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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005

The Achievement and Rewarding of Excellence Is Not Elitism

DR. HELEN BEH
Chief Executive Officer, Australian Orthopaedic Association

First of all I'd like to thank the organisers for inviting me to speak at this meeting today. Some of you may feel that you're being a bit slighted by somebody from the Orthopaedic Association being here and not somebody from some other speciality. But let me tell you that I don't think that was the reason that I was invited to speak. In a former life I was the Dean of the Faculty of Science at the University of Sydney at a time when the graduate medical programme was being developed and implemented and so I guess I'd better declare my interest from the start, that I do have a little bit of a bend towards the basic and medical sciences as playing a larger role in medical education than they are doing at the moment.

What I would like to do today is just to review the changes that have taken place in medical education over the past ten or twelve years and then look at the reasons for those changes being implemented. Finally, look at whether the changes have indeed produced better doctors - have been effective or not. And finally, I'd like to put my tuppence worth in as to what I see as the way forward for medical education.

First of all, there have been changes in three major areas of undergraduate medical education. There have been changes in the selection process so there have been changes in the students that you are teaching, they are not the same students that you were teaching ten years ago. Changes in the course structure and the course content, and changes in teaching methods, which have been alluded to already.

We first look at changes to selection. The change has gone from virtually unrestricted entry as it was when I was a student – five B's in the Leaving Certificate was enough to get you into the University of Sydney Medical School – not that I got 5 B's but that was enough. Early in the 1990's entry to, I think, every Medical School in Australia except the University of Newcastle was on the basis of HSC performance. That has changed now to entry on the basis of performance on a number of selection tools. It's not just the score one gets in the HSC, it's the graduate status if you are going into a graduate medical programme, it's the results of an interview that the students undertake, and the result of the GAMSAT score. Now, there's quite an involved selection process for Medical Schools throughout Australia.

The reasons for undertaking this change were, firstly, there was a restriction placed on the number of medical places in most of the Australian Medical Schools, but more importantly, studies that were undertaken discovered that students were coming into medicine with the wrong motivation. We've already heard about the study where about half of the students were coming into medicine because that was what their parents wanted them to do, they didn't want to waste a really good HSC mark, and reasons like that. Also, a lot of students were coming into medicine with very poor communication skills. This was particularly marked in the 1980's at the University of Sydney where I used to teach at the first year level in that course, and I would estimate that about 30% of the students who were undertaking the medical course at the University of Sydney were below average on their English speaking ability. For something like 20% of them, I think a study showed, English was their second language. It certainly was a problem because you'd go to give a lecture and you'd find all the students --- a lot of the students sitting with tape recorders set up in front of them. They'd be taping your lecture, they'd go away, they'd have it translated, I presume that's what it was for. But it didn't really help them in exams because there was a very high failure rate of non-English speaking students or students who had English as a second language, and it wasn't acceptable that our very best students in terms of HSC scores were subsequently failing in their courses because of communication problems.

It was also found in that same study that a lot of the students coming in based on just an HSC score had very poor social skills and later studies showed that when they actually got into the medical work force the HSC score was no predictor of their capacity as a doctor, once they had in fact graduated.

As well as changes to the selection process there have been changes to course content and structure. In terms of structure you are all aware that some universities have gone from an undergraduate to graduate medical programme. You are also aware that in terms of course content there has been a change from a focus on pure science and medical science to a focus on what I call medical practice and all that that entails – you know, the social aspects of it, the clinical aspects and what have you. And you are also all aware that there has been a change from a subject based approach to medical teaching to a theme based approach, and we'll look at that a bit more in a minute.

Let's look at the reasons for the change in course structure. I guess one of the major reasons was that it was argued that students were coming into the undergraduate medical degree, without adequate motivation – they were sort of falling into that degree pattern without having really decided that they wished to become doctors. It was felt that if there was greater student maturity and wider student life experience that they would get people who were more inclined to remain in the medical profession.

We look at the reasons for the course content change. The reasons given here were that what was needed in the medical courses was a greater integration of medical science and medical practice; that prior to the change students had been exposed pretty much to pure science and medical science, and at the end of their training in the sciences they were then given clinical training. That it was hard for the students to link the knowledge they had obtained in the sciences to their clinical practice. So the aim of this was to integrate the science training or teaching with the actual clinical teaching.

Another reason has been a greater focus on medicine as a community concern, and we've already heard about that from Bill, and a greater focus on patient doctor interaction. Several studies had reported that the bedside manner of doctors had all but disappeared and there was concern about this, and it was believed that if you changed or included in the course content material on patient doctor communication and interaction this would overcome that problem.

So let's look at what it used to be and what it is now and just look at the scope of the changes that are taking place. Probably for the majority of you here today that is the sort of undergraduate medical degree that you completed. You can see that in first year the study was pure science, and in second year you moved from pure science into the medical sciences for years for two, three, four, five and indeed six, although five and six tended to concentrate on clinical teaching. But the basic science was provided as the underlying tool for the understanding of the medical sciences which followed in second year, third year and later courses.

At the University of Sydney today, years one to three, they are the courses that students get – basic and clinical sciences, patient and doctor, patient and community, personal and professional development. Those courses are given in each of the years one, two and three, and in year four, the final year of the graduate medical programme, they undertake courses in --- or they take an option in one of those courses, child and adolescent health, perinatal and women's health, community practice, psychological medicine, drugs and alcohol. They all do those courses but they do in depth study on an option as well.

I did try to get a detailed curriculum from the University of Sydney just to see the detailed extent to which the course had changed since I had been at the university. I was unable to obtain that from the web so I rang some colleagues of mine who were still in the Faculty of Medicine and the response was no, it's not publicly released, it changes too frequently, so we can't provide it to you. And I found that a rather disturbing response to a request for information. But what I did find on the web was this; that if you look at the description of the medical course at the University of Sydney it says the medical programme is integrated across disciplines between years, and learning is based on clinical problems presented in tutorial settings. The programme is organised around four major themes. We have just looked at that in the previous slide. You can see the themes are the basic and clinical sciences, patient and doctor, patient and community, personal and professional development, and those themes run throughout the first three years. The emphasis is on progressive development across the four themes and the themes form the basis for both the design of the curriculum and student assessment. That is another thing that has changed which I haven't gone into today, is the way students in medical faculties are assessed. I don't think we've got time to go into that.

An interesting point that emerges out of what we have just seen is that what those responsible for course development have tried to do is integrate material both across --- or they've got horizontal integration across a given year of training as well as vertical integration from years one through to year four. I believe that that is a very worthwhile aim and is something that anybody developing a course should strive for.

Just to show that it is not just the University of Sydney that has made such major changes I'll just look at some of the other major universities that are involved in medical training. The University of Melbourne of course has gone to a graduate medical programme. They work in semesters rather than years. Semesters one to five are equivalent to years one to two and a half. Their themes are body systems, in which they look at basic sciences in medicine, and human mind and behaviour in health and illness, in which they look at health in society and the introduction to clinical medicine. And then in years two and a half to four they study a choice of options similar to the ones given at the University of Sydney.

The University of Queensland, they of course too have a graduate programme. In first year they concentrate on looking at the foundations of medical practice, and this is where they look at their medical science. Then in year two they become much more clinical in orientation in their courses, which is based on the theme systematic preparation for clinical practice, and then they go into core clinical rotations in years three and four.

Just to show that it is not a graduate medical programme phenomenon that has changed the way that courses are structured, or the content of courses, this is the outline of the programme at the University of New South Wales, which still takes students who are not graduates. They organise their system in what they call phases, and phase one represents maybe two years, two to three years of study; phase two about two years; and phase three would be the final two years of study. But you can see too that the emphasis on basic science and medical science has gone from that curriculum and there's much more emphasis now on the interaction of the doctor in the community, the role of the doctor in the community, learning about the development of individuals, and they also have an independent learning project in phase two where they can concentrate on something that they want to develop there.

Change in the teaching method – there has been a change from didactic teaching to problem based learning, and a change from lecture based teaching to tutorial based teaching. Reasons for changing – there has been a shift in education philosophy from teaching as a passive process to learning as an active process. The shift was largely based on the evidence of the effectiveness of problem based learning, and I believe that problem based learning became fashionable as an educational tool which also directed people to picking this up and bringing it into those programmes. I worry about educational fashion because I remember the Cuisenaire rods in mathematics and the flash cards in reading. I think if you misuse them you get the same problem that you've got if you misuse PBL in university teaching.

Just looking at the summary of changes there, I'll have to skip through those as I'm running out of time. Looking briefly at new system graduates and whether the changes have worked. There's no question that the new system graduates have got better communication skills and communicate better with their patients. The evidence is equivocal whether there's been any change in their social interaction with their patients and in their social skills, and, as we've heard, whether there's been any change in their clinical skills. Certainly there are poorer clinical skills when they come into the advanced specialist training. They are not as prepared to enter those advanced programmes. We've heard they have greater confidence but I question whether that greater confidence is based on greater ignorance – nobody has looked at that – and an interesting finding that has come out is that the new system graduates tend to have a lower career commitment, possibly because they've invested less intellectual capital in their degree.

Three suggestions for improvement. I suggest the pendulum has swung too far away from the sciences, and that the balance between science and social science needs adjustment. One of the arguments put when the graduate medical programme course was being developed was that all that science --- what you are doing is training them to be researchers, and we therefore don't need to give them that much science. Well, my argument is that doctors are researchers. When a patient comes to you with a problem you have to discover why they have got that problem and in the absence of knowledge you are not going to be able to come up with the answer. I also argue that the emphasis on social sciences may be misplaced because of the role of personality in human interaction. There's evidence that our personalities are pretty much set like a jelly by the time we are in our 20's and some people would argue they are set like a jelly from the time we are born. All the teaching in the world about how you interact with your patients and so on – you might know what you should be doing but whether you can do it is another question entirely.

I've just talked about that. Another area I think which might need improvement, selection procedures might need to improve to target those with the social and communication skills, so you don't have to be teaching them, they've already got them. We know they are set at about age 20, pick them, because they are good at interacting. And the third thing – room for improvement – I think there's a need for a better balance of theory and practice and a better balance of didactic and problem based teaching.

I was going to go on and just mention briefly what the AOA is doing but having run out of time, I'll possibly talk about that later if people want to know.