Medicaal Education 1989, 23, 301-304

REPORT O F A CONFERENCE OF THE ASSOCIATION FOR THE STUDY OF MEDICAL EDUCATION, SEPTEMBER 1988

The curriculum for the year 2000

K . M. PARRY

Scottish Council for Postgraduate Medical Education, Edinburgh

Professor Christine McGuire felt that the prospect of trying to predict tlie curriculum for the next decade was a daunting one, let alone for the year 2000. The process of determining goals which led to the construction of a programme which needed to be measured in terms of how the outcome related to the desired goals should be a continuous process, subject to constant re-evalu- ation which should also accommodate con- tinuing change in the purpose of the programme. Goals she preferred to objectives; the latter, although appropriate within departments, could be disastrous a t institutional level where goals should reflect the expected needs of the institu- tion’s patrons, which in health-care terms were the expectations of the general public of medical education to provide the right kind of doctors capable of managing effectively the problems of health. She preferred the term programme to curriculum. It overcame the traditional territorial rights of curriculum committees, which under- mined the overall commitment of a medical school to ensure the best contributions of a learning programme to achieve the goals. Determining ‘outcomes’ also implied higher level of authority than the institution to monitor the programme so as to measure the use of resources as well as the attainment of goals.

Planning the curriculum for the year 2000 should meet societal, professional and individual needs of the teachers and students. To respond to societal pressures, a critical examination of how medical graduates functioned effectively now in meeting perceived health requirements, and how

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

they would adapt to change, were both key issues. Rising public expectations and overt criticism of how limited resources were best deployed had significant consequences for medical education. Increasing the number of providers of health care affected the characteri- stics of medical students. Measures of the out- come ofcurrent medical services were focused on unsatisfactory services, emphasizing technical expectations of the treatment of disease and how a patient was cared for. Preventive and health promotion services were not reflected in the measurement of acts of service, community studies revealed wide variations in the health realized, which could be attributed to educational deficiencies as well as to the inadequate provision of resources. Variety in the quality of health care provided by doctors from country to country reflected professional and public attitudes to the management of services, and British medicine was not so actively intrusive as that of the USA - yet patterns of morbidity and mortality were similar. Styles of medical practice and public expectations were affected by evolutionary trends and cultural factors as much as by eco- nomic considerations, and these should be recog- nized in the educational goals so that emphasis was given to the development of appropriate attitudes, decision-taking skills related to the provision of the best care available, not just the prolongation of life, and emphasis on acute medical care shifting to health promotion, lead- ing to a measurable reduction in morbidity. Future health care should be estimated by iden- tifying specific threats to health, such as pro- blems of ageing, AIDS, drug addition, pandemics arising from increased international travel, the toxicology of adverse environmental

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influences, changing patterns of work subse- quent to the industrial revolution, and stress arising from new technology.

Professional needs were changing because of the rapid growth of knowledge and of informa- tion technology. The rate of increase in know- ledge was such that it was quite impractical simply to attempt to add to an already over- burdened curriculum. The use of computers should be seen as no more than an aid and not a replacement for brain power in handling information and decision-taking - there was a real risk of damaging the doctor-patient relationship if computing was allowed to over- ride medical decision-taking. The trend towards earlier and greater specialization and the division of labour was another outcome of the knowledge explosion, with implications for the medical curriculum, recruitment for and the organization of health-care services. Advances in technology were creating complex moral issues with direct implications for medical ethics to help resolve dilemmas facing doctors and their patients. The effective management of health services was seen to be essential, and here the leadership of the doctor in determining health policies and health promotion was vital. Both students and teachers needed to come to terms with changes in the nature of professional practice. Students’ moti- vation may vary widely from that of established doctors, exaggerated by the stresses of modern society with which they needed help to cope.

The elements needed to plan an educational programme for the year 2000 included the con- text of the curriculum, for which simple addition was not enough - each aspect needed to be analysed critically, and priorities reordered. Structuring the curriculum by discipline, or body system, or particular health problem should be tempered by a psychology of learning to enable students to become informed effectively. A functional context was not readily perceived by medical disciplines which, although well geared for research and development of their subject, were not sensitive to educational needs. Although there was evidence that problem orientation was a valuable educational approach its effectiveness in improving health practice had not yet been validated.

The setting of educational activities raised the issue of hospital and community orientation.

The psychology of learning suggested that people worked best in managing problems which they had encountered before and in situ- ations made familiar in their student activities. Common problems occurred more often in a community setting, but this was not widely applied in current educational programmes. Training in the community rather than within the selected circumstances found in hospitals should enable students to feel more at home with the health-care problems that they would encounter in practice, but whether their per- formance would be improved had not been substantiated. Methods of learning tended to be decided in competitive terms. Lecturing and small-group activities were both known to be effective if they were conducted in the right circumstances, and the key issue was which, where and for what programme each should be provided. This was affected by the learning objectives; lectures could be effective sources of information, and were known to inspire research. However, small-group learning was best in problem-solving, and both learning methods should be available. Each should be chosen for the purpose for which it was most suited and selected with the vigour and insight that surgeons would give to operations they were planning to undertake.

Educational innovation was expected and was often introduced in new medical schools - even overzealously. In more traditional settings cost benefits should be given a fair hearing, and change carefully monitored, involving the whole faculty. Professor McGuire hoped that changes would be catalysed by the declaration issued by the World Federation in Edinburgh which called for active participation by all medical schools.

In discussion the congested curriculum was seen as a key issue; the educational programme should be managed so as to release the student from the need to remember unnecessary information, and this should be reflected in the examination system. In medical practice the computer should be seen as a resource for the storage and management of information, and not as an expert system challenging a doctor’s auton- omy in decision-taking. Measures of the effectiveness of care were needed to enable the medical school to measure its educational achievements; outcome measures had attracted

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most interest, and although immediate outcome measures were helpful, the process of care also should be monitored. Evidence about the effectiveness of different learning methods was being accumulated but was not conclusive nor sufficiently applicable to the aggregation of data between institutions. International cooperation could help data to be collated, leading to more sensitive judgements to be made.

Professor David Shaw foresaw changing needs as not having absolute values, varying according to the qualities of their commodities. A medical curriculum had to satisfy and defend variable needs; high standards of research created an atmosphere of curiosity and problem-solving which influenced students, and there was a need too for medical education to relate to high standards of clinical practice. Traditions of cul- ture and science were at risk of being under- valued and should be defended. Mechanisms for change were necessary to overcome in-built resistance and common inertia, and curriculum committees motivated to be actively committed to the review of their educational programmes. The need for change was widely acknowledged. The care of the dying, communication skills, social factors in medical care, and legal aspects were topics currently promoted by external pressure, and new approaches to ‘functional’ illnesses needed reappraisal so that they were not dismissed as self-induced. There was a movement towards community teaching which was encountering resource problems, with inadequate means for compensating general practice for its education commitments. Remarkable technological advances were also raising major issues for health authorities, and it was unknown what advances would be available by the year 2000. Basic science and medicine were becoming more closely related, and there was a move too for developing health promotion and preventive medicine.

An inventory should be drawn up to enable needs to be defined, but how to implement change was uncertain. The medical school could only play a part, and the assumption that the selection of medical students was a significant issue should not be overrated - it was not possible to select or shape a student population to an ‘ideal’ pattern, nor was it necessary for all to have the same characteristics, bearing in mind the

wide variation in patterns of contemporary prac- tice. Some desirable changes in health-care prac- tices were clearly beyond the scope of medical educators who should avoid taking responsibili- ties which were beyond their capacity for achievement. The current pattern of mortality and morbidity clamoured for more in the direc- tion of effective measures, but how society’s expectations of health care could be influenced was not the exclusive task of medical schools; there had to be other influences over such matters as the use of tobacco and alcohol, and medical adaptation to the future was as much a part of continuing as of basic medical education.

Professor Ronald Harden outlined task-based learning as an educational strategy for the future. In undergraduate education there had been a clear case made for greater integration between theory and practice, and developing the ‘reflective’ practitioner. In postgraduate education more effective planning had been called for, and there was a need too for a more effective continuum of undergraduate, postgraduate and continuing education. Theoretical aspects of practice were overstressed in undergraduate and under- weighted in postgraduate education, and the reverse in respect of clinical teaching. Task-based learning was concerned with the experience of students learning best from the tasks that they undertook in hospital wards, in which a clinical situation was plainly related to the performance ofa task, and the students’ learning related to that task. It was more than an apprenticeship model, since a study guide was specifically provided to guide the student and supervising staffinto how and what to learn from clinical experience. Its advantages were that account was taken of local learning resources and theory was related to practice; it encapsulated educational strategies, including student-centred learning, integration, and problem-based learning, and related edu- cation to a career in medicine.

Professor Gordon Moore called for leadership amongst educationalists to articulate the impor- tant goals of education rather than limit concern to the content of the curriculum. The medical school should not be overly preoccupied with details of practice which were matters for post- graduate education. Rather, undergraduate edu- cation should emphasize general knowledge and skills. He presented a model relating social

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attitudes, and beliefs about health constituencies, to health policies and regulations; these in turn have profound influence on those who were responsible for the provision of services. Des- cribing the interaction between medical specialties, primary-care services, research and education, Professor Moore saw major trends in medical education involving consideration of medical knowledge and technology, accountabi- lity for services, distribution of medical man- power, changes in patterns of ill health and in the management of information. A review of major implications needed leadership and prospective thinking within a community orientation, taking account of identifiable, differing communities, and recognizing that it was how learning took place rather than a prescriptive content that mattered. Changes in the processes of education were needed and required inspiration; it was impractical to cram more into an already over- burdened curriculum, and there was a need to think creatively - otherwise the acquired univ- ersity status would be lost. The real goal was an

educational process which was more interesting and challenging and which excited students.

Professor Moore’s particular interest in computing led him to believe in the value of computer literacy for all students - he found the access to information that it provided saved much time in decision-taking, and it was notjust a matter of sorting information. The content of the medical curriculum should be modified and modernized to provide students with competence in applying health promotion and disease prevention, enhancing the emotional well-being of their patients, developing bio- technical competence, using technological assessment to ensure good standards of practice and to control the allocation of scarce resources appropriately. He advocated careful thought about leaders and who they should be. Medical educators, who must be thinking about the place of medicine in the future, should be articulating those future needs with today’s realities and playing a leadership role in our medical schools.