Report of the Royal Commission on Medical Education 103

the training period, in hospital and in general practice, the young doctor will not be super- numerary but wil l be giving service. Even so, some ‘phasing in’ of the full period may be required. Those who have undertaken the training will earn that place on the vocational register which will be rightly provided for all existing Principals. In the discussions which the Report will promote the voices of the medical students and the young doctors must be heard. It is not the views of the older or reactionary - to whom these new training periods will not apply - but the dedication and professional satisfaction of the young which will decide the destiny of general practice. This point is well taken in the Report.

The new general practitioner - the general physician plus, the doctor with the special interest - wil l need a new context in which to practise and this will indude tire hospital. The Report recognizes

that education, fundamental to the therapy though it be, is only a part of it. The whole therapy is to be administered not in a vehicle of unnecessary elegance, but in one functionally adapted to contemporary needs. A sound and scholarly report is distinguished by the paragraphs on the Future Pattern of Medical Care. With its consciousness of the needs of the patient, the Report makes it clear that new methods of training and of practice are to reinforce the competence of the personal physician and not to supplant him. He may have new know- ledge and new skills, but the old attitudes to people.

These proposed patterns of vocadonal training are practical and possible. Will the patient refuse his proposed treatment ? This seems unlikely as he has already proposed it himself. Will the nation be prepared to afford the therapy for its patient and doctor both? Can it afford nqt to afford i t? The patient is far gone.

The Undergraduate Medical Course

W A L T E R P E R R Y University of Edinburgh

The medical schools have spent the last couple of years ‘waitingfor the Todd Report’. Many schemes for altering the curriculum in one way or another have been deferred to see how they would fit in with the Report. It seemed to many of us that its publication was almost bound to come as an anti- ClimaX.

Many of us, too, really expected very little. It was realized that the mass of evidence submitted to the Commission must necessarily be conflicting and inconsistent; for all of us, in the medical schools, realized that there were as many ideas about the curriculum as there w&e members of the Faculty. The expectation was, then, that the Commission, faced wi* such conflicts,-would recoil from any radical proposals and would end with recommenda- tions that did little more than tinker with the exis- ting patterns of medical education.

How very wrong we were! It is true that this is not a radical report; it is an iconoclastic one. It is packed full of all the ideas that the most outspoken critics of the present curriculum have voiced only tentatively and have held to be unachievable. If, among all these, it has also packed in a few less worthy ideas, then who will cavil ? So far, 53 good. But, despite all this, I am disappointed by the Report, for reasons that I had never thought would apply.

My disappointment lies in the very plethora of good ideas; it lies in the fact that all t h i s food for thought has been combined in a gargantuan meal, well-cooked and garnished with plausibility, but, I fear, very indigestible. It is to be fed to a company of universities, colleges, regional boards, hospital boards, and Government departments - and we all know just how fragile some of their digestive systems can be, capable of coping only with sops. I fear not only dyspepsia; I fear actual vomiting.

Rejection of this Report would indeed be tragic; and it Is because I fear rejection that I find it disappointing. It is very regrettable that the Commission did not devote a section of the Reporr to a discussion of the ways in which its recornmen- dations should be translated into practical actions by the various responsible organizations. Without such guidance, it is very diacult for any one organization to make the change, not knowing whether the very necessary associated changes will be made by the other responsible parties.

How, then, do the recommendations about the undergraduate medical course appear to the medical schools ? Since the medical faculties include every nuance of opinion, reactions vary accordingly; and it is still much too soon for the Report to have been fully studied, and for its implications to have been worked out. What follows will, therefore, be my

104 Report of the Royal Commission on Medical Education

own reactions, and in no sense can it be regarded as a consensus of views.

There will, it seems to me, be very little regret if the proposal to abolish the existing first M.B. is accepted. There has long been a fear that, for most students, it was a very poor initial educational experience. This has been a particular problem in Scotland, where local entrants have mostly not taken ‘A’ levels and where passes in the Scottish Certificate of Education at ‘Higher’ grade have not normally been accepted as exempting from first M.B. For some years we have, in Edinburgh, tried to tackle this problem by allowing such students to sit first M.B. exams while still at school; and, more recently, by exempting students with good passes in the ‘Higher’ grade. The proposals of the Com- mission which would take this process a further stage forward are thus to be welcomed.

The remainder of the proposals for the pre- clinical course represent the biggest changes of all. The Commission’s general suggestions may be summarized as advocating a broad general scientific education, with considerable emphasis on the behavioural sciences, and with wide flexibility for student choice in the selection of his courses. Many faculties have tried in the past to develop their curricula with these ends in view. To quote the local situation again, we in Edinburgh have intro- duced a B.Sc. (Med. Sci.) degree at the end of the existing first three years (including the first M.B. year). The degree of flexibility achieved was, in the end, precisely zero, except for students exemp- ted in part from first M.B. There is no doubt that the virtual disappearance of first M.B., coupled with the maintenance of a three-year period, would allow the introduction of flexibility to a degree hitherto unattainable. Many people, too, will welcome the Commission’s proposals about the acquisition of ‘credits’ as an alternative to the formal and formidable ‘second M.B.’. Moves in this direc- tion have also been taken in the recent past and there is a new willingness to try out new methods and techniques of examination.

There will be considerably less unanimity about the Commission’s other suggestions about the preclinical course. It is envisaged that there should be three types of ‘units’ of education: compulsory units, units selected from a list of limited alterna- tives, and optionalunits. Each ‘unit’ is defined as one half-day per week or as one-ninth of a term’s work. It is, of course, quite practicable to programme courses to fit in with this concept when the courses are offered by the Faculty of Medicine. It is very much more difficult when the courses are provided as a service by other faculties. This applies, for instance, to such subjects as genetics, statistics, psychology, sociology, mathematics, computer science, Ian-

guages, and social anthropology. The normal university courses in other faculties are usually operated on a basis of one-sixth or one-third of a year’s work - that is, of four and a half or nine units spread evenly throughout the year. The programmes, admittedly tentative, illustrated in Appendix 8 would be extraordinarily difficult to implement in an established university. Thus to get three units of French in the first term, plus two in the second term with none in the third term would demand special arrangements. The other faculties have recently faced very large expansion and have rather poor staff/student ratios. Thus it would probably be unrealistic to expect them to mount service courses especially designed to suit the needs of the Faculty of Medi- cine.

The reverse problem also exists. Most pre- clinical departments are also engaged in teaching students of other faculties; and these ‘service’ courses could not, in any sense, be combined wirh the new programmes envisaged for medical students. These are basic problems of logistics and could all be solved by an increase in the money provided - capital to provide new laboratories and recurrent to provide more teachers. It would be fatuous to pretend that, in the present period of financial stringency, they are not formidable obstacles to the ‘new look’ in preclinical education.

There is also a strongly-held suspicion that the degree to which the so-called behavioural sciences are emphasized in the Report goes beyond what is reasonable. A compulsory component of five units plus three units as a limited alternative amounts to a total teaching time of 150 to 240 hours. There are few who doubt that an insight into human behaviour is important enough to warrant such courses; there are many who doubt whether the sciences of human behaviour are suffciently developed as yet to enable the time to be usefully utilized.

The Report also comments upon the problem of the teachers of the preclinical sciences. The recommendation that the responsibility should lie with the professional scientist rather than with the clinician is clear and unambiguous. On the other hand notice is taken of the fact that increasingly the professionals are non-medicals and that ‘in consequence an increasing proportion of the teaching . . . must be done by teachers actively engaged in their clinical application’. All this is true; but the Commission hopes that the problem ‘will not be exaggerated for it is becoming to some extent unreal’. This seems to me to be one of the places where the Commission buried its collective head in the sand. Unless the trend of medical graduates out of preclinical science is checked, the two recommendations will rapidly become irrecon-

Report of the Royal Commission on Medical Education 10s

cilable. It is probable that the solution is, at least in part, a salary problem and that it fell outside the Commission’s terms of reference. Nonetheless, their sanguine view cannot help towards a rectifi- cation of the trend and is, in my opinion, wholly unjustified.

There are, therefore, these cogent reasons for doubting the validity of the Commission’s conclu- sion (in para. 20) that the introduction of their flexible modular curriculum is a practical proposi- tion. This doubt is in no sense a condemnation of their ideas, most of which are very attractive; it is only an expression of the lack of predigestion to which I referred at the outset.

Turning to the clinical phase of the curriculum envisaged by the Commission, we find that the principal changes are the reduction by one year in its total duration, and a change in the emphasis upon the need for experience in all the branches of clinical medicine. It is these changes which are interlocked with the new pattern of postgraduate education that is envisaged by the Commission. It is evident that the new clinical undergraduate programme would be unacceptable as a training leading to full registration as a practitioner; and that it can be implemented only when the independent practice of medicine starts after a period of super- vised postgraduate experience. It is thus probable that medical schools will adopt this pattern of undergraduate course only if they are assured that their graduates will pass into a postgraduate period organized along the lines suggested by the Commis- sion. Thus the whole interdigitated programmes of change require to be accepted as a package deal; and, since no one institution has responsibility for them all, any one change can be implemented only after the agreement of all the institutions. It is this that makes the Report indigestible; it is because of this that I fear for its acceptance and implementa- tion.

Otherwise the suggestions about the clinical course are unexceptionable. There is great emphasis upon integrated teaching. This is something that has already been started in many schools. Integra- tion at this stage of the course has always seemed logical, for clinical medicine is intrinsically the interpretation of all the medical sciences in relation to particular human situations. Essentially, the Commission proposes that this integrated pro- gramme should be implemented by a traditional apprenticeship-type training and that it should aim at the general introduction to clinical method rather than at covering the whole range of disease. Thus the super-specialities would be banished to the postgraduate sphere, and the applied aspects of the paraclinical disciplines would be taught as part of the integrated course of general medicine and surgery.

The whole concept is, to my mind, attractive. If it all comes about we will have moved medical education forward into the twentieth century. Will we have moved into a situation where we can cope with the twenty-first? Here I begin to wonder whether the Commission’s view of the future is really accurate. Will the patterns of medical care be such that the new generations of doctors will fill the bill ? Or will not the time come when the country must face a need for personnel with a training shor- ter and less scientific than that imposed by the Commission’s programme - in other words must not the time come when we must face up to the need for two different kinds of ‘doctor’? The Com- mission firmly rejects the idea. No doubt the profession would do so too. But I am still left wondering if it may not eventually turn out to be inevitable. The Commission has signposted the road to the scientific physician of tomorrow and for this we must all be grateful. If another route were to be discovered later and added, it would in no way detraa from the importance of what the Commission has done at present.

Requirements for Admission to Medical Schools

D . R . N E W T H University of Glasgow

So long as the number of young men and women upon candidates. However, self-interest and public seeking entry to medicine continues to exceed by far responsibility combine to make student selection the number that can be accepted, we may be and the requirements for entry matters to which the cushioned from the worst consequences of poor universities and medical schools should give some methods of selection or of inconsiderate demands fairly urgent and self-critical thought. Chapter five

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