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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005
Professor Ted Cleary
Associate Dean (Curriculum), University of Adelaide
CHAIRMAN: We're now to have the privilege of hearing Professor Ted Cleary, who is Associate Dean dealing with the medical curriculum in the University of Adelaide. I've already explained to Professor Cleary that it was I, in fact, who dobbed him in for this.
PROFESSOR CLEARY: Thanks very much, Frosty.
Bruce and I go back a long way, to primary school, in fact. I've watched with interest the Australian Doctors Fund's activity over the years and I think this is a wonderful thing and I thank you for inviting me. Although, as Stephen said to me, I was set up pretty much as a whipping boy for this, and someone needed to defend the system. I have no intention of defending the system. I came here to attack. Basically, what I want to do is to introduce some data into the system or some evidence that will enable us to see some of the problems.
So that my alternative title might well be the sort of issues that have to be addressed by an Associate Dean for Curriculum, and that is the Curriculum Committee, in meeting today's needs for medical education. As you've heard already this morning, this is a multi factorial problem.
I should declare my prejudices, and that should help to give you some better idea of where I'm coming from. I trained as a physician at the Royal Prince Alfred Hospital and then elected to go back into basic science and have an MD in physiology on - interestingly enough - the biochemistry of artery walls. And I became so interested, having taught myself some biochemistry after graduation, I then became interested in the fundamental electro microscopy, immuno electro microscopy and molecular biology of elastin and micro fibrils associated with elastin, of which fibrilin is one of the proteins. My laboratory actually isolated one of the collagen types, and was responsible for a lot of work on copper deficiency. The reason I went to Adelaide was because I was able to run fifty ewes on copper deficient pastures at Robe for eight years, and study the effects on their copper deficient foetuses. So basic science is high on my list of requirements.
In addition to that, I have practised for at least thirty years - and I've forgotten how many it is, really - as a consultant physician in general internal medicine at the Royal Adelaide Hospital, and I still do that as an outpatient physician.
This is my fifth curriculum revision. And what we need to do, then, is just let's go back to our patient. I can agree that there's a crisis in medical education. I think we all agree with that. Now the question is that we have differences in terms of what are the diagnoses, and especially we have differences about what are the proposed most effective treatments.
So, as with many of the patients that we see today - in fact, most of the patients I see, have multi factorial disease. To offer a uni dimensional solution to this is not going to work, and doesn't work. So what we need to do is to understand the magnitude of the problem and look creatively for solutions that will address those.
So we need to define some terms. The layer cake model of Flexner is the one which has been traditionally taught and I want to oppose that to the model we use in Adelaide. This is Flexner's model, you start with the basic sciences, you layer on some para-clinical disciplines, then a layer of clinical training, then you go out and practice, and you top it all off with a strawberry or a cherry and that's the epitome of it.
Our alternative has been to say we want to have a curriculum which is integrated from top to bottom and though the years, horizontally, so the students don't recognise subjects. We don't teach any individual subjects in the first three years. We call it "scientific basis of medicine". We also start the students on clinical skills training in first year - these are high school graduates - and we do that in our clinical skills laboratory in the medical school. Then we send them out into the hospitals for their second year, and they are supposed to learn some clinical skills there. And then for the third year we deemed that they would be ready to go out into general practice and to have an effective experience there one day a week. That's proved to be an interesting experiment but it hasn't particularly met the students' requirements and so we're bringing them back into the medical school for additional clinical training.
What we have done is to recognise modern advances in how people learn, and there's an enormous discipline and science out there about different learning techniques. I spend five or six hours a day reading about those sorts of things, scheming up ways that we can introduce those and make our teaching more effective, and arguing with people about why we should change again.
The evidence at the moment is that contextual learning is absolutely critical to the long term memory of stuff. If you see --- and the best way to learn medicine is to learn patients. I still remember the names of patients I saw as a fourth year medical student, when I started to take an interest in medicine. I tell the students, when I want to think about problem based learning I think about Trevor Baldock in the Atherton Walker Ward - and Bill Ryan will remember him perhaps - in his grey and blue pyjamas, vertically striped, and we drank beer with him at the Grose Farm when he skipped out. Later on I attended his autopsy - the follow up of education.
The other thing that we did - we started with six blank sheets in the curriculum committee and we said all bets are off. We had an eighteen month induction programme in what the new evidence about learning and teaching is, and what were the goals of medical education as put forward by other different authorities. And we relieved heavily on the Kings Fund research that Angela Towel(?) did in England, and on the Canadian Medical Association's research and on the statements from Beyond 2000, and so on, that the different authorities in the USA and Britain put forward, as objectives of medical education.
Then we said, yes, we would like to do those, and the question was how do we do it and what's the best way of doing it, and we laid down a set of our own principles - developed ab initio. It was quite an interesting exercise to see how paralysed people were by confronting six blank sheets of paper, having to start working out what was the best way to do it, but creatively very interesting.
The first thing we wrote on that bit of paper was that medicine should be --- that medical training should be an enjoyable experience. And I think the students from our school would certainly agree that their undergraduate training is enjoyable, and our survey suggests that between 93 and 97% in different years regard the experience as an enjoyable one.
In addition to that it should be engaging. What we are finding is, by engaging our students in the issues of patients from the beginning they have the motivation and they actually are working a hell of a lot harder than the students in previous years were.
The assessment models are interesting. This is another way of looking at the traditional curriculum. It's the jug and mug model, where the teacher has all the information and knowledge and pours that into the students, and that's called teaching. Or alternatively, they are seen as a nesting mother feeding her young, and what we have more and more is the young squawking louder and louder for more food, and cram feed us with more stuff.
Our curriculum we see as being contextual. That is, they learn around patients from the beginning. It is self directed, and it relies on the principles of adult learning, of which more later.
The assessment model that most of you have been through is the Aintree Grand National model, where you have a flat track and there are little hurdles put on this at every so often, and you cram for it with the intention of knowing it for four days - the information for four days - and then not carrying it forward any more.
The reason why I went back to teaching first year in 1988 - which started me down the path of problem based learning with myself as a sole tutor for a class of 155 - was that the students who were coming to me who had distinctions in anatomy and physiology in second and third year - when they were coming to me in pathology and I was trying to teach them patho physiology and medical decision making, they couldn't remember any of the anatomy that they were said to have known. And when I asked them what had happened to it, the answer was "that was anatomy, we did that in third year". And they had no intention of carrying that forward. So I went back in an optional course to invite the students to actually recognise that the treating of patients and the management of patients required you to carry forward a lot of anatomy and biochemistry and physiology, the basics of it, to understand it and to be able to use it effectively.
What actually happened there was that it was at a time when there were graduates in our course, and as I turned up the heat on the students, and required them to learn stuff and to bring it back, at the end I had eleven students in my class and all of them were graduates. So when we had some feedback about how the course had gone and should we drop it because it was unpopular, the answer was that this was the best thing that had happened to them since they'd been at university, and this was the first time in four years of university training that they'd had to think.
Now, that's shocking, but that's the truth. If you talk to graduate students, undergraduate education is, by and large, in modern universities learn this - cram it, dump it, cram it, dump it. It's not till they get to their Honours year for the first time that students will tell you they had to think about what they were doing. So thinking is an important part of university education, one what have thought.
We have a model then in this - and you've heard some stuff about formative and summative assessment. We need to demythologise that a little bit. Formative assessment is what the student needs to know to alleviate their anxiety about, am I doing enough. And the answer is a lot of them are doing more than enough under the new system. But in addition to that, some of them are trying to learn excessive detail and blowing up. And so the formative assessment is to give them an idea of how they're going, where you should be at this time. We see this spiral staircase as being the requirement for our curriculum. It says that in order to jump the next hurdle you have to be at the next landing. You've got to carry forward the knowledge that you've learned in first, second and third year to jump the fourth and fifth year hurdles. You don't start on a flat track.
Our objectives in medical education and we have pages of them - I won't read them all out - but we do see ourselves as attempting to prepare students for going into practice and seeing patients after ten years from now. There's a long lead time before people start to see patients in their private practices, and so on.
So you need to have a vision for what the practice of medicine is going to be in the future, if you're training people for that. So not only will our students be ready for their internship in those things, but we also are saying that they should practice, and be aware of how to practice ethically; they should be equipped for life long learning and for self care, and we put a large emphasis on that in our personal and professional development strand; and we have decided that destructive competition - competition that leads people to hide books in libraries, that leads people to tear pages out of journals, articles, so that other students can't get at them, which was common in our school when we started this - that should go.
And in the trial course I ran we had no assessment, it was just for interest. A student said, it's got to be assessed if you want the other students to take it seriously - a graduate student told me this. Secondly, it has to be an important part of the passing on, you have to be able to fail. What I said was, I wouldn't assess it, I would ask them to write a reflective journal after the third of the cases that they were dealing with in my form of problem based learning. And the experience of co-operative learning in groups when we introduced that was such that the students, after one year of that, went to the Associate Dean for Student Affairs and asked if all the subjects in the first three years could be non graded pass, because they found the co-operative experience of learning together and not competing with one another for resources was much more effective.
So we've stayed with that, and we're wrestling with the problem, as you've heard earlier in an address, of - is our job to select students into hospitals. In the same way, I would say, is the job of high schools to select students into universities. And my view is that the Tertiary Ranking Examination has reached the stage where it actually is anti educational. I'll come to that in a minute but there are some other major issues that have to be addressed, and you've heard a lot of those already.
Knowledge is increasing exponentially. We're predicting what future needs will be, and you need to put your future glasses on for that.
Students are very different now from what they were five or ten years ago. That has to be taken into account. There are pressures on staff and medical schools that weren't there previously, which have to be addressed now, and a number of those you've already heard talked about. We consulted widely with a whole range of students. For me, the big advance in our curriculum changing was when I abolished the representative membership of the curriculum committee, with the help of the Dean. We got rid of the silo protectors. And we actually now have people who have portfolios, who have special expertise and interest in various aspects of our integrated course.
We have students on this, representing student views - two student representatives. We have, in addition to that, invited the Department of Human services - now called the Health Commission again - to have one of their members on the curriculum committee because we're training their staff. You'd think they'd have some interest in how their staff are going to be trained, but they've managed - between two members and four years - four meetings.
The other persons that we consulted, because we've gone over now in Adelaide to area management, which has proved to be so helpful in all the other parts of Australia - we've gone over to this and we invited Michael Rice who was on one of the earlier curriculum committees with Frosty and myself, who is now the Chair of the Clinical Senate, if he would tell us what they saw as being the things that medical students should know about, and this is part of his wish list.
So we need to address all of those - an aging population; our students should know about the social and economic determinants of health; they need to be involved in looking at the changing burden of disease - the prevention and management of this is going to become an important part. Then they have to address these other issues - health inequalities, changing governments and service delivery, population health focus, and the emphasis on primary health care. So prevention, health promotion, health information and functioning in a multi disciplinary team are essential requirements, he tells us, of a future medical graduate.
So we've accepted all these inputs. We've had a lot of help. The College of Pathologists wrote to us and said this is what they want. Cancer surgeons wrote to us and said this is what they want. Every sub group you can think of has got a curriculum. The palliative care people have their curriculum, and so on and so on. There isn't time.
Some of those things to do with students haven't been ventilated this morning. I've mentioned about the adverse effect on education of the tertiary ranking system in high school. Our students are actually taught and allowed to learn by enquiry learning in the first ten years of school. In years 11 and 12, the principals will tell you, we stop teaching students and we move over to teaching curriculum. And it's anti educational. The students come in straight to us, straight from school, and what they are saying is, tell us what we've got to learn. Your job is to teach, and you just tell us what to learn. We're good at learning it, and we'll learn it. And I said, sorry mate, one of the things you're going to have to do here is learn what's important, and work it out. We'll help point you in the direction, but if you don't master that and get to learn how to learn for yourself you're never going to be going anywhere in the long term.
The whole business of selection - we have a problem. We painted ourselves into a corner on selection. I never agreed with it, and basically I think they've --- I don't see how they'll get out of it easily. But what's happened now with the reverse engineering of the UMAT - there are training programmes. ACER assured us you couldn't study for this and practice up for it. The reverse - it's the opposite of course. And now we're getting better and better monkeys coming into medical school because they've been trained to lie and they've been trained to tell the interviewers what they want to hear, rather than what they believe. So one takes a cram dump course for getting into a self directed learning programme and then we have an enormous amount of time spent trying to convert them to adult learners again. That's a problem for us, it costs us money.
Television and computer games are a major input to students. They are visual learners. Basically their view of medicine comes from ER and other similar television programmes. It's all black and white, it's all instantaneous decision making, or a test sorts it out instantly, and all you've got to do is administer the magic treatment and they all get better and live happily ever after. Now that's true. That's the view that many medical students have when they come into medicine. Whether they will enunciate it or not, that's the answers they give when I run classes with them in the first week of medical school about how - what will we do for this patient now; what else do you want to know about; how do you explain this; how do you explain that.
The students are - just as much as the male medical practitioners - victims of the "get a life" syndrome. And I can put it like that, being past the normal retirement age and working 65 hours a week still. Get a life is a serious issue, and the students are not willing to put in the hours. And in many instances, because of the economic pressures that they are facing, a large proportion of our students are working in order to maintain their quality of life. We did a survey a few years ago of the fourth year students. Some of them were working 25 hours a week. That's why you can't programme classes after 4 o'clock. Because they have to go to their job, we've got to leave. They come up to me when I'm giving a 4 o'clock class and say, we have to go at 4.30 because I've got to be at my job at 5. This is a major problem and we have to address it.
The challenges to assessment - I'm paying 28 thousand bloody dollars a year for this and you've got to pass me. And we have the parents down from Hong Kong to tell us we've got to pass them, and then they go through appeals and appeals and appeals, and it just goes on and on. We have to answer all that stuff. It's going to get worse.
Not only that, but we have a lot of English second language students. The university tells us we've got to have fee paying students. So they don't speak very good English although they've passed a particular standard. Ian Frank helped us to work out the standard they should have. I think they send their brothers. We have a full time staff of three people helping these people to acculturate, and to speak English.
There are pressures from in the university. Promotion is mainly through publications. If I ask someone to come into teaching I am doing them a disservice because they will have major difficulties in getting promoted as a teacher. The funds for teaching are constantly being squeezed and we've heard how that goes on. In our university we have an interesting trick called socialisation. What this means is they take money from the medical faculty, which is given at a higher rate, and pay us at the same base line rate everyone else does, and spread the money around to the other faculties who don't get paid so well. Well, that's good for them but it doesn't help us.
We have a darg of fee paying students we have to take. If we don't get that many up they take that money away from our budget and a penalty as well. Our universities, like most other institutions, are now becoming business model focused. That means the centre gets fatter and the people out at the periphery do all the work and get less and less money to do it.
In our system, you've heard earlier, we're only accepting 39 students from Adelaide this year in the UMAT selection process. We don't have any control over that. That's based on the Australian Constitution. We're not allowed to interfere with free trade between States so we have to take all comers. But we have a large proportion of out of state people as well as full fee paying overseas students, and our clinical staff resent it, and they've got every right to resent it, I believe.
There are big changes in the teaching hospitals and most of those have been ventilated already and I won't go through them in any great detail. You've heard from Guy Maddern about what we're doing with the on-day-of-admission and overnight admissions for surgery, and that's been an interesting thing.
Our rural clinical programme has been a major benefit to us in this regard because we send students out to rural practice in second and third year, as well as in the later years. We've got 19 students doing all of fifth year in the rural setting this year, and we have the attachments there in final year.
Our barrier exam is the end of fifth year, and our students then have an experiential year, half of which is in large institutions and half of which is in primary case.
The staff related issues - the service load is well understood. Many don't value teaching. I've invited someone, as I say, from the Health Commission, and they just can't make it. We're victims in the cost cutting, cost shifting game between the Commonwealth and the State Governments, and so on.
All these changes have effects on teaching hospitals --- in the teaching hospitals, on staff, and a lot of that we've already heard. We're actually offering more time than our clinical staff can deliver. We've talked to the surgery department and said we would like them to take our students for more attachments and they've said we can't do it, we're overcrowded and overloaded, and the person responsible for the fifth year programme has sent out an instruction to the speciality units to say that they think they'll have to withdraw from home unit teaching.
Lack of time for feedback for students - that's serious but it's an important part of education. So, some of the consequences of this - because we've changed the system the students are not going to be the same as they were. We're saying we are allowing access to the basic science people to teach in the later years of the course. We don't expect them to know everything that they used to - or were said to know - by the time they come to fourth year. Which is where I started on this programme.
Basically what we're saying is that the prior knowledge assumptions of the old curriculum were false. I used to go out to the teaching hospitals and tell them about the new curriculum, invite their comments on how it was going, and so on. Five years before the new curriculum was introduced they were telling me the students coming to them didn't know any anatomy or physiology. Proved my point exactly. That's why we're changing the curriculum, I would say, and they'd look confused. Because they'd heard that we were changing the curriculum and assumed that students jumped from day one into fourth year. Wrong.
There's a certain element, I think, of blame shifting going on here. It must be someone's fault because we can't do what we would like to do. But more importantly, this diminishes the relationship between staff and students. And the worst feature of it all is we have some hospital based teachers who are abusing the students as they come in, saying, oh, you're that new curriculum mob, you don't know anything, before they've been given a chance to say a word.
The questions are, are our major tertiary acute care so-called teaching hospitals still the appropriate place in which to teach undergraduate medical students. Some portion of that would be appropriate there. I suspect we're going to have to look for more creative options, as you've heard. We've exploring private hospitals, we're exploring out patients and the surgical admission units. This year we'll have all our students doing emergency training, and a high proportion of those will be doing it in private hospitals.
The question then is what mix of primary care should be included in the medical course, and how can this be staffed and funded. We use private practitioners but the PIP payments are less than adequate to recompense them for what they do.
A whole series of issues I'm not going to address, and some possible solutions. We're having the dialogue. The media frenzy we'll have tomorrow. The willingness of the medical community to provide effective modern focused teaching, and learning opportunities. It's not a God given gift. You have to actually learn something about how to teach. We don't have problem based learning in the clinical years. We actually believe the best way to learn medicine in the clinical years is to go see patients and to be mentored by a clinician. We would like to actively engage the educators and we believe we need to educate the community as well.
So there is a crisis. Modern curricula are trying to adapt to the future, not the present. And so we need to have good will on both sides as we look at this, and I detect an element of that here today which I hadn't expected, given the way I was sold this bill of goods. It's our experience that students from the new curriculum know and can use more of their basic science, and so I differ from Randall in this. The Professor of Anatomy just two weeks ago told me that he was giving a tutorial to some fourth year students in their orthopaedic attachment on the upper arm, and he thought that their knowledge of that was as good as could be expected, even under the old curriculum.
There are overwhelming pressures on clinical staff to divert them from providing adequate training, so we need to look at creative ways of using the limited number of patients, and to provide the best help to our teachers so they can teach effectively, understand what we're doing and become a creative part of that. But if it's to be effective, someone has to be --- our political masters and administrators have to recognise what's going on and be willing to set aside funds and time to do that.
Thanks.
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