the place of the university in medicine

British Journal of Medical Education, 1974, 8, 160-17 1

The place of the university in medicine’ CLIFFORD WILSON2 University of London (London Hospital Medical College)

Key words *UNIVERSITIES *EDUCATION, MEDICAL SCHOOLS, MEDICAL HOSPITALS, TEACHING ORGANIZATION AND ADMIN- ISTRATION ETHICS, MEDICAL LICENSURE, MEDICAL SOCIETIES, MEDICAL GOVERNMENT AGENCIES RESEARCH SCHOOLS. MEDICAL/hkt GREAT BRITAIN

Present state of medicine The central role of the university in medicine is the prosecution of teaching and research. In this it resembles other subjects but medicine differs in the intensely personal nature of its practice. The late Sir James Spence (a great university man in medicine and one of our most distinguished Schorstein Lecturers) once said, ‘The essence of Medicine is the solemn occasion when, in the privacy of the home or the consulting room, a person who is sick, or thinks he is sick, asks for help from the doctor whom he trusts.’

An unfortunate consequence of this personal professional relation has been the tendmcy for doctors to treat with suspicion, and even with antagonism, any outside influence which might endanger or disturb it. During the past two centuries there has been a wide variety of such influences - religious, philosophical, pseudo- scientific, genuinely scientific, economic, and political. It has been the British tradition, following the teaching and example of the great Sydenham, to reject such deviations and to hold tenaciously to the central discipline of clinical medicine.

In the past few decades, however, there have appeared two major influences which cannot be ignored or rejected, for they have extended the range of medical activity and responsibility far outside the purely personal. These are, first, the increasing complexity and sophistication of our society, and second, the revolutionary advances in the exact sciences with their inevitable application to diagnosis and treatment. Both these major influences are continuing to have widespread

‘The Schorstein Lecture for 1973 delivered at the London Hospital Medical College. ‘Requests for reprints to Proressor Cllfford Wilson. London Hospital Medical College, Turner Street, London El 2 h D .

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effects on the pattern of medical practice. Scien- tific advances increasingly demand new tech- nologies, expensive in men and machines, which are diverting the practice of medicine away from the consulting room to the hospital. Hand in hand with this institutionalization goes the transfer of clinical responsibility from the pxsonal doctor to the team of technical experts. The patient may thereby be deprived of one of the mainstays of treatment, the confident: inherent i, the doctor-patient relation. Furthermore, the widespread and understandable enthusiasm of the younger generation of doctors for highly scientific innovations in treatment has raised immensz problems of priorities and of ethical choices in dealing with the growing dcmands on patient care.

On the social side the very fabric of medical practice is subjected to a variety of stresses. Economic and social pressures often make it hard for the doctor to retain his sense of perspective and his professional ideals. Increasingly, the general public, the media, and political parties (especially when in opposition) proclaim a wide variety of prescriptions for what they regard as an ailing medical service, with little knowledge of the first principles of diagnosis. More seriously, the stresses of modern life are leading to a dis- integration of social morality (or reorientation, in the modern idiom) from which there stems a widespread sickness, highly resistant to the healing art, but from which doctors cannot dis- sociate themselves. Perhaps the greatest problem which society has to resolve is the selective use of available resources, financial, human, and scientific, in order to improve and maintain living standards, not only in our local and national context, but throughout the world, and espxially in those developing countries where the applica-

161 The place of the university in medicine

tion of scientific advances has lagged far behind their discovery.

The university cannot escape being deeply involved in the problems and opportunities which arise from the progress of medical science, nor can it detach itself from the growing needs and insistent demands of society.

Responsibility in medicine Consideration of how and with what authority the university is to meet these mounting commit- ments raises the intricate but overriding question of responsibility in medicine. Over the years we have in Britain built into our system of medical practice a remarkable pattern of institutions - some statutory, some traditional, and some - the most important of all-of a highly personal nature. This distribution of responsibility has not been fixed. It has been constantly changing (perhaps at times not as fast as it should), changing in response to social needs and pressures such as those just described. These various institutions have, throughout their varying history, been deeply and increasingly involved with the growth of university influence i n medicine.

First and foremost, the personal responsibility of the doctor for his patient is the basic tenet of medical care, and this is inseparable from clinical freedom in practice. ‘To cure sometimes, to relieve often, and to comfort always’ has been the traditional objective of medicine. Before the advent of modern therapeutics the commonest outcome of medical treatment was spontaneous recovery - ‘v is medicatrix naturae’ of Hippo- crates. But now the doctor has at his disposal a vast range of potent and sometimes dangerous drugs, and responsibility has become ill defined and precarious. This very topical and disturbing situation will be referred to later.

Personal responsibility reaches its highest level in primary medical care - the work of the family doctor which is and must remain the foundation on which all other forms of medical care are based. The wholehearted support by government for the family practitioner, and indeed the cur- rent legislation for his continued independence in the reorganized Health Service, are not merely an indication of our inescapable reliance on this branch of medicine, but also a tribute to the concept and ideal of personal responsibility, which is at the heart of our professionalism. It is imperative to match this administrative con-

cern with a proper development of incentives and with greater participation in the rewarding activities of modern medicine. With the coming reform of medical education this is obviously the field in which the university, through postgraduate training and continuing education, can make a really effective contribution to training for primary medical care.

Statutory and professional bodies (a) The General Medical Council The growing power and complexity of medicine have brought out the need for a re-examination of the responsibility exercised by the statutory and professional bodies which are concerned in the regulation of medical practice. Of these the General Medical Council has (or had until recently) pride of placz. The present widespread discussions on its role and constitution bear witness to the’ changing scene both in medical education and in the attitude of the profession to authority. The G.M.C. was established in the middle of the nineteenth century in order to protect the general public by restricting the practice of medicine to p ropdy qualified practitioners. Its original title was ‘The Gen-ral Council for Medical Education and Registration of the U.K.’. This brings its activities into direct relation with the medical schools on the one hand, and the licensing bodies on the other. From the start it had the power to demand information on courses of training and to inspect examinations. Present controversy fades into insignificance beside the violent disputes of the latter half of the nineteenth cmtury on the desirable pattern of medical qualification and registration; in particular, whether there should be a national examining and lit-nsing board, replacing the 19 separate bodies then in existence. It is important to remember that during this period (i.e. from its origin in 1837 to the end of the century) the University of London was fighting for its sur- vival against the vested opposition of the Univer- sities of Oxford and Cambridge and the Royal Colleges (Medical and Surgical) in London. Eventually within the G.M.C. and outside it there was a general acceptance of the ‘inevitability of gradualness’. The existing licensing bodies were retained and the Council succeeded in greatly improving the scope and standards of examinations. The preclinical subjects were incorporated as an essential part of the curriculum,

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and final clinical examinations were introduced. So much accomplished, the G.M.C. became remarkably relaxed, if not permissive, and thereafter exercised a benign control by issuing recommendations at 10-year intervals. In this way it virtually delegated to university medical schools the task of conducting themselves in a responsible manner.

The weakness of the G.M.C.’s position was that its ability to keep up with the advancing front of medicine was restricted by the statutory limits imposed by the Medical Acts. The Act of 1886 provided that the final or qualifying examination should be such as to ‘guarantee the possession of the knowledge and skill requisite for the efficient practice of Medicine, Surgery and Midwifery’. Here, apart from the preregistration year, the law still stands as far as G.M.C. responsibility is concerned; but no one would now suggest that any doctor without considerable postgraduate training is qualified to practise all or even one of these subjects. The fact is, students of medicine are at present placed on the medical register when they are half way through their clinical training. The G.M.C. can now only fulfil its responsibilities if effective registration for practice is postponed to the end of an ac- credited course of postgraduate education, in whatever branch of medicine the doctor chooses.

An inquiry into the role and functions of the Council was, therefore, inevitable after the radical recommendations of the Royal Commission on Medical Education under the Chairmanship of Lord Todd. These recommendations made the issue crystal clear. Whatever other criticisms and reservations there may be about the Todd Report, surely all who believe in medicine as a learned profession must welcome it as a long- overdue rationalization, after a century of well- meaning, but inglorious muddle.

(b) The medical corporations The slow and un- certain evolution of university medical schools in England is indissolubly bound up with the growth and authority of the medical corporations. These originated in the sixteenth century, and included the Royal College of Physicians, the Guild of the Barber-Surgeons (later to become the Royal College of Surgeons), and the Guild of Apothecaries. The Royal College of Physicians was established with the

primary function of safeguarding the standards of professional skills and of ethical practice. In the words of its Charter of 1518, it was ‘before all things necessary to withstand the attempts of those wicked men who profess Medicine more for the sake of their avarice than for the assur- ance of any good conscience, whereby many inconveniences may ensue to the rude and credu- lous populace.’ The College was highly restric- tive in issuing licences. Its membership was almost entirely limited to graduates of Oxford and Cambridge, and it stipulated a period of training extending over 14 years. This in effect created a monopoly of practice in London for a small group of physicians whose function was inevitably confined to diagnosis and prescribing. The main tasks of general practice, the bleeding and cutting, the purging and dispensing, were carried out by the barber-surgeons and apothecaries. From the mid-eighteenth century to the mid- nineteenth cx tury while the population more than doubled, the number of physicians in London increased from about 150 to 500, while the ranks of surgeons and apothecaries rose from 600 to 3,500. Like the physicians, their handy men formed close corporations to protect their interests and their standards of practic:, and again, like the physicians, they maintained the szparation of examinations from teaching, the latter being based entirely on the apprenticeship system with no theoretical instruciion or formal education. Charles Newman has written that, ‘there were three medical professions in England at this time, and no greater contrast can be imagined than that between the highly cultured, university-trained physicians, and some of the “rude mechanicals” to be found amongst general practitioners’.

This was the context in which medical education developed in England up to the mid- nineteenth century. The power and vested interests of the corporations undoubtedly hindered and delayed the establishment of university medical schools, yet integration of the profession was impossible until all practitioners could b: brought together under a common university discipline.

As the influence and authority of the G.M.C. took effect and the quality of teaching in the medical schools became more acceptable, the responsibility of the Royal Colleges for maintaining standards of practice inevitably came to

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be based on their examining and licensing powers. As they were in no respect teaching bodies, at any rate in the undergraduate stage, the divorce between teaching and examining became a major obstacle to the reform of medical education. This was greatly aggravated in recent times by the high failure rate in the London M.B. examinations (at times approaching 50%) which was thought to demonstrate its high standard, but which in fact led the great majority of London students to qualify by the Conjoint Diploma. As we are all aware, this double external qualifying examination disrupted clinical teaching in the vital final year, and made its integration with assessment impracticable. It also made it impossible to implement the recommendation of the G.M.C. that in all examinations credit should be given for 'in-course' work. In their capacity, therefore, as examining and licensing bodies, the Royal Colleges were jeopardizing the very standards of practice which they were founded to preserve.

At the postgraduate stage of training, the Higher College Diplomas provided a reliable assessment of competence when consulting practice was limited to a fairly well-defined corpus of general medicine and general surgery. With scientific advance and specialization however, the diplomas became inappropriate instruments for this purpose. Since the time when Abraham Flexner gave evidence to the Haldane Commis- sion in 1912 these higher examinations have been widely criticized as requiring young and able doctors to dissipate their energies on the memorization of factual knowledge during those vital years when they should be cultivating their minds by deeper study and developing their initiative by original investigation. These problems are now ripe for solution as dxisions must be made about assessment for specialist registration after postgraduate training.

(c) Other government agencies Although the medical corporations and the G.M.C. have in the past shouldered the main responsibilities for regu- latingstandards of practice, the increasing concern of the State with the health of its population has ledto thecreation by thegovernment ofa varietyof services and agencies which, by allocationoffinan- cia1 resources, provision of public health facilities, and later the institution of a National Health Ser-

vice, have carried very substantial responsibilities for the promotion of medical care. The National Health Acts, and especially the present reorganization of the service, manifest the insistent desire of society for a fair distribution of the highest standards of professional skill. The Department of Health, though responsible in law for the actions of the medical personnel it employs, has religiously observed freedom of clinical practice save in rare situations where financial or social considerations make it impracticable, e.g. the overprescribing of proprietary medicines and the treatment of drug addicts by general practitioners.

The first draft of the National Health Act placed all hospitals, including the teaching hospitals, under control of the local authorities. It is greatly to the credit of the then Minister of Health, Aneurin Bevin, that he took advice from a group of eminent clinical professors and was persuaded to revise the legislation so that the teaching hospitals in England retained their autonomy, and university representation was assured at various levels in order to maintain and improve both educational standards and the quality of staffing. An unforeseen but major benefit which the service dzrived from this enlightened policy was the outstanding contribution which the teaching hospitals were able to make towards the formation and rapid advance- ment of special departments i n medicine and surgery. In the past 25 years this development has contributed, perhaps more than any other single factor, on the one hand to the high reputation of the teaching hospitals as centres of excellence, and on the other to the Health Service as one of the greatest social revolutions ever accomplished. It is to be hoped that the considerable anxiety which so many share that the new organization, with its minimal university representation, and its emphasis at all levels on management performance, may fail to provide either the initiative or the inspiration to reach the same pinnacle of achievement will prove to be ill founded.

Two other government agencies which must be included in a survey of medical responsibility are the University Grants Committee and the Medical Research Council. The University Grants Committee, though now responsible to the Department of Education rather than directly to the Treasury, still acts as a valuable inter-

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mediary between government and the universities in such a manner as to ensure the maximum of academic freedom without the restraints of detailed accountability. As such it is the envy of other countries in which the principle of academic freedom is not deemed to apply to the expendi- ture of public money. The universities owe a special debt to the University Grants Committee for its insistence on the linkage of teaching and research as inseparable academic activities, and for its allocation of funds on this basis. In its quinquennial visits to medical schools the University Grants Committee has been constantly aware of the need for encouraging and financing attempts to provide a university education in medicine. I t has taken as its bible the Goodenough Report of 1944 which made this its central theme especially in its powerful advocacy of professorial clinical departments.

The Medical Research Council carries out a wide variety of research activities with a special emphasis on topical matters of public need. An essential part of its function, therefore, is to maintain a flexibility of planning so that research funds may be applied at any time to obvious areas where there are specific deficiencies in knowledge. In this it complements university research, and has pioneered a variety of projects which have subsequently led to the formation of university units in new disciplines, such as social medicine and medical statistics. By organizing controlled therapeutic trials it has rendered a special service to university clinical units in providing a forum for multicentre research; for example, the use of penicillin in subacute bacterial endocarditis, antibiotic therapy in pulmonary tuberculosis, and steroids in the nephrotic syndrome. In some countries, notably in Russia and Czechoslovakia, and the United States, large resources have been devoted to government research institutes. These have at times had undesirable effects in diverting research funds and talent from university departments, and in depriving students of the opportunity to participate in important research activities which act as a stimulus to both teaching and learning. Government research councils, therefore, and even more so, government departments carrying out contractual research as is now proposed, have a special responsibility to ensure close co-operation and interchange with medical schools in order to maintain a proper balance between teaching and research.

(d) The pharmaceutical industry One cannot com- plete the picture of medical responsibility without referring to the controversial and expanding activities of the pharmaceutical industry. Recent events - the thalidomide case, government con- frontation with the manufacturers of tranquillizers and the imponderable consequences of a continuing sequence of contraceptive drugs - bring into sharp relief this powerful influence in medicine. Whatever the benefits of the new drugs - and in mental illness alone these have more than justified themselves and their creators - here is a complex problem of responsibility, involving research and development, costing, release and distribution, prescribing, clinical trials and supervision, and medical ethics. As events have shown, these problems are indiffer- ently controlled on an ad hoc basis, since responsibility is so ill defined whereas by contrast the profit motive is sharp and clear.

The best hope, indeed the only possible solution to this problem, is a far greater emphasis on the teaching of clinical pharmacology and therapeutics by adequately staffed university departments throughout the undergraduate and postgraduate p2riods, with continuing education thereafter. In fact the key to all these problems is the reinforcement of personal responsibility by an informed and critical discrimination.

When the demand for any group of drugs becomes a social problem this discrimination can be more effectively exercised as a co-operative effort. As reported to the last annual British Medical Association meeting, voluntary prescrip- tion restraint by a group of doctors in Ipswich resulted in -the disappearance of amphetamine abuse in the area, a reduction of barbiturate prescribing by 50 %, and a similar control of the use of tranquillizers. Such an exercise of collec- tive responsibility, if widely applied, could obviously solve the present dilemma to the benefit of the patient, of the tax-payer, and not least of the doctor himself.

The,central role of the university The foregoing review of the distribution of medical responsibility among statutory and professional bodies has emphasized their special relations with the university, and reveals in nearly every instance a growing dependence on and support for academic ideas and objectives.


We now come to the essential responsibilities of the universities themselves.

These are both general and particular; the latter, in so far ‘as they are concerned with the practical aspects of medicine, will be directed and inspired by the former. It is to these general attributes that we must now turn. The university stands unique among the institutions in medicine in that it has the authority and privilege of cultivating in its members from the start, dis- ciplined attitudes of mind towards the profession and towards the community which it serves.

It used to be a widely held point of view that the universities were ivory towers and for the most part out of touch with the world of practical affairs. This may have been so before the time of Benjamin Jowett, but nowadays there must be few academics who would not subscribe to his view that ‘education must aim at preparing men for a life of action’.

The universities from their earliest inception have been the natural products of civilized society. They formed communities of students and teachers searching, by the exchange of ideas, for truth, sometimes for its own sake, but usually inspired by the desire to further the understanding and control of nature. Society accepted and supported universities in their midst because the intellectual discipline they fostered, apart from any concrete benefits which accrued, manifestly added to the quality of life.

In the mediaeval universities medicine was one of the three ‘superior’ (i.e. graduate) faculties, coming in precedence afcer the church and the law, and above the ‘inferior’ faculty of the arts. Thence is derived the traditional standing of medicine as a learned profession. Furthermore, students and teachers formed a corporate society with strong and permanent loyalties, not only to one another, but to the ideals and disciplines which they shared, and to the academic freedom which was at the root of their relation with authority. In the University of Padua, for example, which was at the height of its reputation when Harvey was a student, the State provided financial support but the students themselves were in control of the various faculties, and over a long period they elected their own professors! If’ the civil authorities proved recalcitrant on matters of academic freedom, students and teachers migrated en masse to another city!

High professional standing, a close-knit society

with firm loyalties, and academic freedom - these then supply the traditional background for university education in medicine. But it is in the quality of the intellectual discipline it provides, that the university makes a unique contribution, with its emphasis on the depth, rather than the breadth of learning, its cultivation of critical thinking, and its sense of perspective. These together make possible objectivity of judgment and ensure a universality of approach to any problem. The cultivated and learned physician of the seventeenth century acquired these qualities - if indeed he possessed them - from a study of the classics, of philosophy and religion, and from the example and wisdom of his teachers. But following the writings of Bacon, and for students of medicine the teaching of William Harvey, the scientific method was established as a much firmer and rational basis for the cultivation of this intellectual discipline. I t provided a secure method for critical analysis which had previously relied on instinctive or empirical judgment. Harvey and Sydenham were the classical ex- ponents of these contrasting philosophies. In his discovery of the circulation of the blood Harvey applied with a rare detachment the scientific methcd of observation, hypothesis, and veri- fication by experiment, including quantitative measurement of cardiac output and blood volume (however crude) to clinch the argument. But Harvey was a man before his time, and because his teaching conflicted with the traditional dogma of contemporary medicine, i t brought him only unpopularity and abuse. Sydenham, on the other hand, had no use for theoretical concepts, and it was by his intuitive critical faculty that he was able to clear away the spurious philosophical debris which had obscured the Hippocratic method of clinical observation. This difference of approach presumably explains why Sydenham, who was writing 50 years after the publication of De Motu Cordis, makes no mention of either the discovery or its author.

‘The Medicine of nature’, he wrote, ‘is wiser than the Medicine of philosophy. In writing the history of a disease, every philosophical theory whatsoever that has previously occupied the mind of the author should be in abeyance. This being done, the clear and natural phenomena of the disease should be noted - these and these only. No one can state the errors that have been occasioned by physiological hypothesis.’ NO

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doubt this was an understandable case of over- compensation, but it is interesting to observe a t this early date the reaction of the down-to-earth, practical physician to the clinical scientist - one which has lost none of its freshness of impact down the years !

Growth of university influence It would be appropriate at this point, and helpful for our better understanding of the present situation, to examine briefly the subsequent growth of university influence in medicine. It is a sad reflection that following Harvey and Sydenham there was no great leap forward in medical progress in England. In fact the contri- butions they made were more clearly appreciated abroad than at home. During the next two centuries the centre of medical thought and influence moved from one European university to another, as the application of scientific discovery to medicine and the development of morbid an- atomy spread throughout the Continent. After Padua - Paris, Leiden, Vienna, and later the great German schools of physiology and pathology, with Virchow, Ludwig, and Koch, attracted students from all Europe and beyond. Among those to be influenced and stimulated in recent times by the scientific teaching in the European universities were physicians and surgeons from the clinics of North America, who returned to establish the famous centres of medical research from which so many of us have profited.

Although this country produced no great school of medical thought, comparable to those on the continent, there was no lack of scientific initiative and achievement. After the civil war a new movement of experimental philosophy appeared in Oxford and London, the so-called ‘Invisible College’ which later became the Royal Society, and included among its members Boyle, Locke, Christopher Wren, Willis, and Robert Hooke. The absence of any real attempt to apply their scientific discoveries to medicine can only be attributed to the organization - or disorgani- zation - of the profession in London referred to above, and especially to the fact that London, the capital city and the centre of medical practice and of government,’had no university. Not sur- prisingly salvation came (and no other word is really appropriate) from north of the Border, where the Scottish universities, strongly influ-

enced by the University of Leiden, established faculties of medicine early in the eighteenth century, based on teaching hospitals and medical schools. Professorial chairs were instituted to give theoretical and practical instruction not only in the basic sciences but also in medicine, surgery, and midwifery. The university faculties formed teaching liaisons with the Scottish medical corporations, resulting in a rapid rise in the number of medical graduates, and many of these took up practice in London and the provinces. We find that between 1750 and 1850, while the number of graduates from Oxford and Cam- bridge remained around 250, those from the Scottish universities increased to nearly 8,000. It is apparent that the absence of university medical training in London adequate to provide sufficient doctors to meet the needs of the expanding population, had three effects. First, the integration of medicine and surgery was delayed; second, the training of surgeons and apothecaries continued on a purely technical rather than professional basis; and third, the Scottish medical invasion of England was both massive and spectacular. There can be few hospitals and even fewer students of medicine who have not profited greatly from sharing the cultural heritage and professional achievement which derived from the Scottish universities.

It was about this time, i.e. the mid-eighteenth century, that the first four London medical schools (beginning with the London Hospital Medical College) were established. They were entirely clinical, supported and controlled by the parent hospital. Preclinical teaching, up to the end of the nineteenth century, was largely carried out in private schools, of which the most famous was the one conducted by John and William Hunter.

Even after the medical schools became part of the University of London at the beginning of the present century, medical education, both clinical and preclinical, was still based on technical and apprenticeship training. In fact, when the university first received grants from the Board of Education in 1908, the medical schools were supported as ‘Technical Colleges’ and not as university institutions. Furthermore, from the granting of its charter in 1837 until incorporation of the schools in 1900, the university was purely an examining body without teaching responsibilities. Thus the newly formed university joined forces


with the Royal Colleges to perpetuate this Solomon’s judgment on medical education. One cannot overemphasize the serious delaying action which over the last half-century the absence of strong and enlightened university leadership from London has had on professional training in this country. Up to a few years ago over 40% of the medical graduates in Great Britain trained in the 12 London medical schools. Physicians and surgeons from London acted as external examiners in the provincial universities, and while this provided a common standard in the examinations, it did very little to liberalize medical education.

Reform of medical education It was perhaps inevitable that when the London schools were at last incorporated, both the curriculum and the examinations should suffer from overcentralization. This led to a rigid uniformity aimed at maintaining an acczptable level of performance in all schools. The external character of the London qualifying examination placed it in the same category, and open to the same objections as the Conjoint Diploma. Afrer the forthright criticisms of the Goodenough Com- mittee in 1944 there could be no doubt in anyone’s mind of the true facts of the situation, but a further 20 years of frustrating argument ensued, culminating in the uncompromising strictures of the Robbins Committee on Higher Education in 1963. This committee was uninhibited in its criticism of the overcentralized control of academic affairs by the university, and strongly recommended that its constituent schools should enjoy far greater freedom and responsibility in the arrangement of curricula and examinations. These demands were promptly given effect by the Saunders Committee on University of Lon- don organization, and the field was set for the Royal Commission on Medical Education which reported in 1968. The outstanding feature of that report, which puts it in a different class from reports of previous Royal Commissions, is that it recognized the overriding need for a university education for all doctors, and it pu t forward practical recommendations to realize this objec. tive within the foreseeable future. These recommendations were as follows.

1. The inclusion in the undergraduate curriculum of a 3-year honours degree course for all students. This had hitherto been available only

to Oxford and Cambridge students and to a small minority elsewhere, selected for B.Sc. courses. It was recommended moreover that the third year of specialized study could be either preclinical or clinical. All who have followed such a course will acknowledge the merits of the opportunity to study in depth, to carry out research, to have leisure for thinking and reading, and to develop critical habits of thought, through tutorials and small group discussions. In such an exercise the role of the teacher is not so much the transfer- ence of factual knowledge as to inspire the student with the desire and the ability to learn for himself.

2. A degree course along the above lines could only be achieved within the five years of undergraduate training by making considerable changes in the clinical curriculum. The Royal Commission recommended, therefore, the diver- sion of the major part of vocational training to the postgraduate years. It was possible in this way to relieve the congestion in the present clinical period and to construct a ‘core’ curriculum, in which selective clinica! expxience could play its proper role at this stage, by illus- trating the processes of disease and the principles on which diagnosis and treatment are based. This is, in effect, a belated acceptance of Sir Thomas Lewis’s eloquent plea, 30 years ago, for a proper balance of what he called ‘theoretical’ and ‘vocational’ teaching. Lewis wrote: ‘It is fundamental in medical, as in all other forms of education, that the student should acquire sound habits of learning. He should become acquainted with the history of discovery, coming to under- stand how knowledge has been, and is being, won; he should be taught to recognize sound sourczs of information and he should be taught to study steadily and intelligently, that he may come to possess that great acquisition of the student, a fondness, or more exceptionally a passion, for understanding, and through this achieve con- scious independence of thought and judgment.’

‘Understanding derives from an intelligent and discriminating study of past and present experiences; once attained it unbolts the doors to an understanding of further experiences. Discrimi- nation of true from false relies upon a practised faculty of criticism and upon a firm grasp of the rules of evidence. Understanding is the basis of progress and the vital flame in education; discrimination is the only sure defenci against false doctrine and unsound practice.’

168 Clifford Wilson

3. The key to the successful implementation of the Royal Commission’s first two recommendations is, of course, the systematic planning of postgraduate training for all specialties including general practice. Indeed, it is because the National Health Service has demonstrated the urgent need for properly organized specialist training that the two previous recommendations of the Royal Commission became inevitable on the one hand, and achievable on the other.

On the vexed problem of examinations the Royal Commission came down firmly in support of the integration of assessment with teaching. As Goodenough said in 1944, ‘In its regulations and conduct, training must be the master and the system of examinations the servant.’ In practice this implies progressive ‘in course’ assessment, bearing a constant relevance to teaching. Such a change will inevitably put an end to external qualifying examinations and implies the necessity for Oxford and Cambridge students, completing their clinical studies in London, to take the London qualifying examination. This has indeed already been agreed.

This new pattern of medical education requires greatly increased staffing, improved laboratory facilities and accommodation, and adequate financial suppprt. There is much room for pessi- mism about this prospect, but the University Grants Committee has already taken a number of steps in the right direction. Furthermore, i t is my experience that in a new field of endeavour, making a bold start with inadequate resources is the best way to ensure that funds will be made available. The Todd Commission fully appreciated that an increase in full-time teaching staff would be essential, both in the undergraduate and postgraduate stages. Perhaps one of their most enlightened opinions was that separation of postgraduate from undergraduate training was both unrealistic and contrary to the best educational principles. This was the main reason for the proposed amalgamation of the London postgraduate institutes with undergraduate medical schools: hence the plans to rebuild the Institute of Urology on the London Hospital site.

The new postgraduate training will require very considerable organization if it is to cover all branches of medical practice. The defect of many of the specialist training schemes drawn up by the Royal Colleges is the lack of any significant content of academic instruction. It is apparent

that postgraduate training must have a ready access to the scientific departments of the medical schools just as it will of necessity make use of the clinical practice and teaching faciIities of the special departments in the university hospital. Moreover, in-course assessment at the postgraduate stage will be just as essential as in the undergraduate period. In the U.S.A. specialist training schemes are drawn up and organized by university medical schools which also under- take progressive assessment based on reports of proficiency during training, in place of terminal examinations. A similar policy, substituting supervisor’s reports for the final clinical examination, is being introduced in the Fellowship examination of the Australian College of Phy- sicians. I cannot believe that our Royal Colleges, working in co-operation with the faculties of medicine in London and elsewhere, will not be able and willing to provide a similar integration of postgraduate training and assessment.

This brings me to the most radical and controversial recommendation of the Royal Com- mission, that the 12 medical schools in London should be paired to form joint faculties of medicine, in association where possible with multifaculty colleges. The London, in association with St. Bartholomew’s, are likely to be the first in the field, linked with Queen Mary College. This proposal has the uniqu: advantage of a hospital (at Mile End) adjacent to Queen Mary College, that is, on a university campus, which will make possible integration of clinical and preclinical teaching and interdepartmental co- operation in research. The necessity for these drastic changes in London arises from the rapidly broadeping scientific base of medicine, which requires new departments in a variety of scientific disciplines, both clinical and preclinical, for example : genetics, immunology, nuclear physics applied to medicine, and the various subdivisions of pathology. The creation of such departments at all 12 medical schools in London would be uneconomic and unattainable, particularly from the point of view of staff recruitment. On the positive side the combined preclinical departments forming part of a new faculty of medicine are assured of major advantages in terms of equipment, space, and the opportunities for specialization within the traditional subjects. But even greater benefits could accrue for students, teachers, and research workers from integration

The place ofthe university in medicine 169

wiih the new disciplines which are established, and indeed from contacts with the broad community of university teachers in non-medical faculties.

Medical research There is no need to emphasize the important role of the university in the promotion of medical research. At student level it provides a most important stimulus to learning and to the acquisition of scientific method. It is invaluable in revealing originality and initiative and, therefore, in selecting specially gifted students for future higher training or for an acadzmic career. At lecturer level, research is a great generator of enthusiasm, critical thinking, communication of ideas, and mutual admiration. It also brings a man the greatest and most lasting satisfaceion of his life in the achievement of discovery - some addition to truth which will be unassailable for all time.

Criticisms have been levelled at academic units for spending time and money on irrelevant and even pointless investigations. Anyone who is familiar with the research record of professorial units in this country, often working undx considerable handicaps of space and equipment, not to mention outside pressures, will recognize that such criticisms are ill conceived. But even apart from the actual discoveries which have been made over a broad field, the most striking and heartening development of the past 20 years has been the vast expansion of university clinical units, always with more well-qualified applicants than vacancies, and with a rapidly-growing corpus of scientific endeavour and constructive provocation, which has had a salutary effect on medical education and clinical practice throughout the country. Professor Donald has aptly said that, ‘Modern young doctors, and indeed students, have been taught to look for the authority of the scientific evidence, rather than the authority of the person presenting it’. It is this growth of research opportunities which has helped British medicine to attract and retain the best teachers.

There has recently been much argument between the advocates and opponents of so-called ‘contract’ research, and also concerning proposed plans for national co-ordination of research workers in different centres. There is room for planned research in specific areas, particularly

where there is an obvious community need. This is the less objectionabIe since a well-trained mind readily adapts to any problem with which it is presented. University units must be free, however, to work on problems that appear to have no immediate practical application. The term ‘fundamental research’ is not entirely a happy one but there is no doubt of its vital importance. Furthermore, any properly conducted research may throw up unexpccted and important discoveries, for example Fleming’s discovery of penicillin, von Mering and Minkowski’s discovery of the association of diabetes with the pancreas, and Minot’s discovery that. pxnicious anaemia could be cured by liver. I am a great believer in ’serendipity’: the well-desxved but unsolicited reward of the prepared mind.

Turning now to the social responsibilities of the university in medicine; here is immense scopz for academic work of a highly practical nature. In the first placs a study of disease in populations, research into environmental factors in causation, and attempts to discover methods of preventive therapy, i.e. epidemiology in its widest sense, will certainly involve university units in the training of personnel and the prosecution of research. Investigation needs to be highly sophis- ticated and controlled, using statistical methods of project planning and analysis of results. The SCOPE of community medicin:: envisag2d in the new model Health Service involves among other things the continuous collection and analysis of data in order to match serviczs with patient needs. This adds a new dimension to public health training which can only be satisfactorily met with the help of university teachers. In addition, there are certain diagnostic services which need to be organized on a regional basis, e.g. spxialized investigations in various branches of pathology; the use of radioactive isotopes, and investigations involving computer analysis. University departments will inevitably be called upon to contribute to these regional activities.

A far widor and more urgent commitrnznt is the development of psychiatric services. There is no doubt of the rapidly enlarging scope of community research in this field. This is a full time, and in many of its aspects a truly academic exercise, which will make heavy dzmands on university units for many years to come. These services can be provided only by putting into action the techniques and disciplines of scientific

170 Cliyord Wilson

training at the postgraduate level. Many students are attracted to this specialty and there should be no lack of enthusiastic workers if research opportunities are available.

The Health Service There remains the important question of the impact of the new pattern of organization of the Health Service on the university hospitals, i.e. those traditionally associated with university medical schools. These hospitals survived with remarkable ease the transition from voluntary institutions of two centuries’ standing, to state- controlled, albeit autonomous units. Enjoying considerable independence, they have made a formidable contribution to medical care. Looking back, at any rate as far as the London Hospital is concerned, I think the motivation which made it possible to adapt so readily to new conditions of service, and to new patterns of practice and administration, came from a sense of community, a loose-knit but genuine society, in which hospital and medical school found themselves working together towards a common set of objectives. It was this balance of university influence and hospital achievement, precarious and fluctuating as it was at times, that brought The London its reputation, a staff of clinical distinction, and a flow of students of high calibre. Is this balance between hospital and medical college, this high performance, likely to be sustained under a distant administrative board, weighing our needs and ambitions against those of a dozen or two dozen hospitals, and with minimum (though certainly not negligible) university representation? There are too many imponderables to hazard a guess at the answer, but there are certain grounds for optimism.

First, the university hospital, with its highly organized special departments, and the medical school with its wealth of scientific expertise and university staffed service departments, can together provide an immense fund of professional knowledge which will be in constant demand by both area and region. Second, the teaching hospital is the jons et origo of trained house-officers, who incorrigibly transmute into registrars, who imperceptibly merge into consultants, and all these are the life-blood of the area and regional services. Third, the hospital, notwithstanding present doubts and fears, maintains a high

morale, engendered by its past achievement and sustained by its growing potential, its contact with youth (the great morale-strengthener) and, most important of all, its academic freedom.

The most effective way for the teaching hospital to maintain its independence is likely to be by increasing its academic staff. The professorial units at The London have successfully performed what we called a ‘nursery’ function by making academic appointments in new specialties to which the hospital gave financial support for services rendered. The Royal Commission sug- gested that clinical divisions and departments within divisions might have academic heads, and I can think of no more enlightened strategy for strengthening the full-time staff and advancing the cause of scientific medicine. By this means the teaching hospitals can become university hospitals in spirit and organization, without the hazards and distractions of full administrative control.

Finally one returns to the key function of ‘management’. The final version of the Green Paper on Reorganisation of the Health Service was rather disturbing with its emphasis on ‘management’ - ‘management at all levels’. Man- agement is a somewhat emotive word which may carry antisocial overtones. It suggests unwar- ranted interference, uninformed regulation and control, and in the present context, a hierarchy devised by some arbitary power for ensuring a well-defined but subordinate status for the individual. Some time ago, the Department of Health and Social Security circulated a pamphlet entitled Management Functions of Hospital Doctors. This is a penetrating, skilfully written, and highly relevant document. It contrasts management in hospitals with that in industry. ‘The object,’ it says, ‘is to help ill people; the hospital is a place of anxiety for staff as well as patients. Efficiency cannot be measured as in industry, in simple material terms’. And again, ‘It is essential to see oneself as part of a changing situation, subject in all its parts to constant scrutiny and reassessment of method and of aims, with a growing emphasis on measurement of performance where’this is practicable’. And finally: ‘The scientific habit combines a discipline and an attitude ; success in using resources economically comes from grasping a system and its problems, and being familiar with consequential techniques, for example, the social skills required for team

The place of the university in medicine 171

co-operation. But though knowledge of techniques is important, the practice of management is learnt mainly by managing.’

This brings to mind what A. N. Whitehead, writing of the aims of education, termed ‘style’; for indeed this essay on management is an elaboration of Whitehead’s thesis. ‘Style’, he writes, ‘in its finest sense, is the last acquirement of the educated mind. It is also the most useful. It pervades the whole being. It is an aesthetic sense based on the direct attainment of a foreseen end, simply and without waste. The administrator with a sense of style hates waste; the engineer with a sense of style economises his material; the artisan with a sense of style prefers good work. Style is the ultimate morality of mind.’

Style in this sense and management as defined above are one and the same thing. They bring us back to our starting point - personal responsibility for professional standards in medicine. The essence is critical judgment, and this, amid the complexities and immense changes in medical practice, only the most exacting university discipline can provide. The place of the university - as it has always been-is to make medicine a

learned profession, and the moment of opportunity is now.

Summary The place of the university in medicine is closely identified with the question of professional responsibility. Personal responsibility has been greatly complicated by scientific advances in medicine and by social changes which on the one hand have added to disease and on the other have demanded increasing state intervention in its treatment.

Statutory and licensing bodies, government departments, the publicity media, and pharmaceutical industry are exercising pressures on the individual doctor which cannot be resolved without a radical revision of medical education. The Royal Commission on Medical Education produced a framework for such a revision, and the reorganization of the Health Service provides an opportunity for a more efficient use of available resources.

The central role of the university - by teaching, research, and continuous application of theory to practice - is to make medicine a more learned profession.

the place of the university in medicine

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