Medical Education 1986, 20, 159-161

Editorial Twenty years on

The most recent major review of medical education in the United Kingdom was under- taken by the Royal Commission nearly 20 years ago. Its report (Royal Commission on Medical Education 1968) consolidated a num- ber of important changes which had come about since the previous review by the Good- enough Committee (Interdepartmental Com- mittee on Medical Schools I944), and set out a framework for future developments in line with foreseeable changes in medical care, parti- cularly within the National Health Service. The establishment of sound training schemes for each specialty, including general practice, was seen as the key to the development of a basic undergraduate course as a university education which would produce ‘not a finished doctor but a broadly educated man who can become a doctor by further training’. The Commission gave particular attention to professional train- ing in certain fields, including psychiatry, which, although improved since the Good- enough Committee had deplored its low stan- dards, ‘still leaves a great deal to be desired’.

A comprehensive review of progress since the Commission’s report is hence most wel- comet. A Steering Committee, set up by the Royal College of Psychiatrists, the Association of University Teachers of Psychiatry and the Association of Psychiatrists in Training, under the chairmanship of Professor Henry Walton, took great care to prepare for a conference on ‘Education and Training in Psychiatry’ held in Cambridge in 1982. Working parties prepared pre-conference documents on a variety of topics, including psychiatry in the medical school curriculum, methods of teaching and

tEducation and Trainitzg in Prychiafry: A Care Study in the Continuity of Medical Education. Edited by Henry Walton. Oxford University Press and the King Edward’s Hospital Fund for London, Oxford. 1986. Pp. 231. &rz.oo. ISBN: o 19 724632 X.

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

learning, and specific aspects of education and training in the continuum of education. The report-subtitled ‘A Case Study in the Con- tinuity of Medical Education’-deals in detail with aspects of undergraduate, postgraduate and continuing education. The main features of the report were then discussed at a follow-up conference held at the King’s Fund Centre in November 1983, again chaired by Professor Walton, to which a selected audience of medic- al educationists, health service planners and administrators, and representatives of regula- tory and of funding bodies were invited.

Many of the educational issues discussed in the report are specific to psychiatry, but others are highly relevant to the education and train- ing of all doctors. Does the undergraduate course provide a suitable general education for all medical disciplines? Although there is no ‘national’ curriculum and no two university medical courses are identical, basic medical education is guided by the General Medical Council (GMC). Its latest Recommendations (GMC 1980) set out the knowledge, skills and attitudes which should provide a firm basis for future vocational training. ‘The process of basic medical education necessarily involves the study of many different subjects,’ says the GMC, ‘but the practice of medicine involves more than the mastery of those subjects. It requires the development of certain attitudes and skills and the ability to synthesise and apply them’. Like the members of other disci- plines, psychiatrists make a plea for the import- ance of their own subject in the curriculum, and particularly advance the case for the in- tegration of psychiatry with other specialties in inculcating in students a broadly-based view of illness, balancing psychosocial and biological concepts. For this to be achieved teachers of psychiatrists have not been helped by ideo- logical differences between individual psychia- trists; students’ attitudes can be significantly affected by their overall impressions of their teachers. Nor is teaching ability itself a natural

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attribute of all psychiatrists; the bulk of teaching is undertaken by NHS consultants who should, like their academic colleagues, be assisted in developing their teaching skills. The report proposes explicitly that teaching should be given the weight accorded to clini- cal competence and research experience by committees making teaching appointments. Teaching methods are reviewed, and although encouragement is given to the development of self-instruction using modern learning systems, the importance given to individual and group tutorials is the justification for more teachers and the inevitable demand for a larger slice of the medical school cake.

But is it not a reappraisal of the composite teaching contributions of the medical school as a whole that is needed rather than the contribu- tions of individual subjects? The psychiatrists make a particular point of the need to redress the balance of an overly organic emphasis in medical teaching by physicians and surgeons. They stress the importance of selecting appli- cants to medical school who are ‘psychological- ly minded’ as well as those who have shown their prowess in the basic sciences. They claim that psychiatrists are ‘different’ from other physicians, since the psychiatrist has to ‘recon- cile a clinical scientific approach . . . with empathic awareness of his patients’ subjective experiences’. Because of the individual nature of psychiatric disorder, they say their trainees have to acquire ‘a multi-dimensional view’ of its causality and adopt an ‘eclectic approach to clinical management’, collaborating closely with members of other professions. But is this task unique to psychiatry? Elsewhere it is said that the general practitioner too is ‘concerned to teach the trainee how to respond not only to that component of the illness which can be labelled “disease”, but to the patient’s total experience of illness . . . the general practition- er teacher has to change his trainees’ perspec- tive from that of disease-centred medicine to that of patient-centred medicine’ (Royal Col- lege of General Practitioners 1972).

Understandably, each specialist will be temp- ted to look for future recruits from the undifferentiated mass of undergraduates, but if a generic course is to achieve a true synthesis of its individual subjects, should not the teacher seek to

emphasize its common foundation rather than its different parts? Aubrey Lewis (1970) is quoted as saying that ‘the psychiatrist must combine attitudes of mind which seem incompatible, namely critical scepticism and receptive alert- ness. Education should cultivate in him a habitual balance in his emotional response to the daily material presented by psychiatry in practice, as well as balance between his judgment of ideas and information, and balance between scientific and intuitive appraisal’. The balance may differ for other disciplines, but is not the dilemma in some degree present for all?

Interestingly, ambivalence is expressed about the merits of including a psychiatric module in the pre-registration year, partly on the grounds that the traditional apprenticeship in general medicine and surgery should be retained but also because a few months’ experience is not regarded as sufficient to appreciate the charac- teristics of psychiatric practice. Preference is given to a longer period of postgraduate ex- perience for doctors undecided about their future careers and for those for whom psychiat- ric training would be appropriate, for example general practitioners. Less enthusiasm is shown for future recruits to the specialty undertaking obligatory training in other subjects. As in other debates about the Royal Commission’s recommendations for a period of pluripotential general professional training, the main argu- ment seems to rest on the opportunity such experience would give to doctors to make a career choice; that it is thought to have no particular educational value is implied by the insistence that it should be optional and that ‘high fliers’ would not give it a passing thought. This is a commonly held view of many specialists, reflected in the way in which specialization has developed in the NHS. This fragmentation of the older subjects of medicine creates a problem for those who are trying to influence clinical research. ‘Science, in contrast to the divergence evident in clinical practice, has not been fragmenting but is converging’ (Booth 1986). The modern breed of clinical scientists wishes to be unshackled from a rigid ‘systems’ and specialty approach, yet the foundations of future practitioners are being confined by increasingly narrow specialty boundaries. The attendant risk is that future

Editorial 161

generations of specialists will be clones of today’s, who-however competent they may seem-are not necessarily equipped for the zIst century.

One way ahead is to describe postgraduate training, not in terms of pathways and hurdles, but of broad goals and objectives. This the psychiatrists have made a useful and bold attempt to do, but admit the difficulty of defining attitudes in these terms and the com- plexity of developing an assessment system which matches trainees’ attainments to defined objectives. The membership examination of the Royal College of Psychiatrists is criticized for its weakness in assessing clinical skills and the mechanism for providing feedback to candi- dates. It suffers, like passlfail examinations of other colleges, from relative detachment from educational processes, but new solutions are only tentatively explored.

Training settings differ in psychiatry from other specialties because o f the existence of large, exclusively psychiatric hospitals. Psychiatry differs too in its preference for at least part of general as well as higher training being university based. This leads to the wel- come recommendation that training posts ‘must depend not upon the service needs of the institutions or agencies, but on their suitability for training by reason of the quality of the consultant staff, their teaching capacity, and the ready availability of the resources of the uni- versity department of psychiatry’. The adop- tion of such a policy would not only help the development of better training for U K gradu- ates but would go a long way towards over- coming the present unsatisfactory position for doctors from overseas who, failing to obtain a training post in the specialty of their choice, find that a junior psychiatric post of poor training quality is the only one open to them. In higher training the dilemma of increasing specialization is resolved in part by adopting a model of other specialties, concentrating wholetime specialists in university centres and encouraging the adoption of ‘special interests’ by general psychiatrists. A novel suggestion is that established consultants might undertake further training for a specialty later in life.

Continuing education was given scant atten- tion at the main conference but was discussed

in general at the follow-up meeting at the King’s Fund. Emphasis was given to the need for peer review and audit, and interest shown in the development of alternative learning methods, particularly for psychiatrists working away from major centres. ‘Centres of excell- ence’ d o not, however, necessarily provide an appropriate model and the merit of distance learning is the dynamism it can give to indi- vidual doctors to take an interest in their own continuing education and the assessment of their own practice.

Debate on this illuminating case study of the continuum of medical education in one disci- pline should not be confined to its practition- ers, for it contains messages for all. Moreover, it calls for common educational developments for which no single discipline can hope to find adequate resources. It is time that medical education had regard for its sometimes uneasy bedfellow, medical science; to d o so might help educationists in all disciplines to seek to reduce their increasingly complex structures and sys- tems into a confluent and unifying discipline.

K. M. PARRY

D r Parry is at the Scottish Council for

Postgraduate Medical Education, Edinburgh,

Scotland

References

Booth C.C. (1986) The Stoker Report and the future of Northwick Park. Lancet i, 372-4.

General Medical Council (1980) Recommendations on Basic Medical Education. General Medical Council, London.

Interdepartmental Committee on Medical Schools (1944) Report (Chairman: Sir William Goode- nough). Her Majesty’s Stationery Office, Lon- don.

Lewis A. (1970) Educational objectives. In: The Training ofPsychiatrists (ed. by G. F. M. Russell & H. J. Walton). British Journal of Psychiatry Special Publication No. 5 . Headley Bros, Ashford, Kent.

Royal College of General Practitioners (1972) The Future General Practitioner, Learning and Teaching. British Medical Journal for the Royal College of General Practitioners, London.

Royal Commission on Medical Education (1968) Report (Chairman: Lord Todd). Cmnd 3569. Her Majesty’s Stationery Office, London.