Mcdical Education, 1979, 13, 325-328

Editorial

1. Teaching the teachers

Medical teachers who have come to regard them- selves as professional educators will be aware of aspects of their teaching ability which they may want to develop. Some will want to know more about the methods for improving student motivation; others will want to extend their competence in con- structing and imparting their material in a form that better meets the school's stated objectives (i.e. ex- pected student competencies). They will want to know about interventions that facilitate student achievement. They will seek to extend the range of teaching methods they can use competently, and become expert at selecting the technical method most congruent with their goal at particular times. They will want to become skilled in sequential instruc- tional methods (such as are needed in tape-slide and other self-instructional programmes, which teachers prepare for students to use in their own time), and in effective collaboration with technical experts in medical photography units for preparing and pack- aging such materials, and with library staff to make programmes readily accessible to students. They will want to know how to devise self-evaluation proce- dures for students, and how to construct examina- tions and other assessment procedures that are valid snd reliable. There will also be some teachers who will seek assistance in carrying out educational research, to test the effectiveness of their teaching practices.

The above list is by no means complete. It does serve, however, to convey the support and the re- sources medical teachers need to maintain themselves as credible educators. The stark reality is the neglect and the low priority given to this aspect of medical education: the illusion persists that adequacy as a medical teacher is simply a byproduct of clinical skill and research achievement (the qualities for which medical teachers are appointed). That teach- ing-and knowledge about the conditions for learning-is a technical matter is largely dismissed.

While many competent medical teachers do train

themselves, seeking their own ways for monitoring their competence, reading the educational literature and attending educational meetings and workshops, such activities obtain little recognition in institu- tional terms. This scant regard is not lost on medical students who, of course, adjust their learning to the values prevailing in the school. The increase in use of methods for obtaining student feedback has helped teachers to evaluate their effectiveness, but teachers identified as inept or weak in certain respects have little opportunity afforded to them to repair their defects as educators.

Critical students, as dissatisfied consumers, need not be the only means for identifying the weaknesses of medical teachers. Some responsibility can well be accepted at staff level. A disarmingly modest but informative publication* reports an intercountry workshop in the Western Pacific Region, aiming to promote educational skills in the health professions.

Attention is given in the Report to the conflict that can derive from progressive subject specializa- tion in medical education. The training of doctors is a cooperative venture. In contrast, the preclinical teachers who provide the instruction in the basic sciences and the specialists the students encounter in the teaching hospitals, not surprisingly, focus on the subject or on the organ (eye, ear, heart, etc.) for which each is responsible. When the design of teach- ing comes down to a succession of Departmental responsibilities, without clear information of what is specifically undertaken by other Departments, fragmentation is inevitable with unrecognized di- vergences and schisms in the students' education. Any curricular aims for an holistic approach to patients and avoidance of excessive organ-centered or disease-oriented teaching are hard to achieve,

* Facitlty Development, Eds. A. Rotem, K. R. Cox and M. J. Bennett. World Health Organization Regional Teacher Training Centre, University of New South Wales, Australia (1979). The Clarendon Press, Sydney.

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the more so as technology advances. Secondary and tertiary care may be mainly in evidence, and not primary and continuing care.

Corrective activity on the part of teachers is essential if the student is to attain clarity, given the time that elapses between his instruction in the pre- clinical sciences and the opportunity to witness their clinical application. Students can be pardoned for ascribing the lack of connection or integration between subjects to the ineptitude of the teachers, although properly the onus is a collective one due to faulty curricular development. It compounds the dilemma of the contemporary student: to learn to use information rather than simply to memorize it, and to actualize professional ability by acquiring real skills. Many conventional teaching practices, hallowed by usage, do not enable students to retain and use their knowledge and skills. For that to happen, knowledge and skills must be learned and applied in the context of actual problems.

If the emphasis given to medical education be-

comes greater, questions will arise about the proper means for assisting medical teachers in their technical responsibilities. This may become a matter for statutory bodies concerned with the training of health manpower, in addition to the medical schools themselves. Certain schools, more in some countries than others, have set up centres or units for medical education; rarely, designated staff members are given responsibility for promotion of teaching, sometimes as a fulltime task. Decisions about the way to proceed become the more pressing as finance dwindles and more has to be done with less. Whether medical schools, and other institutions producing health personnel, deploy resources for teaching the teachers will depend on the climate of opinion. A distinct educational commitment is the more likely with increasing accountability to funding bodies and to the public, and as training institutions become more concerned about their effectiveness as places of education.

2. The Royal Commission

on the National Health Service*

The Royal Commission on the National Health Service was born in May 1976, at a time of acri- mony, frustration and irritation in Britain. Profes- sional groups, used to being heard and expecting their opinions to be respected, hurled abuse at the Government and its servants for failing to meet their seemingly reasonable personal and professional expectations. This country’s economic problems hit the NHS at a particularly awkward time; capital investment and the modest growth in annual revenue was plainly inadequate to meet the pressures of medical science and its applications, the good inten- tions of reorganization had gone awry, and everyone working in the Health Service felt-with some justi- fication-that their monopoly employer, the Depart- ment of Health, had traded too long upon the good

* Report of the Royal Comniission on the National Health Service. CMND7615 (1979). Her Majesty’s Stationery Office, London, f8.00. pp. 491.

will of dedicated people. The effects of inflation and pay restraint on their low salary was quite enough to generate an endless chain of complaints, old and new; this, and the vast size and complexity of the service, is reflected in the staggering amount of written and oral evidence submitted to the Royal Commission.

To have digested so much, visited many parts of the U.K. and several Western countries, commis- sioned a series of detailed studies, and completed the report in the space of three years is no mean achievement. The report offers no panacea to rid the service of its several ills and, as the Commis- sioners freely admit, it may be a disappointment to those who imagine there is a single problem or a simple answer. Looking at the NHS from the point of view of the patients, of those who work in the service, and of other institutions, appears at first repetitive, yet on closer reading these angles of view

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bring into focus some key issues. Although the Commissioners make over a hundred recommenda- tions, the real value of the report is its reflection of many views and opinions. The Commissioners have remained true to the commitment it accepted at the outset of its labours ‘to help the NHS to help itself’, and although long, the report contains little padding. It is possible to detect the hubbub of voices behind the cool text, and many familiar themes can be heard. Their collection in one volume will provide an invaluable resource, provided there is sufficient will to resolve the ever changing problems which arise in the uncertain business of promoting good health and relieving the effects of illness and the disabilities it causes.

The implications for medical education are many; three merit immediate attention: audit, medical manpower, and the relationship between the NHS and universities. The views from the patients and from the profession coalesce on the need to measure the quality of care, especially in general practice. There is no ambivalence in the Commissioners’ view about the need for quality control, and they are perceptive about the disadvantages of some monitor- ing systems and the dangers of ‘establishing and perpetuating a rigid orthodoxy’. They add a legal difficulty to the introduction of any system of com- pulsory audit which gives further emphasis to the opportunities within postgraduate education for the evaluation of patient care. They are not convinced, however, ‘that the professions generally regard the introduction of audit or peer review of standards of care and treatment with a proper sense of urgency’, and here is a clear invitation for action.

The Commissioners’ analysis of medical man- power relies heavily upon work which has already been widely discussed. They reiterate the need for a better deal for overseas doctors and greater flexi- bility in the postgraduate training of women doctors with family commitments. The inappropriateness of the hospital career structure is succinctly described and the reasons for the resistance to change identi- fied. Wisely, no new structure is recommended, but by offering an example of a possible revision in an appendix to the report, they offer the NHS the opportunity of adopting a flexible and simple system which will overcome many of the anomalies which have frustrated the rationalization of the staffing and training needs of hospital medicine.

On the subject of the total number of doctors needed and their distribution, the Commissioners

depart from the view of many respondents to the Health Departments’ memorandum ‘Medical Mun- power-The Next Twenty Years’ in that they do not support the need for a new central advisory com- mittee. They fully recognize the importance of planning medical manpower nationally, and quote the regional administrators as saying ‘the key to the re-deployment of manpower resources in the NHS is the re-deployment of medical staff, for the neces- sary support in terms of other professional staff will follow providing the financial resources are likewise deployed’. The number and distribution of doctors is so central to national health policies and the pros- pects for doctors so sensitive to the Government’s investment in the NHS, the burden of medical man- power planning is seen as inescapably on the shoulders of the Health Departments and health authorities. Yet ‘quantity may not be a satisfactory substitute for quality’ and the influence of the pro- fession and its standard setting mechanisms is clearly needed.

In spite of the weight of evidence in criticism of the undergraduate medical curriculum and the criteria by which medical students are selected, the Commissioners are content to rely upon the newly constituted General Medical Council to use its powers wisely in ensuring that basic medical educa- tion responds to changing health needs. They give considerable attention, however, to the mounting problems of the universities and teaching hospitals, particularly since NHS reorganization, although strong supporters of ‘centres of excellence’, the Commissioners believe the teaching hospitals will in the long run gain through their closer integration into the NHS. They propose a formal structure at national level to coordinate the policies of the Health Departments, the UGC and the universities, and urge further research into the costing of many unseen but none the less important features of teaching hospitals which are not reflected in the RAWP* formula. The proposals for an independent enquiry into the special problems of the London teaching hospitals were already foreseen and have been acted upon.

If there is one single, important message from the Report it is that ‘large organizations are most efficient when problemsare solved and decisions taken at the lowest effective point’. In the Commission’s

* The Resource Allocation Working Party (1976) Slfuring Resources for Health in England. London: Her Majesty’s Stationery Office.

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first research paper on ‘the working of the NHS’, Professor Kogan confirmed that there was ‘a great deal of anger and frustration at what many regard as a seriously over-elaborate system of government, administration and decision taking. The multiplicity of levels, the over-elaboration of consultative machinery, the inability to get decision making completed near the point of delivery of

services, and what some describe as unacceptably wasteful use of manpower resources were the current themes in most of the areas where we worked‘. The key decisions in the NHS are taken at the level of patient care; the task of the organization is to re- spond appropriately to those decisions, and if the Royal Commission facilitates a move in that direc- tion it will have justified its i918,OOO.