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APPENDIX I
In the following appendix, a number of quotes from the
literature supporting our position are presented. This format was deliberately chosen in order to preserve the
coherence of the text of the policy platform. The reader is reminded
that this document is not a scientific treatise, but a political
statement of purpose and intent.
"Arising from 19th century precedents, medical
education still includes features which are now outmoded: The
division of training into a scientific/theoretical section and a
clinical section.
At present in medical education there is increasing
recognition of:
- The growing number of different sciences and
techniques involved
- The need, because of the mass of information, to lead
students to understand principles rather than to overload
them with too much factual information.
- The difficulty that basic science is taught at a
stage when the students do not relate it to practical
medicine, whereas at a later stage when they could more
easily grasp the practical value of basic science their
knowledge tends to be forgotten or outmoded.
- The need for new teaching methods in medical
education."
-
(From document no. III/D/32/1/78 EN of the Commission of
the European Community, Advisory Committee on Medical Training.)
"Extensive comparative research data have given
evidence that traditional ME, i.e. lecturing in separate
subjects, fails to provide an effective and efficient way of
reaching sufficient educational goals, e.g. professional
competence. Investigations show that medical training does not
give sufficient consideration to the cognitive aspects of
science and the humanities, to the clinical, social and
scientific skills and to the development of basic modes of
behaviour which everybody needs who is to practice the medical
profession. The
curriculum today offers the students a mass of knowledge with a
distinct bias in favour of clinical medicine." (F.J.A.
Huyjen, General Practice International 3:117, 1981)
"Experience shows that sound curriculum planning and
the improvement of current ME schemes needs the assistance of
efficient and productive units of ME, which need to be
established in every medical faculty." (G.E. Miller, Public
Health Papers, 61:99, WHO 1974)
"Traditional preclinical science studies have been
found to be rather irrelevant and even counterproductive for the
rational acquirement of professional competence of a medical
doctor. Counterproductive in the sense that they lead to
inadequate learning patterns and generally are seen to be a most
ineffective way of studying. Empirical data indicate that
nonscience students will perform as well or even better than
traditional science trained students on almost all performance
measures, which were used in a large investigation. This result is supported
by other similar studies." (D.P. Yens and B. Stimmel, J. Med.
Ed. 57:429, 1982)
"There is strong evidence, theoretically and through
empirical data, that an integrated problem based approach in
teaching/learning is far more effective and efficient than the
currently used subject‑centered approach. This relates to
practical as well as to scientific skills." (W.C.
McGaghie et al., Public Health Papers 68, WHO 1978)
(See also: H.G. Schmidt, Med. Ed. 17:11, 1982)
"The rational planning of ME must be based on
evaluation data. However, in most medical schools the
examinations and the curricula {as such are hardly evaluated. Generally, there is an
absence of valid evaluation of both the students' competence and
of the adequacy of the curriculum. Contrarily, examinations are used which force students to
adopt inappropriate learning patterns." (IFMSA Internal
Information Service, XXXIII,1, 1984)
"Current licensure procedures to a great extent serve
the purpose of legitimising disciplines/subjects included in the
ME curriculum and of granting prestige and status to the
individuals and faculties teaching these subjects. This element is much
stronger in the traditional subject centered type of curriculum
than the guarantee of a given level of competence and the
orientation of the learning behavior of students towards said
competencies, though these are meant to be the purpose of
licensure examinations. This
kind of inadequate function is inherent in regulation systems in
which a number of subjects/disciplines are defined instead of
the competencies required." (H.G. Pauli,
Assessment and Evaluation in Higher Education, 7,3:245, 1982)
"Innovations in ME along the "addition
model," i.e. the introduction of new subjects such as
preventive medicine and general medicine to existing subjects
and the subject‑centered curriculum structure, have been
futile attempts, exemplified by the evidence of no significant
changes in the qualifications of graduates in relation to being
prepared for community medicine where such additions have taken
place." (J. Schmidt, R. Steele and E. Pich, WHO
conference paper, Nov. 1983)
"There is a tendency of a constant increase of the
length of education before licensure for independent practice is
granted. However, systematic investigations make evident that
there is no such thing as a "completely" trained
doctor, but only a graduate who is able to work independently
and safely which includes the ability of cooperating with peers
and specialists and life‑long learning skills. This necessitates a selection of what may comprise the basic
curriculum of medical school derived from professional analysis
in order to rationalize the constant increase of health related
scientific knowledge and practice. Truly integrated and need
oriented medical schools give evidence that such an acceptable
level of competence, allowing independent practice, is reachable
within the time limits of current undergraduate programmes."
(University Center for Health Sciences, Beer Sheva,
Israel, 1982)
"It is considered that postgraduate training is a
costly enterprise in that sense that it compensates to a great
extent for insufficient undergraduate curriculum planning and
poor health manpower planning." (IFMSA, Resolution of
L'Aquila, 1983.)
"Postgraduate programmes are generally hospital
based. Specialization training for general/community medicine
are perpetuating the lack of field training which is also common
in undergraduate education and therefore hardly allow for
completion of an insufficient undergraduate training for
community medicine." (E. Sturm, General Practice
International 1:24, 1980.)
"There is a growing claim of an overproduction of
doctors. However, the qualitative aspects of the qualification
of doctors are hardly considered when "ideal" ratios
are indicated.
The range of doctor‑population ratios in Europe is
37‑fold which clearly implies that other parameters must
be used to adequately describe the state of a health care
system. As well as
for hospital beds (12‑ fold) there are also great
differences for the number of nurses per population (14‑fold)." (H.G. Pauli, D. Hall and H. van Maanen, Health Services in
Europe, Chap. 10, WHO Europe, Copenhagen 1981.)
"Any thoughtful observer of medical schools will be
troubled by the regularity with which the educational system of
these schools is isolated from the health service systems of the
countries concerned. In
many countries these schools and faculties are, indeed, the
proverbial ivory towers. They prepare their students for certain high, obscure, ill‑defined,
and allegedly international "academic standards" and
for dimly perceived requirements of the twenty‑first
century, largely forgetting or even ignoring the pressing health
needs of today's and tomorrow's society." (H. Mahler,
World Health Forum, 2,1:5, 1981.)
"Medical schools often are ivory towers apart from
the demands of the health care system.
However, new approaches in combining health care and
education have proven to be effective. If the medical school as
the academic institution which is responsible for the health
manpower training participates in the planning and
implementation of all levels of health services for an entire
region, and if the community is involved in the planning of the
curriculum, a coordination and a rational curriculum planning
can be effectively achieved." (M. Prywes, Health Policy
and Education 1:291, 1981.)
"Current ME emphasizes the clinical aspects of
diseases and health problems and largely ignores the natural
history of diseases. However,
a large, thorough investigation shows that health, illness and
premature death depend primarily on environmental influences and
behavioural factors, with the exception of those rather
infrequent diseases which are determined at fertilization."
(T. McKeown, The Role of Medicine, Nuffield Provincial Hospital
Trust, London, 1976.)
"The medical profession is supposed to define and
resolve health problems. However,
sociological analyses show that, due to the reductionism to
clinical concepts, the medical profession and the
professionalization (i.e. ME) are characterized by a failure to
take into account the expectations of people." (Gmelin
in Ritter, EARDHE Congress Preparatory Papers, Vol. 1, 1983,
European Ass. for Research Developments in Higher Education.)
"Large investigations, such as "Health Care
‑ an International Study," have shown that the
perception of disease and health problems by the medical
profession (through the medical model of hospital based
university medicine, i.e. including ME) is quite far away from
the actual health problems people suffer from (perceived
morbidity)." (Kohn
and K.L. White, Health Care ‑ an International Study,
Oxford University Press, London 1976.)
"The hospital view of health care problems obviously
leads to an ineffective and uneconomic delivery of health care. The concept of PHC,
however, is likely to improve the effectiveness and efficiency
of health care by using a more comprehensive bio psychosocial
approach and by identifying the most effective phase of
intervention in the natural history of diseases. The neglection
of PHC may explain that health has not improved, exemplified by
the notion of a decreasing life‑expectancy in European
countries, and many needs are not met, especially as regards
community services, although vast amounts of resources and
finances have been absorbed by the present health care systems
in Europe." (E.
Maxwell, Health Care, The Growing Dilemna, McKinsey, N.Y. 1975.)
"The education in as many as possible subjects in ME
was meant to provide a comprehensive education. However, the simultaneous restriction to specialized subjects
that are practiced in hospitals has become a major source for a
limited and questionable qualification of doctors. It is evident that from
a point of view of the function of different services ME has
become most reductionistic by ignoring the level of primary and
practically secondary health care. Universities and
teaching hospitals deal with only those limited problems that
are assigned to different medical subjects that need tertiary
medical care. However, several investigations show that most of
the health problems are resolved by self‑care and self‑medication,
and that from the health problems the medical profession is
confronted with, only 1% need the services of a university
hospital, and 10% need hospital care at all. (L. White,
Scientific American 229:23, 1973.)
"ME is meant to prepare for medical practice. However, a 25‑year
analysis of the medical conditions seen in a British general
practice show that the diseases seen during traditional ME are
at the end of this list, if ranked according to diseases'
frequency, or are not included in ME at all." (
Fry, Common Diseases, Their Nature, Incidence and Care. MTP Medical and
Technical Publishing Co. Ltd., Lancaster, 1974)
"Traditional ME is generally planned or
"arranged" along very arbitrary criteria. However, there is an urgent need to define the goals of ME
clearly in order to cope with the exploding health related
information. These
goals must be socially acceptable which implies an emphasis on
PHC, based on epidemiological considerations and the analysis of
health care demands (health surveys, epidemiology, professional
analysis.)" (J.J. Guilbert, Educational Handbook for
Health Personnel, Offset Publication No. 35, WHO, 1981.)
"An emphasis on PHC has been stipulated at various
occasions. The WHO/UNICEF‑Conference of Alma Ata declared
that PHC was the key to achieving "Health for All",
and the governments committed themselves to foster PHC, which
includes a reorientation of ME and Health Manpower Planning
generally." (PHC,
Int'l Conference on PHC, Alma Ata Report, 1978.)
."The European Governments have reinforced the Alma
Ata Declaration and aim at a reorientation of ME towards PHC, as
stated in the WHO Regional Strategy." (Regional Strategy for
Attaining HFA 2000, WHO Regional Office for Europe, 1982.)
"ME is, among other purposes, to provide the future
doctors with the scientific background for future practice and
more: to make them able to cope with the changing knowledge and
the changing patterns of diseases. However, scientific and
critical thinking and scientifically based practicing must not
be confused with only the recalling of scientific knowledge. Science based on
clinical concepts is dominating the medical models of health and
disease. Investigations and a bio psychosocial approach in
defining concepts of health and disease, however, make evident
that current medical data and perceptions rather describe
illness‑behaviour than illness itself, and thus, the
natural history of diseases without being medically treated is
hardly understood. The
statistics on health and illness are biased. Aetiology of
diseases must be understood in a comprehensive model which
combines psychological and sociological data with biomedical
knowledge." (D.A. Hamburg, G.R. Elliot, D.L. Paron, Health and Behavior,
Frontiers of Research in the Behavioural Sciences. National Academy Press, Washington 1982.)
"Coronary heart disease can be taken as an example of
one of the most prevailing causes of premature death in European
countries. Although
biomedical and pathological research are well advanced they may
explain only a minority of the reasons for the prevalence of
these diseases.
ME and medical practice ignore to a great extent that a
range of behavioural factors (Friedman and Roseman) and
sociological conditions can explain to some considerable extent
the Aetiology of CHD (J. Siegrist et.al.). However, interventions
based on purely medical means, i.e. following the traditional
clinical model, have failed to show a significant impact on the
prevention of this disease, although large amounts of resources
have been invested for it." (M. Oliver, Lancet
ii:37, 1983)
"Current ME takes place almost exclusively in
hospitals. However, a comparison of professional analysis in
primary and hospital care (specialized care) show a significant
difference in the role of different scientific areas, which vary
in their relevance for the health problems in both areas. Primary care needs to be
based on sociology and epidemiology to a large extent, whereas
specialized medicine on the secondary and tertiary level is
rather based on clinical sciences. ME mainly takes place in
hospitals and thus does not provide the scientific background
for medical practice."
(D. Barr in H. Noack, Medical Education and PHC, Croom
Helm, London, 1980.)
"Health problems in primary care are to a great
extent only understandable on the subjective biographical
background of the patient.
Clinical examinations may not help and often are even
qualified to aggravate the health problem by reinforcing a
somatic fixation, which leads to a chronification of the
problem, thus a pure clinical approach must be considered as
obsolete. In order to avoid an irrational use of clinical
facilities and to avoid a chronification of health problems,
which is relevant for well about half of the health disturbances
a doctor sees, a sound approach that includes psychotherapeutic
qualities is essential." (M. Balint, The Doctor,
his Patient and the Illness, Tavistock, London, 1957.)
APPENDIX II
In this appendix, some titles are given as suggested
reading for those interested in the problems touched upon in
this document. Of course, the quotes in appendix I come from
commendable books and articles.
- AAMC 1983: Emerging perspectives on the general
professional education of the physician.
- AAMC 1984: Physicians for the
Twenty‑First Century.
Report of the panel on the general professional
education of the physician and college preparation for
medicine.
- IFMSA 1983: Resolution
on Medical Education, L'Aquila, Italy
- IFMSA 1984: Resolution
on Medical Education, Solbacka, Sweden
- WHO 1984: Report
from the Exeter Expert Committee meeting on undergraduate
medical education.
- Illich, Ivan, 1976.
Limits of Medicine.
- EEC Commission 1979: Protocol of the Advisory Committee on Medical Education.
- Mager, Robert F. 1961: On the Sequencing of Instructional Content. Psychological Reports, 1961, 9 pp. 405 ‑413.
- Barrows, H. S. and Tamblyn, 1980: Problem Based
Learning. Springer, N.Y.
- Schmidt, Henk, 1983: Problem Based Learning ‑ Rationale and
Description. Journal
of Medical Education 1983, 17, pp. 11 ‑ 16.
- Piaget, J., 1954: The Construction of Reality in the
Child. N.Y. (A
cogent and contemporary analysis of learning processes, very
much applicable to ME)
- Illeris, Knud, 1973: Problem Orientering
og Deltager Styring (Problem Orientation and Participant
Steering) Munksgaard, Copenhagen. Unfortunately, this and other books of
Illeris are not available in English.
- Kaufman, A., et. al., 1982: Undergraduate
Medical Education for Primary Care. Southern Medical
Journal 75:9,
1982, pp. 1110 ‑ 1117.
- Guilbert, J.J., 1980: Educational Handbook for Health Personnel, 2nd. Ed. WHO publications.
- Berg O. 1975: Health and Quality of Life, J. Scand.
Sociol. Ass. 18:3, 1975
- Cartwright A., 1967: Patients and Their Doctors, A
Study of General Practice, Routledge and Keagan Paul,
London.
- Cartwright A. Anderson R., 1979: Patients and Their
Doctors (II), J. of Royal College of Gen. Prac. occasional
paper.
- Dubos R., 1980: Man Adapting, Yale University Press,
Hew Haven, USA.
- Feinstein AR, 1970: What kind of basic science for
clinical medicine? New
England J. of Med. 283:847.
- McGaghie, et. al. 1978: WHO Public Health Paper No.
68
- Katz FM and Fülop T, 1978 ‑ 1980: WHO Public
Paper No. 70 and 71
- Katz FM and Snow R., 1980: WHO Public Health Paper
No. 72
APPENDIX III
In this appendix, the activities of the IFMSA concerning
medical education are listed.
Although the activities began before 1979, the list is
not complete for this period due to a lack of continuity in the
infrastructure of the IFMSA.
- August 1979: IFMSA
Declaration of Kiljava ‑ on PHC and ME
- August 1980: IFMSA
Declaration of Cairo ‑ on PHC and ME, reinforcing and
deliberating on the Kiljava Declaration.
- April 1981: Regional
Assembly Iceland. The
Standing Committee on ME (SCOME) was reorganized on a
European scale, and the regional organisation was
rejuvenated.
- April 1982: Two‑Country
seminar on ME. German
and Swiss national member associations hold a critical
seminar on ME.
- August 1982: Workshop
on ME. Title: Fitting ME to the needs of whom? First SCOME workshop
with the assistance of WHO
- Sept. 1982: AMEE‑meeting,
Cambridge. Contacts
to AMEE cemented, SCOME participates.
- April 1983: Workshop
on ME. Title:
ME in crisis. SCOME
explores the scope and depth of the inadequacy of ME with
the assistance of leading experts on the subject.
- May 1983: Network
of community oriented educational institutions for health
sciences symposium. SCOME
establishes contact with Network.
- July 1983: WHO
expert committee meeting, Exeter. Title: PHC in undergraduate ME. SCOME broadens its collaboration with WHO.
- August 1983: General
Assembly, L'Aquila, Italy.
Resolution of L'Aquila ‑addressing the constant
lengthening of pre‑licensure ME without improving the
adequacy of undergraduate ME. Workshop on ME with WHO
assistance. Title: ME Evaluation: Roulette or valid
assessment?
- Sept. 1983: AMEE
conference Prague, Czechoslovakia. SCOME contacts to AMEE are cemented and broadened.
- Nov. 1983: WHO
conference on PHC in industrialized countries. SCOME is
invited to present a paper.
SCOME establishes itself as manifest entity in ME
discussions.
- Dec. 1983: Expert
Committee on health manpower planning, WHO Geneva,
Switzerland. SCOME participates.
- April 1984: Regional
Assembly, Denmark. The
policy platform is drafted and the editing process
instigated. Workshop
on ME. Title: PHC
in undergraduate ME with assistance of WHO and leading
experts.
- April 1984: SCOME
participates in a collaborative effort with the
International Pharmaceutical Students Federation. Areas of common
interest are explored.
- August 1984: General
Assembly, Sweden. Workshop
on ME. Title:
Workshop planning and implementation. WHO assists. Resolution of Sweden
on ME ‑ concerning the creation of ME institutes at
medical schools.
- Sept. 1984: SCOME
is invited to moderate a session on ME at AMEEs annual
meeting in Oslo, Norway.
- Oct. 1984: SCOME
is invited to a planning session for a Network meeting
concerning strategies for change in existing medical schools
in order to bring them into line with current ME theory.
- Nov. 1984: SCOME
is invited as planner of a session on ME at Milanomedicina
in Milano, Italy, describing the crisis in ME.
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