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WHAT IS WRONG WITH THE MEDICAL CURRICULUM ?
301
SPECIAL ARTICLES German, and a third foreign language, has an advantage WHAT IS WRONG WITH THE MEDICAL over his fellows which, should he show any real ability enormous value to him I career. find it impossible to believe his throughout that it would not be easy for those in charge of our public schools to give their pupils this instruction, and I think it would be more than reasonable if the General Medical Council were to insist that every student, before registration, should have passed an examination guaranteeing his competence to read
for
CURRICULUM ?
(A Series of Opinions Contributed by Request) IX BY T. IZOD DEAN
BENNETT, M.D., F.R.C.P.
OF THE MEDICAL SCHOOL, MIDDLESEX HOSPITAL; BEIT MEMORIAL FELLOW FOR MEDICAL RESEARCH
LATE
IT might reasonably be argued that the principle .difficulty of the present medical curriculum is that the length of time necessary for carrying out the .requirements of the educational authorities is such that an impossible economic burden is placed upon many students. Anyone who has the advancement
medicine, will be of
French, German, and one other foreign language. A much higher standard than this is demanded in many continental medical schools, but the capacity to read is all that is really essential, and it is acquired much more easily than any great knowledge of grammar or facility in pronunciation. From the utilitarian point of view it seems to me that the preliminary educational necessities for the medical student are : (a) A knowledge of English sufficient to enable him to write his own language with some facility and correctitude; ’
’of medical science at heart must feel that this economic .stress deprives us of many students of very high intelligence, and diverts them to other occupations where their ability is often wasted. A somewhat (b) A knowledge of mathematics sufficient to enable -desperate problem is constantly confronting us ; on him to assimilate physics and chemistry ; and the one hand the advance of knowledge calls for (c) A knowledge of written modern language of the .an increase in the period of education, and, on the standard set out above. .other hand, the cost of education calls for a diminution It is undoubtedly useful for a student to know enough in the time demanded from the student. Latin to understand the meaning of certain scientific If one sits down with pencil and paper and makes terms, but it may be assumed that such knowledge .a rough calculation of the cost of medical education, will be acquired in reaching the standard of English including examination fees and books, and adds to indicated above. this the cost of supporting a student during five or The universities will certainly demand a much -six years after leaving school, one cannot but admire higher standard of general education than this, but the fortitude of parents who encourage such an whatever they may decide in this respect I feel it undertaking. If the calculator will proceed to con- highly desirable that in no circumstances should it .template the hours of arduous work which confront be possible for a boy or girl to become a medical the student, the strain upon his health which is student without possessing such a moderate knowinvolved, and the hazards which imperil his ultimate ledge of modern languages. The policy of permitting success, the philosophy and good humour of the brilliant scholars to secure exemption from the medical student must give rise to admiration, particu- qualifying examinations for the various universities larly when these are contrasted with the grumbling by passing the examination for the higher certificate and discontent which seem to prevail in the junior in two subjects only, is no doubt an excellent one xanks of other professions. from many points of view, but it remains desirable
The regulations concerning medical education made by the General Medical Council must be framed, .:first and foremost, with a view to ensuring that the public is served by general practitioners of a certain minimum standard of technical ability. The various -examining and educational bodies are confronted by a more complex problem, in that they must decide whether to cater for this minimum requirement or whether they must endeavour to produce men competent to advance medical science and carry out .duties of a much higher technical standard. I take it, however, that the present discussion is chiefly concerned with discovering whether any improvement - can be brought about calculated to produce a better trained medical man in the minimum time available. Are we making the best use of the time given to us? At present there are four sets of examinations to be passed before qualification. In my opinion the possibility for improvement lies chiefly in the training for the earlier of these examinations, and the hope - of producing a higher category of qualified medical men is to be found by modifying these preliminary
that the future medical student shall begin his work with sufficient instruction in the subjects I have mentioned, in order to enable him to escape grave handicap when it becomes necessary for him to study the literature of his chosen profession. 2. THE PRE-MEDICAL EXAMINATION
This examination, which usually consists of chemistry, physics, and biology, can now be taken by a pupil whilst he is still at school. Advantage is often taken of this in order to shorten the subsequent period at a medical school. The value of this examination in giving the medical student a general grounding
in science is undoubted. I do not think that very much would be gained, or lost, by such minor changes as the omission of botany from the syllabus, although this science bears very little relation to medical science to-day. On the other hand, there is a general feeling that the standard achieved by pupils who are taught these subjects at school is usually considerably below that of those who pass their first 12 months in a medical school. Much more important, in my opinion, is :standards. the fact that one of these subjects, chemistry, is the 1. THE PRELIMINARY EXAMINATION basis on which much of the student’s future capacity Without broaching the controversy between classical to advance the science of medicine must depend. and" modern " education, it is surely indisputable But it is to be noted that organic chemistry and that the medical student who has had training physical chemistry, rather than inorganic chemistry, sufficient to enable him to read modern are the two branches in which knowledge is required,
French,
’
302 and
branches which occupy
secondary a great deal might be gained by making the pre-medical examination such that it could be reasonably passed from school by an intelligent pupil, whilst organic chemistry and physical chemistry should be actively pursued in the period immediately following, and should be much more thoroughly taught in the medical schools, and harmonised and correlated with the teaching of biochemistry, both in its physiological
they
place
in
are
our
a
present curriculum. I feel that
and pathological applications. It would not be in any way difficult to continue this instruction throughout the period when the student is engaged in the study of anatomy and physiology. 3.
THE FIRST PROFESSIONAL OR PRE-CLINICAL
EXAMINATION
It is often argued that an unnecessarily high standard of knowledge is required in anatomy; I doubt whether this is the case ; at any rate, the ordinary student manages to pass his examinations without undue strain. In.,.t4e teaching of physiology I believe that there has been a great improvement during the last decade, and the present tendency to study the functions of the healthy human body rather than the intricacies of the phenomena of life in lower animals, is very welcome. There is a movement in many medical schools towards bringing the student more in touch with his future work at this stage. Demonstrations are given on selected cases showing the applications of physiological knowledge to disease. All with experience of this are agreed that it is of benefit in encouraging enthusiasm amongst students, and it is also of value in counteracting any possible tendency amongst teachers to concentrate on purely academic aspects of biology. It is perhaps desirable that applied physiology of this type should become a regular part of the curriculum. I have already discussed the desirability of including organic chemistry and physical chemistry in this section of the student’s work. 4.
THE CLINICAL PERIOD AND FINAL EXAMINATION
problem of the final examinations seems to to be more what to exclude than what to add. There has been a healthy tendency in recent years to replace compulsory lectures by clinical lectures and practical demonstrations. In many of the London medical schools routine lectures in medicine and The
me
There has, on the surgery have been abolished. other hand, been a tightening up of the course of work prescribed, so that students attend for regular periods in all departments, including not only the major specialties but departments such as those for X ray diagnosis and radiotherapy. There is, I believe, a general agreement, at any rate in the London medical schools, that the general standard of medical education has thereby been improved. In contrast to this are the demands received almost weekly, by those in authority in medical schools, for enforced instruction in all manner of subjects ranging from inhalation therapy to the study of parasitic worms. A recent article by the Dean of St. Mary’s Hospital Medical School emphasised the danger of such propaganda. It is to be hoped that the General Medical Council and the examining bodies will not permit themselves hastily to be persuaded to make compulsory lectures on such subjects a necessary part of medical education. Let us have students capable of writing their own language fluently. Let us have students eager for knowledge, and possessing the capacity for reading Let us a reasonable number of foreign languages.
have students capable of following with intelligence the future advances of chemistry and physics. Let us have students with a real working knowledge of £ organic and physical chemistry. Given these things, I believe the medical schools can be entrusted to teach the functions of the human body in health and the phenomena of disease, and further to stimulate enthusiasm amongst their students and to produce
practitioners of high standard, together with a proportion of men and women capable of carrying on the great traditions of our country as regards the furtherance of medical science. HIGHER EXAMINATIONS
I have purposely limited my comments to medical education designed for the training of practitioners. I believe that it is quite possible on the lines I have indicated to give a student sufficient grounding to permit him, if he shows unusual ability, to continue his education and to begin useful work on medical research or to qualify as a teacher of medicine or surgery. At the same time, a more extensive know. ledge of biology, chemistry, physics, physiology, and anatomy will clearly be of incalculable value to him if he is going to occupy one of the higher ranks in our profession. The older universities have recently been engaged in devising plans whereby the additional time given by their undergraduates to the pre-clinical subjects may be better employed. The increasing number of candidates who work for the primary examination for the diploma of F.R.C.S. is an indication that there is no lack of students desirous of achieving a higher standard in these pre-clinical subjects. It would seem desirable that there should be more coordinated system for such candidates, and particularly that the passing of such an examination as the primary F.R.C.S. should entail study in the laboratories and class-rooms rather than book work alone. It is doubtful whether the high standard which competition for this diploma has created really leads to a genuine improvement in education amongst the successful candidates. Much of what they have learnt by such concentrated effort they forget with deplorable rapidity. If the Royal Colleges were to institute a conjoint primary examination, for which 12 months’ extra study in the anatomy theatres and physiological laboratories was a qualifying condition, I am sure that a great many medical students would work for this extra period, and so would enter upon the study for the clinical period with a genuinely better education in these subjects than they possess at present. NORTH
OF
ENGLAND
HOSPITALS.—Last
week
Sir John Priestman, in opening the new Monkwearmouth and Southwick Hospital at Sunderland, stated that he was giving 250,000 towards its maintenance-he had already subscribed 15,000. The hospital has cost .8110,000, but owing to the industrial depression in the area only one-half of the wards can at present be put into use. There are 104 beds. Each self-contained ward-unit contains one large ward of 16 beds and two wards of two beds; the children’s ward has 22 cots and isolation wards.-When Boundary Park poor-law hospital at Bolton was taken over by the town council the Ministry of Health pointed out that the medical and nursing staffs were insufficient. The former was increased, but it was impossible to make better provision for nursing until more domestic accommodation had been built. This has now been provided, and the new buildings were opened last week.-Lord Bolton has formally opened extensions and modernisations of the Rutson Hospital, Northallerton.-The foundation-stone has recently been laid at Lancaster of a joint infectious diseases hospital which
is to serve Lancaster, Morecambe, Heysham, the urban district of Carnforth, and the surrounding rural area. The hospital, which will cost .860,000, will have 56 beds in two ward blocks and two cubicle blocks, with provision for extension.
SPECIAL ARTICLES German, and a third foreign language, has an advantage WHAT IS WRONG WITH THE MEDICAL over his fellows which, should he show any real ability enormous value to him I career. find it impossible to believe his throughout that it would not be easy for those in charge of our public schools to give their pupils this instruction, and I think it would be more than reasonable if the General Medical Council were to insist that every student, before registration, should have passed an examination guaranteeing his competence to read
for
CURRICULUM ?
(A Series of Opinions Contributed by Request) IX BY T. IZOD DEAN
BENNETT, M.D., F.R.C.P.
OF THE MEDICAL SCHOOL, MIDDLESEX HOSPITAL; BEIT MEMORIAL FELLOW FOR MEDICAL RESEARCH
LATE
IT might reasonably be argued that the principle .difficulty of the present medical curriculum is that the length of time necessary for carrying out the .requirements of the educational authorities is such that an impossible economic burden is placed upon many students. Anyone who has the advancement
medicine, will be of
French, German, and one other foreign language. A much higher standard than this is demanded in many continental medical schools, but the capacity to read is all that is really essential, and it is acquired much more easily than any great knowledge of grammar or facility in pronunciation. From the utilitarian point of view it seems to me that the preliminary educational necessities for the medical student are : (a) A knowledge of English sufficient to enable him to write his own language with some facility and correctitude; ’
’of medical science at heart must feel that this economic .stress deprives us of many students of very high intelligence, and diverts them to other occupations where their ability is often wasted. A somewhat (b) A knowledge of mathematics sufficient to enable -desperate problem is constantly confronting us ; on him to assimilate physics and chemistry ; and the one hand the advance of knowledge calls for (c) A knowledge of written modern language of the .an increase in the period of education, and, on the standard set out above. .other hand, the cost of education calls for a diminution It is undoubtedly useful for a student to know enough in the time demanded from the student. Latin to understand the meaning of certain scientific If one sits down with pencil and paper and makes terms, but it may be assumed that such knowledge .a rough calculation of the cost of medical education, will be acquired in reaching the standard of English including examination fees and books, and adds to indicated above. this the cost of supporting a student during five or The universities will certainly demand a much -six years after leaving school, one cannot but admire higher standard of general education than this, but the fortitude of parents who encourage such an whatever they may decide in this respect I feel it undertaking. If the calculator will proceed to con- highly desirable that in no circumstances should it .template the hours of arduous work which confront be possible for a boy or girl to become a medical the student, the strain upon his health which is student without possessing such a moderate knowinvolved, and the hazards which imperil his ultimate ledge of modern languages. The policy of permitting success, the philosophy and good humour of the brilliant scholars to secure exemption from the medical student must give rise to admiration, particu- qualifying examinations for the various universities larly when these are contrasted with the grumbling by passing the examination for the higher certificate and discontent which seem to prevail in the junior in two subjects only, is no doubt an excellent one xanks of other professions. from many points of view, but it remains desirable
The regulations concerning medical education made by the General Medical Council must be framed, .:first and foremost, with a view to ensuring that the public is served by general practitioners of a certain minimum standard of technical ability. The various -examining and educational bodies are confronted by a more complex problem, in that they must decide whether to cater for this minimum requirement or whether they must endeavour to produce men competent to advance medical science and carry out .duties of a much higher technical standard. I take it, however, that the present discussion is chiefly concerned with discovering whether any improvement - can be brought about calculated to produce a better trained medical man in the minimum time available. Are we making the best use of the time given to us? At present there are four sets of examinations to be passed before qualification. In my opinion the possibility for improvement lies chiefly in the training for the earlier of these examinations, and the hope - of producing a higher category of qualified medical men is to be found by modifying these preliminary
that the future medical student shall begin his work with sufficient instruction in the subjects I have mentioned, in order to enable him to escape grave handicap when it becomes necessary for him to study the literature of his chosen profession. 2. THE PRE-MEDICAL EXAMINATION
This examination, which usually consists of chemistry, physics, and biology, can now be taken by a pupil whilst he is still at school. Advantage is often taken of this in order to shorten the subsequent period at a medical school. The value of this examination in giving the medical student a general grounding
in science is undoubted. I do not think that very much would be gained, or lost, by such minor changes as the omission of botany from the syllabus, although this science bears very little relation to medical science to-day. On the other hand, there is a general feeling that the standard achieved by pupils who are taught these subjects at school is usually considerably below that of those who pass their first 12 months in a medical school. Much more important, in my opinion, is :standards. the fact that one of these subjects, chemistry, is the 1. THE PRELIMINARY EXAMINATION basis on which much of the student’s future capacity Without broaching the controversy between classical to advance the science of medicine must depend. and" modern " education, it is surely indisputable But it is to be noted that organic chemistry and that the medical student who has had training physical chemistry, rather than inorganic chemistry, sufficient to enable him to read modern are the two branches in which knowledge is required,
French,
’
302 and
branches which occupy
secondary a great deal might be gained by making the pre-medical examination such that it could be reasonably passed from school by an intelligent pupil, whilst organic chemistry and physical chemistry should be actively pursued in the period immediately following, and should be much more thoroughly taught in the medical schools, and harmonised and correlated with the teaching of biochemistry, both in its physiological
they
place
in
are
our
a
present curriculum. I feel that
and pathological applications. It would not be in any way difficult to continue this instruction throughout the period when the student is engaged in the study of anatomy and physiology. 3.
THE FIRST PROFESSIONAL OR PRE-CLINICAL
EXAMINATION
It is often argued that an unnecessarily high standard of knowledge is required in anatomy; I doubt whether this is the case ; at any rate, the ordinary student manages to pass his examinations without undue strain. In.,.t4e teaching of physiology I believe that there has been a great improvement during the last decade, and the present tendency to study the functions of the healthy human body rather than the intricacies of the phenomena of life in lower animals, is very welcome. There is a movement in many medical schools towards bringing the student more in touch with his future work at this stage. Demonstrations are given on selected cases showing the applications of physiological knowledge to disease. All with experience of this are agreed that it is of benefit in encouraging enthusiasm amongst students, and it is also of value in counteracting any possible tendency amongst teachers to concentrate on purely academic aspects of biology. It is perhaps desirable that applied physiology of this type should become a regular part of the curriculum. I have already discussed the desirability of including organic chemistry and physical chemistry in this section of the student’s work. 4.
THE CLINICAL PERIOD AND FINAL EXAMINATION
problem of the final examinations seems to to be more what to exclude than what to add. There has been a healthy tendency in recent years to replace compulsory lectures by clinical lectures and practical demonstrations. In many of the London medical schools routine lectures in medicine and The
me
There has, on the surgery have been abolished. other hand, been a tightening up of the course of work prescribed, so that students attend for regular periods in all departments, including not only the major specialties but departments such as those for X ray diagnosis and radiotherapy. There is, I believe, a general agreement, at any rate in the London medical schools, that the general standard of medical education has thereby been improved. In contrast to this are the demands received almost weekly, by those in authority in medical schools, for enforced instruction in all manner of subjects ranging from inhalation therapy to the study of parasitic worms. A recent article by the Dean of St. Mary’s Hospital Medical School emphasised the danger of such propaganda. It is to be hoped that the General Medical Council and the examining bodies will not permit themselves hastily to be persuaded to make compulsory lectures on such subjects a necessary part of medical education. Let us have students capable of writing their own language fluently. Let us have students eager for knowledge, and possessing the capacity for reading Let us a reasonable number of foreign languages.
have students capable of following with intelligence the future advances of chemistry and physics. Let us have students with a real working knowledge of £ organic and physical chemistry. Given these things, I believe the medical schools can be entrusted to teach the functions of the human body in health and the phenomena of disease, and further to stimulate enthusiasm amongst their students and to produce
practitioners of high standard, together with a proportion of men and women capable of carrying on the great traditions of our country as regards the furtherance of medical science. HIGHER EXAMINATIONS
I have purposely limited my comments to medical education designed for the training of practitioners. I believe that it is quite possible on the lines I have indicated to give a student sufficient grounding to permit him, if he shows unusual ability, to continue his education and to begin useful work on medical research or to qualify as a teacher of medicine or surgery. At the same time, a more extensive know. ledge of biology, chemistry, physics, physiology, and anatomy will clearly be of incalculable value to him if he is going to occupy one of the higher ranks in our profession. The older universities have recently been engaged in devising plans whereby the additional time given by their undergraduates to the pre-clinical subjects may be better employed. The increasing number of candidates who work for the primary examination for the diploma of F.R.C.S. is an indication that there is no lack of students desirous of achieving a higher standard in these pre-clinical subjects. It would seem desirable that there should be more coordinated system for such candidates, and particularly that the passing of such an examination as the primary F.R.C.S. should entail study in the laboratories and class-rooms rather than book work alone. It is doubtful whether the high standard which competition for this diploma has created really leads to a genuine improvement in education amongst the successful candidates. Much of what they have learnt by such concentrated effort they forget with deplorable rapidity. If the Royal Colleges were to institute a conjoint primary examination, for which 12 months’ extra study in the anatomy theatres and physiological laboratories was a qualifying condition, I am sure that a great many medical students would work for this extra period, and so would enter upon the study for the clinical period with a genuinely better education in these subjects than they possess at present. NORTH
OF
ENGLAND
HOSPITALS.—Last
week
Sir John Priestman, in opening the new Monkwearmouth and Southwick Hospital at Sunderland, stated that he was giving 250,000 towards its maintenance-he had already subscribed 15,000. The hospital has cost .8110,000, but owing to the industrial depression in the area only one-half of the wards can at present be put into use. There are 104 beds. Each self-contained ward-unit contains one large ward of 16 beds and two wards of two beds; the children’s ward has 22 cots and isolation wards.-When Boundary Park poor-law hospital at Bolton was taken over by the town council the Ministry of Health pointed out that the medical and nursing staffs were insufficient. The former was increased, but it was impossible to make better provision for nursing until more domestic accommodation had been built. This has now been provided, and the new buildings were opened last week.-Lord Bolton has formally opened extensions and modernisations of the Rutson Hospital, Northallerton.-The foundation-stone has recently been laid at Lancaster of a joint infectious diseases hospital which
is to serve Lancaster, Morecambe, Heysham, the urban district of Carnforth, and the surrounding rural area. The hospital, which will cost .860,000, will have 56 beds in two ward blocks and two cubicle blocks, with provision for extension.