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THE CAMBRIDGE MEDICALCURRICULUM

A MEMORANDUM on th course and examinationstaken by medical students at Cambridge, with a

covering letter endorsing it, was submitted early lastyear to the Vice-Chancellor of the University. Thememorandum was designed to show that a scrutinyof the educational curriculum of the medical studentsduring residence at Cambridge required radicalchanges. The present situation is, the memorandumsubmits, that the students time is over occupied, if,in addition to sitting for the M.B. examinations,he wishes to graduate through the natural sciencestripos. They find a strong feeling in the Universitythat graduation through an honours tripos is the rightprocedure, if the full benefit of university training isto be obtained, but the pressure upon the medicalstudent has become such that those who supervisetheir studies at the various Colleges have found itdifficult to insist that their charges should take thislarger view. ,

From the group of University authorities whosubmitted and endorsed the memorandum a com-mittee of three was selected to draw up the document,which, therefore, is the work of the Regius Professorof Physic (Sir Humphry Rolleston), the Professorof Pathology (Dr. H. R-. Dean), and Dr. E. D. Adrian,these having the assistance at the majority of thesessions of Dr. T. S. Hele, supervisor of medicalstudies at Emmanuel College.

The Memorandum

The committee began by studying an analysis ofthe whole situation supplied to them by Dr. A. E.Clark-Kennedy, supervisor of medical studies- at

Corpus College. This showed how difficult it was forthe medical student to combine the courses forthe 2nd M.B. with those for Pt. I. of the naturalsciences tripos, with the consequence that medicalstudents either took that tripos under a handicapor did not sit for it. The committee accepted thisview and addressed a close questionnaire to the

collegiate supervisors and directors of medical studies.In this they asked how far the degree obtained

through the natural sciences tripos, Pt. I., is ofvalue to the average medical student, and whether,for example, the time spent could not be more valuablydirected to the primary F.R.C.S. examination ;if, supposing the student decides to take Pt. I. ofthe natural sciences tripos, this should be done beforeor after passing the 2nd M.B. Pt. II. ; if the numberof medical students who take the natural sciences

tripos is decreasing, and whether some adjustment oftwo sets of examinations, which offer differentstandards but require the same essential subjects,could be made ; and, if such adjustment shouldtake the form of a medical sciences tripos, whetherthe supervisors would approve of the procedure.This questionnaire was fully and helpfully answered;in almost every case a written reply was sent, andin addition, 22 supervisors of medical studies, repre-senting 18 Colleges, expressed their views personallyto the committee. 19 meetings of the committeewere held and their memorandum covers the groundexposed by the questionnaire.

Cambridge, the committee point out, is not a

complete medical school, only the pre-clinical yearsbeing spent in residence, so that the reputation ofthe school depends on the quality of the trainingprovided in the fundamental branches of natural

science. They divide the training into three stages:(1) the work for the 1st M.B., consisting of elementarytraining in physics, chemistry, and general biology;(2) the work for the 2nd M.B., comprising two stages,(a) anatomy, physiology, some organic chemistry,pharmacology, and a slight introduction to pathologyand bacteriology; (b) a period of specialised (and inthe case of anatomy and physiology, relativelyadvanced) training in those branches of science anunderstanding of which is essential to the study ofmedicine ; and (3) clinical practice and training,concerning which the report is largely silent, suchwork not being done to any extent by students inresidence.The memorandum deals next with the relation of

university to vocational training. It runs :-, Stage I occupies from one to two or more years, and as timegoes on larger numbers of students complete this stage atschool before coming into residence at Cambridge, and goto a London hospital at the end of the third year. Clinicalstudy at a London hospital occupies three or more years.That is to say, out of a total period of study, which is seldomless than seven years, the time spent in Cambridge is in themajority of cases not more than three years.The courses given in Cambridge for the 2nd M.B. do notdiffer essentially from those given in other English and

Scottish universities, and there is no reason to think thatthe standard is higher in this examination than in manysimilar examinations in other universities. The great advan-tage and the only advantage which the medical school,as apart from the general influence, of the University ofCambridge has to offer to the medical student is the oppor-tunity to obtain the training in the fundamental scienceswhich is provided by preparation for the natural sciencestripos. Unless a medical student works for the naturalsciences tripos, he misses the scientific advantage of residencein Cambridge, and it is possible that a student who proposesto limit his effort to the courses provided for the 1Z.B.examination might get a better training at some other Imedical school.

It must be a matter of grave concern to the Universityif any large number of medical students refuse or even arereluctant to take the natural sciences tripos. If it can b&shown that in the course of time it has become undulydifficult or even inadvisable for a medical student to attemptthe natural sciences tripos, then it is obvious that thecurriculum of the medical student in Cambridge is in urgentneed of reconsideration and reform.

The committee took information as to whetherchanges in society or the University caused by th&war have altered the attitude-of the student towards

sitting for the natural sciences tripos, and foundthat it had done so. Most of the supervisors heldthat medical students ought to take the naturalsciences tripos, but admitted that they had not

enough time to profit by studying for it, and said thata certain number devoted the third year of theirstudentship to preparation for the primary examina-tion of the F.R.C.S. Eng. as more likely to be useful.Investigation showed that in the period 1906-191177 per cent. of the medical students took the tripos,whereas in the period 1920-1926 the proportion hadfallen to 44 per cent., and this in spite of the fact thatan increasing number of students completed theirstudies for the lst M.B. before residing. The com-mittee found that the majority of medical students whotake the tripos take the 2nd M.B. at the end of theirsecond year. The work for the 2nd M.B., Pt. 11.,is difficult and important, and when it is passed the.student has a great part of his special work for thetripos still before him ; work during the long vacationmay assist him, but in the tripos he will have to face,competition with those who have prepared for it

unhampered by medical examinations. With so

little time at his disposal he limits his endeavoursin the tripos to three subjects-physiology, anatomy,1 Elsewhere it is indicated that the clinical work need not be

done at a London hospital.

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and zoology-and says the report, "to sum up, thedifficulties appear to be that the student has so

much work to do in preparation for the 2nd

42.B., Pt. II., that his preparation for the tripos iscrowded into his third year, and what should be a

period of thoughtful study of the theories and

principle of science is apt to degenerate into ninemonths cramming of facts. At present a medicalstudent attempts or is encouraged to attempt to reachthe standard of the B.A. (or as it would be calledelsewhere, B.Sc.) with honours in three years, andat the same time to pass a series of rather difficultexaminations for the M.B., trusting for success toextra work and to the overlap between subjects ofthe 2nd M.B. and the tripos examinations." Further,the committee points out there is a grave differenceof opinion as to the best sequence of the examinations-i.e., whether Pt. I. of the tripos should be takenbefore or after the 2nd M.B. The knowledge requiredby the student in chemistry and biology has increasedmanifold, and new subjects, like chemistry and

pathology, have appeared. " The increase of know-ledge," they say, " has led to a multiplication ofcourses, and an addition to the demand made on thestudent’s time and industry. We think that themedical student is overworked, over-examined, andharried by a very complicated lecture-list and time-table... and is not able to take a reasonable share inthe social, athletic, and other College and Universityactivities which play so large a part in the trainingwhich the University provides for the students ofother faculties." The committee point also to theconfusion produced by the fact that the M.B: andtripos examinations are arranged by several differentFaculties of the University.The committee discuss, as a compromise measure,

the modification either of the 2nd M.B. or the naturalsciences tripos, so that the passing of one or otherwould suffice for graduation and passage to the 3rdM.B. They do not recommend the compromisein either direction, but give reasons for thinking thatthe institution of a medical sciences tripos is logical.They are also strongly of opinion that it would beprejudicial to the general education of the majorityof schoolboys if they were required to pass the1st M.B., as at present constituted, before cominginto residence.

In a closing summary, the chief difficulties aheadseemed to the committee to be : (1) the absence ofa definite opinion either in the University or the

Colleges as to the preparation which an intendingmedical student should have before he comes intoresidence ; (2) the amount of work involved by anattempt to complete all parts of the 2nd M.B., andPt. I. of the natural sciences tripos within threeyears ; (3) the complexity of lectures and practicalclasses for two concurrent but almost uncoordinatedsystems of examinations, and the multiplicity ofthose examinations ; and (4) the absence of agreedopinion as to the best arrangement of the student’stime, which led to different advice from collegiatesupervisors.An appendix prepared for the committee by Dr.

Hele, Dr. Clark-Kennedy, and Mr. Ranner containsthe statistical evidence derived from the Universityrecords.

Report of the Syndicate on the MemorandumThe syndicate appointed to consider the matter

report that they agree with the main conclusions.Accepting the classification of the examinations,they point out that an increasingly large proportionof medical students pass the 1st M.B. while still at

school. They find that to reach the standard of theB.A. with honours in three years, and at the sametime to pass a series of examinations for the M.B.degree, has the difficulty that the subjects for thenatural sciences tripos and the 2nd M.B., thoughoverlapping, require different standards, so that itis difficult for the medical student to do as well ina science degree as the non-medical competitor.But they point out that unless the student worksfor the natural sciences tripos he misses the educationaladvantages of residence in Cambridge. " He mayreceive an adequate technical training but can layno claim to special merit, which detracts from thereputation of the school."The syndicate point out that at the present time

the curriculum is supervised by three separate FacultyBoards, and that while the interests of the Board ofMedicine have been confined to the M.B., those ofthe Faculties of Physics, Chemistry, and Biology haveregard to the natural sciences tripos. They considerit the business of the University to produce mencompetent and ambitious to undertake research, andagree with the memorandum that the curriculum is

unsatisfactory and that the need for revision is

urgent. -

SUGGESTIONS FOR REFORM

While the syndicate propose no change in the

regulations which permit students to take any partof the 1st M.B. before or after matriculation, theydo propose: (1) that in the 1st M.B., Pt. II.(mechanics) and Pt. III. (physics), the subjects shouldbe combined into one Pt., and the present Pt. I.of the 2nd LB. (organic chemistry and pharmacology)should form Pt. IV. of the 1st M.B. In Pt. I.(chemistry) stress, they say, should be laid on physicalrather than inorganic chemistry. 2

They consider that the only satisfactory wayto lighten the burden of the student is to remove theconfusion of duplicate examinations, and hold thatall students should be compelled to attempt a

tripos. The modification of Pt. 1. of the existentnatural sciences tripos, so that the student who hadpassed it should be able to proceed to the 3rd xI.B.,would substitute that tripos for the 2nd M.B. Ascheme whereby the existent 2nd --NI.B. should be aqualifying examination for Pt. II. of the tripos wouldalso do away with duplicated examinations. Butfor reasons stated they hold that neither of thesechanges could be made in a satisfactory manner,and came to the conclusion that a medical sciencestripos should be instituted, the passing of Pt. I. ofwhich should qualify the student, obtaining honours,to proceed straight to the 3rd M.B. They pointout that in such a tripos, in order to secure a breadthof view, subjects should be included which are notincluded in the 2nd M.B., but they recognise thatcertain students would be well advised to sit for theexistent natural sciences tripos, and are prepared toarrange modifications in the regulations, both forthe natural sciences tripos and for the M.B. degreeto facilitate the situation.

THE MEDICAL SCIENCES TRIPOS

The subjects to be included in the medical sciencestripos, Pt. I., as approved by the syndicate, are setout and here the difference between the new examina-tion and the 2nd M.B. lies mainly in the importanceplaced upon embryology and morphology which areto be taught with topographical anatomy under one

2 The existing plan of the present curriculum will be foundin the Students’ Number of THE LANCET, August 29th,1931 p.440.

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inclusive head-anatomy. With regard to physiology,provision will be made to combine the instruction

given in the departments of biochemistry and physio-logy and to give instruction in pharmacology with thelatter. The suggestions in respect of pathologyare that this subject, which at present falls underPt. II. of the natural sciences tripos should comeinto Pt. I. of the medical sciences tripos, but as thesubject forms Pt. I: of the 3rd M.B., it is not suggestedthat candidates should necessarily take pathologyin the tripos. For the tripos anatomy and physiologyare compulsory and a third subject is necessary.If the student elects to omit pathology he should offertwo other subjects, such as special courses in anatomy,biochemistry, or zoology, where comparative anatomy,paleontology, and embryology of vertebrates wouldbe required with knowledge of parasitism and genetics.The syndicate stress the educational importance ofthese latter subjects, and feel that any scheme fora medical sciences tripos, Pt. I., must be elastic andwell planned to cater for the needs of different students.With regard to the medical student sitting for theexisting natural sciences tripos instead of the medicalsciences tripos they proposed that compulsory anatomyand physiology should have the same scope as in eachtripos and that the examiners should be largelyidentical.The time to be allotted to the different subjects

is stated in terms of hours per week, the syndicatehaving given careful consideration to the opinionsof the authors of the memorandum that under presentconditions the medical student is not able to take areasonable share in the social, athletic, and otherCollege and University activities.They propose that the arrangements for the medical

sciences tripos, Pt. I., and for admission to the3rd M.B. should be as follows :-

1. That the subjects for Pt. I. of the tripos beclassified in the following way:Anatomy (including topographical anatomyand some embryology and morphology) .. 2 units

Physiology (including pharmacology and somebiochemistry taught in the BiochemicalDepartment. 2 units

Optional Anatomy ........ 1 unitZoology ............ 1 unit ’,Pathology............ 1 unitBiochemistry .......... 1 unitChemistry............ 1 unit

2. That the examination for the medical sciencestripos, Pt. 1., be constituted as follows :Physiology : 2 units. Two papers and practical, and

viva voce.

Anatomy : 2 units. Two papers and practical, andviva voce.

Other Subjects : 1 unit each. One paper and practical, and.

viva voce.

Each unit is to carry with it the same number ofmarks. The questions set in any paper are to be

approved by the whole body of the examiners.3. That a student be required to take some

combination of subjects equivalent to six units.The syndicate are of opinion that anatomy,

biochemistry, pathology, and physiology, shouldbe transferred from Pt. II. of the natural sciencestripos to the medical sciences tripos, regulationsfor admission remaining unaltered. And they findit essential that all the courses and examinations.taken by medical students, either for the medicalsciences tripos or the M.B. degree, should be underthe control of one faculty board.

The report closes with a note on certain modifica-tions in respect of the M.D. thesis, and brief commentson the financial alterations implied in their recom-

mendations. They consider that the scheme as setout could probably be financed if each medical studentpaid a terminal composition fee of 15 or 16 guineaswhile reading for Pt. I. of the tripos. They recom-mend that general approval be given to the proposals,and this is made with a promise that they will putforward a report recommending the necessary changesof ordinances in so far as they are competent to do so.

IRELAND

(FROM OUR OWN CORRESPONDENT)

B.A]:.A. MEETING, 1933

IT appears to be decided finally that the annualmeeting of the British Medical Association for 1933will be held in Dublin. Some suggestions have beenvaguely current to the effect that the politicalatmosphere might render it advisable to hold themeeting elsewhere, but these suggestions have notaffected the Council or the Representative Meeting.The preparations for the meeting are already wellforward in the hands of the local executive. Thetwo Universities, the City of Dublin, the two RoyalColleges, and the Royal Dublin Society have beengenerous in their offers of hospitality, placing theirrespective premises at the disposal of the committee.It is intended to hold the Representative Meetingin the lecture hall of the Royal Dublin Society, atBallsbridge, while the reception rooms and the tradeexhibition will be in the Mansion House, and thesectional meetings will be held in the lecture roomsof Trinity College and University College. For

presidency Dr. Thomas Gillman Moorhead was theunanimous choice of the Leinster branch, and thatchoice has now been ratified by the Association.Dr. Moorhead, who is Regius professor of physicin the University of Dublin since 1925, is also at themoment president of the Royal College of Physiciansof Ireland, president of the Royal Academy ofMedicine in Ireland, and president of the Associationof Physicians of Great Britain and Ireland. Itneed hardly be added that he is an outstandingfigure in Irish medicine.

FIRST-AID WORK AT THE EUCHARISTIC CONGRESS

The great numbers of people who visited Dublinat the time of the Eucharistic Congress, when religious

services attracting an audience of more than half amillion were held, made a heavy demand on the workof the St. John Ambulance Brigade in Ireland.Some 700 voluntary workers-ambulance men andnursing sisters-were mobilised for the work, and forseveral nights the first-aid service was continueduntil three or four in the morning. In all, nearly7000 cases were attended, the great majority beingfaints, heart weakness, and exhaustion from heat.

Only two fatal accidents occurred.

JUBILEE OF THE

FRENCH OPHTHALMOLOGICAL SOCIETY

La Societe Francaise d’Ophtalmologie celebratedlast week the fiftieth anniversary of its foundation,.when representatives from all over the world wereentertained as guests of the society from July 17th-21st at the Hotel Majestic in Paris. The morningswere devoted to scientific meetings, which began at