Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Many Hazards, Few Challenges Jorgen Nystrup To cite this article: Jorgen Nystrup (1979) Many Hazards, Few Challenges, Medical Teacher, 1:4, 197-199 To link to this article: http://dx.doi.org/10.3109/01421597909012601
Published online: 03 Jul 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [Australian National University]
Date: 06 November 2015, At: 03:32
MY MEDICAL EDUCATION
Many Hazards, Few Challenges
Downloaded by [Australian National University] at 03:32 06 November 2015
J0RGEN NYSTRUP Jorgen Nystrup, MD, is Secretary General of the Nordic Federation f o r Medical Education and a Psychiatrist, The Institute of Dermography, The Psychiatric Hospital, DK-8240 Risskov, and The Department of Psychiatry, The University of Copenhagen, Rigshospitalet, 9 Blegdamovej, DK-2100, Copenhagen 0, Denmark.
Aarhus is the second largest city in Denmark, with a population of 245,413. Its university, founded in 1928, was the second to be established in Denmark - over 400 years after the University of Copenhagen was founded in 1497. Following the European tradition, medical education in Denmark is confined to the universities. In the same tradition, there were no formal educational requirements for admission until 1976. The first 45 students were admitted to the medical school at the University of Aarhus in 1933. At that time there were facilities for preclinical studies only. It was not until 1953 that the school was completed, and in the following year the first 57 physicians trained entirely at Aarhus, finished their studies. The school grew rapidly, and, at its peak in 1973, it had 3,000 students and 183 teachers. My Medical Student Days The 1960s was a period of affluence, and the universities got their share of the wealth. It was during this time, in 1964, that I entered.medica1 school. The curriculum consisted of three years of preclinical subjects (chemistry, anatomy, biochemistry and physiology), one year of paraclinical subjects -microbiology, pharmacology, pathology, hygiene and an introduction to medicine and surgery (during which one might see a patient, though this was not part of the plan!)-and finally 2; years of clinical study (medicine, surgery, psychiatry and the various subspecialties).
In order to be fair, everyone had three chances at taking the examinations. If a student used up all his chances, or was a little reluctant to take his exams, he could spend up to 10 years in the medical school. Even then he could be forced to leave if he failed the preclinical examination, which formed the portal of entry to clinical studies and becoming a doctor. It was an additional sad fact that despite all the years of learning about the complexities of human form and function, this skill was not a marketable commodity and the student would have to start from scratch in another career.
Learning by Rote We were told that medical education had improved considerably. We were given lectures and were taught in small groups. The risk of being asked a question was considerably higher in the small groups, but the ob-
Figure 1. The medical school at Aarhus University. (Copyright Billed tjenesten, A a r h w . )
T h e Preclinical Phase Due to the lack of formal educational requirements for admission, an important function of the faculty was to reduce the number of students by means of examinations. These were increasingly difficult up to the culminating preclinical examination at the end of the third year. At that time, one was examined in all the preclinical subjects by means of both written papers and oral tests. Medical Teacher Yo11 No 4 1979
197
jectives of both types of teaching were similar: we should be able to memorize and repeat, word for word, the subject matter. The senior students, who often served as teachers in the small classes, were particularly candid, consoling us with “Never mind if you do not understand, just know it by heart”. They were often quite right: there was nothing to understand, just facts to remember. Perhaps it was acceptable to have to remember information in order to pass examinations, but it is hard for me to forgive the teachers for telling us that all the facts were necessary tools of a competent doctor.
Downloaded by [Australian National University] at 03:32 06 November 2015
On the Trail Despite the anticlimax after passing the hazardous preclinical examination (Was there not more to it? Why did I not feel like a different person?), the paraclinical period was different. We, the medical students, were suddenly treated like prospective physicians. It was a difficult transition, not least because we only occasionally saw a patient. Most of the teaching in the paraclinical years was still theoretical. The sessions in pathology were run along familiar lines, but the new method of teaching anatomy was much more exciting, with its claim that there was now something to learn which could be helpful in understanding the process of disease. The intensive microbiology and pharmacology sessions were frustrating, not least because the teachers were disappointed that their subject was no longer regarded as a ‘real clinical’ subject. They passionately believed in it, but felt that we would never be able to grasp it while, as yet, we did not have the traditional clinical experience on the wards. They held the view that medical education would be greatly improved if microbiology and pharmacology were the very last course in medical school. It never occurred to them that their audience was largely unspoiled and that they could mould their students as they wished. At that stage, we students were prepared to model almost any clinical behaviour that was claimed to work. We did not know that much of what we were being taught was old fashioned in clinical practice. We believed that we were on the right track, a belief reinforced by the smell of the laboratories, which reminded us of visiting sick relatives in our childhood.
The Essential and the Obscure Throughout medical school, I remembered the message: ‘How fortunate you are to hear this or see that phenomenon. You might never meet it again’. I appreciate that without this advice I would probably have failed to detect rare conditions later in life. I also became aware, quite early on, that rarities add to the richness of life. In addition, I accept that an exception can sometimes help illustrate the norm. However, I challenge the emphasis placed on peculiarities, instead of the commonplace, in medical school. I realize that teachers in medical school are highly specialized and can be fascinated by the exception rather than the rule, but I suspect that some teachers concentrate on obscure 198
material as a cover up for lacking certain basic skills. I believe that the following example is symptomatic of a general attitude to teaching in medical school. While studying epidemiology, which was included in the hygiene course, we suddenly became short of time (the usual problem of too much to teach and learn in too short a period). We were told to familiarize ourselves with the WHO International Classqication of Diseases. The teacher, showing us some examples of the disease categories, commented: “It is unnecessary to spend much time on this as you will have plenty of opportunity to familiarize yourselves with the system later when you are in clinical practice”. The teacher was correct - I have had plenty of opportunities to practise diagnosis, but I have misused the system many times because I was not instructed properly how to use it. Enrolment in the Medical Student Council in 1967 marked a turning point in my education. The whole structure of the university was in the melting pot, and students were gradually becoming involved in the new, democratic decision-making bodies that were constituted. For the first time, medical education was viewed from the longitudinal perspective instead of as a disjointed collection of components. With this came an appreciation of time wasted and learning opportunities missed. The desire to improve education was thus established, and this made the rest of my days as a medical student much more meaningful. T h e Clinical Phase I went through the clinical phase thinking that the practice of medicine would be much improved if more attention were paid to the problems of medical education. It was difficult to be of practical use on the wards: there was so much going on at any one time that we did not really know how best to participate and how to divide our time. Some of the obstacles to learning during this period had their root cause in the organization of the programmes. Other obstacles stemmed from unfortunate habits acquired previously. For example, having wasted much time on irrelevant laboratory exercises in the past - which took us away from our books, on which our examinations were based - we had grown to resent any kind of practical work. We had also learned, through the examination system, that to be lacking in knowledge was a punishable offence. So we tended to hide away on the wards to avoid being examined on a patient before we knew everything from the books. As a result, diagnosis was more important than the process of medical care. The attending staff on the wards were there to help patients get rid of their diseases. How could we help? We were embarrassed to approach the patients with our inadequate knowledge, and it was awkward for patients to have to suffer the presence of unknowledgeable students around them, discussing their diseases. Becoming a Basic Doctor The declared aim of my medical education was to produce a basic doctor, though no-one really understood Medical Teacher Voll N o 4 1979
Downloaded by [Australian National University] at 03:32 06 November 2015
what kind of person this basic doctor was. The general idea was all right - to turn out a person who could undertake any kind of postgraduate medical education, be it as a researcher, a general practitioner or a specialist in any field of clinical medicine. Very little theoretical information was reserved for the postgraduate phase. However, there was a marked tendency to excuse the teaching of clinical skills during undergraduate years on the grounds that this would be covered during the postgraduate phase. I firmly believe that medical school is the right place to teach practical examination of patients. Indeed, this is the only place where there is sufficient supervision to ensure that the student is proficient in this area. Medical education would be vastly improved if teaching clinical skills were given higher priority and more time. The undergraduate years are the ideal time for students to examine each other, to use simulators, and to supervise one another’s handling of patients, both physically and psychologically. My Medical School in Retrospect I am aware of many improvements but also, it seems to me, changes for the worse, since I began my medical education. I have remained in touch with the school and have periodically solicited the opinions of a number of key persons at the school to supplement my own view. Listed below are some of the questions I posed and their answers.
What are the School’s Positive Features? 1. The structure of medical education. 2. The surrounding countryside. 3. The early introduction into the curriculum of community medicine. 4. Good social facilities (abundant dormitories situated close at hand). 5. The clinical students are homogeneous, knowledgeable and motivated. Good relationships exist between teacher and student. 6. Introduction of new features into the curriculum, such as clinical symposia, the early inclusion of community medicine, reduction in the chemistry component of the curriculum. 7. The programme of introduction to medical studies.
What are the Unfavourable Trends? 1. Uncertainty and frustration amongst teachers with regard to pedagogy and teaching ambitions. 2. Late patient contact (to be improved by a modified curriculum). 3. Too large a gap between the teaching of anatomy and the application of anatomy in clinical medicine.
Medical Teacher Vol 1 No 4 1979
4. Lack of adjustment of preclinical subjects. 5. The lack of a division of biostatistics.
6. The lack of a division of medical chemistry. 7. The limited number of patients with common diseases seen by students. 8. The subspecialization of the clinical wards of the University Hospital. 9. The 50 per cent student representation on the curriculum committee, which often results in resistance to change. This is because the students are concerned about possible increased content of the programme. 10. The late introduction of clinical medicine. Students should be able to acquire practical experience at district hospitals with the formal teaching continuing to be carried out at the University Hospital. 11. The lack of teaching in general practice. What Changes would be Useful? 1. The use of preclinical tools in clinical teaching. 2. Time for students to study in depth. 3. Greater integration of preclinical and clinical teaching. 4. The teaching of medical ethics and the patient/doctor relationship. 5 . Early clinical experience on the wards. 6. The transfer of some subject matter from undergraduate to postgraduate education. 7. More opportunities for students to engage in research.
Postscript Sustained interest in medical education is rare. No wonder. Not only are rewards lacking, but it is easy to be criticised. Serious involvement in medical education means less time for research ar patient care, areas where prestige can be derived. Looking back on my medical education it is not so much the content I deplore - that is largely forgotten anyway - as the attitudes I absorbed. Some of these have been unhelpful, to say the least. I was trained to think of the physician as a helper, as a result of which I have sometimes manipulated patients and forgotten that given the right tools, people can best help themselves. I have also viewed the ideal physician as a kind and understanding, but essentially distant, person. That has often prevented me from sharing feelings which might have created a genuine relationship with my patients. I am sure that this attitude has also severely limited the quality of information I have elicited from patients in order to make a diagnosis.
199
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Many Hazards, Few Challenges Jorgen Nystrup To cite this article: Jorgen Nystrup (1979) Many Hazards, Few Challenges, Medical Teacher, 1:4, 197-199 To link to this article: http://dx.doi.org/10.3109/01421597909012601
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 6
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [Australian National University]
Date: 06 November 2015, At: 03:32
MY MEDICAL EDUCATION
Many Hazards, Few Challenges
Downloaded by [Australian National University] at 03:32 06 November 2015
J0RGEN NYSTRUP Jorgen Nystrup, MD, is Secretary General of the Nordic Federation f o r Medical Education and a Psychiatrist, The Institute of Dermography, The Psychiatric Hospital, DK-8240 Risskov, and The Department of Psychiatry, The University of Copenhagen, Rigshospitalet, 9 Blegdamovej, DK-2100, Copenhagen 0, Denmark.
Aarhus is the second largest city in Denmark, with a population of 245,413. Its university, founded in 1928, was the second to be established in Denmark - over 400 years after the University of Copenhagen was founded in 1497. Following the European tradition, medical education in Denmark is confined to the universities. In the same tradition, there were no formal educational requirements for admission until 1976. The first 45 students were admitted to the medical school at the University of Aarhus in 1933. At that time there were facilities for preclinical studies only. It was not until 1953 that the school was completed, and in the following year the first 57 physicians trained entirely at Aarhus, finished their studies. The school grew rapidly, and, at its peak in 1973, it had 3,000 students and 183 teachers. My Medical Student Days The 1960s was a period of affluence, and the universities got their share of the wealth. It was during this time, in 1964, that I entered.medica1 school. The curriculum consisted of three years of preclinical subjects (chemistry, anatomy, biochemistry and physiology), one year of paraclinical subjects -microbiology, pharmacology, pathology, hygiene and an introduction to medicine and surgery (during which one might see a patient, though this was not part of the plan!)-and finally 2; years of clinical study (medicine, surgery, psychiatry and the various subspecialties).
In order to be fair, everyone had three chances at taking the examinations. If a student used up all his chances, or was a little reluctant to take his exams, he could spend up to 10 years in the medical school. Even then he could be forced to leave if he failed the preclinical examination, which formed the portal of entry to clinical studies and becoming a doctor. It was an additional sad fact that despite all the years of learning about the complexities of human form and function, this skill was not a marketable commodity and the student would have to start from scratch in another career.
Learning by Rote We were told that medical education had improved considerably. We were given lectures and were taught in small groups. The risk of being asked a question was considerably higher in the small groups, but the ob-
Figure 1. The medical school at Aarhus University. (Copyright Billed tjenesten, A a r h w . )
T h e Preclinical Phase Due to the lack of formal educational requirements for admission, an important function of the faculty was to reduce the number of students by means of examinations. These were increasingly difficult up to the culminating preclinical examination at the end of the third year. At that time, one was examined in all the preclinical subjects by means of both written papers and oral tests. Medical Teacher Yo11 No 4 1979
197
jectives of both types of teaching were similar: we should be able to memorize and repeat, word for word, the subject matter. The senior students, who often served as teachers in the small classes, were particularly candid, consoling us with “Never mind if you do not understand, just know it by heart”. They were often quite right: there was nothing to understand, just facts to remember. Perhaps it was acceptable to have to remember information in order to pass examinations, but it is hard for me to forgive the teachers for telling us that all the facts were necessary tools of a competent doctor.
Downloaded by [Australian National University] at 03:32 06 November 2015
On the Trail Despite the anticlimax after passing the hazardous preclinical examination (Was there not more to it? Why did I not feel like a different person?), the paraclinical period was different. We, the medical students, were suddenly treated like prospective physicians. It was a difficult transition, not least because we only occasionally saw a patient. Most of the teaching in the paraclinical years was still theoretical. The sessions in pathology were run along familiar lines, but the new method of teaching anatomy was much more exciting, with its claim that there was now something to learn which could be helpful in understanding the process of disease. The intensive microbiology and pharmacology sessions were frustrating, not least because the teachers were disappointed that their subject was no longer regarded as a ‘real clinical’ subject. They passionately believed in it, but felt that we would never be able to grasp it while, as yet, we did not have the traditional clinical experience on the wards. They held the view that medical education would be greatly improved if microbiology and pharmacology were the very last course in medical school. It never occurred to them that their audience was largely unspoiled and that they could mould their students as they wished. At that stage, we students were prepared to model almost any clinical behaviour that was claimed to work. We did not know that much of what we were being taught was old fashioned in clinical practice. We believed that we were on the right track, a belief reinforced by the smell of the laboratories, which reminded us of visiting sick relatives in our childhood.
The Essential and the Obscure Throughout medical school, I remembered the message: ‘How fortunate you are to hear this or see that phenomenon. You might never meet it again’. I appreciate that without this advice I would probably have failed to detect rare conditions later in life. I also became aware, quite early on, that rarities add to the richness of life. In addition, I accept that an exception can sometimes help illustrate the norm. However, I challenge the emphasis placed on peculiarities, instead of the commonplace, in medical school. I realize that teachers in medical school are highly specialized and can be fascinated by the exception rather than the rule, but I suspect that some teachers concentrate on obscure 198
material as a cover up for lacking certain basic skills. I believe that the following example is symptomatic of a general attitude to teaching in medical school. While studying epidemiology, which was included in the hygiene course, we suddenly became short of time (the usual problem of too much to teach and learn in too short a period). We were told to familiarize ourselves with the WHO International Classqication of Diseases. The teacher, showing us some examples of the disease categories, commented: “It is unnecessary to spend much time on this as you will have plenty of opportunity to familiarize yourselves with the system later when you are in clinical practice”. The teacher was correct - I have had plenty of opportunities to practise diagnosis, but I have misused the system many times because I was not instructed properly how to use it. Enrolment in the Medical Student Council in 1967 marked a turning point in my education. The whole structure of the university was in the melting pot, and students were gradually becoming involved in the new, democratic decision-making bodies that were constituted. For the first time, medical education was viewed from the longitudinal perspective instead of as a disjointed collection of components. With this came an appreciation of time wasted and learning opportunities missed. The desire to improve education was thus established, and this made the rest of my days as a medical student much more meaningful. T h e Clinical Phase I went through the clinical phase thinking that the practice of medicine would be much improved if more attention were paid to the problems of medical education. It was difficult to be of practical use on the wards: there was so much going on at any one time that we did not really know how best to participate and how to divide our time. Some of the obstacles to learning during this period had their root cause in the organization of the programmes. Other obstacles stemmed from unfortunate habits acquired previously. For example, having wasted much time on irrelevant laboratory exercises in the past - which took us away from our books, on which our examinations were based - we had grown to resent any kind of practical work. We had also learned, through the examination system, that to be lacking in knowledge was a punishable offence. So we tended to hide away on the wards to avoid being examined on a patient before we knew everything from the books. As a result, diagnosis was more important than the process of medical care. The attending staff on the wards were there to help patients get rid of their diseases. How could we help? We were embarrassed to approach the patients with our inadequate knowledge, and it was awkward for patients to have to suffer the presence of unknowledgeable students around them, discussing their diseases. Becoming a Basic Doctor The declared aim of my medical education was to produce a basic doctor, though no-one really understood Medical Teacher Voll N o 4 1979
Downloaded by [Australian National University] at 03:32 06 November 2015
what kind of person this basic doctor was. The general idea was all right - to turn out a person who could undertake any kind of postgraduate medical education, be it as a researcher, a general practitioner or a specialist in any field of clinical medicine. Very little theoretical information was reserved for the postgraduate phase. However, there was a marked tendency to excuse the teaching of clinical skills during undergraduate years on the grounds that this would be covered during the postgraduate phase. I firmly believe that medical school is the right place to teach practical examination of patients. Indeed, this is the only place where there is sufficient supervision to ensure that the student is proficient in this area. Medical education would be vastly improved if teaching clinical skills were given higher priority and more time. The undergraduate years are the ideal time for students to examine each other, to use simulators, and to supervise one another’s handling of patients, both physically and psychologically. My Medical School in Retrospect I am aware of many improvements but also, it seems to me, changes for the worse, since I began my medical education. I have remained in touch with the school and have periodically solicited the opinions of a number of key persons at the school to supplement my own view. Listed below are some of the questions I posed and their answers.
What are the School’s Positive Features? 1. The structure of medical education. 2. The surrounding countryside. 3. The early introduction into the curriculum of community medicine. 4. Good social facilities (abundant dormitories situated close at hand). 5. The clinical students are homogeneous, knowledgeable and motivated. Good relationships exist between teacher and student. 6. Introduction of new features into the curriculum, such as clinical symposia, the early inclusion of community medicine, reduction in the chemistry component of the curriculum. 7. The programme of introduction to medical studies.
What are the Unfavourable Trends? 1. Uncertainty and frustration amongst teachers with regard to pedagogy and teaching ambitions. 2. Late patient contact (to be improved by a modified curriculum). 3. Too large a gap between the teaching of anatomy and the application of anatomy in clinical medicine.
Medical Teacher Vol 1 No 4 1979
4. Lack of adjustment of preclinical subjects. 5. The lack of a division of biostatistics.
6. The lack of a division of medical chemistry. 7. The limited number of patients with common diseases seen by students. 8. The subspecialization of the clinical wards of the University Hospital. 9. The 50 per cent student representation on the curriculum committee, which often results in resistance to change. This is because the students are concerned about possible increased content of the programme. 10. The late introduction of clinical medicine. Students should be able to acquire practical experience at district hospitals with the formal teaching continuing to be carried out at the University Hospital. 11. The lack of teaching in general practice. What Changes would be Useful? 1. The use of preclinical tools in clinical teaching. 2. Time for students to study in depth. 3. Greater integration of preclinical and clinical teaching. 4. The teaching of medical ethics and the patient/doctor relationship. 5 . Early clinical experience on the wards. 6. The transfer of some subject matter from undergraduate to postgraduate education. 7. More opportunities for students to engage in research.
Postscript Sustained interest in medical education is rare. No wonder. Not only are rewards lacking, but it is easy to be criticised. Serious involvement in medical education means less time for research ar patient care, areas where prestige can be derived. Looking back on my medical education it is not so much the content I deplore - that is largely forgotten anyway - as the attitudes I absorbed. Some of these have been unhelpful, to say the least. I was trained to think of the physician as a helper, as a result of which I have sometimes manipulated patients and forgotten that given the right tools, people can best help themselves. I have also viewed the ideal physician as a kind and understanding, but essentially distant, person. That has often prevented me from sharing feelings which might have created a genuine relationship with my patients. I am sure that this attitude has also severely limited the quality of information I have elicited from patients in order to make a diagnosis.
199
