in his first or second year at the medical school to a family consisting of mother, father, o n e or two children wi_th another expected shortly. The student observes the birth of the baby and then follows the growth and development of that baby for the next three or four years. At the same time the student observes and records the impact of the new child upon all the members of the family and upon the life of that family. He notes and discusses all incidents of illness and the use the family makes of health and welfare services and resources (including the chemist shop). All this material is discussed at regular intervals between small groups of students, the family's family doctor and various members of the staff. A wide variety of physical, psychological, sociological, and medical problems are presented. Much detailed knowledge can be introduced (e.g. growth and development; family structures; social roles of members of families; details of health and welfare services), and habits of self-appraisal, thoroughness, and sensitiveness in handling people can be developed. The student is helped to work in a team, to develop a comprehensive outlook, and to gain confidence in establishing a professional relationship with people in their own homes. None of this is exclusive to the "Public Health Approach". My thesis is that to achieve our objectives we must start where the students start and capitalize upon the motivation they already have. F o r success we must become part of the whole and then create and seize our opportunities.
Social and preventive medicine Epidemiology and medical sociology will continue to be taught during the clinical years, when social medicine a~d preventive medicine are introduced.
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The meaning of the term social medicine provides enormous ~:,::~'~pefor disputation; I am using the term to cover the study of the various social factors contributing to and arising from illness in an individual and the problems oforganising, deploying and administrating health and medical care services. Preventive medicine is the study of the prevention of illness and disability. Social and preventive medicine have their origins in medical sociology, epidemiology, and clinical medicine. During the clinical years of the student's training, the principles of social and preventive medicine nmst be demonstrated in relation to and with relevance to the needs of patients seen by the students. In most of the London teaching hospitals this means that our point of departure for social and preventive medicine teaching must be an introductory series of tutorials followed by case-studies of the problems presented by patients who are in the wards of the teaching hospitals, or who are attending outpatient departments. Social medicine case conferences I will return later to the unnecessary limitation this imposes on the teaching, but even given the very selected and unrepresentative medical problems seen in a teaching hospital, much can be done by the use of social medicine case conferences first developed in London by Dr. J. Brotherston. I believe that these conferences should be organized by the department of social medicine. One should not attempt to present the social aspects of a patient's problems at the end of a clinico-pathological conference; the C.P.C. endeavours to comprehend the relationship between clinical findings and pathological changes and to understand the whole pathogenesis of the changes observed; frequently the patient whose condition is being studied is dead. This fact alone makes the C.P.C. an inappropriate occasion for a detailed consideration of the preventive and social medical aspects. The areas of medical care that a social medicine case conference are particularly concerned with are the aetiological factors, the possibilities of prevention, the opportunities for early diagnosis, and the after-care of the patient. One is concerned with the ascertainment and correct diagnosis of social and medical need (as distinct from diagnosis of the presenting n~cdical syndrome); the initiation of action to see that needs are met and the ensurance of continuity of action to see that effective co-ordinated use is made of the services available. At the Royal Free Hospital I organized social medicine case conferences in conjunction with two of the consultant physicians and all of the consultant paediatricians. The procedure that I used was to have an.initial discussion with the students, setting out the purpose of the exercise, and delineating the scope of the information required. Two or three weeks later I met the students again. By this time they had chosen a patient for study and so I was able to guide them in the collection of their material and arrange for any special visits. After a few more weeks the final conference was held and all the various
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aspects discussed. ]n addition to the students and staff of the department of social medicine, the key people in this type of exercise are the hospital consultants whose patients are to be discussed, the hospital medical social workers, and the family doctors; without their co-operation nothing can be achieved. It would be invidious and tedious t', list all the people who are frequently or infrequently concerned in this teaching, but I must take this opportunity of thanking our local health authority and especially the divisional medical officer, Dr. W. G. Harding, and his staff for their continuous and inexhaustible interest and contributions to this work.
Bedside teachOlg--G.P, attachment--Family attachment There are, of course, other approaches Io presenting the social medical aspects of a patient's illness. The family attachment schemes which ~ have already mentioned afford m a n y opportunities for this teaching. General practitioner attactmaent schemes are equally valuable. In some hospitals social and preventive medicine is taught at the bedside either by a specialist in social medicine conducting the ward ro~snd himself or by such a specialist contributing to the ward teaching of a clinical specialist. I do not favour this method because I believe the ward is the wrong place for a social medicine discussion, and that this method o f teaching leads to a too hasty and insufficiently detailed preparation by the students.
Visits and projects. So far I have stressed the teaching of service responsibilities for the individual and his family. A vital aspect of our teaching is the fostering of a feeling for the total health needs of the community in which the doctor practices. Some aspects of community health services can be demonstrated very convincingly by the use of films, but these should be supplemented by very carefully programmed visits. In some schools and perhaps outstandingly in the new medical school at Lexington, Kentucky, the students spend up to five weeks on what is termed a "'project" or community study. The student is required to study the operation of the local health services, accompany various members o f the health department staff on their duties, and visit places o f industrial, social, medical, administrative, and political interest. The student is challenged to explain how these factors and his observations are related to the health and medical care problems of the community he is studying.
The "'elective" period M a n y medical schools now offer an "elective" period during the clinical course. This should be a period o f three months, free o f mr/oh o f the routine lectures and ward rounds, during which the student m a y s t u d y in depth some aspect of medicine of his own choosing. Where this period has been introduced and where there are active departments of preventive and social medicine, some
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students each year have elected to spend this period in such departments. During this time the student m a y pursue some epidemiological or sociomedical study of his own, he m a y take part in some studies that are being undertaken in the department or he m a y even spend some time abroad working in a developing country, (e.g. Hedley and Snaith, 1965): The elective period provides immense opportunities for teaching and for fostering the interest and understanding of the student in some of the more specialized aspects of preventive and social medicine. (For further discussion of the various methods of teaching see Brockington, Silver, and Vuletic, 1964.)
Pre-registration period I cannot deal at length with the pre-registration period which all too often is an abuse of educational intent. The pre-registration year should be part of the medical training. It is the time to teach detailed knowledge about community services. This can be done by holding weekly meetings at which all the patients who have been discharged during the week are discussed. This is also the time to discuss broad problems of medical care and community medicine, such as the determination of priorities o f spending on healtfi and medical services, the need for comprehensive planning o f health and medical services, and the need to measure what contribution each service makes to health care.
The hospital and the community I have referred to the need for students to study problems outside the teaching hospital. The disadvantages of hospital-based teaching are the relative isolation of the hospital from the community, the protective atmosphere of the hospital, the limited nature of its service, and the marked selection of its patients. As t?rofessor R. Acheson (1963) has so admirably expressed these points, "the biologist's cell in vitro is in m a n y ways analogous to the patient in hospital, for here a person, an individual cell has been isolated from the tissue of society and is being studied under closely controlled and artificial circumstances. It is, therefore, about as ridiculous to expect a medical student to obtain a complete picture of a m a n and his disease by studying them during a period as a hospital patient, as it is to expect him to conjure up an idea o f a kidneyMlet alone the monkey from which it c a m e - - b y examining a tissue-culture preparation". These defects in the experience available to medical students are being partially remedied by the establishment of general practice attachment schemes, general practice teaching units, and health centres. However, we must face the fact that a considerable proportion of the training of doctors will take place within the medical school and the hospital and, therefore, as well as establishing extra-mural teaching facilities, it is necessary to integrate the hospital and its services into the whole complex of the c o m m u n i t y medical services. The field training area of the medical, nursing, and the other students at the hospital
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should be the surrounding community. In London some of the teaching hospitals are assuming district hospital responsibilities and will thereby be able to demonstrate a wider range and greater variety of medical conditions and of patient~ to their students. There is immense scope in London at the present time for partnerships to be developed between teaching hospitals and the new boroughs wlfich surround them; nowhere should this partnership be closer ~han between the public health department and the department of preventive and social medicine.
The teachers The training of the medical student in the public health approach must be the constant concern of m a n y medical and non-medical teachers working inside and outside the hospital. Statisticians, economists, sociologists, pa~diatricians, geriatrieians, psychiatrists, other clinicians, public health staff, general practitioners, and specialists in preventive and social medicine must all be involved. However, in order that all these teachers should not build a Babel's tower, it is necessary for there to be someone responsible for programming the teaching, for integrating the various contributions with each other and with the other teaching of the students and for the evaluation o f the teaching. This person should hold a full-time senior appointment in the medical school and on the hospital staff. Only if he holds such an appointment can he be in a position to carry out the necessary programming and be fully acquainted with and contributing to the planning of the whole medical curriculum. In addition to his administrative duties he will have teaclfing duties, will be directing and carrying out research work in epidemiology, preventive medicine, social medicine, and/or the organization of health and medical services. He should have a definite function within the hospital (e.g. Warren, 1965). To carry out these functions the person in charge of the preventive and social medicine teaching must have supporting staff. Integrated teaching, small group discussions, personal supervision of students, all consume a considerable a m o u n t of staff time. "'Formal" teaching time required The programme outlined in this paper will need about 200 hours of so-tailed " f o r m a l " teaching time. Spread out, as I have suggested, over the five years of training then the requirements are forty hours per year or less than 2 per cent. of the available teaching time. The 200 hours do not include time spent on an elective period or on special project work. SUMMARY
There is a particular difficulty in teaching medical students to think "preventively" and "socially" because of a prevalent attitude among them and among their teachers that "public health knowledge" is at best tangential and at worst irrelevant to the practice of medicine as they conceive it.
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The objectives of the teaching of preventive and social medicine are that the students should acquire detailed knowledge of the ways in which the environment, both physical and social, can affect the health of people, of the techniques and resources available for prevention of disease, and of the social and cultural settings in which medical practice is carried on. The subjects that must be taught although not all must necessarily be taught by the staff of departments of preventive and social medicine, are statistics, epidemiology, human growfll and development, medical sociology, social medicine, and preventive medicine. Statistics should be taught early in the course; indeed, it should form a school subject. H u m a n growth and development and some aspects of epidemiology and medical sociology should be included in the pre-clinical years, while the practical applications in terms of helping patients and understanding disease processes should be discussed and demonstrated in the clinical years of the training. Various methods o f teaching need to be used. In addition to the more traditional methods of lectures, tutorials and classroom practical work, discussion groups, general practitioner attachment schemes, family attachment schemes, visits, project work, and case studies should be introduced. To give reality to much of its teaching it is necessary for each teaching hospital to assume some "district hospital" responsibilities and to become concerned with the health and medical problems in its area, The responsibility for organizing the teaching should be given to the head of a department of preventive and social medicine. REFERENCES ACHESON, R. (1963). The Role of the Department of Social Medicine in Undergraduate Medical Education. Jr. reed. Educ., 38, 676. BROCKINGTON, F., SmVER, G., and VULL~rIc,A. (1964). Teaching of the Medical Student for Comprehensive Medical Practice. Wld. Hlth. Org. (Educ.). 126. BURNS, C., and WARREN, M. D. (1965). The Presymptomatic Diagnosis of Disease. In the press. COKER, R., BLACK, K., CONNELLY,Z., MILLER, N., and PHILLIPS, B. (1959). Public Health as Viewed by the Medical Student. Amer. J. Publ. HIth, 49, 601. FULMER,H . S. (1964). Teaching Community Medicine in Kentucky. Harv. Publ. I-Ilth. Alumni Bull. 21.2.2. GRtmDY, F., and MACKI~rosn, J. M. (1957). The Teaching of Hygiene and Public Health in ]Europe. tFld. _Tilth Org. Monogr. Ser. 34, 109. HEDIJ~Y, A. J., and SNArrH, M. L. (1965). Overseas Scholarships. Lancet, i, 314. HILL, Sir A. B. (1961). Principles of Medical Statistics. Lancet, HORDER, J., LOVELL,E. A., MARVIN,¥ . M., and WARREN, M. D. (1962). A Study of Normal Families. Lancet, i, 263. McKEow~, T. (1957). The Preparation of a Syllabus in Social Medicine. d. reed. Edue. 32, 110. MALL~ON, N. (1963). Schools of Medicine and Human Biology. MILLER, G. E. (Ed.) (1961). Teaching and Learning in Medical School Commonwealth Fund, Harvard University Press. Suss~R, M. (1964). The Uses o f Social Science in Medicine. SUsSER, M., and WATSON, W. (1962). Sociology in Medicine. 2,425 London: Oxford University Press.
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WARREN, M. D. (1960). The Hospital Resettlement Clinic and the Community Care of Handicapped People. Med. Offr, 106, 69. WARREN, M. D. (1961). Social and Preventive Medicine. Brit. Jr. Clin. Pract. 15.217. WARREN, M. D. (1965). The Medical Officer of Health as a Consultant in Preventive and Social Medicine. Publ. Hlth, 72, 62.
Discussion
Dr J. F. Warin (Medical Officer of Health, Oxford) felt the medical student of today was too much in the hospital and should be brought more into the community. The local Medical Officer of Health should have his place in a department of preventive medicine in the hospital as on him would depend to a great deal how much of the preventive outlook would prevail throughout the hospital and its teaching. His own links to the teaching hospital in Oxford had started with the Control of Infection committee which had developed into a Health and Hygiene committee and from there there has spread a veryimportant preventive outlook. He felt that public health visits should be related to local authority staff such as Health Visitors and others in contact with general practitioners. It was much better for them to go out with these workers rather than to visit premises. The more the general practitioner and the public health side come together the better for ordinary day-to-day work and for teaching medical students. In this way the lesson can be learnt more quickly and more easily than if local authority work was felt to be unrelated to the work of the family doctor. Col. M. M. Lewis (Professor of Army Health, R.A.M. College) said that he saw a large saanple of newly qualified doctors at the Army College. Unlike his colleagues in the medical and surgical departments, he found that he could not count on these doctors having any basic knowledge whatsoever of public health and he had to start by giving them what is, in fact, undergraduate teaching. He regarded the general practitioner as the leader of the public health team. In the field in the Army the duties were combined; the Army general practitioner has his public health nurse who helps him in his general practitioner duties and who is also health visitor, midwife, home and school nurse. The basis of the teaching which he had to give concerned man and his reaction to envionment and also ways and means of improving the environment or of man's behaviour in it. As far as higher qualifications are concerned, we should have a Royal College of Preventive Medicine. There was a real need for a higher degree but the M.R.C.P. was not the answer and the M.D. varied considerably in standard. It was difficult to get consultant status in preventive medicine in the armed forces because the D.P.H. was not regarded as a high enough qualification. D r E. W. Maeara (Bristol University) spoke as the only full time lecturer in Bristol in his subject. He was trying to cope with far too much work and he felt that Dr Warren had brilliantly painted the ideal ways of teaching our
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subject. His impression was that the undergraduate student was neither as hostile nor indifferent to our teaching as v,;csupposed. He was very encouraged by tile response of the students to public health clerkships in tile fifth year and lie felt that they should have links with his department as with other departments, and for longer than one month. His aim was to give tile student for the first time some idea of what are the priorities in medicine and what lhe doctor should be in the community, and encourage him to take a long coot look at medicine and at the whole body of care. The General Medicine Council was reappraising the medical curriculum, and he felt strongly that the Society of Medical Officers of Health should fight for what we want. Dr A. P. WhRfiekl (Principal Medical Officer, Middlesex) gave "a short perhaps negative story" concerning her daughter who is a final year clinical medicine student. She was enjoying the type of case conference described by Dr Warren and in the course of investigating a family allocated to her had contactcd the Superintendent Health Visitor for permission to talk to the health visitor concerned, but was refused on the grounds that the inibrmation was highly confidenlial and not for medical students. Later she was very grudgingly told a time at which she could contact the health dsitor on the telephone. All health educators should know what wc were trying to get at in training medical students. Dr a. 1-17,Walker (University of Newcastle-upon-Tyne) said that Newcastle had followed the G.M.C, lead with a new medical curriculum and in Newcastle our subject was taught in association with the general practitioner. In the fourth year there was a four week period for family and community medicine which only slightly involved the hospital and was much more orientated towards the G.P., with concentration on how thepublic health services impinge on the family doctor. The student paid visits with the health visitors and were encouraged to see the links between social conditions and health. Parallel with this ran eight mornings attached to G.P.'s. Every student was given a family, each of which was selected and had something in common, e.g. a family with teenage children. At the end of the period there was a seminar which tended to become lopsided with more members of staff attending than students. The scheme was still experimental but he felt that it had possibilities.
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THE T R A I N I N G OF U N D E R G R A D U A T E S PUBLIC HEALTH A P P R O A C H By M 1 C H A E L D. W A R R E N,
IN THE
M.D., D.t'.IL, D.I.11.
Senior Lecturer ht Preventive and Social Medichte, London School o f ttygiene and Tropical Medichte It is common experience that there are peculiar difficulties in effectively teaching undergraduate medical students "'The Public Health Approach". One reason for this is the prevalent atlitudc among medical students, and among their teachers, that "public health" knowledge is at best tangential and at worst irrelevant to the practice of medicine. Furthermore, the speciality of public health is seen as one of low caste among the specialties (Coker, et aL, 1959). For the present we must accept that the m'kiority of our students begin their study of medicine with starry-eyed and unrealistic ideas of the quality and quanlily of the work of a doctor. This is no new phenomenon. Many distinguished doctors now specializing in public health ~tnd/or preventive and social medicine decided on their choice of specialty as a result of alterations in their attitudes following experiences after graduation (Fulmer, 1964). For some this alteration in attitude followed experience with the health problems of developing countries; for others service in the Armed forces brought renlization of the contribution that the principles of preventive and social medicine can make to the health of people. The challenge to us is to develop the right attitudes, lmbits, and skills in the undergraduate medical students. OBJECTIVES
The objectives of our teaching must be clearly defined. We have to avoid the grandiloquent expressions of intent, such as "teaching comprehensive medical care", as these are tao vague to challenge the siudent and they imply unacceptable and arrogant criticism of our clinical colleagues. The student must understand the purpose of our teaching, must perceive intermediate goals of achievement along the course, and must believe that all the work required of him is an essential part of what he wanted to accomplish by coming to the medical school. The objectives of our teaching to undergraduates may be summarized under three headings which follow the pattern of the statement of objectives of medical education made by the Association of American Medical Colleges (Miller, 1961). These are:
1. To acquire certaht detailed knowledge of (a) the manner in which the environment, living habits, and social forces affect pebple, both favourably and unfavourably; (b) the techniques and resources available both to the individual and to the community for the prevention of disease and the maintenance of health; (c) the social, cultural, and administrative settings in which medical practice is carried on.
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All this is the basic content of our specialty. 2. To ('-I) (b) (c)
contrihute to the fi~rmat/on o f habits o f continuing self-education, self-criticism, and self-appraisal; thoroughness and accun~cy in carrying out all work; consideration and perceptive,less in the handling of patients.
3. To help the .~'tudent to achieve basic skills ht: (a) eliciting an accurate and adequate history; (19) interpreting findings; (c) gaining lhe conlidence of palients and their relatives; (d) working as a member ot" a learn; (e) balancing his concern for the individual by concern for the community and its hcallh problcms.
C O N T I I NT O ]" TI!F, TIiA Cll IN G The content of the tcaching ol" departmcnts of prcvcnlive a~K] social medicine h'is been discussed clsewhcrc (e.g. Grundy, Mackintosh, 1957; McKeown, 1957, "tnd W,uTen, 1961). llro'~dly speaking, the sulzjects and related subjec,ts that must be presented, although not necessarily by members of the department of prevcnlive and social medicine, :ire Statistics Epidcm iology Human growth and development Medical sociology Social mcdicine Prcventive medicine ldcally Ihc content of the statistics teaching should include most of the knowledge cncoz,npassed by Sir Austin Bradford Hill's famous textbook. Epidemiology must be taught as a basic scientilic discipline of prevenlive and social medicine. The teaching will present the major health problems of the community, discuss the range of normality, the aetiology of disease, the identification of vulnerable groups in the commtmity, methods of clinical trials, field surveys and the examination of the operation of health services. More emphasis wants to be placed on the teaching of the structural, physiological, and psychological changes associated with human growth and development from conception to death. The content of Medical Sociology iS perhaps not so f a m i l i a r ~ a t least under this title. Susser (1964) and Susser and Watson (1962) have detailed and discussed much of the substance that this part of the course should contain. The committee considering the syllabus for the School of Medicine and Human Biology (Malleson, 1963) have also set out the areas of knowledge to be presented. The aspects of the subject that should be covered include the develop-
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ment of the social services in relation to medicine; the structure of families; demographic studies; social determinants of behaviour; social obligations, duties, relationships and expectations as influenced by sex, age, marital, educational and occupational status and cultural background; ecological concepts; the social causes and consequences of physical and psychological illness; the role of the doctor in society; medicine as a social institution and the study of systems of medic:" ~? including the planning, organization and evaluation of medical, healti .velfare services. These latter aspects of the subject I would include as p .... of social medicine. Preventive medicine is concerned with primary prevention (e.g. control of environmental hazards; immunization and chemo-prophylaxis) with the presymptomatic screening of population groups (e.g. see Burns and Warren, 1965), and the aftercare, including rehabilitation and resettlement, of patients (Warren, 1960). METHODS
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Our objectives are ambitious. The knowledge we want to present is extensive. How can all this be accomplished within the present medical course? The answer lies partly in our methods of teaching and partly in integrating much of our teaching into the mainstream of the School's teaching. Statistics and the principles of epidemiology can be taught by lectures and tutorials followed by practical classes. I would like to see statistics taught at school. I am sure it is as satisfactory a subject for the teaching of logic as is geometry; and has the considerable advantage of relevance to life as it is lived today. However, until " O " level maths, is changed to arithmetic, algebra, and statistics, we shall have to continue teaching even elementary statistics at medical schools. Statistics must be taught early, because an understanding of statistics is necessary for handling biological data, comprehending epidemiology and some aspects of medical sociology and evaluating the worth of new and even old treatments. At the Royal Free Hospital School of Medicine I was associated with an experiment to teach a group of ist M.B. (Biology, Physics, and Chemistry) students some elements of statistics. We found that at this stage we could hold their interest, that the students retained a reasonable amount of the teaching, and that a discussion of the major causes of death and illness in various countries added a very acceptable flavour to their studies. Because many students have completed their pre-medical studies before entering a medical school, the statistics course should be in the first term of pre-clinical teaching (anatomy, pyhsiology, etc.). This, I understand, is now done at the Royal Free Hospital School and the application of statistics is emphasized in various practical classes in physiology and pharmacology.
Epidemiology and medical sociology Epidemiology, medical sociology, and human growth and development should be taught as part of the pre-clinical group of subjects, as well as during
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the clinical course. The leaching of these subjects will be partly by lectures, by practical exercises in epidemiological problems, by group discussions (which are particularly valuable for the teaching of medical sociology), and by visits and family attachment schemes. During the pre-clinieal year~, visits should be paid to child welfare sessions, day nurseries, and old people's clubs and communal homes, so that growth, development, and ageing can be observed; at the same time these visits can be used to introduce the student to health problems outside the hospital setting. For example, a visit may be made to a day nursery in order to compare children of different ages. Following such a visit a discussion can be held under the guidance of the medical sociologist about the problems of day nurseries, illegitimacy and/or employed mothers of pre-school children. In this way, time is saved and our objectives of increasing the sensitivity of the students and the comprehensiveness of their understanding of a situation, are approached.
Family attachment schemes Family attachment schemes are used in some American and British medical schools. I have had limited experience of ~ e s e schemes (Horder, Lovell, Marvin, and Warren, 1962) and I feel that this is a valuable method of teaching. The student is introduced in his first or second year at the medical school to a family consisting of mother, father, o n e or two children wi_th another expected shortly. The student observes the birth of the baby and then follows the growth and development of that baby for the next three or four years. At the same time the student observes and records the impact of the new child upon all the members of the family and upon the life of that family. He notes and discusses all incidents of illness and the use the family makes of health and welfare services and resources (including the chemist shop). All this material is discussed at regular intervals between small groups of students, the family's family doctor and various members of the staff. A wide variety of physical, psychological, sociological, and medical problems are presented. Much detailed knowledge can be introduced (e.g. growth and development; family structures; social roles of members of families; details of health and welfare services), and habits of self-appraisal, thoroughness, and sensitiveness in handling people can be developed. The student is helped to work in a team, to develop a comprehensive outlook, and to gain confidence in establishing a professional relationship with people in their own homes. None of this is exclusive to the "Public Health Approach". My thesis is that to achieve our objectives we must start where the students start and capitalize upon the motivation they already have. F o r success we must become part of the whole and then create and seize our opportunities.
Social and preventive medicine Epidemiology and medical sociology will continue to be taught during the clinical years, when social medicine a~d preventive medicine are introduced.
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The meaning of the term social medicine provides enormous ~:,::~'~pefor disputation; I am using the term to cover the study of the various social factors contributing to and arising from illness in an individual and the problems oforganising, deploying and administrating health and medical care services. Preventive medicine is the study of the prevention of illness and disability. Social and preventive medicine have their origins in medical sociology, epidemiology, and clinical medicine. During the clinical years of the student's training, the principles of social and preventive medicine nmst be demonstrated in relation to and with relevance to the needs of patients seen by the students. In most of the London teaching hospitals this means that our point of departure for social and preventive medicine teaching must be an introductory series of tutorials followed by case-studies of the problems presented by patients who are in the wards of the teaching hospitals, or who are attending outpatient departments. Social medicine case conferences I will return later to the unnecessary limitation this imposes on the teaching, but even given the very selected and unrepresentative medical problems seen in a teaching hospital, much can be done by the use of social medicine case conferences first developed in London by Dr. J. Brotherston. I believe that these conferences should be organized by the department of social medicine. One should not attempt to present the social aspects of a patient's problems at the end of a clinico-pathological conference; the C.P.C. endeavours to comprehend the relationship between clinical findings and pathological changes and to understand the whole pathogenesis of the changes observed; frequently the patient whose condition is being studied is dead. This fact alone makes the C.P.C. an inappropriate occasion for a detailed consideration of the preventive and social medical aspects. The areas of medical care that a social medicine case conference are particularly concerned with are the aetiological factors, the possibilities of prevention, the opportunities for early diagnosis, and the after-care of the patient. One is concerned with the ascertainment and correct diagnosis of social and medical need (as distinct from diagnosis of the presenting n~cdical syndrome); the initiation of action to see that needs are met and the ensurance of continuity of action to see that effective co-ordinated use is made of the services available. At the Royal Free Hospital I organized social medicine case conferences in conjunction with two of the consultant physicians and all of the consultant paediatricians. The procedure that I used was to have an.initial discussion with the students, setting out the purpose of the exercise, and delineating the scope of the information required. Two or three weeks later I met the students again. By this time they had chosen a patient for study and so I was able to guide them in the collection of their material and arrange for any special visits. After a few more weeks the final conference was held and all the various
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aspects discussed. ]n addition to the students and staff of the department of social medicine, the key people in this type of exercise are the hospital consultants whose patients are to be discussed, the hospital medical social workers, and the family doctors; without their co-operation nothing can be achieved. It would be invidious and tedious t', list all the people who are frequently or infrequently concerned in this teaching, but I must take this opportunity of thanking our local health authority and especially the divisional medical officer, Dr. W. G. Harding, and his staff for their continuous and inexhaustible interest and contributions to this work.
Bedside teachOlg--G.P, attachment--Family attachment There are, of course, other approaches Io presenting the social medical aspects of a patient's illness. The family attachment schemes which ~ have already mentioned afford m a n y opportunities for this teaching. General practitioner attactmaent schemes are equally valuable. In some hospitals social and preventive medicine is taught at the bedside either by a specialist in social medicine conducting the ward ro~snd himself or by such a specialist contributing to the ward teaching of a clinical specialist. I do not favour this method because I believe the ward is the wrong place for a social medicine discussion, and that this method o f teaching leads to a too hasty and insufficiently detailed preparation by the students.
Visits and projects. So far I have stressed the teaching of service responsibilities for the individual and his family. A vital aspect of our teaching is the fostering of a feeling for the total health needs of the community in which the doctor practices. Some aspects of community health services can be demonstrated very convincingly by the use of films, but these should be supplemented by very carefully programmed visits. In some schools and perhaps outstandingly in the new medical school at Lexington, Kentucky, the students spend up to five weeks on what is termed a "'project" or community study. The student is required to study the operation of the local health services, accompany various members o f the health department staff on their duties, and visit places o f industrial, social, medical, administrative, and political interest. The student is challenged to explain how these factors and his observations are related to the health and medical care problems of the community he is studying.
The "'elective" period M a n y medical schools now offer an "elective" period during the clinical course. This should be a period o f three months, free o f mr/oh o f the routine lectures and ward rounds, during which the student m a y s t u d y in depth some aspect of medicine of his own choosing. Where this period has been introduced and where there are active departments of preventive and social medicine, some
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students each year have elected to spend this period in such departments. During this time the student m a y pursue some epidemiological or sociomedical study of his own, he m a y take part in some studies that are being undertaken in the department or he m a y even spend some time abroad working in a developing country, (e.g. Hedley and Snaith, 1965): The elective period provides immense opportunities for teaching and for fostering the interest and understanding of the student in some of the more specialized aspects of preventive and social medicine. (For further discussion of the various methods of teaching see Brockington, Silver, and Vuletic, 1964.)
Pre-registration period I cannot deal at length with the pre-registration period which all too often is an abuse of educational intent. The pre-registration year should be part of the medical training. It is the time to teach detailed knowledge about community services. This can be done by holding weekly meetings at which all the patients who have been discharged during the week are discussed. This is also the time to discuss broad problems of medical care and community medicine, such as the determination of priorities o f spending on healtfi and medical services, the need for comprehensive planning o f health and medical services, and the need to measure what contribution each service makes to health care.
The hospital and the community I have referred to the need for students to study problems outside the teaching hospital. The disadvantages of hospital-based teaching are the relative isolation of the hospital from the community, the protective atmosphere of the hospital, the limited nature of its service, and the marked selection of its patients. As t?rofessor R. Acheson (1963) has so admirably expressed these points, "the biologist's cell in vitro is in m a n y ways analogous to the patient in hospital, for here a person, an individual cell has been isolated from the tissue of society and is being studied under closely controlled and artificial circumstances. It is, therefore, about as ridiculous to expect a medical student to obtain a complete picture of a m a n and his disease by studying them during a period as a hospital patient, as it is to expect him to conjure up an idea o f a kidneyMlet alone the monkey from which it c a m e - - b y examining a tissue-culture preparation". These defects in the experience available to medical students are being partially remedied by the establishment of general practice attachment schemes, general practice teaching units, and health centres. However, we must face the fact that a considerable proportion of the training of doctors will take place within the medical school and the hospital and, therefore, as well as establishing extra-mural teaching facilities, it is necessary to integrate the hospital and its services into the whole complex of the c o m m u n i t y medical services. The field training area of the medical, nursing, and the other students at the hospital
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should be the surrounding community. In London some of the teaching hospitals are assuming district hospital responsibilities and will thereby be able to demonstrate a wider range and greater variety of medical conditions and of patient~ to their students. There is immense scope in London at the present time for partnerships to be developed between teaching hospitals and the new boroughs wlfich surround them; nowhere should this partnership be closer ~han between the public health department and the department of preventive and social medicine.
The teachers The training of the medical student in the public health approach must be the constant concern of m a n y medical and non-medical teachers working inside and outside the hospital. Statisticians, economists, sociologists, pa~diatricians, geriatrieians, psychiatrists, other clinicians, public health staff, general practitioners, and specialists in preventive and social medicine must all be involved. However, in order that all these teachers should not build a Babel's tower, it is necessary for there to be someone responsible for programming the teaching, for integrating the various contributions with each other and with the other teaching of the students and for the evaluation o f the teaching. This person should hold a full-time senior appointment in the medical school and on the hospital staff. Only if he holds such an appointment can he be in a position to carry out the necessary programming and be fully acquainted with and contributing to the planning of the whole medical curriculum. In addition to his administrative duties he will have teaclfing duties, will be directing and carrying out research work in epidemiology, preventive medicine, social medicine, and/or the organization of health and medical services. He should have a definite function within the hospital (e.g. Warren, 1965). To carry out these functions the person in charge of the preventive and social medicine teaching must have supporting staff. Integrated teaching, small group discussions, personal supervision of students, all consume a considerable a m o u n t of staff time. "'Formal" teaching time required The programme outlined in this paper will need about 200 hours of so-tailed " f o r m a l " teaching time. Spread out, as I have suggested, over the five years of training then the requirements are forty hours per year or less than 2 per cent. of the available teaching time. The 200 hours do not include time spent on an elective period or on special project work. SUMMARY
There is a particular difficulty in teaching medical students to think "preventively" and "socially" because of a prevalent attitude among them and among their teachers that "public health knowledge" is at best tangential and at worst irrelevant to the practice of medicine as they conceive it.
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The objectives of the teaching of preventive and social medicine are that the students should acquire detailed knowledge of the ways in which the environment, both physical and social, can affect the health of people, of the techniques and resources available for prevention of disease, and of the social and cultural settings in which medical practice is carried on. The subjects that must be taught although not all must necessarily be taught by the staff of departments of preventive and social medicine, are statistics, epidemiology, human growfll and development, medical sociology, social medicine, and preventive medicine. Statistics should be taught early in the course; indeed, it should form a school subject. H u m a n growth and development and some aspects of epidemiology and medical sociology should be included in the pre-clinical years, while the practical applications in terms of helping patients and understanding disease processes should be discussed and demonstrated in the clinical years of the training. Various methods o f teaching need to be used. In addition to the more traditional methods of lectures, tutorials and classroom practical work, discussion groups, general practitioner attachment schemes, family attachment schemes, visits, project work, and case studies should be introduced. To give reality to much of its teaching it is necessary for each teaching hospital to assume some "district hospital" responsibilities and to become concerned with the health and medical problems in its area, The responsibility for organizing the teaching should be given to the head of a department of preventive and social medicine. REFERENCES ACHESON, R. (1963). The Role of the Department of Social Medicine in Undergraduate Medical Education. Jr. reed. Educ., 38, 676. BROCKINGTON, F., SmVER, G., and VULL~rIc,A. (1964). Teaching of the Medical Student for Comprehensive Medical Practice. Wld. Hlth. Org. (Educ.). 126. BURNS, C., and WARREN, M. D. (1965). The Presymptomatic Diagnosis of Disease. In the press. COKER, R., BLACK, K., CONNELLY,Z., MILLER, N., and PHILLIPS, B. (1959). Public Health as Viewed by the Medical Student. Amer. J. Publ. HIth, 49, 601. FULMER,H . S. (1964). Teaching Community Medicine in Kentucky. Harv. Publ. I-Ilth. Alumni Bull. 21.2.2. GRtmDY, F., and MACKI~rosn, J. M. (1957). The Teaching of Hygiene and Public Health in ]Europe. tFld. _Tilth Org. Monogr. Ser. 34, 109. HEDIJ~Y, A. J., and SNArrH, M. L. (1965). Overseas Scholarships. Lancet, i, 314. HILL, Sir A. B. (1961). Principles of Medical Statistics. Lancet, HORDER, J., LOVELL,E. A., MARVIN,¥ . M., and WARREN, M. D. (1962). A Study of Normal Families. Lancet, i, 263. McKEow~, T. (1957). The Preparation of a Syllabus in Social Medicine. d. reed. Edue. 32, 110. MALL~ON, N. (1963). Schools of Medicine and Human Biology. MILLER, G. E. (Ed.) (1961). Teaching and Learning in Medical School Commonwealth Fund, Harvard University Press. Suss~R, M. (1964). The Uses o f Social Science in Medicine. SUsSER, M., and WATSON, W. (1962). Sociology in Medicine. 2,425 London: Oxford University Press.
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WARREN, M. D. (1960). The Hospital Resettlement Clinic and the Community Care of Handicapped People. Med. Offr, 106, 69. WARREN, M. D. (1961). Social and Preventive Medicine. Brit. Jr. Clin. Pract. 15.217. WARREN, M. D. (1965). The Medical Officer of Health as a Consultant in Preventive and Social Medicine. Publ. Hlth, 72, 62.
Discussion
Dr J. F. Warin (Medical Officer of Health, Oxford) felt the medical student of today was too much in the hospital and should be brought more into the community. The local Medical Officer of Health should have his place in a department of preventive medicine in the hospital as on him would depend to a great deal how much of the preventive outlook would prevail throughout the hospital and its teaching. His own links to the teaching hospital in Oxford had started with the Control of Infection committee which had developed into a Health and Hygiene committee and from there there has spread a veryimportant preventive outlook. He felt that public health visits should be related to local authority staff such as Health Visitors and others in contact with general practitioners. It was much better for them to go out with these workers rather than to visit premises. The more the general practitioner and the public health side come together the better for ordinary day-to-day work and for teaching medical students. In this way the lesson can be learnt more quickly and more easily than if local authority work was felt to be unrelated to the work of the family doctor. Col. M. M. Lewis (Professor of Army Health, R.A.M. College) said that he saw a large saanple of newly qualified doctors at the Army College. Unlike his colleagues in the medical and surgical departments, he found that he could not count on these doctors having any basic knowledge whatsoever of public health and he had to start by giving them what is, in fact, undergraduate teaching. He regarded the general practitioner as the leader of the public health team. In the field in the Army the duties were combined; the Army general practitioner has his public health nurse who helps him in his general practitioner duties and who is also health visitor, midwife, home and school nurse. The basis of the teaching which he had to give concerned man and his reaction to envionment and also ways and means of improving the environment or of man's behaviour in it. As far as higher qualifications are concerned, we should have a Royal College of Preventive Medicine. There was a real need for a higher degree but the M.R.C.P. was not the answer and the M.D. varied considerably in standard. It was difficult to get consultant status in preventive medicine in the armed forces because the D.P.H. was not regarded as a high enough qualification. D r E. W. Maeara (Bristol University) spoke as the only full time lecturer in Bristol in his subject. He was trying to cope with far too much work and he felt that Dr Warren had brilliantly painted the ideal ways of teaching our
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subject. His impression was that the undergraduate student was neither as hostile nor indifferent to our teaching as v,;csupposed. He was very encouraged by tile response of the students to public health clerkships in tile fifth year and lie felt that they should have links with his department as with other departments, and for longer than one month. His aim was to give tile student for the first time some idea of what are the priorities in medicine and what lhe doctor should be in the community, and encourage him to take a long coot look at medicine and at the whole body of care. The General Medicine Council was reappraising the medical curriculum, and he felt strongly that the Society of Medical Officers of Health should fight for what we want. Dr A. P. WhRfiekl (Principal Medical Officer, Middlesex) gave "a short perhaps negative story" concerning her daughter who is a final year clinical medicine student. She was enjoying the type of case conference described by Dr Warren and in the course of investigating a family allocated to her had contactcd the Superintendent Health Visitor for permission to talk to the health visitor concerned, but was refused on the grounds that the inibrmation was highly confidenlial and not for medical students. Later she was very grudgingly told a time at which she could contact the health dsitor on the telephone. All health educators should know what wc were trying to get at in training medical students. Dr a. 1-17,Walker (University of Newcastle-upon-Tyne) said that Newcastle had followed the G.M.C, lead with a new medical curriculum and in Newcastle our subject was taught in association with the general practitioner. In the fourth year there was a four week period for family and community medicine which only slightly involved the hospital and was much more orientated towards the G.P., with concentration on how thepublic health services impinge on the family doctor. The student paid visits with the health visitors and were encouraged to see the links between social conditions and health. Parallel with this ran eight mornings attached to G.P.'s. Every student was given a family, each of which was selected and had something in common, e.g. a family with teenage children. At the end of the period there was a seminar which tended to become lopsided with more members of staff attending than students. The scheme was still experimental but he felt that it had possibilities.