Emerging problems with graduate medical
education:An academic surgical
perspective
John P HarrisProfessor of Vascular Surgery
Associate Dean Surgical SciencesUniversity of Sydney
Chairman Division of SurgeryRoyal Prince Alfred Hospital
Aims of medical education Trends and outcome Student assessment, ranking,
honours Implications of age Suggested directions
Australian Medical Council
Goals and objectives of basic medical education
Doctors must be able to care for individual patients by both preventing and treating illness, to assist with the health education of the community, to be judicious in the use of health resources, and to work with a wide range of health professional and other agents. They must possess a sufficient educational base to respond to evolving and changing health needs throughout their careers.
Curriculum themes
1. Basic and clinical science2. Community and doctor3. Patient and doctor4. Personal and professional
development
Dean SJ et al Preparedness for hospital practice among graduates of a problem-based, graduate–entry
medical program. MJA 178:163-7, 2003
Aims of medical education
Prepare young doctors to serve the Australian community as clinicians
Lesser but important aims: The doctor as a social engineer
Patient/Doctor Society/Doctor(Public health)
The doctor as a scientist/researcher PhD
Medicine as vocational choice
Pre-Med degree
3 years
Enter Medicine
4 years USydGMP
Medicine as vocational choice
Pre-Med degree Miss out
3 years ?career options
?lost opportunity Enter Medicine
4 years USydGMP
Medical Science versus Arts background
0
5
10
15
20
25
30
35
40
1997 1998 1999 2000 2001 2002 2003
pe
rce
nta
ge
of s
tud
en
ts
Medical Science
Arts
Move to Graduate Medical Education
•Clinician student•Didactic lectures•Basic sciences•Bedside teaching•Emphasis on history and examination
•Tutorial room•Self directed learning•Problem Based Learning•Non-clinician facilitator•Societal skills•Preparation for life-long learning
Move to Graduate Medical Education
•Clinician student•Didactic lectures•Basic sciences•Bedside teaching•Emphasis on history and examination
1960’s75% clinical teaching at beside
•Tutorial room•Self directed learning•Problem Based Learning•Non-clinician facilitator•Societal skills•Preparation for life-long learning
Now<16% Ann Int Med 126:217-220, 1997
In ascendancyMedical educatorComputer based resourcesPublic health
In declineClinician based teachingClinical content in the modern curriculumUniversity clinical academic departments
Anatomy formedical graduates
Traditional undergraduate dissection is no longer sustainable Cost Time constraints Shortage of skilled staff
Innovative programmes Self-directed learning, PBL, supervised
practical classes Option term dissection
L Bokey & P Chapuis ANZ J Surg 71:781, 2001
Anatomy teaching in ANZ medical schools
Medical School DissectionAdelaide No ElectiveAuckland YesCurtin NoFlinders No ElectiveGriffith No ElectiveJames Cook No ElectiveMonash NoMelbourne NoNewcastle NoNSW NoOtago YesQueensland YesSydney NoTasmania NoWollongong NoWestern Australia No
Dissection in 3/16
19%
Anatomy:Teaching in other courses
Programme HoursSydney Graduate Medical Programme 65
No dissection, prosected specimens, self directed
Sydney Undergraduate Medical Programme 500Science 6 unit science Anatomy (dissection) 91-98
13-14 week semester, Abdomen/Thorax, Head & Neckx2 1hr lecture, 1hr tutorial, 3hrs dissection/week
Chiropractor 156No dissection, 13-14 week semester Limbs, back & trunk, head and neck x4 hr/week x2 lectures, x2 hr practical with tutor
~15% of US hospital residents from osteopathic schools of medicine
Implications? 1995-2000 x7 fold increase in medico-
legal claims based on anatomic error (UK MDU)
Future doctors may be proficient in the general and social aspects of medicine but it would seem that their knowledge of the basic facts of anatomy, physiology and pathology and their understanding of the mechanism of disease may be no better than that of a “medicine man”.
R Magee MJA 179:224, 2003
Getting the balance right
Trends and outcome
Student assessment, rank, honours
5 yr Undergraduate programme Honours based on cumulative success Incentive to excel in each subject
USydGMP Honours based on extra-project Unrelated to core and distracting from
the programme
Student assessment, rank, honours
5 yr Undergraduate programme Honours based on cumulative success Incentive to excel in each subject
USydGMP Honours based on extra-project Unrelated to core and distracting from
the programme No University Medal in Medicine No Year Book 1997-2002
Clinical surgery USydGMP
Graduate MB BS Surgical content
32 week block in Year 3 16 topics (1 lecture & 1 tutorial) Integrated Clinical Attachment
Formative assessment Year 3 Surgery
0
2
4
6
8
10
1 3 5 7 9 11 13 15 17 19 21
Mark out of 20N
o.
2004
Formative assessment Basic assessment of course
Attendance voluntary31 of 50 sat
Results anonymous11 of 31 unsatisfactory
Left up to individual to seek remedial preparation for barrier exam
Absence of ranking
Satisfactory/unsatisfactory How to sift out the poor student? How to reward the good student?
Absence of objective criteria for: Residency placement Selection into specialty training Award of honours
Implications of age
UGMP USydGMPHigh school 5 HSC 6UGMP 6 PreMed 3
USydGMP 4Mean age at graduation 29+speciality training 4-7Enters definitive vocation 33-36
Age on graduation
0
5
10
15
20
Age
%
Implications of age 14% >35 at graduation Vocational choice
Length of specialty training Short effective practice life ?return to the tax payer
Life-style Financial, housing, family
Learning hand/eye skills Elite performance relates to age
of first exposure and practice Manturzewska in a sample of
190 elite musical performers found no individual who had started later than age nine
Psych Review 100:363-406, 1993
… And herein lies the rub. Despite continued calls for educational research that matters …, the medical education community has yet to report solid evidence to support the intentions of these resource-intensive changes. The profession, hardened by the evidence-based medicine movement, expects no less.
Martin B Van Der Weyden, Editor letter in MJA 181:518, 2004
Medical education and hard science
The way forward…. Emphasise clinical training
Base curriculum on feedback from students & doctors in practice
Universities & Colleges Fusion of resources & skills
Apply AMWAC projections to plan medical school entry Shorten medical education
Early streaming in medical training New teaching tools
Surgical skills centres Simulators, video-instruction systems
Consider the impending demise of clinical academic medicine
Weedon D. Whither pathology in medical education? MJA 178:200-2, 2003
Top Related