R. S. Williams Senior Visiting General Surgeon Modbury Public Hospital Adelaide South Australia

My background

Graduated 1971 Adelaide Medical School General surgeon FRACS , FRCS (Eng)1979 Teaching students since 1970’s; Royal

Adelaide and Modbury Public Hospital, S.A. Currently teach 4th and 6th year students from

Adelaide Med School

My view of current undergrad. medical education Hard sciences and academic excellence

gradually devalued Clinical students keen & enthusiastic but

struggle Eventually most will overcome deficiencies in

undergraduate education, but is this right? Proud traditions of Adelaide Medical School

( founded 1885) under threat

Changes in medical education since 1990 Problem Based Learning adopted late

1990’s My impression since; anatomy and other basic sciences

neglected social and behavioural sciences promoted.

Is this what the community needs? What was so wrong with previous

curriculum?

Changes in medical education Communication skills “holy grail”

Students’ basic scientific knowledge ‘?’ now

inadequate for clinical medicine

Clinical tutors and postgraduate Colleges “plug the gaps”

Communication , interactive skills and teamwork

Rightly emphasized in modern medical curriculum

Possibly too little training in past

But…. Scientific training must always receive highest

priority.

Adelaide Medical School preclinical years 1-3

1965 40 contact hours /week

Emphasis

• Didactic teaching - physics - chemistry - anatomy - histology embryology - physiology - biochemistry “Medicine and the

humanities”

2005

25 contact hours/week

Emphasis

• Problem orientated, self-directed learning

- Social sciences - interaction and communication skill - some anatomy and histology, no embryology

Human Anatomy ; the basis of Medicine

1960’s

progressive dissection of cadaver during 18 months , regular viva’s and final exam.

600-700 hours 2000 onwards

self-directed study of prosections

100 hours

Is anatomical knowledge adequately

tested?

“ Core Curriculum”

Anatomy should be core curriculum

Students must demonstrate competency before progressing

Anatomy “electives” promoted

Problems in medical education

Pendulum Effect

• 1960’s arguably too much detailed basic sciences

• 2000’s Too Little

80% reduction in anatomy, histology, embryology teaching, and reductions in physiology, biochemistry

Where should the pendulum be?

Basic science teaching “ 3 R’s ” analogy

1980’s and 1990’s basic language and math skills downgraded in schools

Deterioration in literacy and numeracy Will we have to learn this lesson in medical training?

Compounding the problems

Teaching in clinical years relies on goodwill of

clinicians who may not wish to, or be best qualified to teach basic medical science

Reductions in working hours for junior

doctors limits clinical experience and stimulus to add to knowledge

Basic science teaching

Concerns expressed by RACS Royal College

Pathologists Australasia

Australian Med Students Society

Many individual clinicians via conferences, journals and media

RACS Anatomy Working Party 2004• “ crisis in the teaching of anatomy in medical

schools”

• “soft subjects jeopardising anatomy”

• “the current problem-based learning model has been a failure in teaching basic sciences”

• “RACS will have to fill the gaps”

Flinders University Graduate Medical School

Anatomy taught in first year, but can fail anatomy and still pass overall

Anatomy “elective” in second year optional

But graduate entry; most have already studied basic sciences including anatomy

Changes in medical education The concept that less training in anatomy and

other basic sciences produces better doctors is counter-intuitive

Is there any evidence that radical curriculum changes have been necessary or produce better doctors?

What do Adelaide students say?

•“ not prepared for PBL in first year” • “thrown in at deep end”

•“not enough didactic teaching” • “not enough lectures and demonstrations of anatomy”•“ too much self-directed learning”• “not sure where I am, if I know enough.”•“can’t access tutors easily

Justifications for new medical curriculae“Doctors have been poor communicators”

Address this but not at expense of scientific knowledge

“Medical knowledge expanding exponentially” All the more reason for have thorough grounding in basics “Medical practice in future will be based on public health / preventative

medicine” = IVORY TOWER stuff For the conceivable future we will have an ageing population needing medical and surgical treatment

“Dumbing down” of medicine Medical education post 1990’s;

less theory, less basic sciences, lower standards

Nursing education since 1990’s;

more theory, more basic sciences, higher standards

Other issues in medical education

Adelaide Med school 2004 ;

70% female, 30% local Flinders graduate school similar ratios Workforce projections ? based on outdated

models Changing work ethic (male and female ) Future medical workforce ?

Other issues. . .

Adelaide Med School’s non graded pass/fail system (rationale; discourage competition between students working in groups)

Analogy with primary and secondary schools discouraging competition ;

It didn’t work!

Competition and excellence

non-graded pass/ fail = failure to reward merit

does this foster mediocrity?• How do we identify excellent students?• Does it prepare students for medicine or life in

general?• Good students don’t like it ; lazy students love it!• Has this approach already failed in pre- university

education?

Medical Student Selection

TER, UMAT, Interview Academically gifted students missing out Selection interviews reward verbal and

communication skills. Is this assessment reliable at age 17? (also, females better at this age.)

Evidence of coaching for UMAT & interview What effect on quality of future graduates? Majority of future doctors female = serious workforce implications

other thoughts. . . Is the move away from didactic teaching of

basic sciences aimed at reducing costs and staffing in medical schools?

Allow me a moment of paranoia ! Are there wider agendas? e,g, deskilling in hard sciences reduces status of medical doctors -- become “health care

workers”

Current Medical EducationSome good things! Students keen, enthusiastic, well presented Communicate and engage well with staff and

patients Work well in teams Recognize deficiencies and seek help and

direction from clinical teachers to improve in these areas

Aware of need for balanced lifestyle

What can medical schools do? Change selection process; stop “dumbing down!” Make sure basic medical science knowledge is

properly taught and assessed. ( esp. anatomy)

Intersperse PBL with more didactic teaching

If persist with PBL, consider change to graduate entry

Listen to concerns of students and clinicians and act on them!

Rescuing medical education conclusions (At least in Adelaide) current pre-clinical

medical education inadequate in basic sciences

Urgent review of medical student selection needed

Urgent review of anatomy teaching needed.

Students struggling , need more didactic teaching

“Softer” sciences should not dominate curriculae

Views of senior clinicians and students must be heeded.

Rescuing Medical Education

My thanks to the organizing committee for asking me to contribute.

I hope this meeting leads to reform in medical education !

R.S. Williams , Sydney February 2005