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AUTHOR: Richard
Steele, Coordinator for medical Education, IFMSA‑Regional
Organization Europe, Denmark,
THE PRESENT SITUATION
ME is at a crossroads, ideologically and pedagogically
speaking. Owing to
the rapidly changing health situation in the European region due
to an aging population beset with an increasing number of stress
factors in a technological consumer society, less than optimal
nutritional status, unemployment and/or other shifting
demographic conditions, the IFMSA‑ROE finds it imperative
in economic, social and professional terms to search for, find
and implement solutions to the problems contributing to the
deterioration, in relative terms, of the health care systems
which can be traced, among other things, to inadequacies in ME. These inadequacies are
manifested in the increasing inability of the health care
systems in the European region to meet the service demands of
the populations they serve adequately as evidenced by manifest
criticism of the present health care systems and the increasing
incidence of non‑ official and non‑sanctified health
care.
The impact of the structure and implemtation of ME on the
health care systems must not be underestimated. Traditional ME, based on developments stemming from the 19th
century, when medical students were expected to learn the sum
total of medical knowledge, still attempts to impart the medical
student with an ever-increasing mountain of knowledge with bits
and pieces included from each subspecialty, which arises. The ensuing workload,
comprised primarily of fact‑learning, makes it very
difficult for the average medical student to embark on
individual projects or studies, thus contributing to the
stiffness of health care systems by enhancing conformity and
inhibiting the problem‑solving abilities of medical
graduates. Skills in integration of knowledge, communication,
problem solving, population health care appraisal (epidemiology
in a broad sense), professional collaboration, etc. are taught
but little, if at all, and the lack of competence of medical
graduates in these important areas is evident in the relative
inefficiency of the health care systems. This relative
inefficiency is evidenced by the enormous and increasing cost of
health care which is not correlated to a similar betterment of
public health, also when corrected for an aging population.
Generally, it can be said that ME produces doctors who are
ideologically committed to the institutional status quo rather
than oriented towards promoting and protecting the health of
society and are medically committed to the increasingly
inadequate "biomedical," hospital‑oriented
concept of disease rather than the "bio psychosocial"
and primary health care‑oriented concept of health and
disease and are thus inadequately equipped to deal with the
complicated health care problems of modern society.
For specific details and references, see Appendix I.
THE ISSUES AT HAND
The major deficiencies in ME which are reflected in the
inadequacy of the health care systems to meet societal needs as
outlined above can be summarized as follows:
I. PEDAGOGICAL ISSUES.
The preclinical phase of ME is largely a fact‑
learning enterprise with little room for the development of
reasoning in terms of biological knowledge along well founded
scientific principles, and much less an exercise in working
knowledge of the integrated functioning of the human body in
health and disease, all factors taken into account.
II. STUDENT MOTIVATION.
As an indirect result of the above, student motivation is
poor, and the major driving force behind the students' study is
the desire to pass examinations.
III. THE INADEQUACY OF ME LEGISLATION.
Such legislation contributes to the motivation problem, in
that it is generally subject‑specifying, with subject
content being specified by specialists and not by doctors and/or
educators active at the level of the primary/secondary health
care unit.
IV. CURRICULUM QUESTIONS.
The primary emphasis in clinical studies is of a tertiary
health care nature, and hygiene and prophylactic medicine are
neglected correspondingly, despite the proven cost/benefit value
of prophylaxis and the proclaimed accept of the primary health
care (PHC) concept as defined at the Alma Ata conference of the
WHO in 1978.
V. ADEQUATE TEACHING METHODS.
ME teachers are generally poorly qualified educators with
resultant deficiencies in teaching methods and adequate
evaluation.
VI..ADMISSION SYSTEMS.
ME admission systems are a cause for concern, in that
society has vested interests at stake when selecting those
individuals who will promote and protect the health of society.
These points will be shortly discussed in terms of the
policy of the IFMSA‑ROE below.
I. Regarding the PEDAGOGICAL ISSUES, there is
unanimous agreement among ME experts that the fact‑learning
aspects of ME are grossly overemphasized. Medical students are
submerged by details and the memorization of facts to such an
extent that individual academic activity on the part of the
student to integrate this knowledge and assimilate it in terms
of clinical and biological relevance is precluded. Medical students are
expected to develop scientific thought processes and critical
evaluation skills, but these skills are rarely taught at medical
schools, and in the rare case in which such skills are taught,
it is most often as an afterthought. Contrarily, the sheer
amount of knowledge to be assimilated is so large that the great
majority of students must set critical thinking aside in order
to have time enough to assimilate facts. Motivation is poor, as
the fact learning process is dull and the purpose of it most
often remains unclear. As
a result, also taking the mechanics of human memory into
account, unduly large proportions of the assimilated facts are
later forgotten, and the time used to learn them has thus been
wasted. The
implications of this basic problem are enormous. The
"biomedical" model of man being divided up into
separate categories (subjects, if one will) is propagated
through the integrative thought limiting attributes of rote
learning. This
inbuilt scientific conservatism in ME is hindering progress on a
comprehensive "biopshychosociological" model of man,
which seeks to take behavioral factors into account in the
rational treatment of disease.
The importance of this barrier must be considered in the
light of the obviously increasing behavioral risk to health in
modern society. It
is imperative that ME be reorganized so that training in
critical scientific thought in relevant clinical terms and
integrative intellectual skills giving the medical student the
capability of organizing his/her knowledge in bio psychosocial
terms is instigated at the beginning of ME. Training in skills in
interpersonal communications and collaboration in the primary,
secondary and tertiary settings of the health care system must
also be stressed. The
curriculum must be as dynamic and flexible as the health needs
of society and be regulated through constant evaluation and re‑evaluation
to meet current demands. Behavorial sciences as well as the
biological sciences must be emphasized together in an integrated
curriculum which must be delineated according to a rationally
devised system placing a reasonable emphasis on the basic
knowledge and skills required in order to meet the demands
specified by the well-defined goals of the medical
faculty.
II. The
immediate results of poor STUDENT MOTIVATION are poor
working efficiency during study time, student/teacher conflicts,
lack of interest in related fields and disillusionment with the
profession. The benefits of improving student motivation, however, reach
far beyond these relatively uncomplicated problems. Poor study efficiency is expensive for society not only
because of the high cost of the education of doctors but also
because the wasted time could otherwise have been spent
educating medical students in skills demanded by modern illness
treatment as discussed above. Student motivation can be improved through the use of the
normal working conditions of doctors in the educational setting. Although it can be
argued that such an approach is impractical, its merits cannot
be questioned. The
working conditions of doctors can be simulated to a large degree
through use of the problem-based approach. This approach has
numerous advantages over the traditional system of rote learning
related to traditional examinations. The working processes
involved in problem solving are of the same form regardless of
the level of the background knowledge necessary for solving the
problem. Thus,
students may be trained in these processes from the very
beginning of their studies.
The rationale of the problem based approach is basically: Through presenting the
student with a set of problems representative of those
encountered by the "basic doctor" (read: intern), the
knowledge and skill requirements necessary for solving the
problems become obvious for the student who is thus optimally
motivated for acquiring these skills. Delineating the
curriculum through the problems, which due to natural conditions
will be subject to individual variation, then becomes the
primary planning problem for medical faculties. Each student is to a
high degree left to find his/her own optimal learning technique,
and the tools acquired through this approach create the basis
for self‑assessment, learning from and teaching peers and
life‑long learning skills, all recognized as being
necessary skills for a doctor but not presently widely
cultivated in undergraduate ME.
(For extensive literature on problem-based learning, see appendix II.)
III. The INADEQUACY OF ME LEGISLATION has to
do with the tendency of these laws to specify the subjects and
subsequent examinations medical students must complete before
being eligible for licensure, dealing lightly or not at all with
the skills which can be considered as a prerequisite to working
as a doctor, leaving the matter of content up to specialists. This situation is the result of historic developments with
their roots in the last century.
As medicine expanded, specialties arose, and with each
specialty arose an institute and corresponding ME subject. Although this
development has been reasonable and, indeed, a logical
necessity, it must now be evaluated in the light of the sheer
mass of medical knowledge. This knowledge mass is now utterly
beyond the scope of any individual, but interests other than the
health of society work to determine what level of detail should
be taught in each specialty; namely the economic and research
interests of the specialists.
This is not surprising, in that specialists have for many
years had free reigns in determining their own relevance to ME. Although specialists
certainly have a position in medicine giving them, and them
alone, the necessary overview to determine the content of
the subject matter to be taught, specialists are not necessarily
the best qualified persons to determine the value
(relevance to society's health care needs) of the same content. This evaluation must be
undertaken by representative bodies including faculty and non‑faculty
medical staff as well as non‑medical persons, i.e. the
contractors and users of the health care systems. In order to be effective
in terms of the needs of society, ME legislation must consider
the skills required in medical practice and the education
required to achieve these skills.
This will necessitate a departure from the present ME
legislation form, which must simultaneously rid itself of
subject specification and specify, in general terms. The basic
skills and level of competence to be achieved in undergraduate
ME which are required by the health authorities for licensure.
Provisions must be made specifying the role of curriculum
planning bodies independent of faculty institutes with the
permanent function of devising and revising the curriculum to
meet the goals set out in ME legislation. The urgency of this
project increases steadily as the increasing mass of medical
knowledge threatens to completely overwhelm ME with fact
learning, leaving less and less time to devote to developing
scientific problem solving skills in the areas pertaining to
clinical medicine, facilitating the increasing one‑
sidedness of ME which reflects a divergence from community
oriented ME.
IV. CURRICULUM
QUESTIONS. It is a complicated task to determine which areas of
medical endeavour are appropriate as clinical study/experience
in undergraduate ME. This
task has traditionally been carried out, again, by specialists
indirectly or directly battling for the importance of their own
specialties. This
has led to a moderately effective system of clinical experience
which unfortunately emphasizes secondary and tertiary care, with
tertiary care generally taking the largest part of the available
time at the expense of experience at the primary care level. Clinical experience with
a general practitioner is at best a minimal fraction of the
study period, usually optional and at worst not available during
undergraduate study. It
should be obvious that the traditional emphasis on tertiary care
during the study period along with economic and/or academic
incentives dominated by specialization minimizes the student's
motivation for preventive and primary practice. Although it is
clear that an effective specialization system is desirable, it
should be equally clear that an effective primary care
educational system is one prerequisite for increasing student
motivation for entering the primary care area. Increased
emphasis on primary care is officially promoted by all European
governments through their involvement in WHO.
The content of ME must therefore be reorganized to create
a more appropriate balance of clinical contact than is now the
case. This reorganization must be accompanied by parallel
changes in the theoretical basis of ME, so that students are
introduced to medical problems at all levels in an integrated
fashion. Special attention should be paid to those areas now
grossly underrepresented in traditional ME, i.e. the behavioral
sciences and the area of PHC.
Clinical contact should be very early in ME, including
experience with general practitioners, PHC centres, occupational
health care centres, old age homes, etc. besides the usual
battery of secondary and tertiary clinical clerkship areas. A net increase in study time should be avoided by
rationalizing the ME curriculum based on the approach outlined
above. This means
that undergraduate ME should turn out doctors with the basic
scientific and practical skills necessary for limited
independent practice and who at the same time are familiar and
comfortable with the need for lifelong learning (continuing ME)
and the further deepening of skills and knowledge for their
specific professional areas.
It also implies that medical graduates must be well‑prepared
for further study in any area of medical endeavor, thus
highlighting the concept of learning skills and problem solving
abilities rather than a fixed sum of knowledge.
V. The lack of
ADEQUATE TEACHING METHODS at the university level is not confined
to ME. Teaching at
universities is generally the most neglected educational system
in pedagogical terms. That university graduates, generally hired
according to academic and research merits, are not necessarily
good teachers, is nothing new.
Students are left to fight their way through the mountain
of knowledge they must answer for at examination time. The
hopelessness of this situation is especially acute in the
undergraduate medical field where outdated teaching methods are
very deeply rooted. The
lecture form is the most common at medical school, with the
teacher giving a more or less inspired recounting of what could
have been read in a fraction of the time expended, while at the
same time the student has received no individual counselling or
motivating (formative) evaluation in the material to be learned.
The traditional examination in ME is a humiliating and
debasing experience. Evidence of this is given in the level and
ubiquity of stress related health problems among medical
students during and immediately after examination periods. The
examinations are at best only moderately objective and re‑presentative
of the student's level of detail recollection and problem
solving in relation to clinical competence. Although these examinations are officially designed to
measure medical students' competence, they are seldom designed
to be even remotely representative of doctors' working
conditions.
Medical educators have, theoretically speaking, a dual and
conflicting role in the examination situation. The teacher's responsibility to the student is to ensure that
he/she has received the necessary knowledge or skills and
motivation to pass the examination. On the other hand, it is
simultaneously the teacher's responsibility to ensure society at
large that the passing student has the specified skills
required. Unfortunately, most teachers perceive the latter
responsibility as the more important, making students' animosity toward the teacher
natural. Furthermore,
the required competency to pass the examination is rarely
specified in detail and even more rarely correlated to specific
goals with clinical relevance. Evaluation is therefore
necessarily less than optimal, and medical candidates are
notoriously unable to utilize more than a fraction of what they
are supposed to have learned at medical school when confronted
with clinical problems.
This situation has been accepted as being inevitable, but
experience at experimental medical schools in the last two
decades has shown that this is not so. Valid, objective and
reliable evaluation is possible through tutor‑led, problem
based and integrative learning experiences devised to match
doctor’s working conditions as far as possible while at the
same time motivating students to learn more and more. This radical departure
from outdated methods will require a concerted effort on the
part of students, faculties, health authorities and politicians
to upgrade the incentive to actively participate in the
educational process both on and off campus, facilitating
rational curriculum planning and evaluation. Such incentives could
include ME research facilities (implying ME professorships),
curriculum planning units, organized student/teacher research
cooperation in the primary health care field, academic prizes
and scholarships in ME, etc.
VI. A great
disparity exists between the need for open‑minded,
compassionate, critical and intelligent doctors and the
effectiveness of ME ADMISSION SYSTEMS
in selecting such candidates. That such selection is
desirable is obvious, but the process is elusive. In the face of what is
by some considered as overproduction of doctors, tendencies
towards stiffening present day selection procedures on academic
terms alone are prevailing in Europe. Although the students
thus selected can perhaps be expected to do well at medical
schools with traditional curricula {(there is no conclusive
evidence that even this is the case), there is increasing
awareness that isolated academic achievement is not a sufficient
criteria for defining a "good doctor," indeed, such
academic prowess can be an obstacle to developing the open‑mindedness
and compassion needed by doctors to deal reasonably with modern
society's diseases. In other words, the prevailing methods of selecting students
for a medical career have little to do with considerations
concerning the quality of doctors, but only concerning these
students' ability for academic achievement. Furthermore, the
position that there indeed is an overproduction of doctors is
questionable, since for example one of the most serious
obstacles in the adequate practice of modern medicine is the
lack of adequate doctor‑patient interaction time.
In the lack of selection systems proven to be effective in
selecting medical students according to their potential for
being good doctors, the IFMSA‑ROE favours random selection
of qualified candidates on the grounds that this procedure will
in all probability maintain a reasonable proportion of community
service oriented students at medical school.
NECESSARY CHANGES
CONTENT AND CURRICULUM.
The division of ME into a clinical and preclinical period,
being irrational and counterproductive in terms of meeting
society's health care needs, must be abandoned in favour of a
problem based, integrated ME aimed at producing doctors capable
of competent management of diagnostic, epidemiological,
therapeutical, prophylactic and communicative skills based on
abilities in problem solving, collaborative and learning skills
developed specifically in the ME program. These skills must be
taught in an interwoven manner with emphasis on the management
of health problems at the primary level with a comprehensive
understanding of all of the major health risk factors, including
not only traditional medical views but also comprising social,
psychological and mileu factors.
Emphasis on a broad understanding of disease processes
should be facilitated by expanding the educational setting to
include all the major aspects of the health care system without
the gross overrepresentation of the tertiary system that
predominates today. Emphasis
should be placed on preventive medicine and the cost/benefit
analysis of the actions undertaken by the doctor in his/her
setting in the health care system, thus helping to assure that
doctors' actions do less harm than good.
EDUCATIONAL
METHODS AND EVALUATION
The cardinal points in the recommendations of the IFMSA‑R0E
for a revised ME are that it should be problem based and
integrated with early and continuous patient contact. This implies a new role
for the medical teacher, who in the envisaged system would
function more as a tutor and/or counsellor than as a teacher in
the traditional role. In
order to be effective, this system must be based on rational
curriculum planning with inbuilt evaluation systems devised to
maintain the flexibility of the curriculum. Students should work in
small groups in a real life or simulated real life setting,
facilitating self‑learning, self‑assessment and
teaching skills development.
Student participation in faculty research projects should
be encouraged, and community health research projects should be
devised. The
curriculum should be built around a solid base of scientific
thinking and basic knowledge, which, when defined as being
necessary, should be repeated in a number of different settings
to facilitate the usability of acquired knowledge.
ME LEGISLATION
As mentioned above, we deem it necessary that ME
legislation maps out the skills deemed appropriate to acquire
recognition as a basic medical doctor in order to free ME from
the non‑system of competing institutes. Faculty bodies,
administratively independent from institute bodies, should
coordinate and direct the use of faculty teaching resources. ME faculty bodies should
take all areas of medical practice into their ranks, including
general practitioners. The
legislation, besides giving broad curriculum outlines, must
include provisions giving community bodies the authority to
condemn educational developments contrary to the health needs of
the community while at the same time guaranteeing the expertise
of these bodies. Provisions should be devised giving incentives for developing
and bettering ME, taking health manpower planning into account
(health manpower planning, though extremely pertinent to ME, is
beyond the scope of this document.) Student participation in
the process is valuable for all parties, and should be
guaranteed in the legislation.
SELECTION PROCEDURES.
Regarding selection procedures, we favour random selection
of qualified applicants to medical school in the lack of
appropriate selection procedures of proven quality, as mentioned
above.
IMPLEMENTATION STRATEGIES
- The IFMSA‑ROE does not see its role in the
field of ME as a prime mover, naturally, but rather as a
watchdog. It is
our firm belief that much can be done to improve ME simply
by assuring that information pertaining to ME from expert
bodies reaches the target groups, i.e. medical teachers and
students, and governmental and nongovernmental groups with
special interests in ME.
- The IFMSA‑ROE seeks to create a ME information
office on a permanent basis, to which student organizations
can direct requests for literature lists at different
levels, materials, activities planned in various countries,
local, national and international contact and support
information etc. The
funding for this work is to be sought internally and from
external sources. The contact network described above should
be computerized so that mailing lists for important
information can be developed.
- Collaboration with other organizations is to be
sought and pursued. This
collaboration should include information exchange,
conference and workshop participation, funding for specific
projects such as workshops, and mutual feedback and idea
exchange.
- A handbook on student activities regarding ME is to
be prepared.
- A handbook regarding the organizing and execution of
workshops is to be prepared.
- The IFMSA‑ROE seeks to increase the level of
student activity on ME through workshops, information
dissemination and personal contacts with special
responsibility for ME in as many countries as possible.
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