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