Medical education worldwide

Medical Education, 1985, 19, 487-502

REPORT

ASSOCIATION FOR THE STUDY OF MEDICAL EDUCATION

Report of a Conference held at the Royal College of Physicians of London on 24 May 1985

Medical education worldwide

K. M. PARRY

Scottish Council for Postgraduate Medical Education, Edinburgh, Scotland

Introduction

A meeting was held on 24 May 1985 to consider some of the immediate issues facing medical education in the United Kingdom in the light of the changing contribution of western medicine to the health needs of the world as a whole. The meeting first took stock of the present and predictable future contributions of the U.K. to the undergraduate and postgraduate training of doctors from overseas and of teachers and others who visit overseas countries. The meeting then considered the need for change in both undergraduate and postgraduate education to meet the future health care needs of particular populations and the development of medical science and practice worldwide. Professor A. Crisp, chairman of the Education Committee of the General Medical Council, chaired the morning session, and Professor H. J. Walton, President of the World Federa- tion for Medical Education, chaired the after- noon session.

Over the years, doctors from western countries have made notable contributions to the investigation, treatment and control of disease throughout the world. They have contributed to the development of medical schools in other countries and have provided postgraduate training in a variety of settings. Students from developing countries have come to the West in large numbers, particularly to undertake post-

Correspondence: Dr K. M. Parry, Scottish Coun- cil for Postgraduate Medical Education, 8 Queen Street, Edinburgh, EH2 IJE, Scotland.

graduate work. The number has been largely uncontrolled, and unfortunately the training they receive is not always appropriate for practice in their country of origin, with the consequence that on their return either they cannot obtain employment or the use of their skills demands a commitment of limited resources that the country can ill afford.

The need for a better system of selection and placement for overseas-qualified doctors was the subject of an Association for the Study of Medical Education conference in 1979 (Bishop, 1981), and the recommendation that a new organization should be established to sponsor overseas doctors for training is still under consideration by the health departments. The royal colleges and faculties are also developing sponsorship schemes to assist overseas-qualified doctors to obtain their higher diplomas. Uni- versity medical schools have long-established arrangements for receiving overseas-qualified doctors to undertake research and/or study for a higher degree. The British Postgraduate Medical Federation of the University of Lon- don provides special facilities for postgraduate training and the World Health Organization makes a substantial financial contribution to a fellowship scheme which assists doctors to obtain postgraduate qualifications as well as to study particular health topics.

These arrangements assist the career development of individual doctors but they beg the question whether the education and training provided by western countries is appropriate for practice in other parts of the world where

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the health problems are markedly different. In the context o f international medical care needs, consideration is to be given at the World Conference in 1988 of the World Federation for Medical Education to the definition of author- itative, internationally agreed opinion about the principles that should n o w apply to the training o f doctors equipped to meet the contemporary health needs o f populations and able to provide health services capable of improving the health status of nieniber countries. The World Con- ference is to be preceded by national conferences and then by six regional conferences, to which ASME will make a contribution.

The role of universities in the training of overseas medical students

Professor K. C. Calnian, Dean o f Postgraduate Medicine at the University of Glasgow, considered that overseas medical students presented a special challenge to the universities both at undergraduate and postgraduate level. Training overseas was a traditional way of sharing scholarship and exchanging information, tcch- riiques and skills, but he raised a number o f issues to focus attention on the educational value of medical training in another country. These included:

0 cultural differences and the use o f language; variations in the pattern o f disease; variations in the delivery of health care; innovations, research and technical devclop-

developments in niedical education and its

the effect on matipowcr planning in the

ments in the host country;

organization; and

country of origin and the host countries.

Despite these potential problems he stresscd that the relatively sniall number o f overseas students bought with them their o w u particular expertise and background, which broadened the experience o f home students and provided ‘I

valuable input to U . K . medical schools. The tiuniber of overseas postgraduate studcnts, on the other hand, was high, although this might well change in the light o f recent goverrinient controls on immigration. Professor Calman thought it was essential that the universities in association with other bodies dcvelopcd a

mechanism for giving maximum assistance to these doctors in training. T h e particular role o f universities was to provide research and teaching experience and postgraduate courses and degrees, such as specially designed MSc courses.

A separate but related issue applying to both undergraduate and postgraduate students was the current importance o f income generation, and there was a danger that pursuit of this policy could cloud important educational issues in the training programmes provided and the facilities offered for study. H e stressed that in spite of these financial pressures every effort should be made to ensure that the education provision was adequate and appropriate.

Notwithstanding the cultural problems that faced some overseas students, and the difficul- tics they could encounter in applying the sometimes inappropriate skills and knowledge they had acquired in the western world to health care problems elsewhere, Professor Calman believed that thcre was real value in doctors coming to the U . K . f rom other countries. There was, however, a need to explore newer techniques 111 medical education-particularly in distance learning and the assessment of professional competence-and it should be recognized that the system of organization o f postgraduate education in the U.K. was not necessarily appropriate for other countries. H e suggested that universities should consider providing language and orientation courses and specific career guidance for overseas doctors, arid should reorganize their postgraduate courses to ensure that they were relevant to practice overseas. H e also considered that universities should assist in the development of alternative training models to enable overseas doctors to learn the skills and attitudes appropriate to the needs of their individual countries without depleting the local-often scarce-medical manpower resources.

The overseas-qualified doctor in Britain

Sir ])avid Innes Williams, Chairman of the Overseas Committee of the General Medical Council (GMC) , referrred to the value of the G M C registration records as a guide to the number o f overseas-qualified doctors entering

Medical education wovldwide 489

the U.K.; however, without careful interpreta- tion they could be misleading. Between 1945 and 1980 the number of new registrations of overseas doctors rose steadily from 389 to around 3000. In 1976, there were actually more registrations from overseas countries (3 I 33) than from the U.K. (3048). At this time Indian graduates received full registration as of right under reciprocity arrangements, and they provided the largest element of the inflow. There was no direct way ofjudging how many had subsequently left the country but estimates had been of the order of 85%. There was no doubt that many who came during this period stayed, and now occupied posts of varying seniority in the hospitals and in general practice.

The Medical Act of 1978 introduced a new system of recognition for full registration of the degrees of some commonwealth universities and acceptance for limited registration of some of those of a much wider group, including India and the Middle East. The number of doctors from countries with university degrees which entitled them to full registration had not changed significantly between 1980 and 1984, although registration then should not be taken to imply that the doctors entered the U.K. The largest number came from Australia-usually as trainees who had been qualified for 2 or more years-and they remained for less than 4 years. In general, overseas doctors coming into the U.K. under the full registration arrangements encountered little difficulty in their postgraduate training since their educational system was similar and they could benefit readily from the postgraduate facilities in the U.K.

O n the other hand, the position for the doctors entering for limited registration was much less satisfactory. The annual new registrations had fallen significantly since a peak in 1980 but not as rapidly as might have been expected. Admission to the limited register required an acceptable primary qualification and a pass in the Professional and Linguistic Assessment Board (PLAB) examination or an exemption from it. The exemptions, which amounted to 30-40Yo of the total, applied to doctors who were sponsored by an authority in their own country and by an institution in the U.K. such as the British Council, or by an individual consultant. They had to have been

qualified for 3 years and to have spent at least 2

years in the specialty in which they were seeking training. The initial job was secure, but not infrequently they sought additional posts which offered them subsequent full registration leading to a permanent stay. The other group, which took the PLAB examination, had to secure a post in order to gain registration. From January to July 1983 there were, for instance, 1272 candidates for the PLAB examination, of whom 425 were successful. By October, 90% had applied for limited registration but only 13% had obtained a substantive post in the specialty of their choice, 6% in another specialty and 50% in locum posts only. Unless doctors had ‘preserved rights’ (i.e. temporary registration before 1978) their limited registration was subject to an aggregate maximum period of 5 years; full registration could be obtained before the end of this period either by re-qualifying through a non-university primary examination or by satisfying the G M C that they had the requisite knowledge, skill and experience ( 5 years since qualification, an acceptable internship with one year’s further general experience, 2 years in registrar posts, and unequivocal references). Over the preceding 5 years one third of the doctors on limited registration had transferred to full registration, almost all with the intention of staying in the U.K.

Sir David said that new immigration rules would clearly have an important consequence for this group of overseas qualified doctors. Although the effect would be gradual, eventually none would come to the U.K. with the intention of staying to practise. Whether there would be a drop in the number who came for training would depend on the facilities offered them; for example, very few currently came in order to study geriatrics, although many per- force took jobs in the specialty, perhaps with a view to establishing themselves while studying books. If, however, this was all the U.K. continued to offer trainees who had no more than 4 years to spend in the country there would be a rapid fall-off, with major conse- quences for those specialties which were dependent on doctors on the limited register. He predicted that in the specialties of geriatrics, ENT, ophthalmology, mental handicap-and

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possibly also general surgery and ortho- pedics-there would need to be a major change in the hospital staffing structure if overseas doctors were to be attracted to well- structured programmes of training and experience.

Sir David thought the immigration rules presented an opportunity to effect a major improvement in the contribution the U.K. made to the training of doctors from developing countries, for whom it should be possible to reserve good training programmes without the risk that they would stay permanently in the U.K. There was clearly a need for a sponsorship scheme and if this was not to be undertaken nationally there were colleges, universities or district health authorities that should provide schemes of their own. In the acute specialties, which were those the majority of overseas doctors wanted to study, schemes could follow the lines of the Overseas Doctors’ Training Scheme proposals which had been presented to the Department of Health and Social Security. Four years was not a long period for effective training, however, and in medicine and surgery sponsorship might start with doctors who had already passed the primary FRCS or MRCP Part I examinations, taken abroad or in the U.K. with a visitor’s permit. A sponsorship organization inevitably cost money, and the colleges could only find the necessary resources by charging a fee; some countries were now often willing to pay such a fee and it would be important that their contribution should to some extent subsidize poorer countries. For individual doctors, however, sponsorship must have evident advantages over operating in a free market, and the colleges might well have package deals which could include short courses, assistance in obtaining short-term locum appointments and preparation for examinations as well as guidance into earmarked posts. lt should be noted, however, that some countries were now prepared to send postgraduate students to the U.K. for university diploma courses lasting up to 9 months without practical experience. These were more appropriate in medical and surgical specialties and at a relatively advanced level. They had been very succesfully organized by several institutes of the British Postgraduate

Medical Federation and other institutes had comparable plans.

For doctors seeking junior hospital appointments clearly definable objectives were important in all specialties. For general medicine and general surgery these would no doubt continue to be the MRCP and FRCS examinations, but college diplomas following hospital experience should be available in other disciplines, where a diploma examination was taken at a later stage in training. Sir David felt that other diploma examinations should be specifically geared to the needs of overseas doctors. This should include general practice, for which the new immigration rules opened up new possibilities of training now that the hazard of permanent recruitment into that discipline had been re- moved.

The royal colleges: home and overseas

Dr J. Lawson, Director of Postgraduate Studies at the Royal College of Obstetricians and Gynaecologists (RCOG), described postgraduate medical education in Britain as an evolution from a typical compromise between the historical roles of the universities and the royal colleges. The universities had concentrated on investigation and research, whereas the contribution of the colleges had mainly been based on guided clinical experience during which trainees were strongly influenced by personal precept and the example of their teachers.

Export of British postgraduate medical education to new countries by the colleges- only one half of the compromisc-had not been entirely successful. The main weakness had been difficulty in incorporating new educational methods and ideas, and overseas doctors who had inherited British traditions had been particularly resistant to change. Involvement of the colleges overseas had originated in local esteem for the British postgraduate qualifications held by expatriate specialists. As a result, ambitious local doctors had begun to travel to Britain in search of these prestigious labels; on return the local specialists commanded high personal incomes. In the process of development the need for health services for whole populations, rather than just the urban elite, became apparent, and this necessitated the

Medical education worldwide 49 1

creation of local postgraduate training schemes. Usually these were university-based and-in India and Egypt, for example-concentrated more on research and less on sound clinical practice than in Britain, where the influence of the royal colleges predominated. Fortunately, the mastership programmes of Sri Lanka, Sing- apore and anglophobe sub-Saharan Africa had tried to redress the balance with a judicious mixture of approved clinical training and inquiry-based theses.

By assisting in the development of curricula and examination systems some colleges had given valuable practical help in building up postgraduate training overseas. The provision of external examiners had been particularly useful: they ensured local respect for the cx- amination, and during their visit gave lectures on recent advances and advice on teaching methods. Concentrated short courses by teams of teachers (such as the pre-MMed courses in obstetrics and gynaecology in Singapore) were also valuable. In the opposite direction the RCOG brought two or more senior teachers of postgraduate students from overseas to take part in the twice-yearly MRCOG examination in London. These were some of the ways in which the colleges could help to prevent inward-looking parochialism.

Some colleges had recently extended their role overseas by holding their final diploma examinations (FRCS, MRCOG, etc.) in developing countries, but the object of this, and their value to the regions concerned, must be questioned. Examinations alone, without being based firmly on preceding training programmes, were unconstructive. Badges of initials after the names of local specialists might result, but this was more to the advantage of their private practices than to their profession as a whole. There would, perhaps, be financial advantages to the colleges (there was currently a lively interest by certain Scottish and Irish colleges in activities in Saudi Arabia and the Gulf states) but Dr Lawson doubted in the long run this would be to the advantage of the countries concerned. The development of a two-tier system, where the local higher qualification was second best to one with the prestigious imprint of a royal college, would be particularly unfortunate.

Dr Lawson saw the modern role of the colleges overseas as the strengthening of local postgraduate training programmes; the countries which had no local postgraduate qualifications, such as Hong Kong or Ghana, still needed to export promising candidates to Bri- tain for some of their postgraduate training before sitting U.K. examinations. However, high flyers from overseas should be encouraged to come to Britain for further training after acquiring their local postgraduate diploma, to fertilize their national professions on return. This was a far cry from the present situation in which doctors from developing countries came to Britain to take college diplomas having previously had little or no postgraduate training at home. At present most were self-selected and frequently demonstrated that ambition and enterprise were inadequate substitutes for ability. Others, equally disastrously, were awarded scholarships by their governments, or were even put forward for British Council, Com- monwealth or W H O fellowships, on the basis of service, seniority or political pull.

The first essential for training was an adequate scientific background, which could be assessed before the ,doctor’s entry to Britain by a pass in the first part of one of the college diplomas. This could now be taken in many overseas countries, and the RCOG also gave exemption to those who had passed comparable primary examinations in Nigeria, Sri Lanka and Pakistan. The second essential was a good knowledge of English, which could be assessed if necessary by the English language test con- ducted all over the world by the British Coun- cil. The third essential was acceptable postgraduate experience in their own country in a subject to be studied in Britain.

This initial grounding was very important, as otherwise re-adaptation to conditions in a developing country on return home might be very difficult. For instance, in the last 1 5 years or so the practice of obstetrics had greatly changed in Britain with the virtual elimination of maternal mortality and concentration on perinatal mortality and morbidity as the yard- stick of success. The introduction of high technology into obstetrics, and laboratory- based endocrinology into gynaecology, were examples of modern changes which had

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widened the gap between British practice and that in developing countries. As a result, training for the MRCOG had become less relevant for those who would practice in developing countries. There, obstetrics had to be d

community-based subject, not only concerned with the cliirical problems of the individual patient. Under W H O influence concentration oti maternal and child health had devcloped, and rightly, but the place to study this was at home iti a developing country and not in the British National Health Service. So the relevance of the study of obstetrics and gynaecology in Britain for doctors from developing countries had to be questioned. This observa- tion applied to other clinical disciplines as well.

Listing these criteria for selection for training in Britain led to considcration of the sponsorship of overseas graduates, which should become the basis of the activities of all colleges and faculties in Britain on behalf of overseas trainees. The Overseas Iloctors’ Training Scheme inspired by Sir David had been widely discussed, but this educationally excellent idea was endangered by the widcr political issues of the dependence of the National Health Service on overseas graduates, a problem which it did not seem able to solve.

O n his return to Britain in 1969 after 17 years in Nigeria, Dr Lawson had been shocked by the large number of poor quality overseas doctors in hospital posts. H c had been placing two or three Nigerian trainees each year in good units in Britain to complete their training for the M R C O G (which they had all passcd), and he had imagined that this was the common pattern. This was not so: doctors from developing countries had been recruited wholesale to fill junior posts in peripheral hospitals unable to attract British graduates. Unselected except by the Temporary Registra- tion Assessment Board (TRAB) examination or PLAB, working as pairs of hands and receiving little training, it was not surprising that they swelled the failure lists of the college higher diplomas. Among them, however, were some potentially excellent trainees, who should have been identified and given every assistance to achieve their goals. Dr Lawson suggested that each college or faculty should arrange to select suitable overseas trainees in their disciplines

beforc they came to Britain. As well as ensur- ing that the selection criteria mentioned above were met, the RCOG depended heavily on recommendations from its overseas representative committees in an increasing number of countries, which were composed of elected local fellows and niembcrs. There were other ways of obtaining local recommendations but as the RCOG representative committees were responsible for fostering recognized training for the MRCOG in their own countrics their advice could be very valuable.

When selected trainccs were acccpted for sponsorship they should become the responsibility of a named college official, who would place them in a training post after arranging for their limited medical registration. Placement either in a post funded by the National Health Service or a recognized supernumerary post with scholarship support depended 011 the cooperation of consultants who were prepared to accept overseas trainees on trust. Thc responsibility of the colleges should not end with initial placement: appropriate guidance and supervision must follow, based on the network of local regional advisers which already existed.

The British teacher overseas

Professor M . Hutt reviewed the development of undergraduate and postgraduate training in the so-called developing countries. Before the Second World War the only medical schools in dcvcloping countries had been in South Africa, in the English-speaking countries of sub- Saharan Africa, in the Caribbean, and in Malaysia, Papua New Guinea and the other Pacific Islands. British teachers, however, had played an important role in the development of many of the medical schools in the Indian sub-continent, of the small but well-established schools in Singapore, Khartoum and Cairo, and of some schools in the Middle East.

After the war, increased political awareness in the countries of the ‘new commonwealth’, which eventually led to the large scale dccol- onization of the 1950s and ’6os, necessitated the development of universities and medical schools in regions where previously there had been no institutes of higher education. In the late 194os, medical schools were founded in

Medical education worldwide 49 3

Uganda (Makerere), Nigeria (Ibadan), and Jamaica (University of the West Indies); in the 1960s they were established in Malaysia (Kuala Lumpur), Ghana (Accra), Nigeria (Lagos and Zaria), Zimbabwe (then Rhodesia and with a predominantly white intake), Ethiopia (a non- Commonwealth country but with strong Brit- ish links) and later Papua New Guinea (with a large intake from Australia) and Zambia (Lu- saka); the mid 1970s saw the development of large numbers of new medical schools in Libya, Africa and Nigeria. During this time there was also a rapid expansion of student numbers in all the schools, and the demand for doctors increased as secondary schools produced students with appropriate entry levels.

These developments were matched by a great increase in the number of British medical teachers working overseas, which reached a peak in the late 1960s. At that time the majority of teaching posts from registrar or lecturer level to professor or consultant were held by British expatriates, mostly on 2-, 4- or 6-year con- tracts. For many this was a period of great opportunity with few drawbacks: there was scope for regional research on the many problems of medicine in the tropics and also for experimentation in curriculum design and teaching methods. The technological gap between the practice of medicine in these new institutions and those in the U.K. was not wide, and it was not difficult to fit the younger doctors back into the less structured postgraduate training programmes in the U.K.; indeed, a period spent in a developing country was usually regarded as an advantage when applying for a job. During the 1970s the situation began to change for a variety of reasons. By this time many of the lecturer and registrar posts and a few senior lectureships, consultant posts and chairs were filled by nationals of the country, most of whom had returned with higher qualifications obtained in the U.K. At the same time the flow of funds into these countries decreased, and their own economies, with a few exceptions, began to fail as the world economic crisis took effect. In some countries the position was worsened by political unrest. All these factors, combined with inflation at home and increasingly complex postgraduate requirements in the U.K., meant

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a marked decline in the number of British teachers in the medical schools of the developing countries. During this time the rapid expansion of the medical schools of the oil-rich Middle East offered high standards and a technological level of medicine with adequacy of facilities and supplies similar to the U.K., and they became increasingly attractive to Brit- ish doctors who sought a change or challenge in their professional careers. This, Professor Hutt said, was the position today.

Because of his connections with Africa over 24 years Professor Hutt concentrated on the needs of that continent. It was unfortunate that in many discussions on overseas problems the inclusive terms ‘third world’ and ‘developing countries’ were used, whereas the gap between the richer developing countries and the U.K. was probably smaller than between such countries and most of those in sub-Saharan Africa. The needs of countries such as Malaysia, Thai- land and Singapore, for example, were quite different from those of Tanzania, Zambia or Uganda. The latter urgently needed teachers; the former were largely self-sufficient.

T o meet the needs of Africa it was essential that nearly all undergraduate and postgraduate education should be undertaken in these countries or within the region, for two reasons. Firstly, it was becoming more difficult to obtain suitable training positions in the U.K. due to financial restrictions and increasing com- petition for such posts from U.K. nationals. Secondly, the training received in the U.K. did not meet the needs of the African countries because it was often inappropriate in content (disease pattern and technological complexity), there was a low average number of personnel for long periods of time, it caused social and family disruption, and it often resulted in permanent loss of the best individuals, who became accustomed to a new lifestyle and the western practice of medicine. For all these reasons it was now the intention of most African institutions to organize all undergraduate and postgraduate education and qualifications locally, though it was hoped that exchange of personnel for shorter periods of time for specific training or research in Europe or North America would continue.

Professor Hutt believed that there was still an

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expressed need for British teachers to take contract posts for 2 or more years in certain disciplines in the medical schools of Africa, though at present such recruitment was mini- mal and the obstacles considerable, particularly for younger doctors. The possibility of forced early retirement in the U.K. could provide opportunities for some individuals willing to continue their teaching careers in a new and demanding environment. The problems per- ceived by potential applicants were often not the actual ones that they would have to face if they were successful. For the most part, British teachers working in Africa in the future, particularly those in the early phases of their careers, were likely to be on a short-term secondment and to be involved in supplementing local or regional postgraduate teaching courses. Short- term secondments could be very valuable to both parties, provided there was good communication between those running the course and the seconded teacher or between the departments in the U.K. medical schools and those in Africa. Specific links between schools were valuable and at present appeared to be more successful with schools in other European countries than those in the U.K. It would be sad if these institutions, initiated and developed by British initiatives, should have to look increasingly to countries other than Britain for assistance in their continuing development.

Matching education to health needs

Professor J . Hamilton, Dean of the Faculty of Medicine at the University of Newcastle, New South Wales, Australia, described his experience in devcloping an undergraduate medical curriculum at the University of Ilorin, Nigeria. The Nigerian Universities’ Commission had made it clear that new medical schools should train students with a strong sense of comniun- ity needs, a strong orientation to service and with an emphasis on preventive health care. This provided a springboard for the development of the curriculum in Ilorin.

Thc surrounding social and environmental circumstances of Ilorin had their own special characteristics, as had other medical schools, so there was in Nigeria an opportunity for wide diversity of experience; activities relevant to

local needs necessarily took different forms in different schools. However, there were certain generic skills which any doctor required which were applicable in whichever setting a doctor might ultimately work in. These generic skills included those of communication, interpreta- tion of social and environmental circumstances and their impact on health, epidemiological skills to analyse the pattern and outcome of disease, ability of doctors to think critically and continue to learn ‘&-om experience and to sus- tain their own education, and ability to educate others and to develop and lead a health team within a community. These skills were not themselves sufficient for all the responsibilities of a doctor because especially in a developing country, a high level of individual technical competence was required, given the relativcly isolated circumstances of many practitioners. So there was no question of putting aside the scientific basis of medicine or skills in the care of individual patients. To respond to the broad needs of the community these generic skills were crucial. In the context of the role of the U.K., the point was niadc that while these generic skills stood out as particularly rclcvant to Nigeria they werc, although less well recognized, equally relevant in the U . K . This principle was the basis upon which education Lvithiii the U.K. could be relevant to future work in a developing country.

In Ilorin, a major priority was to makc the undergraduate experience rclcvant to the circumstances of the region. This required a direct csperiencc of the factors that came to bear upon health; this was achieved by posting students in groups to live in villages and to study the social, cultural, cnvironmcntal and health circumstances mithin which the village lived. The aim of the student group was t o identify and study specific problems, and to explore the broad ramifications of their origin and impact. The skills that were brought to bear and were learnt in the study of the problems were those of epidemiology, de- mography, geography. selected clinical skills and social enquiry. To make progress at all students had to learn how to introduce thcm- selves into a community, to identify the in- fluential members and to gather up the nionientum of the community to the under-

Medical education wor ldwide 49 5

standing and improvement of its own circumstances. The specific problems that the group studied were sometimes identified by themselves and sometimes by academic staff. Examples included a study of nutritional status and origins of malnutrition with a view to establishing and developing a nutrition programme, a study of water-supply and water- related diseases, a study of the utilization of health services and perceptions of need and expectations of services. This last study of consumer satisfaction was particularly revealing and very salutary to prospective doctors. By living in the village the students had the opportunity of becoming part of the village and placing themselves beyond the limits of formal studies to learn and appreciate the priorities of the community.

The community experience started at the very beginning of the curriculum and before formal clinical skills had been developed. This was particularly important because the matter of individual diagnosis was less important than the matter of community diagnosis. Taking a medical history was less important than listen- ing to people’s perception of their problems.

A cardinal principle was that students should not only study but should also help to remedy the problems that beset the community. To this end they undertook health educational activities, usually in cooperation with members of the community, or they set up small health committees, or took part in the initiation of new programmes such as a nutrition programme. It was very important that these activities took place and were seen to have some impact. Unless a community programme was shown to work, students would not have the expectation that it could indeed work. It was also important that the students learnt that their role was as part of a team and not in the main as isolated individuals.

The matter of the long-term impact of an educational programme such as the one described was discussed. The biggest difficulty facing undergraduates who had gained skills in relation to community needs was that the health service itself was often not geared to proper deployment of these skills, either from lack of career opportunity, lack of resources or lack of appropriately balanced manpower. The

danger, then, was that the skills acquired were put to one side because there were no circumstances in which they might be used.

Since the matter of relevance was key to the discussion, it was important to define whether training in another country, such as the U.K., could in fact have any relevance to the solution of problems in a community such as had been described. Professor Hamilton felt that the best place for primary undergraduate training was certainly within the country of origin of the student, although the full benefit of this would only be realized if there was a community- based programme such as had been described. Advanced and postgraduate training would also benefit from relevance by taking place in the home country, although it could also be undertaken in other settings and in other countries. Relevance to home problems was assured by concentrating particularly on generic skills that could be brought to bear on several circumstances and in several settings; these generic skills have been identified above.

A number of specific concrete examples were pointed out from experience in Nigeria where- by Nigerian medical teachers, having undertaken their first degree in Nigeria, benefited by subsequent experience in Canada or the U.K., although they retained their orientation to the needs of their own home country. Several of the founding members of the staff in Ilorin had been through such an experience and were able to come back and bring their generic skills to bear in a most creative and relevant manner to the programme of education and research development in Ilorin. On the other hand, activities abroad which relied heavily on technology or skills requiring a large technological support for proper deployment were worse than useless in that they led to frustration and disillusion- ment. Skills that relied upon analytic capability, critical thinking and communication were the most adaptable and it was in these areas that major contributions could be made.

Resources for the developing country

Professor M. Kerr, University of Calgary, described a colloborative programme between the Institute of Medicine of Tribhuvan Uni- versity, Nepal, and the Faculty of Medicine at

the University o f Calgary; this had been developed over the preceding 5 years in the training of various categories of health profes- sionals in Nepal. Nepal had been closed to the outside world since 1950 and it was only within the last 3 5 years that the West had been able to bring any influence to bear on its development. Economically the country was one o f the poorest in the world with an annual per capita income of $80. T h e government was able to spend only one dollar per head per year on all aspects of health care; this compared with an estimate of $1000 per head for health care in Alberta in 1985. Geographically, the country lay within the Himalayas, its terrain rich, furrowed by mountains and gorges and traversed by fast-running rivers. It had the fewest kilometres of motorable road per head o f any country in the world, which coiise- quently created serious communication problems.

These historical, economic and geographical constraints severely liniited development within the country. The health needs were reflected in a life expectancy at birth of 44 years for males and 42 for females, together with an infant mortality rate almost certainly far higher than the official one o f I 50 per thousand births. There was a great deal o f preventable morbidity; it had been estimated that villagers on average had some health problem every 2-3 weeks, many o f the complaints being due to acute or chronic infections or trauma superim- posed on a background o f subnutrition and inadequate water supply and sanitation. T h e health problems were only part of a much wider problem o f lack o f essential resources and this could not be solved by traditional medical intervention alone. T h e importance o f appropriately trained doctors was not in doubt, but Nepal nccded a new style o f niedical training and a new concept o f doctors' roles 'is participants in, or managers of, a health team dedicated not only t o the management but also to the prevention o f ill health. Although there were approximately 500 doctors in Nepal n o more than 100 were based outside the Kath- mandu Valley, where the vast majority o f the population lived. All categories o f health pro- fessionals were trained a t the Institute of Medi- cine at Tribhuvan University, which came into

existence in 1973. It had responsibility for training auxiliary nurses, midwives, community medical assistants, health assistants, nurses and laboratory technicians, but until 1978 it did not have the capacity to train doctors. Nepal had been entirely dependent on sending young students to India for medical training; unfortunately, the type of training provided was totally inappropriate for the unique health chal- lenges encountered in Nepal.

Late in 1976 consultation with the University o f Calgary resulted in the development of a curriculum and agreenient on educational principles and general adniinistrative policies for the medical school programme. Unique fea- tures o f the progranime were that students were recruited only from the ranks of the health assistants and not straight from high school, so that applicants for medical school had to denionstrate in a practical way their commitment to the health needs of their couii- try. The curriculum was geared strictly to the peculiar health needs of Nepal and was very unlike a traditional medical curriculum, Z ~ " / O of the training being community oriented. T h c University o f Calgary provided educational and training opportunities and seconded niem- bers of its teaching staff to Kathmandu to contribute to teaching programmes.

More recently the Nepalese Ministry of Health and the Tribhuvan University had asked Calgary University to help with the training o f anaesthetists, since the t w o or three qualified Nepalese anacsthetists set against an estimated need of at least 28 constituted a deficiency which had frequently paralysed the health system. A onc-year training programme held entirely in Kathmandu was dcvcloped, leading to a new diploma in anacsthesiology awdrded by Tribhuvan University. Until that time Nepal had had no means of providing postgraduate training for its doctors, w h o had always obtained their training abroCxd, primarily in India, the U.K. and North America. Howcvcr, the economic recession put an abrupt end to the opportunities, and by late 1981 few trainmg positions remained open to Nepalese doctors. O f even more significance was the recognition that the type of postgraduate training offered was entirely inappropriate; it was inevitably directed towards A subspcci-

Medical education woddwide 497

alty in technological medicine, so the doctors aimed to qualify in one of the traditional western medical or surgical specialties. Many of the Nepalese doctors had not returned to their country after their training, and those who had returned found that their skills were not needed and that there was no infrastructure to support their work; this inevitably led to frustration, and as a result even more doctors left the country. Health administrators recognized that the type of doctor needed in Nepal was a generalist who could cope with the wide range of preventive and curative medicine required in rural parts of the country, and the University of Calgary was invited to discuss ways of improving the situation.

A training programme was devised for medical officers to staff district hospitals-that is, to cope with the total health needs of a population of up to 200000 based on 1 5 - to zo-bed hospitals, with perhaps two other medical colleagues and a modest provision of paramedical assistance. A 3-year programme leading to the award of a diploma in general practice was developed, and the qualification was created by the Department of Advanced Education of the Government of Alberta. This qualification was not recognized in Canada or other western countries but was regarded as specifically for practice in Nepal. The first 12

months of training were based on teaching hospitals in thc University of Calgary by way of a modified internship in which Nepalese residents rotated primarily through the departments of emergency medicine, internal medicine, obstetrics and gynaecology, paediatrics, surgery, anaesthetics and family medicine, supervised by personal preceptors. Members of the teaching staff of the university spent varying periods in Nepal gaining first-hand experience of its health needs, and were consc- quently able and committed to act as preceptors. Provided the first year’s training was satisfactory the Nepalese residents were assigned to a rural teaching centre designed to offer experience of working in a community practice in a rural setting in western Canada. Following this they returned for one year’s further training in various hospitals in Kath- mandu with a final 6 months in a new rural teaching hospital in the mid-west region of

Nepal. Early in 1985 a tripartite agreement was made between Tribhuvan University, the Nepalese Ministry of Health and the University of Calgary to develop the district hospital in Surkhet as a rural teaching centre. This was a zo-bed hospital which catered for the health needs of a population of approximately ISOOOO

in an area almost zoo miles west of Kath- mandu. The agreement committed- the Ministry of Health to continue to provide the hospital with health personnel and supplies, Tribhuvan University made available educational resources, and the University of Calgary undertook to upgrade the hospital in basic aspects of sanitation, water supply, electricity generation and a portable X-ray machine. The university also recruited a new teaching staff member who was seconded to the Institute of Medicine in Surkhet and who had wide experience of working in isolated areas of Nepal and was fluent in the Nepalese language.

Professor Kerr stressed that many complex issues were involved in this collaborative programme and had contributed to the mutual trust and understanding that had developed between the two institutions. Several community groups in Alberta were interested in the programme; for example, the rotary clubs were currently exploring the possibility of building a new district hospital close to Surkhet and at least one other agency was considering a programme of child health care in Nepal. This current involvement was regarded as crucial and it was hoped and anticipated that the programme, which had been initially confined to medical institutions, would expand into wider and closer contacts with Alberta and Nepal.

The extension of the pcogramme from health and manpower development to health care delivery raised the obvious point that the ‘medical’ component o f health care was an important but minor factor and that health care relied heavily on many other disciplines, including specialists in education, management and appropriate technology. There was approximately 90% illiteracy in all Nepalese districts; and there was no method of communication apart from travel on foot; there was virtually no middle management throughout the country and there was an urgent need for various

498 K . M . Parry

types of technology, for example the application of solar energy to the provision of refri- geration for vaccines in isolated subtropical areas. The possibility of expanding the institutional cooperation between the universities in providing a comprehensive programme of human resource development was now being explored.

Summarizing, Professor Kerr stressed that he was not describing the collaborative programme as necessarily a model for other schemes since it was too early to say how successful it had been. In any scheme it was essential to establish clear goals; for example, in a donor/ recipient model it was essential to establish whether assistance with medical education was aimed at meeting the health care needs of a country or the career development of individual doctors-aims which could be in contra- diction. The needs of the donor should be as explicit as the needs of the recipient country; thus, the encouragement of trade was a wholly legitimate interest, although this must be explicit in any programme of international aid.

Experience from the collaboration to date had shown the importance of determination in pursuing clear goals; an appropriate curriculum to meet the health needs of the rural population in Nepal looked very different from conven- tional curricula and needed courage to follow through. Similarly, earlier plans for postgraduate training had had to be modified to acknow- ledge that it was better for Nepalese doctors to be trained as rural doctors in other parts of Asia than to receive their training in the western world. The scale of commitment of a donor country must be long term and its scope expanded beyond expectations so as to fulfil the logic of an initial venture; for example, it had been clear that manpower development alone was insufficient and that further help was needed to develop the basic facilities which doctors needed to apply their skills. Further, the medical component was small as compared with all the other essential parts of the health care programme. Here, there was a strong case for niobilizing a whole university to assist in human resource development and Professor Kerr felt that a university was more appropriate than, for instance, an unwieldy multilateral government aid programme.

Professor Kerr questioned whether the donor/recipient model, with its ‘charitable’ im- plications, was appropriate. He preferred a collegiate model, bringing with it mutual benefit to collaborating universities and unique research opportunities.

The interchangeability of educational planning

Professor R. M. Harden, of the Centre of Medical Education a t the University of Dun- dee, discussed whether medical education was interchangeable, whether experience gained in one context could be transferred to another, and whether teachers with experience in one school could help a school overseas to design and implement a curriculum appropriate for a medical school in that particular country. He considered that this was possible but only if teachers appreciated the basic principles of medical education and analysed in terms of these principles their own experience, cxperi- ences elsewhere, and the facts about the local situation. It was inappropriate if teachers had a ‘do as I do’ philosophy and simply attempted to reproduce their own curriculum or educational concepts regardless of local resources and needs.

Experience in countries such as Malaysia, Indonesia, Egypt and Saudi Arabia had shown that a curriculum exported from Britain to another country without modification in line with educational principles was unlikely to meet that country’s needs. The SPICES model (Harden ct a l . , 1984) offered one model of curriculum planning. This identified six educational strategies related to the curriculum in a medical school, each issue of which could be represented as a spectruni or continuum:

( I ) Student- centred . . . . . . . . . . . . . . .Teacher-centred

( 2 ) Probleni- based.. . . . . . . . . . , . . . . . . Information gathering

(3) I titegrated.. _ _ _ _ . .. . _ _ .Discipline based (4) Community-

based.. . . . . . . . . . . . . . . . . Hospital-based (5) Electives.. . . . . . . . . . ..... Standard progratnme (6 ) Systematic.. . . . . . . . . . . .Apprentice-based

or opportunistic

Medical education worldwide 499

There were local, national and educational factors which supported a move towards each end of the continuum presented for each strategy: newer schools tended to be more to the left of the continuum, established schools more to the right. Each school, however, had to decide where it stood on each issue and establish its own profile. It was likely that the optimum decision for any school would be a t some point between the two extremes. The composition of SPICES, therefore, would vary from school to school.

The issues raised in the SPICES model provided a framework for decisions about the educational strategies underlying curriculum planning. The model was useful in that it helped the school to review its curriculum and provided a vocabulary which was a basis for discussion between schools in the same or different countries. Only if the principles represented by the SPICES model were understood could experiences in medical cducation become interchangeable between different countries. Imposition of a rigid model imported from elsewhere was likely to lead to local rejection.

Overcoming cultural handicaps

Dr J. Cox of the Department of Psychiatry of the University of Edinburgh described from two different perspectives some of the cultural handicaps experienced by an overseas doctor in Britain and by a British doctor working overseas.

Firstly, there were the personal difficulties which resulted from the migration experience itself and the subsequent adjustment to a new society. The distinction betwccn a ‘settler’ and a ‘sojourner’ conceptualizcd these difficulties and determined the extent of the links with the home country. Many of the overseas medical graduates in Britain experienced a conflict of roles between a ‘student’ needing to pass examinations, a ‘visitor’ who must comply with immigration rules and a ‘client’ paying large fees and expecting good value for money.

Secondly, there were the cultural handicaps experienced within the clinical dialogue of the doctor-patient relationship. While this handicap was more obvious when a doctor and patient were from different ethnic back-

grounds, other differences of social class, reli- gion or language could also threaten the professional competence of the doctor and determine the extent to which a patient complied with treatment.

Increasing the sensitivity of doctors working in a culturally alien society to both these perspectives was a necessary component of medical education; failure to appreciate this sociocultural dimension of routine medical practice could result in diminished job satisfaction, inferior patient care and the risk of exploiting foreign doctors.

Overcoming cultural handicaps depended initially on recognizing when they were present; this could be a difficult task because cultural norms were usually taken entirely for granted. Dr Cox discussed the overcoming of these handicaps, using the traditional headings ‘attitudes’, ‘skills’ and ‘knowledge’. In the first instance, doctors needed to increase their cultural awareness in a variety of ways, for example by experience abroad (as during a student elective), by obtaining a post overseas after qualifying, or by working in a part of Britain with a large minority ethnic group; attendance at a cultural awareness or racial sensitivity group was also believed by some to be helpful. Clinical skills in such tasks as the use of interpreters, cross-cultural counselling and ethnographic interviewing could also be acquired. Knowledge could be increased at undergaduate level by a greater emphasis on the contribution of medical anthropologists; the ‘bio-psycho-social model’ could provide a useful theoretical model for such teaching. In- formation could be acquired about the naming systems, family structure and food preferences of minority groups. Postgraduate courses on transcultural medicine and the provision of services for minority groups in the U.K. and overseas were also important. Reference was made to the increasing number of books and research papers published on these topics in the preceding 5 years.

Discussion

In discussion a number of possible practical solutions to a variety of immediately apparent problems were explored. Outstanding was the

recognition that the present largely uncontrolled influx o f overseas-qualified doctors into the U.K. was wholly unsatisfactory. T h e training that many received was often of poor quality and inappropriate for practice in their country o f origin; furthermore, their employment by the NHS had deflected attention froni the resolution o f medical inaiipowcr problems which were n o w creating difficulties for U .K. medical graduates. N e w immigration controls introduced on I April 1985 created an entirely new opportunity to exercise better control over the number o f overseas-qualified doctors entering the U . K . , although both a new system for selecting candidates for postgraduate training arid for arranging suitable programmes would still be needed. T h e colleges were believed to be best placed, because o f their authority in postgraduate matters and their contacts overseas, to select doctors for training and to organize their programmes, although the universities had an important role in providing complementary courses, including orientation courses to help with English usage and t o overcome cultural difficulties. Any new arrangenicnts however, would, nccd to take account of the relevance of British postgraduate qualifications, which to date had been a niajor incentive for overseas doctors coming to the U . K . They had been passports to specialist practice internationally, but although they helped the career prospects of individual doctors their revelance to practice in countries with very different health care problems from those in the western world was questioned.

The ‘relevance’ of the training and the qualifications to which it led turned the discussion from ininiediate practical issues to the underlying theme o f the conference-the interna- tionality of medical education. Were the health care problems so different from country to country that medical training in one country was inappropriate to put their skills into practice in another? There were niany examples o f doctors trained in the West failing to return to their o w n countries because o f lack of opportunity to put their skills into practice or o f doctors returning home using their authority there to divert scarce resources inappropriately. O n the other hand, there were some returning doctors w h o had developed a critical approach

to practice and had applied rigorous scientific standards to the resolutiou of the health care problems peculiar to their home countries. That these problems differed from those they had encountered in the U.K. had not deflected them applying basic problem-solving skills which were generic to all good medical practice. They often faccd substantial difficulties in bringing about significant change in approaches to practice, and it was felt that the colleges and universities in the U.K. could give them significant support, for instance by giving legiti- macy to the development of appropriate higher qualifications overseas and reorienting health services from institutional to community care and from curative to prevciitive practice. There was, however, a danger in assuming that doctors from westerti countries were better able to resolve health care problems overseas than overseas-born doctors. Familiar modcls of hcalth care developed in the West were often inappropriate for other countries, and indeed there was n o room for complacency that \\rest- ern systems did not themselves ticed to change. Criticism o f doctors working in the West was in itself one of the benefits o f international exchange-no nation had the right to assume that its doctors had superiority o f knowledge and skill over those of other nations. T h e coni~iioti ground was not the development o f specific technical skills but the application of fundamental educational skills; there was a need for a jargon-free language o f education which crossed all specialty boundaries, and there should be rewards for educational as well as clinical ability in medical teachers.

Commentary

The purpose o f the meeting was d n exchange of ideas and the identification of common problems between participants froni different medical disciplines with an interest and experience in international medical education. Speci- fic solutions could not be expected, yet a number o f promising proposals had been put forward. Before summarizing these, the key point made by Professor Kerr should be stressed-that medical practice, the vais i r i d’ i t vc o f medical education, is only a part o f health care, and that complex issues need to be taken

Medica 1 education worldwide SO 1

into account in any proposals for change. In the context of today’s extreme specialization it is difficult enough to find common ground within the medical profession; to try to extend it to all other professions with a commitment to health care, and yet further to those which influence the health of whole communities is, to say the least, daunting. No wonder that grand solutions become enmeshed in bureaucratic entanglement and political conflict. Logic may breed scepticism about the value of individual efforts, categorizing and condemning them as piecemeal and uncoordin- ated; yet they are so often the shining examples of the progress we all seek. Experience suggests that capitalizing on these islands of achievement is more fruitful than devising complex theoretical solutions which often become only fodder for filing cabinets.

The African satellites of British medical schools in the post-war years brought a rich harvest of mutual benefit to both visitors and visited. Today many of these links have been lost and young British graduates are deterred from leaving their place on the increasingly restricted career ladder. With the development of such a variety of schools overseas freelance arrangements can readily be misunderstood and undervalued. New links between institutions in the U.K. and abroad could provide a framework for the interchange of undergraduate and postgraduate medical students and also for a sharing of commitment to health care among all the disciplines concerned. An inter- collegiate model as described by Professor Kerr, rather than a donor-recipient relationship, should ensure that the exchange is of mutual benefit and that inappropriate solutions to health care problems are not imposed by one country upon another. The establishment of firm institutional links should ensure that cultural difficulties between individuals working in unfamiliar environments can be foreseen and proper preparation made for exchange visits.

Collegiate arrangements between universities are easier to envisage than between national bodies such as the royal colleges, not least because there are very few equivalent organizations to the colleges in non-U.K. countries. Arrangements for postgraduate training overseas are many and varied, and a single solution

33

would be wholly inappropriate. Furthermore, it is in the specialized aspects of medical practice that the greatest care is needed to ensure that inappropriate skills are not developed. It is right that the royal colleges in Britain should continue to build on their substantial experience of setting high standards of practice in their specialty and to contribute worldwide to its development. Varied arrangements are needed, matched to the particular needs of overseas countries. These too should be based on mutual benefit, a sharing of experience, and not simply on a teaching hierarchy, with one nation’s practitioners prescribing their health care solutions for others.

Some colleges have already made a significant start in developing specific arrangements with postgraduate organizations overseas that they know and understand. The exchange is not always mutual, however, with British examiners visiting overseas and overseas students coming to the U.K. The new immigration rules will mean that these arrangements should become the main means of overseas doctors obtaining postgraduate training in the U.K. This should be greatly welcomed, but the task ahead is formidable. There should be no standard solution-each link overseas should be established on its own merits, acknowledging the variety of need even within individual countries, and based on mutual understanding and, ideally, an exchange of both teachers and students.

One issue is abundantly clear: no country, particularly in the affluent west, should accept that another should bear the cost of the basic education and training of any section of its medical manpower. Of the 7113 new full and limited registrations granted by the General Medical Council last year, 3740 were of graduates of U.K. medical schools-just over 50%. Many of the overseas-qualified doctors come to this country for postgraduate training, but most of them contribute to the work of the NHS in the process. Many do not or are not able to settle, and the new immigration rules will ensure that they will in future be will be able to stay no more than 4 years. The number of overseas doctors who will continue to seek postgraduate training in the U.K. with no prospect of settling cannot be foreseen; whether

502 K . M . Parry

they should be encouraged to come must to sponsored postgraduate training for overseas depend on what the U.K. has to offer, and not doctors. Medical Education, 15. 246250.

Harden, R.M.. Sowden, Susette 8: Dunn, W.R. on the needs of the NHS for junior doctors. (1984) Educational strategies in curriculum de-

velopment: the SPICES model. ASME Medical References Education Booklet No. 1 8 . Medical Education, 18,

284-297. Bishop, J.M. (1981) Report: The British contribution

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Medical education worldwide