ADF Archive Files : For Browse View Click Here

From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005

The Downgrading of Basic Sciences – A Student's Perspective

DR. ANDREW PERRY
Former Vice President, Australian Medical Students Association

Thank you very much, Lindsay. Now, before I start, I want to make something perfectly clear. As Lindsay mentioned I am the past Vice President of the Australian Medical Students Association but I am not speaking to you in that capacity. The views and opinions that I'm going to express today are my own and those that I've collected from other fellow medical students. So if I'm not speaking on behalf of AMSA, who am I speaking on behalf of? As Lindsay has mentioned, I've just graduated from medical school so I'm fresh out of just being six years into the system. What's more, the system under which I trained was a hybrid course which combined didactic teaching and PBL, or as Ted Cleary would put it, the worst of both worlds. At present, I'm currently two months into my internship so I think I'm in a fairly unique situation where not only have I freshly completed my medical training, I've also got a chance to see whether that's actually prepared me for actually putting it into practice.

If you look at the topic that I'm ascribed to on the programme you will see that it is the downgrading of basic sciences – a student's perspective. Well, ladies and gentlemen, the programme has changed. The reason for that is over the last two months while I've prepared for this presentation I've spent a lot of time researching, looking at the literature that is out there, and I think even more importantly, speaking to the people that are involved in medical education, both the students and also the medical education deliverers. As such, I've made a decision to change my topic to the following - that is, teaching the art and the science of medicine.

I am very heartened to hear some of the comments of the previous speakers, such as Bill Glasson, when he's emphasised that it's important not just to have the science but also the ability to put it into practice. I think you can summarise that by saying that there is a dual importance of raw knowledge and data and also the ability to put it into action.

So what will I talk about? Three things. Firstly I want to talk about content; secondly, I'll be talking about feedback; and lastly, I'll be talking about apprenticeship. So, where does the current opinion lie? We've already started to hear from some of the speakers what they think on this topic and I think it's probably fair to say that the room here is split into two camps; that is the academics, those people who are involved in the medical education units and the day to day delivery and implementation of medical education at the universities; and the clinicians, those doctors who may or may not hold dual appointments with the universities, who are responsible for taking these graduates from the university from the classroom, and making sure that they can actually put it into practice in the wards.

If you talk to these guys, though, I think that they will describe themselves in different terms. Firstly, the clinicians will describe the academics as people with their heads in books, that these people are divorced from the realities of clinical medicine and as such, their opinions can only go so far. That's not to say that the academics have great love for the clinicians, and if you ask them what they think, they'd probably say that clinicians are dinosaurs, that they long for the good old days.

So, what do the students think? To answer that question I went to the medical student associations, and to do so, there's two that you need to think of. Firstly, AMSA, which since 1960 has been the peak representative body of all medical students, and which every single medical school – including the three that were established this year – have representation. I've also gone to the local medical student societies which are present at every medical school. And the answer to this – do these students have any firm policy on this issue – the answer is no, there's nothing in writing. So, does that mean that students don't have an opinion? The answer of course is that they do, and that furthermore, there is a growing awareness of the importance of this issue. That medical students are realising that perhaps the course that they are being taught, that they are being told is best for them, could be improved to some extent. And as such, I'm told by Dror Maor, who is the 2005 AMSA President, that this is a major issue on their first agenda in March.

So what I'm putting to you today is not those of the local medical student associations, but rather my personal opinion combined with the experiences that I've been able to gain from speaking to people over the last three years when I've been a member of the AMSA Council.

Content – what do I think of it? Well, I think it is pretty clear that the battle lines are drawn on the competing interests of hard versus soft science. Hard science is seen as that of anatomy, physiology, biochemistry, etc, and soft science is more that humanity side of medicine, whether it's ethics, personal and professional development and so forth. Twenty years ago there's no doubt that the emphasis was solidly on the hard science, that the medical schools back then were turning out graduates who were very well versed in areas such as anatomy. However, as many speakers have said today, there has been a swing in the pendulum.

So where do I think the pendulum lies. Ladies and gentleman, I'll put it to you in black and white. I think the pendulum has swung too far in favour of soft sciences. I want to say something else though, that soft science is important. That the reason why we've seen a change in curriculum over the last twenty years is that there was too much emphasis on the hard sciences and that the population, our patients, wanted to have different doctors, doctors who have more training in that area. So I think we need to keep that in mind when we've looking at this debate. I believe that there's not enough anatomy, physiology, biochemistry, pharmacology, etc in the course. So, how much do I think there should be? Well, it's almost how long is a piece of string, but I think it must be said that there can be too much of a good thing. I still remember my first lecture in medical school. I know there's two people out the back here who were present at that and probably remember it too. It was on chirol(?) carbons. Now, I can remember very little about that lecture except for the fact that apparently thalidomide had something to do with chirol carbons and that that's bad. But over eight lectures, if that's all I got out of it, I think you've got to question whether or not that's a good use of time. But regardless of the fact that perhaps that lecture wasn't a great use of time, there's no doubt that more hard science in the curriculum is something that the students are after.

What we then need to say is, does this have to be at the expense of the soft science. Now, one of the things that's changed in medical education is a shift from the didactic lecture based teaching to more problem based small group learning and tutorials. In fact, at Adelaide, you may be interested to know, that we've now down to about five hours of lectures a week whereas in my course it was close to about fifteen. I would put it to you that there probably is room in the curriculum to put more hard science into it. The medical academics would say that the reason why there's less contact (inaudible) in how the students are going and tell the students how they're doing, whereas when the cook tastes the soup – that is the student looks at it – they get a way of feeling how they're going.

So, what is my opinion on this? Well, to answer this I bring your attention to a phrase that was used in the promotional material for this conference, and that is "when none admire, tis useless to excel". My belief is that this is a true statement. I believe that the current medical education climate is such that we encourage the achievement of basic competencies, and put that over and above trying to encourage people to go beyond them. In my view that is encouraging mediocrity at the medical school level. Having said that I think there is a lot to be said for making sure that students achieve basic competencies rather than getting over an arbitrary line of 50%. We need to make sure that if you got 51% that means you have actually achieved all the competencies that you are expected to have as a doctor, not just because relative to others, you are 1% better.

I would actually say that there is no reason why you can't combine the two. Instead of having them as "versus", put the two together. Ensure that basic competencies must be reached, at the same time encouraging and rewarding excellence.

But I think the central message I'm hearing from students over the last three years is that really they want more feedback, and they don't really care if it's formative or summative. Really so long as they are getting something, something to tell them how they're going, that is primarily what they're after. So if I had one take-home message in that area it would be, if the MEU's were to consider increasing the amount of assessment that takes place for the students.

So, is there anything on which all the stakeholders agree, and I'll put it to you that there is. And that is the area of apprenticeship. Bill has mentioned this before and it's almost like we've swapped speeches. The reality I think is that it's very important not only to be taught the facts of medicine, but also how to put it into play. My opinion is that medicine needs mentoring, whether it's on the ward round, whether it's a tutorial, whether it's in out patients, whether it's in any other setting in which you sit down with the doctor who actually applies that medicine and learn something from him. The question then is, is that taking place to a sufficient level? I think other speakers have echoed my comments with my belief that it isn't.

So what's the problem, why is this taking place? I mean, whenever we're doing this we usually play the blame game, we want to point to someone and say this is the reason why we have a problem. I think, given that this conference is set here in New South Wales, it's probably very appropriate that we look at another case where a finger of blame was pointed, and that was the Camden Hospital enquiry, where obviously there were a number of adverse patient outcomes and an enquiry was put up to determine why those problems had occurred. Now, if you spoke to hospital administrators or the Department of Health they would point to the individual doctors and say, they were the ones at fault, they were the ones that caused the muck-up. However, if you speak to the individual doctors and to groups like the AMA they would very clearly say that the system is the problem here, and that the system is designed to fail.

So what is the problem here, is it individuals, do we have slack teachers or medical academics? I would put it to you that it is not. It's actually a system failure, and that the way things are going now, it is impossible for medical education to continue in its current sustainable format. As such, that the reason for this – and it's been mentioned before – is that service delivery is taking priority over teaching. Now, this applies not only to the teachers, the senior consultants, but it's just as equally applying to the students, and when I use the term students here I'm actually meaning the junior doctors, the interns and the RMO's, who are so bogged down with writing out discharge summaries and doing all the administrative side of things that they don't have time to actually listen to the teachings that the consultants may or may not have time to do.

Now who's responsibility is this? I mentioned before it's the system, but let's get a little bit more specific than that. In my opinion the responsibility for fixing this problem lies squarely with the State Departments of Health, at least until the current funding model is switched to a Commonwealth level. Obviously right now the State Departments of Health are responsible for the public hospital system and hence I hold them accountable. Some of you might say no, it's the universities' fault, they should be held equally responsible. But let's be honest with ourselves, the universities have absolutely no money and under the current government that's not going to change. So I think we need to be realistic and work with those people who actually have the ability and – just as importantly – the cash to do so.

What needs to be done? Well, as always when you're looking at these problems there's usually two magical ingredients that are required, and it's usually the same old story, we need more money and we need more time. Okay. With that money and time we need to look at the public health system and we need to start providing more recognition, more protection and more quantification in terms of both time and money to clinical teaching. We need to look at the enterprise bargaining agreements, we need to look at the hospitals' performance indicators, and make sure that the place of clinical teaching is enshrined and enforced within all of those.

So, outcomes – outcomes from my speech. Obviously that's what we should all be looking for. To that effect I've actually produced a number of recommendations, and those recommendations I've passed on to the conference conveners, and hopefully at some stage they will be included in the Outcome document that comes out of this. Most of them deal specifically with that issue of apprenticeship but there are others that are included, and I welcome your comments and feedback on them later.

The thing I would like to emphasise to you though – it's very important that the recommendations and outcomes we suggest from this conference are listened to by the right people, and I say "listened to" as opposed to "heard by". It's very easy to make a lot of noise, a lot of racket, and to be heard by people but it's another thing altogether to be actually "listened to". The difference between those two words is that "listen" implies that people are taking note, are paying attention, and I think we've got to be very careful that this conference does that. I mean, with a title like "Rescuing Medical Education", do we actually think we are endearing ourselves to the people who implement it at the coal face, medical academics.

So who do we need to talk to, who are these "right people" who I believe need to be listening. To answer this question I've looked at the current set-up in which medical education is accredited, and there's no doubt that the Australian Medical Council at present is the body that sets the standards for medical education. I want to say right now that I think they work very very hard at this, and it is very heartening to see that Ian Frank out there in the back row, the Executive Director of the AMC, has attended today.

I think we also need to work with groups such as CDAMS(?), the leaders of the medical schools, to make sure that they are hearing our views, and what's more, that we're not alienating them in what we produce. Finally, we need to be working and talking to the academics and the MEU's, the people who are – let's face it – the ones who are usually deciding and implementing the medical curriculum at each medical school. The reason why we especially need to talk to these people is that in many cases they form the AMC, so it's a round loop.

I'd like to finish by making a few thank you's. I'd like to thank David Hewitt who, as of last Sunday, is now the Chair of the Federal AMA Doctors in Training Committee who, at last year's AMA national conference really brought the issue of mentorship at public hospitals into the spot light. I'd also like to thank Ted Cleary. Ted failed me in PBL in second year and I'm certainly not thanking him for that. And I wouldn't say that we agree on everything, in fact probably the only thing we agree on is that we disagree. But you can't doubt the man's belief in the system and his perseverance and his commitment to the cause. And if anything else, he makes all of us question where we stand on medical education. The last person I'd like to thank is Mathew Hutchinson who's here at present, and the reason I'd like to thank him --- he's the past AMSA President --- is that over a 34 minute conversation a couple of nights ago he encouraged me to move away from what was a fairly safe but really a very boring speech to something I feel had a bit of pepper in it.

The last thing I'd like to thank – and I know I'm sounding a bit like the Academy Awards here – but I'd like to make a thank you to all the that attendees here. The fact that you're present shows that you have a commitment and that you have an interest and passion for medical education and that is something that we need. The thing I encourage all of you to keep in mind here is that we all have that same passion, that we're all working for the same goal – sure we might have different opinions, but at the end of the day we're all playing for the same team.