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Medical Education

REVISION OF THE CURRICULUM

Proposals of the Royal College of PhysiciansOVERLOADING of the curriculum is a confession of

educational failure. But so long as medical schools tryto provide a comprehensive training in all branches of

medicine, their curricula will be increasingly overloaded.The Royal College of Physicians believes that the essentialfirst step towards reform is to encourage teachingauthorities to study their problem afresh, with liberty toexperiment; and it therefore proposes 1 that the detailedRecommendations issued from time to time by the GeneralMedical Council should be discontinued, and replaced bya general statement on educational objectives. The

college’s views on these objectives will be found in thefollowing extracts from a further memorandum, signedby Sir Russell Brain, which it has now sent to thecouncil.

The Aim : a Basic Professional Education

To give, before registration, a full training for anybranch of medicine has become impossible, and to tryto do so has become harmful. Instead of a comprehensivevocational training the aim in future should be to givethe student a basic professional education of highstandard : he should acquire a soundly rooted stock ofknowledge on which any branch can be grafted later.It is true that a great many facts must be assimilated byanyone who is going to do any kind of medical work ;but, both for the future general practitioner and for thefuture specialist, factual knowledge is in the long runless important than the ability to learn and go on

learning.On qualification the student will be neither a general

practitioner nor a specialist, but should be fit to practiseunder supervision. His training in science should havegiven him a scientific outlook, and his training in clinicaltechniques should have given him skill in collectinginformation. His methods of thought should enable himto approach any clinical problem rationally, but heshould already possess knowledge and experience of thecommoner diseases and disorders of function, especiallyin their early stages, and of the management of emer-gencies. He should appreciate the doctor’s responsibilitiesto his patient and to the community, and he should be aperson of sympathy and understanding.

Premedical Education

Whether a medical curriculum produces graduateswith these qualities depends partly on the education thestudents have received before entering upon their medicalstudies. The General Medical Council in 1947 describedthe desideratum here as " a broad general educationincluding the principles of Physical and Biologicalscience," and it would now be reasonable to ask eachteaching authority to consider whether or not this kind ofeducation is in fact promoted by the conditions on whichstudents are accepted for medical training.Insistence on the attainment of a high standard (the

" advanced " level of the General Certificate of Education)in three or even four scientific subjects may have the advan-tage of eliminating candidates who cannot be expected tocope with the scientific side of medical education, and ittherefore has some value as a means of selecting students whowill later qualify. But it has countervailing disadvantages :first, that the candidate, being induced to amass temporarilya great body of facts, may be led thus early into unsoundhabits of learning ; and secondly that, for most of the futuremembers of the medical profession, a genuinely generaleducation is made to stop at the age of 16 or earlier. Probably

1. See Lancet, 1955, ii, 132.

few teaching authorities believe that the study of sciencefrom this early age, to the exclusion of other school subjects,is the proper basis for medical education ; yet the effect oftheir regulations is to ensure that the large majority ofentrants come to their medical schools with this alreadyspecialised education. From 16 these boys and girls havebeen taught little or nothing but science, and often they havebeen taught it less for its own sake than as a subject ofexamination.

In selecting future medical students all teaching authorities,presumably, attach importance to achievements outsidescience ; yet by their own restrictive conditions-for whichthe General Medical Council are not to blame-they maydeprive themselves of liberty to choose candidates whosegeneral attainments they would recognise as outstanding.

A teaching authority, though it may ask for GeneralCertificate of Education passes at

" ordinary " level in

English, a foreign language, mathematics, chemistry,physics, and zoology (or biology), ought not to insist onpasses at

" advanced " level in more than three subjects,one of which should be non-scientific. Concentration ofeffort on two scientific subjects, rather than three orfour, should leave a boy free for sixth-form work in otherdisciplines which can help to make him a more cultivatedperson and eventually a better doctor.

Preclinical Studies

At the age of 18-but no earlier-the student who hasbeen adequately prepared may enter upon his preclinicalstudies.

The purposes of these studies are to obtain furtherunderstanding of scientific method; to strengthenscientific habits of thought; and to learn, in outline,what is known about the structure and function of thenormal body and mind. These purposes will be fulfilled

chiefly through training in anatomy, physiology, bio-

chemistry, and psychology ; but the overwhelming sizeand continuous expansion of each of these subjects makesit essential that the student’s courses in them should be

explicitly designed and undertaken as parts of the basiceducation of a doctor-not as training for a futureanatomist, physiologist, biochemist, or psychologist.Furthermore, as part of a continuous process of education,their selective presentation should be closely connected,in the minds of teacher and student alike, with thestudies in biology, chemistry, and physics that havegone before, and with the clinical studies that lieahead.

Generally devoting two years to preclinical studies,some teaching authorities start in the later terms to turnthe student’s attention from health to disease, withteaching in pharmacology and general pathology, andsometimes with clinical demonstrations. In some medicalschools abroad there is, indeed, no formal preclinicalperiod, since the student does some workin the wardsfrom the beginning of his course. Whatever the means

adopted, the main object will be achieved if the student isled to look on his academic studies as a useful part of hiseducation for medicine, and if he tries to learn thoroughlyin order to equip himself for his later work, not super-ficially in order to pass the next examination.The proposal that the preclinical subjects should be taught

" in outline " does not imply that they are unimportant.Clearly their importance is fundamental, and every encourage-ment should be given to some students to study them morefully as subjects for an honours degree. But in actual factthe endeavour to teach them comprehensively to everybodyhas very often led the student to regard them as something tobe committed to memory and then forgotten, and i’t hastended to obscure their fundamental relationship with clinicalmedicine. As this relationship cannot be fully appreciatedwithout some knowledge of disease, medical schools will do wellto arrange that the teaching of preclinical subjects (especiallyphysiology) shall continue during the clinical period, when* itwill usually be given to best advantage by members of the

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clinical staff of the teaching hospital in collaboration withpreclinical teachers.

The college also wishes to point out that the verynecessary integration between preclinical and clinicalstudies cannot be achieved unless the character of theexaminations which separate them is altered.

Clinical Studies

During this period a thorough training in clinicalmethods and clinical thought has to be combined withincreasing acquisition of knowledge of disease and thecare of the sick. The student must learn how to useclinical techniques ; he must learn how to interpret signsand symptoms of disease in terms of disordered structureand function ; and he must gain a working knowledgenot only of the causes and effects of disease but also ofthe requirements of physical and mental health. Allthe time, factual information has to be kept in balancewith clinical facility.

Such studies fall naturally into three stages : (1) a perioddevoted largely to methods of examination, both clinical andancillary ; (2) a period in which clinical practice is associatedwith the more academic study of disease processes (clinicalpathology, morbid anatomy, and environmental pathology) ;and (3) a period of practice with increasing responsibility butstill under supervision. During this last stage much may begained by arranging for the student to spend some monthswholly or mainly in any department chosen by himself ; forboth his interest and his understanding will be stimulated byworking in an atmosphere of progress and research. In

addition, teaching authorities will no doubt wish theircurricula to be sufficiently variable to allow students of unusualaptitude and ability to avail themselves of opportunities forspecial experience.

Throughout the clinical period, the fundamental unityof medicine should be emphasised, and the barriersbetween departments must not be such as to prevent thestudent from moving from one to another-either in

person or in thought.As to how the time of the clinical curriculum should be

divided between different branches of medicine and its

specialties, the college hopes that the General Medical Councilwill make no formal recommendation, since it is preferablethat each school should work out the kind of curriculum bestsuited to its own character and capacities. In general, how-ever, it may be stated that, though clinical principles can belearnt in any clinical department if the teacher has skill inteaching them, the early training in method is ordinarily bestgiven in departments of general medicine and general surgery,and then strengthened in selected special departments.

Provisional-registration YearA year of responsible practice under supervision will

normally complete the doctor’s basic education by fittinghim to take full responsibility for the care of patients,even thougheat first he is unlikely to practise indepen-dently. Teaching authorities will note, however, thatthis year following qualification provides them with anopportunity to assess every student’s clinical abilitymore satisfactorily than has hitherto been possible. Likethe learner-driver of a motor vehicle, the student is calledupon to display his trustworthiness ; and, if he fails todo so, a further period of work under supervision oughtto be prescribed. Senior members of the medical pro-fession accepting responsibility for this final stage ofbasic medical education should recognise its importanceboth to the young doctor and to the public, and should notregard their final certificate as a formality to be fulfilledeven .if their pupil’s performance has been below thestandard they expect.

Length of Curriculum

The scope and possibilities of medicine have so muchenlarged that its efficient practice is in many respects

becoming harder. The period at present assigned to thepreclinical and clinical studies preceding qualification is aminimum of five years ; and this minimum cannot bereduced until the council are satisfied, by observation,that a basic medical education need not last so long. Acomprehensive vocational training would clearly have tolast much longer.

Because of the importance of preserving the student’sfreshness of mind during this protracted period, care

must be taken to give him sufficient holidays.

Reconsideration of Curricula

The difficulty of judging the relative merits of differenteducational methods makes it desirable to permit, andeven promote, experiments in medical education. Bytheir diversity (which the General Medical Council havealways striven to maintain), and also by their stability,medical schools in this country are well fitted to explorefresh possibilities for the teaching of the future doctor.In refraining from detailed recommendations, the councilwould give much-needed encouragement to teachingauthorities to reconsider their curricula as a whole, inthe knowledge that, within wide limits, variation will bepermissible. Equal freedom to differ on method couldperhaps be accorded to separate medical schools governedby a single teaching authority.A curriculum must be largely an expression of the

particular features and facilities of each medical school,and in the final analysis its success will depend not onregulations but on the teachers’ attitude of mind andthe facilities at their disposal. The subjects will oftenmatter less than the circumstances in which they are

taught.In each school there must be enough teachers able to give

the time required for the realisation of their concept of

teaching, and it is the responsibility of the school to build ateaching team capable of carrying into effect its particularscheme of education. In such arrangements it should beborne in mind that full use of the valuable clinical teachers Iwho ’work both in teaching hospitals and in regional hospitalsis impossible unless they are enabled to spend some sessionsat the teaching hospital additional to those arranged for thecare of the patients in their charge.

Specialisation and the advent of the National HealthService have substantiallv altered the clinical facilitiesoffered to students by the teaching hospitals. Alreadydifferent patterns of teaching hospital have emerged;and, though the relative merits of these patterns cannotyet be evaluated, a duty rests on each board of governorsto see that the clinical facilities for its students are as

good as it can make them.To this end some teacliing hospitals and universities may

feel it necessary to request alterations in the arrangementof the hospital service, and in such cases the council should bewilling to offer advice and, where appropriate, support.Students in their clinical period could profit by experience ofmedical practice outside hospital, under conditions withinthe immediate control of their medical schools, and thecreation of facilities of this kind-e.g., universitv health

centres-exemplifies not only the need for medical schools tobreak new ground but also the problems they will face in sodoing. The college hopes that in the solution of such problemsthe council will wish to help.

’

Just as the imposition of a single curriculum wouldstifle the initiative of the medical schools, so uniformityof the curriculum in any one medical school can stiflethe initiative and ignore the particular requirements ofparticular students. To subject all students to a commoncourse in .which knowledge is acquired passively, frominstruction, is a partial confession of failure. Instead,

* A brief period as observer in a general practice may also beuseful in showing the student what sort of work general practi-tioners do. But, in the college’s view, such observation issupplementary to basic medical education and not an essentialpart of it.

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given time and opportunity, the teacher will study thevarying needs of individual students so that each may beaided, guided, and inspired to learn for himself.

The Council’s Responsibility

The duty of the General Medical Council to ensure that,on registration, practitioners possess " the requisiteknowledge and skill for the efficient practice of their

profession " has hitherto been discharged (1) by recom-mendations as to the conditions on which teachingauthorities should grant registrable qualifications, and(2) by inspection of the qualifying examinations of thelicensing bodies. Discontinuance of the issue of detailedrecommendations (as proposed by the college) is now

possible because the General Medical Council’s power ofinspection has been extended by the Medical Act, 1950,to the medical schools in which the candidates for

registration are taught. Believing the quality of theseschools to be of primary importance, the council maydecide to make use of this power of inspecting them, andwill thus be in a position to make recommendations

specifically to individual schools rat]4er; than generallyto all. " .

Examinations are potential instruments of education,though they should not control its course ; and theytherefore form an integral part of a curriculum. The

college suggests that, to encourage teaching authoritiesto review their curricula fully, the council should issueno general instructions on the content or timing of anyexaminations ; for such instructions would limit the

scope of the review and might prevent the developmentof a method of progressive assessment which could be analternative to the present examination system. Since acurriculum and its examinations need to be consideredtogether, the council’s inspection of a medical school’sexaminations should henceforward be part of theirinspection of the medical school itself.

In inviting teaching authorities to reconsider theircurricula, and licensing bodies to reconsider their examina.tions, the council might ask each such authority or bodyto submit, within two years, a statement on its policyand on how this policy is to be realised.

Special Articles

TOOTHBRUSH HYGIENE IN HOSPITAL

FRANK BROOK

F.D.S., H.D.D.ASSISTANT DENTAL SURGEON, LEEDS GENERAL INFIRMARY;CHAIRMAN OF LEEDS (GROUP B) HOSPITAL MANAGEMENT

COMMITTEE

ORAL hygiene is difficult to maintain in patients withsevere mental disease. In the training of nurses stress islaid on the importance of a clean mouth, but in over-crowded and understaffed wards there is a wide gulfbetween theory and practice.

In many hospitals the nurse hands out the tooth-brushes immediately before their use, and collects themafterwards. For each brush to be inspected and placedin its individual container, ready for the same patient touse next time, takes more time than can normally begiven.

In some hospitals the brushes are tagged with thenames of the patients, but are then placed in an antisepticsolution in a single container ; the bristles of differentbrushes often come into contact with one another, andsome antiseptics injure the attachment of the bristlesto the head of the brush.

THE ANTISEPTIC

Viefhaus 1 in 1932 reported that toothbrushes can besterilised quickly and efficiently with a 1 in 200 solutionof Carvasept,’ which is, I am informed,2 a preparationof monochlorisothymol. Viefhaus said that after dippingthe brush in the solution enough antiseptic remained onthe bristles to make them spore-free in ten minutes.There were no deleterious effects on the brushes, evenwhen they were immersed in the solution for three weeks,and the bristles remained hard and elastic. Furthermore,the odour and flavour of monochlorisothymol were inno way unpleasant, and were, in fact, more pleasant thancertain mouthwashes.

Preparation.-Monochlorisothymol3 is insoluble inwater, but a stable 10% emulsion may be preparedfrom the following materials 4 :

1. Viefhaus, K. Arch. Hyg., Berl. 1932, 107, 155.2. By Mr. R. Cobb, of the medical department of Messrs. Boots

Pure Drug Co.3. Obtainable from Messrs. Howards, of Ilford.4. This method was devised by Mr. J. G. Dare, of the pharmacology

department, University of Leeds.

Monochlorisothymol .. 100 ml. Oleic- acid.B,P, ... q,s.Castor oil B.P... 50 g. Alcohol 95 % B.P... 250 nil.Potassium hydroxide Water sufficient to -

B.P. 10-5 g. produce.... ICOO.mL

Dissolve the potassium hydroxide -in 10 ml. of distilledwater and mix this with a solution of the castor oil in 50 ml.of the alcohol. Allow to stand for one hour, or until a smallportion remains clear when diluted-with 19 times its volumeof water.

c ,

Stir in the oleic acid until a few drops of the solution givea bluish-green colour with bromothymolblue (B.P.). Dissolvethe monochlorisothymol in ’the remainder of the alcohol andmix it with the above solution. Carefully add sufficient waterto 1000 ml. and mix well.

To obtain the 1 in 200 dilution required for sterilisingtoothbrushes, add a litre of water to 50 ml. of this 10%emulsion. -

Investigations.-Bristles from 6 used toothbrushesgave an average bacterial count of 1200 million organismsper bristle. After soaking in a 1 in 200 solution of mono-chlorisothymol for various periods the brushes were

washed in sterile saline and the bristles were cultured.Organisms were present on brushes soaked for five,tifteen, and thirty minutes, but not on those soaked forone hour or longer.5 5 c

.

, ,

Experiments on mice suggest that monochlorisothymolis not toxic in concentrations likely to be used for

sterilising toothbrushes. .

The conclusion reached was that used toothbrushesshould be soaked in a 1 in 200 solution of monochloriso-thymol for two hours, and washed in water before theyare used again.

THE STERILISING CABINET AND ITS USE

This is not a new idea.

Bartlett 6 described toothbrush cabinets varying in sizefrom those holding 100 brushes to those holding 20. No brushcame into contact with its neighbour, and the brushes wererenewed monthly, or oftener, as circumstances demanded.Eacli cabinet was equipped with a metal container holding afresh solution of 10% formalin, which was inaccessible to thepatients.The toothbrush cabinet which is in use at Meanwood

Park Hospital, Leeds (see figure), is made of stainlesssteel, the inside measurements being 15 X 12 X 71/2 in.?The lid is perforated so that the brushes may dry, and isdivided into two equal parts by a vertical partition. The

5. Investigations by Prof. C. L. Oakley, of the bacteriology depart-ment, University of Leeds.

6. Bartlett, D. S. Med. Bull. Veterans Adm., Wash. 1931, 7, 961.7. The cabinet is obtainable from Messrs. Chas F. Thackray, Leeds,