Conference on 14 July 1975 on the educational implications of The Report of the Committee of Inquiry into the Regulation of the Medical Profession

Medical Education. 1976, 10, 67-75

REPORT

Conference on 14 July 1975 on the educational implications of The Report of the Committee of Inquiry into the Regulation

of the Medical Profession*

Introduction by Professor H. Walton: Chairman of the Association

Professor Walton opened the Conference by referring to deficiencies considered to exist in the education and training of doctors in Britain. The Merrison Report gave prominence to some of these deficiencies, particularly the unsatisfactory features of the pre-registration year following graduation from medical school, and the failure in the years since 1968 to develop the Royal Commission’s concept of general professional training. The Merrison solution -the introduction of a graduate clinical training phase for all medical graduates-would call upon the Royal Colleges to review their requirements and the Joint Higher Training Committees their training programmes. Clear roles in postgraduate training were also prescribed for the Councils for Post- graduate Medical Education and for the General Medical Council. The questions now arose, could these educational bodies meet the demands that would be made of them? could the medical schools (in addition to their undergraduate task) contribute to the development of well-coordinated training programmes? could the National Health Service both meet medical service requirements and also respond to the training needs of doctors? would the universities’ influence upon postgraduate medical education decline?

An over view of the educational implications: Dr A. W. Merrison

The Chairman of the Committee, introducing his Report, said that the chapter on education com- prised a quarter of the Report, but it was important

* Published by Her Majesty’s Stationery Ottice, Cmnd. 6018, 1975. Chairman: Dr A. W. Merrison.

Correspondence: Dr K. M. Parry, Scottish Council for Postgraduate Medical Education, 8 Queen Street, Edinburgh EH2 1JE.

to regard the Report as a whole. The educational issues were difficult because it was important to get the principles right, since the Report was proposing that every doctor should be included on a register. The purpose of a register was, and had been from the inception of the GMC, to recognize doctors who were qualified. The education chapter set out three important issues : (1) that medical education should be planned as a whole; (2) that every doctor should undertake postgraduate medical education; (3) that general professional training had not worked well.

Paragraph 47 set out the three tiers of medical education, i.e. (1) learning the science and skills which lead to graduation; (2) treating patients and gaining experience of practice (pre-registration and general professional training) ; (3) specialist training leading to independent practice.

There should of course be flexibility within the three stages, but for the purpose of regulation it was necessary to define the stages. Dr Merrison considered, however, that too much specialist training should not be allowed to leak into graduate clinical training; a graduate needed experience of patient care generally, although he should not necessarily be discouraged from exhibiting a specialist interest.

The Report proposed that all three stages of medical education should be supervised by the GMC in a similar way to its present supervision of undergraduate education: the GMC had the power to recognize medical schools, to inspect them and to give advice. The latter was the most powerful weapon but it only worked because the Council had the background power of withdrawal of recognition. The GMC should have the same power in relation to the postgraduate bodies, its main power being advisory.

Dr Merrison drew attention to the composition of the proposed GMC (chapter 6 in his Committee’s Report) : the Education Committee (composed of six university representatives, six from the Royal Colleges and Faculties, and six elected members)

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68 Committee of Inquiry

would be a powerful committee, and free to act relatively independently of the Executive Committee. Only one Education Committee was proposed, but this did not mean that it should not set up working parties or sub-comrnittees to look after various aspects of education and training. He outlined the main problems he foresaw in implementation of the Report:

(1) Specialist training should not cause difficulties : training programmes should be well defined, and organized by specialists in each field of practice. There might be some practical problems for the GMC as to who should be entrusted with developing the programmes and their supervisson.

(2) Undergraduate training presented fewer problems. The only criticism of medical education had been by the Department of Health and Social Security on the grounds that students were not motivated to enter the ‘shortage’ specialties. He thought that undergraduate education was a small factor in this matter, and it was for the NHS to think this out much more deeply.

(3) Two issues would affect the undergraduate course : (a) The present undergraduate curriculum was aimed at producing a ‘safe’ doctor who could practise medicine, surgery and midwifery after graduation. But undergraduate teaching could not be seen in isolation from graduate clinical training, and this must lead to serious changes in undergraduate teaching. Universities would find it difficult to assume responsibility for graduate clinical training since the resources involved were not under their control. Close association would be needed with NHS clinical teachers. (b) All doctors would receive specialist training, and this would enable the universities to be free to get undergraduate training and graduate clinical training right educationally.

Dr Merrison stressed that the changes in the practice of medicine were wholly unidentifiable in economic terms. He was extremely wary of economic arguments in the field of health ; economists’ contri- butions in health matters, he felt, had been negative to date. He thought the following changes would be needed : (1) Medical educators would need more time for education and less for practice; this would, therefore, require more educators. (2) Leaving aside the health benefits to the nation, the early stages of medical education could not be regarded as produc- tive. In contrast, at the end of training, a doctor’s contribution to patient care was almost entirely pro-

ductive. During the intervening stages of postgraduate training, some of a doctor’s time was spent learning and some practising; at this intermediate stage it was especially important to ensure that the young doctor was carrying responsibility at the earliest possible stage.

The specialist phase of training : Professor K. Rawnsley

A member of the Committee, Professor Rawnsley considered that a main innovation suggested by Merrison, foreshadowed by the Report of the Royal Commission in 1965, was the proposal for a specialist indicative register, and for the coordination of the whole of medical education by a single body. This would entail looking closely at the present point of entry and existing training programmes. Specialist training was ill-defined at both extremes. The point of entry was ill-defined because the Royal Com- mission’s proposal for general professional training had not materialized and tended to be used as early specialist training. Graduate clinical training-the duration of which would be decided by the GMC- was intended to include the present pre-registration and general professional training periods, and specialist training would follow. The point of exit from specialist training was at present related to entry to a consultancy (or a principalship in general practice), but most senior registrars had completed their training before this point. Accreditation of an individual by Joint Higher Training Committees, overseen by the Councils for Postgraduate Medical Education, now identified the point of completion of training. The equivalent body to the Joint Higher Training Committee for General Practice was its Postgraduate Training Committee. The Merrison Report now considered that statutory powers were necessary to formalize these recent changes. It was appropriately the GMC’s task, but many other existing organizations should continue to foster what was already happening, i.e. (1) the development of training programmes ; (2) monitoring the pro- gress of those in training; (3) assessment of the pro- gress of trainees; (4) working out the procedures for vocational training.

Professor Rawnsley said implications for timing arose from: (1) the shortening of the undergraduate curriculum by 1 year; (2) the graduate clinical training phase for all doctors; (3) the duration of specialist training.

Regulation of the Medical Profession 69

The Royal Colleges and Faculties needed to reconsider their training programmes and methods of assessment, and the time of awarding their diplomas, i.e. whether to make this nearer to the point of entry of training, or towards the time of exit as specialists from training.

The resources involved in postgraduate training were mainly those provided by the NHS, and it should be recognised that NHS consultants had a postgraduate training responsibility. Professor Rawnsley stressed the influence in these matters of the Councils for Postgraduate Medical Education, the Regional Postgraduate Committees and the Royal Colleges and Faculties. The danger was of in- built rigidity of the whole training structure, and to avoid this there must be close collaboration between accrediting bodies in order that there could be interchangeability between training programmes at various stages.

He supported the proposal for an indicative rather than restrictive specialist register. Employing au- thorities (mainly NHS) and the general public (private patients) would clearly need to know the qualifications of a doctor. The General Medical Council’s sanctions would be against false claims of specialist skills. In extreme circumstances, the Council could proceed against a doctor who practised highly specialized medicine to the detriment of the public.

Referring to the implications of joining the Com- mon Market, he said there was inevitably some con- flict between European countries and programmes of training in Britain. Specialist requirements were less stringent in Europe than in Britain, but the Merrison Report had not recommended a particular standard period of training. Specialist training tended to continue for 5, 6 or 7 years in the United Kingdom and the question had been raised as to whether there was a need for a certificate to indicate a point in time during a training programme when a doctor had achieved what would be understood in Europe as specialist status. He felt there was great danger in legal recognition of specialist status by such ad hoc arrangements, and he called for this matter to receive the urgent attention of the Councils for Postgraduate Medical Education.

Commentary by Dr J. F. Stokes

Dr Stokes stressed that, although he wished to com- ment principally on the implications of the Merrison Report for the Royal Colleges, he was expressing his

personal views. He saw the Merrison Report as the fourth milestone in the development of training for physicians, the first being the Royal College of Physicians’ booklet on ‘Training for Consultants’ (1971); the second was the Report of the Royal Commission, which had stressed the need to recognize posts rather than courses (as in the United States); and the third, the establishment of the Joint Higher Training Committees, which were under- taking the practical work of accrediting posts, founded on the College ‘bricks’.

The Merrison Committee formalized postgraduate medical education by extending the General Medical Council’s functions to the whole of medical education. Was this a threat to the Royal Colleges? Four points could be made;

(1) The greater control by the GMC could not be regarded as a take-over-bid for the Colleges.

(2) The universities had not found themselves ground down by the GMC in their control of undergraduate medical education.

(3) The recommendation was generally to be wel- comed for an indicative rather than a restrictive register; the register must be kept somewhere, and it was more economical for this to be made central.

(4) The Royal Colleges and Joint Higher Training Committees would look after standards of individuals at specialist training levels, and although the ultimate imprint was by the GMC, the Colleges would retain their present influential role.

Dr Stokes then reviewed the respective roles of the Joint Higher Training Committees and the Royal Colleges. The Royal College of Psychiatrists and the Association of University Teachers of Psychiatry were associated in a Joint Committee for that specialty. He suggested that the Royal College of Pathologists would look after training programmes in its specialty. The Royal College of General Prac- titioners would have to come to terms with the General Medical Services Committee, and the Royal Colleges of Surgeons and of Physicians had created their Joint Higher Training Committees from within their own ranks. Pooling of resources made sense; the Royal Colleges of Physicians of Edinburgh, London and Glasgow had not lost sovereignty by working in close collaboration. He was uncertain about the recommendation in paragraph 138 of the Merrison Committee Report (i.e. the power assigned to the GMC over accrediting bodies); there must be trust in the Joint Higher Committee to act as the


accrediting body, and the Council must not breathe down the necks of the Committees in the recognition of individuals. They should be entrusted with the task of setting fair standards.

The duration of specialist training in the United Kingdom (normally 7 years) was Ionger than that in most EEC countries (mainly 4 years). The longer period for U.K. doctors to achieve specialist accreditation had caused concern amongst some junior doctors. The Treaty of Rome permitted free movement of doctors in the private sector of member countries, and there was nothing to prevent the application for NHS posts by doctors from other countries. A national panel would have to ensure that accreditation by British Joint Higher Training Committees or Royal Colleges had been achieved before a doctor was appointed to a consultancy.

Britain had signed the European Economic Com- munity directives on 16 June 1975; it was important that the whole profession should have been concerned in this step, and that a clearly identifiable responsible individual should be seen to speak for the profession. The Educational Advisory Com- mittee referred to in paragraph 215 of the Merrison Report was of vital importance.

His main anxiety about the Merrison recommendations was that organized postgraduate education would proceed too quickly in a predetermined direc- tion. Medical education was like a bus journey. The final destination was unknown, and any passenger should be able to get on and off the vehicle-it should not travel so fast that one could not dismount without injury. He was concerned also at the heavy dependence proposed for the Education Committee upon the parent GMC, the members of which were not necessarily interested in education.

General discussion by participants at the conference

Concern was expressed about some of the implications of joining the European Economic Commu- nity; too little was known about the criteria for entry to specialist registers in Common Market countries in which there was shortly to be free movement of doctors. Professor Rawnsley expressed anxiety about the proposal by some Colleges to make ad hoc arrangements to ‘recognize’ specialists; he asked what the legal significance was of a ‘piece of paper’ conferring specialist status, if specialist registration were later to be introduced. Dame Albertine Winner

thought that it was a temporary problem; if the Merrison recommendations were implemented, specialist registration would follow 4 or 5 years after full registration, and this was reasonably in line with other European countries. She thought we should expect doctors trained in Europe to apply for consultant appointments in Britain, and their specialist registration would be taken into account by Ad- visory Appointment Committees. Professor Gerald Russell said that the Merrison Committee had fully discussed the merits of the NHS regulatory system of Advisory Appointment Committees, and set out a well-argued case for not accepting this as a standard-setting mechanism; he was concerned at the increasing authority of these committees in the reorganized NHS. Professor George Smart (also a member of the Merrison Committee) felt that we could not go into the European Economic Com- munity with our present staffing structure. In the U.K. consultants originated in pre-NHS days at a time when they had to earn their living outside the hospital, and hence depended upon a retinue of junior medical staff. This staffing pattern, for each consultant to have supporting staff, was now im- posed nationally, with the consequence that the Health Service in the U.K. was wholly dependent upon over 2500 overseas doctors who did not proceed to consultant appointments. This was logistic- ally unacceptable; in spite of the political ‘hoo-ha’ that might arise, specialists might be appointed earlier, and the majority might then remain specialists and only a minority achieve consultant appointments. Dr R. Wiedersheim reported that the European office of WHO had tried to foster some order in postgraduate training. This had been complicated by recent rapid changes in specialist requirements; there were now eighty-eight main specialties in Europe, and fifty to sixty sub-specialties. There were wide variations in the duration of training; for example, cardiologists received 2 years postgraduate training in Italy, 4 in France and 6 in Scandinavia. Dr Merrison agreed with Professor Smart; he said the career problems in the NHS were long- standing, and had simply been highlighted by his Committee’s Report. The Advisory Appointments Committee procedure, when consultants were appointed by competition at interview, was a bad way of maintaining standards; Royal College and university representatives on these committees were there to say which of all the candidates achieved a certain level of competence. It was very difficult for

ReguIation of the Medical Profession 71

them to decide whether an appointment should be filled with a bad doctor or left vacant.

Dr Neil McIntyre expressed concern that the members of the Education Committee, selected from the main GMC, would not always have the necessary educational expertise for its heavy responsibilities. Dr Merrison acknowledged that medical education was a highly technical matter, and for this reason his committee had not recommended lay members on the Education Committee; he felt that, since the main GMC was composed of members elected by universities, Royal Colleges and by the profession, a satisfactory Education Committee would be selected. Professor Henry Walton said that it was widely recognized that many teachers in medical schools were primarily appointed because of professional competence and interest in their specialist subject, rather than for educational interests; a teacher who was good at his subject was not necessarily also concerned about teaching. Wider acceptance was developing that the skills of teaching were specific. Professor Rawnsley said that the Merrison Com- mittee had found it difficult to design a committee which was small enough to be effective but also representational; the Education Committee had been accorded the power to coopt experts.

Dr Shaw considered that undergraduate medical education, although it encountered problems in London, was largely satisfactory in peripheral universities and he saw no reason to change the terms of its present supervision by the GMC. He feared that the Merrison Committee proposals would decrease the sovereignty of the universities, which would then be subject to increasing vocational pressures. He did not accept the case for a single educational committee as suggested, and felt that there should be separate undergraduate and postgraduate sections. Dr Merrison stressed that universities would not be less powerful under the proposed arrangements, and he underlined the need for unification of the whole of medical education. This could be undertaken either by the proposed GMC or delegated to its Education Committee: he preferred the latter but unity between the phases of training was essential. Professor Rawnsley agreed that if sovereignty of the medical schools seemed to be imperilled by the Merrison recommendations, it would be imperative for graduate clinical training to be fairly and squarely under the universities and necessary resources made available to the medical schools. The proposals were intended for planning for years ahead.

AFTERNOON SESSION-Chairman: SIR JOHN BROTHERSTON, Vice-President of the Association

Graduate clinical training: Dr D. H. Irvine

Dr Irvine, also a member of the Merrison Com- mittee, said that the phase of graduate clinical training advocated by the Merrison Committee was more specific than the present period of pre-registration training and general professional training; it was enclosed within a single regulatory category, and had closely defined goals which were: (1) that the new GMC would define its aims clearly; (2) that there should be an effective regional organization; (3) that programme evaluation should be related to goals, and (4) that there should be a legal framework for the GMC and the universities to operate graduate clinical training satisfactorily.

He stressed the importance of clearly setting out the objectives of graduate clinical training; he considered that this had not been done for the pre- registration period of training, for which only general aims had been specified through the GMC's recommendations. The aim of the newly-recommended phase of graduate clinical training was similar to that of the pre-registration year, i.e. to enable the graduate to exercise clinical responsibility and to develop appropriate attitudes to patient care. There was, however, a need to break down the objectives from the broad aims, and to help individual teachers to develop these objectives in practice. Dr Irvine illustrated the need for defining learning tasks. It was not sufficient, for instance, to state that one objective was for the trainee in graduate clinical training to gain practice in understanding people. This was too broad. A trainer responsible at regional level must understand how this was achieved, and which skills a house officer should be able to exercise after graduate clinical training should be clearly

~ described, e.g. to demonstrate how understanding a patient as an individual influenced his medical care. He thought the following developments would be necessary: (1) For the GMC to produce a legal docu- ment as to what a doctor should be able to do after graduate clinical training. (2) For the GMC to produce a clear set of broad goals for this period of training, after consultation with such bodies as ASME. (3) For each medical school to examine their curricula in the light of the general statement by the GMC.

He thought that graduate clinical training would


make call upon a number of hospital posts which were presently not used for pre-registration training; he stressed, however, that resource allocation must be where it was most needed, and there was also a need for re-thinking the basis for valid assessment procedures. Young doctors must be able to know what was expected of them. An effective regional organization would be essential, and there would be a need to further develop teaching resources. Hence there was a need for active discussion about the relationship between universities and the National Health Service regionally, and to identify teachers and posts in the National Health Service.

In conclusion, Dr Irvine stressed the importance of graduate clinical training, which he felt needed as much care and attention as basic medical education. It should be based upon learning by doing, and he hoped that it would help towards the integration of teaching hospitals and district general hospitals.

Commentary on graduate clinical training: Professor Neil Kessel

Professor Kessel said that he had no wish to be critical of the concept of graduate clinical training, although he found this a grey area in the Merrison Committee’s Report. The undergraduate period had been well defined, and specialist training was increasingly defined with rigidity by the Royal Colleges. He drew attention to the effect that graduate clinical training would have upon the medical student’s life. Students were very constrained by the curriculum, and the delicate balance between university education and apprenticeship could be affected by graduate clinical training. Students already found a lot of medical education unsatisfactory; shortening the curriculum might reduce this period of inactivity. However, he stressed the importance of the inter-relationship between undergraduate teaching and graduate clinical training. The Report had said ‘doctors learn best by doing’; students were the same. The danger of graduate clinical training was that doctors might be required to do everything twice, each time superficially, i.e. to try to repeat clinical teaching they had already, been given in medical school, in graduate clinical training. There was a need to be bold in concept, but it was important to guard against duplicated clinical teaching. The background of the British system of medical education based on Flexner was in involving students

in the care of the sick. Osler too had stressed the importance of reliance upon students to do much clinical work, and we must not lose sight of this backbone. He underlined the need for unity in medical education, and said that we must define clearly what a student learnt from apprenticeship and what he learnt from other modes of teaching.

He said the educational chapter in the Report had not put in details for making graduate clinical training workable. He wanted to add to Merrison’s goals the factor of ‘career choice’; it was surely important to demonstrate how input to graduate clinical training was to be converted to the output needs of the NHS. Further detailed consideration would be needed to clarify phrases used in the Report such as ‘skilled supervision’, ‘wide clinical experience’, ‘some specialist work’, ‘university tutorial system’, etc. The cost was said to be ‘not small, but small in proportion to the benefits gained’. His university would lose fifty- five clinical posts, i.e. approximately E400,OOO per annum, if a clinical year was lost in the undergraduate curriculum. This would offer scope for developing graduate clinical training.

There were a number of matters for further discussion: for instance was learning to be all master/ pupil? Or would part be by peer group? Or by one- to-one tutorial method? Was graduate clinical training to be resident or non-resident? Were the tutors going out to trainees, or were the trainees expected to come to their tutors-were there to be multiple tutors by subject, or one ‘in charge’ of a whole programme? What were to be the means of assessment?-these would have to be different from the testing of clinical competence and knowledge.

It had been said that the teacher’s task was to assist the student to learn for himself. An NHS consultant might not be in a position to take a sufficiently close interest. He strongly supported close university/NHS consultant links, but he suspected that consultants would say they needed to get their work done and although graduates would contribute to this, it would be hard for them to coordinate their clinical work and a satisfactory educational programme. The need for close working between the consultants and the university would be essential if a junior doctor’s graduate clinical training was to be related to his future specialist interest.

Professor Kessel said that many 6-month house officer posts were divided into two 3-month periods, for example, medicine/geriatrics. He thought, therefore that 4-month posts would not be so different


from the present arrangements; a period of graduate clinical training might, therefore, be six of such appointments. As an example he suggested that a period of graduate clinical training might include one in general medicine, one in a specialized field of medicine, one in general surgery, one in applied surgery (including gynaecology or anaesthetics), one in a field of special interest of the doctor concerned, and one mandated period-for example to learn techniques of examining ears, eyes, etc.---to fill in what had not been covered in the undergraduate period. He concluded by saying that the drive to create graduate clinical training must come from the universities; Regional Postgraduate Committees might be influenced by the Royal Colleges and by local interests.

Undergraduate medical education: Professor G. Smart

Professor Smart, a Merrison Committee member, referred to the Medical Act 1886 which required all doctors, in order to become eligible for registration, to have passed qualifying examinations and the ‘standard of proficiency required from candidates at . . . qualifying examination(s) shall be such as sufficiently to guarantee the possession of the knowledge and skill requisite for the efficient practice of medicine, surgery and midwifery.’ This was now im- possible to attain; the General Medical Council had been moving away from this requirement without ignoring the law, and had led the medical schools by giving detailed advice. The Merrison proposals suggested that the quoted requirement should be re- placed by ‘promoting higher educational standards’. The charging of the GMC with the general duty to promote high educational standards complemented the Merrison Committee’s recommendation that the GMC ought to coordinate the planning of all stages of medical education (paragraph 70 of the Report). ‘If, as now, what is required at any stage of education is statutorily prescribed, flexibility is inhibited. We believe that medical educators will be interested in the potential of the regulatory system we propose for greatly increased flexibility.’ It was for the GMC to decide what was needed, not an act of Parliament.

The change in the regulatory system would enable universities to reconsider the aims of undergraduate medical education. Universities might move away from the dominance of apprenticeship, but should not lose emphasis on the motivation of caring for

patients in their medical teaching. He stressed the need to produce medical graduates whose education was relevant to the needs of society; the graduate should be an educated individual, not simply in the behavioural sense. To form an educated man, alternative options should be open, for example, for those with a scientific bent. Future doctors should be educated in medicine as a discipline in its own right. Graduate clinical training translated the graduate into a practising doctor; he did not think this phase of training would be necessary, therefore, for those who did not wish to take on responsibility for the individual care of patients.

In conclusion, Professor Smart stressed that the flexibility of the proposed GMC was in its overall responsibility for medical education.

Dr J. P. D. Mounsey

Dr Mounsey thought that the changes proposed would cost a lot of money; the financial constraints of the present time would, therefore, inevitably delay any changes. The Report was not about undergraduate medical education per se, but impinged upon it. The GMC had already moved away from setting minimum standards towards promoting high standards. The continuum of medical education was also accepted, but this needed to be made smoother. He thought it essential for the universities to be in full control of graduate clinical training.

Dr Mounsey referred to a number of snags that he foresaw that could arise from implementation of the Report :

(1) Finance would be needed from the Health De- partments as well as the UGC; he stressed the risk of accepting the Merrison Report without first ensuring that extra money was available.

(2) Compressing the present basic 5-year undergraduate course to 4 years would not lessen staff teaching time. Trying to cover the same number of subjects with a smaller staff in a shorter time could result in a crash course which would not be satisfactory. How could the present pre-clinical period be shortened?

(3) There was at present a dearth of pre-registration posts; it was in question where the graduate clinical training posts were to come from.

(4) Tutors and administrators would be essential if graduate clinical training was to be successful, but this was not the backbone of the problem. The main burden of teaching would fall upon high-quality


hospital posts, and Dr Mounsey doubted whether these were available in sufficient numbers.

(5) Many universities had revamped their curricula and examination systems recently; this was a difficult task and it would be hard to persuade teachers and consultants to drop their traditional contribution to the curriculum.

(6) The main difficulty, however, if the universities were given overall responsibility for standards of graduate clinical training, would be the perpetuation of the pre-registration situation in which universities were unable to assume effective control over the posts concerned. Referring to paragraph 118 of the Merri- son Committee Report, Dr Mounsey suggested that the first step should be to try to improve the pre- registration period, before experimenting with graduate clinical training.

General discussion

Professor Gerald Russell asked what was presently wrong with the pre-registration year? He was not convinced by the evidence offered that it had been a failure. The Merrison Committee was proposing ‘more learning by doing’, but was not this what the pre-registration year was about? Professor Smart stressed that graduate clinical training went beyond pre-registration training and included the Royal Commission’s concept of general professional training. Medicine had a core of medical knowledge which it was the universities’ task to teach; this knowledge was applied during the period of graduate clinical training when the doctor acquired basic skills and attitudes which were the prerequisite of every practising doctor. Professor Duncan said that this would need a radical reappraisal of the whole undergraduate curriculum-not simply what subjects would be dropped from the present one. This would be a hard task for-the universities; meantime there was much in the Merrison recommendations that could be implemented now.

Dr Morris agreed with Dr Mounsey that there was a risk of the undergraduate curriculum being reduced to a crash course. He felt the apprenticeship system had served well in the past, although the pre-registration period was very unsatisfactory. He suggested that this should be improved first; there was a risk of trying to implement Merrison too quickly, resulting in an unsatisfactory 4-year medical undergraduate course. Professor McGirr expressed sympathy for the overall philosophy and agreed that

the present course attempted to teach too much at too superficial level. But he suspected the ‘manipu- lation’ of graduate clinical training. There was a need to look basically at the undergraduate curriculum and possibly to pursue the idea of greater choice of electives. But it was essential to be clear what the university degree in medicine was intended to achieve, what the medical school was examining for, how students were to be assessed, and how they were to be supervised. Unless this was clearly understood the changes proposed could lead to a disparity of standards which were presently largely uniform in the U.K. He favoured a 6-year course, including graduate clinical training, like some continental systems.

Dr Irvine emphasized that the Merrison Com- mittee was not prescribing a 4-year undergraduate course followed by 2 years graduate clinical training. It was not the Committee’s task to prescribe the educational content, but simply the regulatory framework. It was now for educationalists to re-examine the objectives of medical education within the registration system suggested. Dr Walls said that he thought a 3-year basic medical science course followed by 1 year’s introductory clinical work would be possible for the universities, but this would only be acceptable if the universities could have a much stronger hold over graduate clinical training than they presently had over pre-registration training. Dr McIntyre questioned whether we could claim high standards of medical education in the United Kingdom. There were no facts or evidence to support this, since he did not believe there was a satisfactory mode of assessment of educational standards. He was optimistic that the Merrison Committee Report could lead to the raising of standards, but he was very worried how the Education Committee of the GMC as suggested could promote higher standards of medical education. Dr Harden asked Dr Irvine if he could give practical examples of the kind of graduate clinical training the Merrison Committee had in mind. Dr Irvine replied that the Committee had been most anxious to avoid suggesting rigid packages; the prime need was for graduate clinical training to be integrated into the undergraduate course. Although it was necessary to specify what a particular post could offer, this should be in terms of the scope it gave the doctor to acquire basic skills and attitudes, to use evidence critically, and to develop the ability to cope with the unknown. Dr Buckley-Sharp said that Merrison provided a framework for a number of alternative outcomes: for no


change, or evolutionary change, or revolutionary change. He foresaw the development of specialist training going ahead, but he was not sure how medical teachers would be able to grapple with the problems of change in the undergraduate course.

In summary, Dr Mounsey stressed the danger of subdividing medical education rather than developing it as a continuum. Professor Smart emphasized that the Merrison Committee Report had not recommended reducing the undergraduate curriculum and having 2 years graduate clinical training-the periods referred to were simply examples for the purpose of discussion. It would be disastrous if a crash course resulted, i.e. 3 years basic science plus one introductory clinical year; this reflected an entirely out- dated philosophy. The Merrison Report offered the opportunity to reexamine the education of a medical student using medicine as an education in its own right. He agreed that there was some risk of a disparity of standards, but underlined the need to regard the Report as a framework for discussion and not a prescription for a specific change. Professor Kessel thought that standards of medical education had declined, and in particular the quality of apprenticeship. Merrison now offered the opportunity to improve both teaching and apprenticeship. Dr Irvine said that the recognition of general practice as a specialty triggered off the need for all doctors to undertake specialist education and for this to be recognized by a specialist register. This could be regarded as a challenge, or the opportunity to pre- serve the status quo; but the new situation was that the specialist register would become a reality.

From the chair, Sir John Brotherston remarked that graduate clinical training appeared to be the most difficult concept in the Report, and the debate and discussion which had been initiated would continue for some time.

Commentary

In spite of the insistence by the Merrison Committee members that it was simply the task of the Committee to recommend a regulatory framework within which medical educationalists could find enhanced scope to revise present systems of medical education, many participants felt constrained by the examples and the time scales referred to in the Report, and by con- siderations of curricula with which they were

familiar. This may have been because the shackles of the Medical Act of 1886 from which the Merrison Committee sought to release medical educationalists were not seen to be as real as the Committee foresaw, or the desire for change so earnest. It was not legal but practical difficulties which seemed the greater obstacle: the complexities of obtaining consensus within medical schools, the exercise of university control over NHS resources, and the shortage of finance. The Report did not give evidence of criticism of undergraduate medical education, but as Dr Merrison reported, this had not been sought and was only referred to somewhat obliquely by one witness (the Department of Health and Social Security). Given that the GMC advises but does not dictate to the universities, and that it adopts a similar role in respect of the Royal Colleges, its overall coordinat- ing responsibility for the whole of medical education seemed generally acceptable, except to those who believe its Education Committee should be a more powerful instrument of change. Revolution in medicine is anathema to its practitioners, and evo- lution a painful process. The ‘delicate’ balance between education and apprenticeship is perhaps more robust than some speakers suggested, and likely to remain so as long as the members of medical faculties in universities are predominantly in clinical practice, and medical education is regarded as a means towards the making of a practising doctor, not an end in itself.

Such consensus as there was would accept the extension of the GMC’s role to postgraduate medical education, with the establishment of a specialist register, and to leave provisional and full registration alone. The trend of early specialization, that is, that a fully registered doctor should spend all his practising life in one specialty, did not appear to be a cause for concern, given some flexibility between similar specialties in the early years of training. Whether it was the complexities of supervision or of assessment of graduate clinical training, or whether Merrison’s argument for ‘clinical responsibility gained by exer- cising it’ did not carry weight, marked enthusiasm for the concept of graduate clinical training was not expressed. If the profession does not feel the desire for change or see the need for it, the scope which the Merrison Report offers may be disregarded; it will fall to those who can demonstrate the need to take the initiative.

K. M. PARRY

Documents

Conference on 14 July 1975 on the educational implications of The Report of the Committee of Inquiry into the Regulation of the Medical Profession