433
be the leader; in my own practice, in some regards, health visitor is the leader. Possibly he will find that the Beveridge myth of wonder-cure with scalpel and penicillin continues to be untrue and that most doctors will spend most of their time helping patients to avoid making themselves ill or to adapt to irreversible disorders. Certainly doctors will have to become much more critical. Twenty-five years ago it was still possible to suppose that everyone in the U.K. could receive every treatment if only they would wait. Today we are on the edge of formally recognising that everyone has an equal right to care but that we must have priorities for cure, and we are skirting round the moral issues involved. Ideally, student selection should be largely self-selection. This requires school leavers to have an appropriate picture of a medical career. Do we give them a picture of an adaptable profession working in teams at awkward hours, coping with uncertainty and with competing priorities in helping sick people to make choices? I think not
Medical Education
IF I WERE A DEAN ...
JOHN WOODALL* "By the time they qualify, they probably reflect more of their teachers’ attributes than they do their own juvenile characteristics". This remark (in the G.M.C. 1977 report, Basic Medical Education in the British Isles) suggests not only that the teaching methods encourage students to model themselves on their teachers but also that the students selected are conformist and picked for their similarity to their teachers, which is what selection by interview does. It was fine for top doctors to produce doctors like themselves just so long as medicine was unchanging. Now that so many "facts" are discarded each year it may not be surprising that the alcoholism and suicide rates of doctors are high, particularly since as students we model ourselves on doctors who work in hospitals with perhaps half their patients referred by other specialists, only to find ourselves going on to quite different jobs-in district hospitals, where the main job is curing and caring for people and not teaching (so that "work-ups" are appropriate only when a clinical decision depends on them), and in general practice, where the contrast is even more stark. Now is the time for experiment. For the first time since the 1950s plenty of doctors are qualifying. When there was a dearth of young doctors it would have been risky to change a system which resulted in low student "wastage". But now, embarrassed by large numbers of applicants, medical schools tend to select those with high, and ever-higher, examination results. Whilst a natural response, this may not be a wise one, since people who do very well at school exams, particularly science exams, will probably be convergent thinkers who will find it difficult to question established practice, adapt to change, be creative, and above all cope with the uncertainties inherent in medical practice-a sphere which bears more relation to the humanities than to the orthodoxies of school science. We have to make some judgments about the sort of people we want our future doctors to be. One can make two statements. The first is that the range of medicine is so enormous that there are opportunities for thinkers, teachers, physicists, politicians, and mountain climbers, and that medicine allows for late development of interests. This is why I should have been glad for my children to have entered medicine. The second is that most doctors will be working in teams serving people. Gone are the days when an authoritarian person, such as convergers tend to be, is appropriate. Gone are the days when a strictly hierarchical organisation is likely to be the best. Not only will doctors tend to be members of a team, but the team will be multidisciplinary and he may
*
General practitioner, 186 Leesons Hill, Chislehurst, Kent.
a
school leavers see a prestigious, secure, well-paid profession making authoritative decisions of life and death-a
picture encapsulated doctor". If I bit about the
were a
in a mother’s pride in "my son the dean I would have to do my little of medicine and it would include
image writing to career masters.
What else can we do? It seems to be important to select adaptable students who will also have the independence of mind to resist better the conformist and enclosing pressures of a medical school. How can this be done? We should study the personalities of medical students and see what can be done to widen the intake, to include more with an arts bent. Experience between school and medical school is helpful. A year in a factory would be fine. A degree in something different might do-the most engaging and inquiring visitor to my practice was an American medical student who already had a degree in Chinese.
TEACHING STUDENTS ABOUT RADIODIAGNOSIS KENNETH SWINBURNE
Wharfedale General Hospital, Otley,
West Yorkshire LS21
2LY
Should students be taught radiological anatomy, and X-ray diagnosis, from the very beginning of the medical curriculum? If they were, perhaps X-ray departments would be spared the burden of a twice-yearly influx of scores of newly qualified young doctors, all ordering innumerable X-ray examinations for the investigation of skin folds, breast shadows, nipple shadows, companion shadows, composite shadows, epipericardial fat pads, scalloped and humped diaphragms mistaken for pulmonary collapse or consolidation or tumour, plethoric hila mistaken for enlarged lymph nodes or neoplasms, anterior ends of ribs which simulate gallstones or (in lordotic projection) rachitic cupping, vascular channels and impressions which mimic fractures, accessory ossification centres mistaken for fractures, normal variations in bone texture- mistaken for fractures or secondary de-
be the leader; in my own practice, in some regards, health visitor is the leader. Possibly he will find that the Beveridge myth of wonder-cure with scalpel and penicillin continues to be untrue and that most doctors will spend most of their time helping patients to avoid making themselves ill or to adapt to irreversible disorders. Certainly doctors will have to become much more critical. Twenty-five years ago it was still possible to suppose that everyone in the U.K. could receive every treatment if only they would wait. Today we are on the edge of formally recognising that everyone has an equal right to care but that we must have priorities for cure, and we are skirting round the moral issues involved. Ideally, student selection should be largely self-selection. This requires school leavers to have an appropriate picture of a medical career. Do we give them a picture of an adaptable profession working in teams at awkward hours, coping with uncertainty and with competing priorities in helping sick people to make choices? I think not
Medical Education
IF I WERE A DEAN ...
JOHN WOODALL* "By the time they qualify, they probably reflect more of their teachers’ attributes than they do their own juvenile characteristics". This remark (in the G.M.C. 1977 report, Basic Medical Education in the British Isles) suggests not only that the teaching methods encourage students to model themselves on their teachers but also that the students selected are conformist and picked for their similarity to their teachers, which is what selection by interview does. It was fine for top doctors to produce doctors like themselves just so long as medicine was unchanging. Now that so many "facts" are discarded each year it may not be surprising that the alcoholism and suicide rates of doctors are high, particularly since as students we model ourselves on doctors who work in hospitals with perhaps half their patients referred by other specialists, only to find ourselves going on to quite different jobs-in district hospitals, where the main job is curing and caring for people and not teaching (so that "work-ups" are appropriate only when a clinical decision depends on them), and in general practice, where the contrast is even more stark. Now is the time for experiment. For the first time since the 1950s plenty of doctors are qualifying. When there was a dearth of young doctors it would have been risky to change a system which resulted in low student "wastage". But now, embarrassed by large numbers of applicants, medical schools tend to select those with high, and ever-higher, examination results. Whilst a natural response, this may not be a wise one, since people who do very well at school exams, particularly science exams, will probably be convergent thinkers who will find it difficult to question established practice, adapt to change, be creative, and above all cope with the uncertainties inherent in medical practice-a sphere which bears more relation to the humanities than to the orthodoxies of school science. We have to make some judgments about the sort of people we want our future doctors to be. One can make two statements. The first is that the range of medicine is so enormous that there are opportunities for thinkers, teachers, physicists, politicians, and mountain climbers, and that medicine allows for late development of interests. This is why I should have been glad for my children to have entered medicine. The second is that most doctors will be working in teams serving people. Gone are the days when an authoritarian person, such as convergers tend to be, is appropriate. Gone are the days when a strictly hierarchical organisation is likely to be the best. Not only will doctors tend to be members of a team, but the team will be multidisciplinary and he may
*
General practitioner, 186 Leesons Hill, Chislehurst, Kent.
a
school leavers see a prestigious, secure, well-paid profession making authoritative decisions of life and death-a
picture encapsulated doctor". If I bit about the
were a
in a mother’s pride in "my son the dean I would have to do my little of medicine and it would include
image writing to career masters.
What else can we do? It seems to be important to select adaptable students who will also have the independence of mind to resist better the conformist and enclosing pressures of a medical school. How can this be done? We should study the personalities of medical students and see what can be done to widen the intake, to include more with an arts bent. Experience between school and medical school is helpful. A year in a factory would be fine. A degree in something different might do-the most engaging and inquiring visitor to my practice was an American medical student who already had a degree in Chinese.
TEACHING STUDENTS ABOUT RADIODIAGNOSIS KENNETH SWINBURNE
Wharfedale General Hospital, Otley,
West Yorkshire LS21
2LY
Should students be taught radiological anatomy, and X-ray diagnosis, from the very beginning of the medical curriculum? If they were, perhaps X-ray departments would be spared the burden of a twice-yearly influx of scores of newly qualified young doctors, all ordering innumerable X-ray examinations for the investigation of skin folds, breast shadows, nipple shadows, companion shadows, composite shadows, epipericardial fat pads, scalloped and humped diaphragms mistaken for pulmonary collapse or consolidation or tumour, plethoric hila mistaken for enlarged lymph nodes or neoplasms, anterior ends of ribs which simulate gallstones or (in lordotic projection) rachitic cupping, vascular channels and impressions which mimic fractures, accessory ossification centres mistaken for fractures, normal variations in bone texture- mistaken for fractures or secondary de-
