Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Neurology Teaching in UK Medical Schools Iain Wilkinson, Jill Rogers & Richard Wakeford To cite this article: Iain Wilkinson, Jill Rogers & Richard Wakeford (1979) Neurology Teaching in UK Medical Schools, Medical Teacher, 1:2, 87-93 To link to this article: http://dx.doi.org/10.3109/01421597909019398
Published online: 03 Jul 2009.
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THE WAY THEY DO IT ...
Neurology Teaching in UK Medical Schools
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IAIN WILKINSON, JILL ROGERS and RICHARD WAKEFORD Iain Wilkinson, B.SC, M A , MD, MRCP, iS Consultant Neurologist at Addenbrooke’s Hospital, Cambridge. Jill Rogers, BA, was formerly Research Fellow, Centre f o r Medical Education, University of Dundee. Richard Wakeford, B A , is an educational researcher working in the Office of the Regius Professor of Physic, Cambridge University School of Clinical Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ UK.
From time to time, Medical Teacher will publish surveys of topical aspects of medical educational practice in the UK and elsewhere. T h e first article in this series reports the results of an enquiry into the teaching of the expanding specialty of neurology and neurosurgery in clinical medical schools in the UK.It shows wide differences in the arrangements made for teaching the specialty, and considerable dissatisfaction amongst many teachers with what they regard as insufficient teaching provision. The report of the General Medical Council’s survey of Basic Medical Education in the British Isles (GMC 1977) described in detail the teaching programmes in British and Irish medical schools. In addition to reporting upon the curricula of individual schools, chapters were written on each of 35 “component disciplines/specialties of the medical course as a whole”. These describe the arrangements for teaching the subject, objectives and teaching methods, student assessment mechanisms, and problems and developments. Information about the teaching of the smaller specialties, such as chest medicine and rheumatology, was not sought in any detail, and the report subsumes the limited data within the chapter on the major, parent specialty. Clearly, not every subspecialty could be investigated in such an exercise, and neurology was one of the most important not to be separately examined. In view of the fundamental importance of the subject in medical education, and the fact that it is an expanding discipline - the number of neurological consultants in the National Health Service in England and Wales rose by almost 50 per cent in the 10 years up to 1976 (NHS 1971; Health Trends 1977)-we decided to conduct a survey of the teaching of neurology in clinical medical schools in th UK. This article reports upon the results. A questionnaire was designed which roughly parallelled those used in the GMC survey. It sought overall information about teaching arrangements generally (e.g., the existence of a clerkship, its length and timing in the course, the size of student groups); teaching methods used and preferred; responsibilities normally Medical Teacher Vol 1 No 2 1979
entrusted to students: and student assessment. Finally, the questionnaire invited respondents to comment on any notable aspects of their teaching and/or any difficulties. The questionnaire was despatched in the summer of 1978 to a senior clinical neurologist or neurosurgeon at each of the 29 clinical medical schools in the UK. A 100 per cent response was achieved. It should be noted that, as the questionnaire was answered by neurologists and neurosurgeons, the replies indicate the teaching involvement of these specialties: some neurological teaching may also be given, and frequently is, by nonspecialists. Overall Plan and Teaching Arrangements Clinical neurologists and/or neurosurgeons from 13 schools participate in the preclinical phase of the medical course (Table 1, Column A). This participation takes the form of between three and 12 lectures/demonstrations to illustrate the clinical application of neurophysiology, neuroanatomy, neuropharmacology and biochemistry. The demonstrations are generally to the whole class simultaneously, usually in the second year of the course. Such sessions are generally reported to be worthwhile, and in four schools (Birmingham, Guy’s, Newcastle and Nottingham) they are singled out as particularly valuable elements of the teaching programme. Almost all clinical medical schools run ‘introductory courses’; participation in these by neurologists/neurosurgeons is common, taking place in 19 schools (Table 1, Column B). This vanes between one and six, but generally two, sessions demonstrating the special features of history-taking and physical examination of patients with neurological aspects to their illness. These sessions usually involve the whole class simultaneously, though in five schools the group of students is subdivided into smaller groups. Lectures, Case Demonstrations and Clinical Attachments Neurologists and neurosurgeons give lectures to the students in the majority of the clinical schools- 25 (Table 1, Column C). The number of lectures varies widely, 87
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from three to 20. Sometimes given by individuals, less often by a multidisciplinary team, these lectures are normally given to the whole class, though in at least two schools (King's College Hospital Medical School and Oxford) the lectures are only given in alternate years. The timing of the lectures in the clinical course varies but is more often in the first or second clinical years. Specific final year lectures, either revision or orientated towards clinical problems, are given in five schools (Bristol, Royal Free, St George's, UCHMS and Westminster). Case demonstrations and discussion sessions with large audiences of students (20 to 100) occur on a regular basis in 10 schools (Table 1, Column D). Clinical attachment to the neurological/neurosurgical department was regarded by respondents as the cornerstone of teaching neurology and neurosurgery to under graduates. No school is without this, but it is available to
every student in only 20 of the 29 schools. Table 1, Column E indicates the length in weeks of the clinical attachment in each of these schools. Figure 1 shows the principal characteristics of the clinical attachment in these 20 schools. The attachment is full-time in only 10 schools and the attachment invariably combines teach ing of other specialist subjects when it is longer than four weeks' duration. The most common arrangement (five schools) is a four-week full-time clerkship. Figure 1 also shows the preponderance of neurology teaching over neurosurgery. In the remaining nine schools, not all students receive an attachment to the neurological/neurosurgical department. Generally, this is because the curricular structure is arranged so that students rotate through some, but not all, of the 'subspecialties' (Table 1 , Column F). The approximate proportions of students receiving a
Figure 1. Features of the clinical attachment in those schools where this is provided f o r A L L students. (a) Duration of clinical attachment (F = full time, P = part time, * = full-time equivalent, 2wk F + 2wk P). (b) Approximate percentage of neurology in the clinical attachment (as compared with neurosurgey).
12
St Thomas's"' Nottingham"'
-
1110
-
98-
76-
5Dundee"' Edinburgh' Charing x"'
4-
3-
Newcastle"' Liverpoor"
St George's"' St Mary's"' Royal Free"' Cambridge"' Guy's1" Leeds"' Oxford" Belfast" London"' KCHMS" GlasgW
Middlesex"'
'*I
Sheffie r'
100
90 Liverpool St George's Belfast Glasgow
Newcastle KCHMS Charing X Leeds Dundee Cambridge
Guy's Middlesex St Mary's
Sheffield Nottingham St Thomas's Royal Free Edinburgh
Oxford
40
30 20
London (Not known)
10
88
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Table 1. Summary of aspects of neurology teaching in UK medical schools.
89
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clerkship in neurology/neurosurgery in these schools is shown in Table 2. Figure 2 records the features of the attachment in these schools. The period tends to be longer than in the other schools, but is more frequently not full-time. The most common location for the neurologylneurosurgery attachment in the curriculum is in the middle year of a three-year clinical course. However, a number of attachments occur in the final year of the course and, especially when the attachment is not provided for all students, some are given in the first year of the course. The size of the student group attached to the neurology/neurosurgery unit is most frequently six to 10 students. In five schools there may be 16 or more students (Charing Cross, Edinburgh, Glasgow, Middlesex, St Thomas's) and in three schools the number is five or less (St George's, Southampton and the second of the attachments at Newcastle). It is interesting to compare the average size of the schools in which a clinical attachment to the specialty is available to all students with those in which it is not.
Table 2. Approximate percentage of students receiving a clerkship in neurology/neurosurgery when this is not available to all.
Percentage
Schools
10
Southampton Aberdeen
20
Wales
Manchester St Bartholomew's
30 40
-
50
UCHMS
60
Westminster
70
~
Bristol Birmingham
80
90
There is no significant difference between the two. Similarly, the average total reported amount of time devoted to teaching by staff in the two groups of schools is almost identical.
Figure 2 . Features of the clinical attachment in those schools where this is N O T provided f o r A L L students. (a) Duration of clinical attachment (F = full time, P = part time). (b) Approximate percentage of neurology in the clinical attachment (as compared with neurosurgery).
Manchestel" UCHMS' Bristor"
Wales"
Southampton"' Birmingham"'
a
Bristol Manchester Wales 100
Westminster UCHMS
80 70
60
-I
Southampton
50
I
40 Birmingham 30 St Bartholomew's 20 Aberdeen (Not known) 10
90
Medical Teacher Vol 1 No 2 1979
Elective Period
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T h e opportunity of spending an elective period in neurology/neurosurgery is available a t 14 clinical schools (Table 1, Column G ) . Such electives are usually undertaken by only a minority of students, late in the course; the length of these varies between one and 16 weeks, four weeks being the most common. T h e availability of a n elective period was reported as a particularly valuable component of the teaching programme by two schools and its lack of availability as a weak point by one school (St George’s), which reported that elective attachments were impossible at present. Experience of Neurological and Neurosurgical Emergencies Specific arrangements to give students experience of neurological and neurosurgical emergencies are only made in six schools (Table 1, Column H). T h e importance of this aspect of teaching may not be recognized everywhere and is difficult to resolve when it is. A period of residence in hospital for this purpose during the clinical attachment is exceptional. More commonly, students merely see all emergencies that occur during working hours during the period of the attachment. Alternatively, they may take part in an emergency rota in which students see all emergency admissions to hospital, some of which will be neurological or neurosurgical.
Standardization of Student Experience Twelve schools (Table 1, Column J ) issue students with checklists of conditions and procedures, to try to ensure comprehensive experience of the subjects. Students’ Responsibilities Respondents were asked to indicate on a pro-forma the extent of senior students’ normal permitted responsibility in their departments. They indicated for each of a number of responsibilities whether i t would ‘routinely’, ‘occasionally’ or ‘not normally’ be entrusted to students. T h e results are shown in Table 3 . Teaching Group Size T h e questionnaire then enquired into the size of student group typically present at neurological/neurosurgical teaching sessions. T h e number frequently differed between in-patient and out-patient teaching (Table 4). Teaching Methods Respondents were asked what use was made in their teaching of a variety of teaching methods, and how valuable they regarded these (Table 5 ) . Respondents would apparently like to make more use than at present of small-group tutorials, clinical teaching using out -patients, audiovisual materials and projects. Student Assessment T h e assessment of students in neurology/neurosurgery (Table 1, Column K ) is crucial in only one school, Ox-
Medical Teacher Vol 1 N o 2 1979
Table 3. Extent of senior students’ responsibility. Number of schools in which responsibilityis entrusted to students Responsibility
Not Routinely Occasionally normally
The students’ clinical notes form part of the patients’ records ‘
6
Students have the opportunity to act as locums in the absence of house officers, including: Talking to relatives’ Eking first contact in an emergency ’
4
18
13
8
8
13
8
13
Students have the opportunity to play a role similar to that of the house officer (but house officer present)
4
4
21
Students assist in neurosurgery theatre
3
3
23
’
( =Not all respondents replied to these items.)
Table 4. Size of student group present at in-patient and out-patient neurological/neurosurgical teaching sessions. Typical group size
Number of schools
In -patient teaching 1-5 6-10 11-15 16-20
7 16 4 2
Out-patient teaching 1-5 6-10 11-15 16-20
15 8 1 1
No out-patient teaching sessions
4
ford; crucial in the sense that a separate examination in these subjects must be passed as a prerequisite to qualification. I n eight more schools students are specifically assessed in neurology/neurosurgery by means of MCQ or other tests. These examinations d o not form part of the formal ‘critical’ assessment system in these schools, however, and would only possibly ’count’ in the case of a borderline student. In nine of the remaining 20 schools, neurologists record their general impression of students: again, this is unlikely to have any effect upon a student’s progress towards qualification, except in marginal cases. In the remaining 11 schools, no specific assessment whatsoever is made of students’ knowledge, clinical skills and attitudes in neurology a n d neurosurgery. T h e 91
Table 5 . Teaching methods used and their considered value. How much used Teaching method
A lot
Clinical teaching using in-patients Students’clerking patients Clinical teaching using out-patients Small-grouptutorials Large-groupdemonstrations Books
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Lectures Teaching by other specialists Audiovisual materials Projects Teaching by paramedical staff Teaching by general practitioners
Hardly at all (or not used)
Moderately
25 16
Value
3 6
High
0 6
27
1
18
7 3
15
7
7
24
11 5 4 3 2 1
14
4 13 4 11 17 16
21
25 6 8 2 3 6 4
19
1
28
0
11 16 15
8 10 6 9 0
1 0 0
Moderate
Low
3
0 0 2 0
10
10
15 15 7 10
1 10
10
13
5 8
9 4
13
8
Note: Not all respondents checked each item.
subjects simply form an unspecified examination of the parent specialties.
part
of the
Table 6. Particularly valuable features in the teaching of neurology and neurosurgery. Number of medical schools mentioning
Strengths and Weaknesses of the Teaching
Feature
The questionnaire asked neurologists and neurosurgeons to identify, if possible, particularly valuable features of their clinical teaching, and also weak points and difficulties (Tables 6 and 7: only features mentioned twice or more have been included).
Good integration between neurology/ neurosurgery/neuropathology/
neuroradiology Ability to teach in small groups Participationin preclinical teaching Good clinical material
5 5 4
4
Discussion We do not propose to comment upon the data in any detail: neurologists, neurosurgeons and curriculum planners may draw their own conclusions. We would like to highlight only three areas. Problems in optimizing the clinical attachment (e.g., making it long enough, full-time and available for all students) constitute the most commonly identified difficulty in teaching neurology and neurosurgery, emphasizing its importance. The preponderance of neurology over neurosurgery in the clinical attachment is probably appropriate for undergraduates, but the exclusion of neurosurgery, which occurs in at least eight schools (and which is regarded as a weak point of the teaching programme in five) cannot be satisfactory. Regarding teaching methods, there is some agreement that lectures are overused and that students would benefit from additional clinical teaching in small groups, especially using out-patients. Respondents who had achieved what they regarded as a well-integrated course, with neurologists and neurosurgeons (and often neuropathologists and neuroradiologists as well) teaching in a coordinated fashion, invariably reported it as satisfactory. Finally, no fewer than 10 returns reported dissatisfaction with the assessment arrangements. T h e general lack of formal assessment in the specialty means that students may not have the opportunity for selfassessment, and moreover, the incentive value of an examination is lost. The question of the desirability of students’ qualifying in medicine without having been
92
Table 7. Weak points and difficulties in the teaching of neurology and neurosurgery. ~
Number of medical schools mentioning
Feature Something wrong with the clinical attachment (too short: ‘mixed’; not for all students) Not enough teachedtoo many students Curriculum problems (planners unsympathetic: overcrowded: curriculum too complex: out of control of professors) No neurosurgery Neurology and neurosurgery not integrated Lectures not a useful teaching method Neurology teaching too early in the course
12 11
11 5 3
3 3
formally and systematically assessed in neurology is one which needs further discussion. References General Medical Council, Basic Medical Education in the Brztirh Isles. Vols 1 and 2, The Report of the General Medical Council Survey, Nuffield Provincial Hospitals Trust, London, 1977. Health T r e n h , HMSO. London, August 1977. NHS, Staffing Figures, HMSO. London, 30 September 1971.
Medical Teacher Vol 1 No 2 1979
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CONFEKENCE REPORTS
The Great American Dream Shrinks a Little American Government thinking about the future of medical education was outlined by Joseph Califano, Secretary of the US Department of Health, Education and Welfare, addressing the American Association of Medical Colleges meeting in New Orleans. Health care is America’s third largest Industry. In 1978 it used some 180 billion dollars and almost six per cent of the national work force; by the year 2000 health costs are expected to reach one trillion dollars and 12 per cent of the entire gross national product. And the decisions taken by individual physicians account for 70 per cent of all such expenditure. Califano’s first message was clear-“The men and women you train today and tomorrow will make decisions governing several trillion dollars of our Gross National Product over the next two decades”.
Oversupply of Physicians Imminent The number of US medical school graduates has virtually doubled, from some 8,000 in 1963 to more than 15,000 in 1978, in response to concern during the early 1960s about an impending physician shortage. With the influx of foreign medical graduates, the number of doctors in active practice increased by 46 per cent between 1960 and 1975, the ratio of doctors to population increasing from 143 to 177 per 100,000 people. Califano stated that the first tenet of national policy in this area is that an oversupply of physicians is immi-
Medical Teacher Vol 1 N o 2 1979
nent. Depending on how one estimates need for physicians, an excess of 23,000 to 150,000 doctors is predicted by 1990, with 594,000 active doctors in practice, 242 per 100,000 of the population. The second major problem is that “we are producing too many medical specialists and subspecialists, such as surgeons, and there is a corresponding and disturbing decline in the proportion of primary care physicians”. Califano concluded, from a number of studies, that “as the number of surgeons rises in an area, the number of operations also goes up-with no clear evidence that all this extra surgery is necessary”. The USA has twice as many surgeons as England and Wales, for instance, and twice the surgery rate. In some parts of Maine where the ratio of surgeons to population is highest, the number of gall bladder operations is more than double the number performed in other parts of the State. Other studies suggest that the greater the number of surgeons in an area, the higher the surgeon’s fees. Califano voiced his concern about the decline in primary care. In 1931, fully 94 per cent of practising doctors in the USA were in full-time primary care. By 1975 that proportion had fallen to 38 per cent, compared with 72 per cent in West Germany and 60 per cent in Canada. Despite considerably greater efforts to reduce this trend in the last decade, it seems that only 35 to 40 per cent of doctors now in training in America are completing residency programmes in primary care fields. Distribution problems abound. Despite the “excess medical manpower”, more than 25 million Americans live in underserved areas with fewer than one doctor for every 2,000 people. The percentage of doctors practising in such areas actually fell between 1963 and 1976. In the areas with excellent doctor/ patient ratios (better than 1 to 300) the percentage increased sharply. So the rich get richer and the poor poorer. Britain, Germany, and Canada are experiencing similar problems. The next major problem Califano identified was the need for medical schools to be far more active in making physicians responsive to
demographic, social and economic changes -the ‘graying’ of America (the increasing proportion of the population over 65 years old); the need for greater emphasis on chronic and long-term rather than acute conditions, on palliative and rehabilitative rather than curative practice; the increasing importance of emotional and psychosocial problems; the need to learn to work with other varieties of health care personnel and to be more sensitive to ethical issues.
Action t o Deal with Problems Califano proposed action to deal with these problems. Federal funding and incentives will be realigned. Schools will be encouraged to reduce gradually the size of classes. It is extremely unlikely that new schools will be created, and strong opposition to the admission of foreign graduates will be continued. Efforts to increase the production of primary care physicians will gain more support, and Departments of Family Medicine can expect more funding and encouragement. Geographic maldistribution will be tackled by increased support and scholarships for the National Health Service Corps (an internal-service version of the Peace Corps); by encouraging the admission to medical school of students from underserved areas; and by clinical rotations in community health centres during training. Psychosocial, ethical and economic aspects of health care should receive more emphasis, too. Califano’s news may not have been uniformly welcome to all who heard him, but he is to be commended for his directness, his realism and his optimism. “We are approaching the day” he said “in health care as in the field of energy when we simply cannot sustain the costs of chromefinned, gas-guzzling, option-rich technology. ” At long last, it appears that we are talking about planning medical education on the basis of a realistic assessment of health care problems, apart from a few romantic rhetorical flourishes. 93
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
Neurology Teaching in UK Medical Schools Iain Wilkinson, Jill Rogers & Richard Wakeford To cite this article: Iain Wilkinson, Jill Rogers & Richard Wakeford (1979) Neurology Teaching in UK Medical Schools, Medical Teacher, 1:2, 87-93 To link to this article: http://dx.doi.org/10.3109/01421597909019398
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 17
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [University of California, San Diego]
Date: 07 November 2015, At: 04:05
~
THE WAY THEY DO IT ...
Neurology Teaching in UK Medical Schools
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IAIN WILKINSON, JILL ROGERS and RICHARD WAKEFORD Iain Wilkinson, B.SC, M A , MD, MRCP, iS Consultant Neurologist at Addenbrooke’s Hospital, Cambridge. Jill Rogers, BA, was formerly Research Fellow, Centre f o r Medical Education, University of Dundee. Richard Wakeford, B A , is an educational researcher working in the Office of the Regius Professor of Physic, Cambridge University School of Clinical Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ UK.
From time to time, Medical Teacher will publish surveys of topical aspects of medical educational practice in the UK and elsewhere. T h e first article in this series reports the results of an enquiry into the teaching of the expanding specialty of neurology and neurosurgery in clinical medical schools in the UK.It shows wide differences in the arrangements made for teaching the specialty, and considerable dissatisfaction amongst many teachers with what they regard as insufficient teaching provision. The report of the General Medical Council’s survey of Basic Medical Education in the British Isles (GMC 1977) described in detail the teaching programmes in British and Irish medical schools. In addition to reporting upon the curricula of individual schools, chapters were written on each of 35 “component disciplines/specialties of the medical course as a whole”. These describe the arrangements for teaching the subject, objectives and teaching methods, student assessment mechanisms, and problems and developments. Information about the teaching of the smaller specialties, such as chest medicine and rheumatology, was not sought in any detail, and the report subsumes the limited data within the chapter on the major, parent specialty. Clearly, not every subspecialty could be investigated in such an exercise, and neurology was one of the most important not to be separately examined. In view of the fundamental importance of the subject in medical education, and the fact that it is an expanding discipline - the number of neurological consultants in the National Health Service in England and Wales rose by almost 50 per cent in the 10 years up to 1976 (NHS 1971; Health Trends 1977)-we decided to conduct a survey of the teaching of neurology in clinical medical schools in th UK. This article reports upon the results. A questionnaire was designed which roughly parallelled those used in the GMC survey. It sought overall information about teaching arrangements generally (e.g., the existence of a clerkship, its length and timing in the course, the size of student groups); teaching methods used and preferred; responsibilities normally Medical Teacher Vol 1 No 2 1979
entrusted to students: and student assessment. Finally, the questionnaire invited respondents to comment on any notable aspects of their teaching and/or any difficulties. The questionnaire was despatched in the summer of 1978 to a senior clinical neurologist or neurosurgeon at each of the 29 clinical medical schools in the UK. A 100 per cent response was achieved. It should be noted that, as the questionnaire was answered by neurologists and neurosurgeons, the replies indicate the teaching involvement of these specialties: some neurological teaching may also be given, and frequently is, by nonspecialists. Overall Plan and Teaching Arrangements Clinical neurologists and/or neurosurgeons from 13 schools participate in the preclinical phase of the medical course (Table 1, Column A). This participation takes the form of between three and 12 lectures/demonstrations to illustrate the clinical application of neurophysiology, neuroanatomy, neuropharmacology and biochemistry. The demonstrations are generally to the whole class simultaneously, usually in the second year of the course. Such sessions are generally reported to be worthwhile, and in four schools (Birmingham, Guy’s, Newcastle and Nottingham) they are singled out as particularly valuable elements of the teaching programme. Almost all clinical medical schools run ‘introductory courses’; participation in these by neurologists/neurosurgeons is common, taking place in 19 schools (Table 1, Column B). This vanes between one and six, but generally two, sessions demonstrating the special features of history-taking and physical examination of patients with neurological aspects to their illness. These sessions usually involve the whole class simultaneously, though in five schools the group of students is subdivided into smaller groups. Lectures, Case Demonstrations and Clinical Attachments Neurologists and neurosurgeons give lectures to the students in the majority of the clinical schools- 25 (Table 1, Column C). The number of lectures varies widely, 87
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from three to 20. Sometimes given by individuals, less often by a multidisciplinary team, these lectures are normally given to the whole class, though in at least two schools (King's College Hospital Medical School and Oxford) the lectures are only given in alternate years. The timing of the lectures in the clinical course varies but is more often in the first or second clinical years. Specific final year lectures, either revision or orientated towards clinical problems, are given in five schools (Bristol, Royal Free, St George's, UCHMS and Westminster). Case demonstrations and discussion sessions with large audiences of students (20 to 100) occur on a regular basis in 10 schools (Table 1, Column D). Clinical attachment to the neurological/neurosurgical department was regarded by respondents as the cornerstone of teaching neurology and neurosurgery to under graduates. No school is without this, but it is available to
every student in only 20 of the 29 schools. Table 1, Column E indicates the length in weeks of the clinical attachment in each of these schools. Figure 1 shows the principal characteristics of the clinical attachment in these 20 schools. The attachment is full-time in only 10 schools and the attachment invariably combines teach ing of other specialist subjects when it is longer than four weeks' duration. The most common arrangement (five schools) is a four-week full-time clerkship. Figure 1 also shows the preponderance of neurology teaching over neurosurgery. In the remaining nine schools, not all students receive an attachment to the neurological/neurosurgical department. Generally, this is because the curricular structure is arranged so that students rotate through some, but not all, of the 'subspecialties' (Table 1 , Column F). The approximate proportions of students receiving a
Figure 1. Features of the clinical attachment in those schools where this is provided f o r A L L students. (a) Duration of clinical attachment (F = full time, P = part time, * = full-time equivalent, 2wk F + 2wk P). (b) Approximate percentage of neurology in the clinical attachment (as compared with neurosurgey).
12
St Thomas's"' Nottingham"'
-
1110
-
98-
76-
5Dundee"' Edinburgh' Charing x"'
4-
3-
Newcastle"' Liverpoor"
St George's"' St Mary's"' Royal Free"' Cambridge"' Guy's1" Leeds"' Oxford" Belfast" London"' KCHMS" GlasgW
Middlesex"'
'*I
Sheffie r'
100
90 Liverpool St George's Belfast Glasgow
Newcastle KCHMS Charing X Leeds Dundee Cambridge
Guy's Middlesex St Mary's
Sheffield Nottingham St Thomas's Royal Free Edinburgh
Oxford
40
30 20
London (Not known)
10
88
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Table 1. Summary of aspects of neurology teaching in UK medical schools.
89
Medical Teacher Vol 1 No 2 1979
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clerkship in neurology/neurosurgery in these schools is shown in Table 2. Figure 2 records the features of the attachment in these schools. The period tends to be longer than in the other schools, but is more frequently not full-time. The most common location for the neurologylneurosurgery attachment in the curriculum is in the middle year of a three-year clinical course. However, a number of attachments occur in the final year of the course and, especially when the attachment is not provided for all students, some are given in the first year of the course. The size of the student group attached to the neurology/neurosurgery unit is most frequently six to 10 students. In five schools there may be 16 or more students (Charing Cross, Edinburgh, Glasgow, Middlesex, St Thomas's) and in three schools the number is five or less (St George's, Southampton and the second of the attachments at Newcastle). It is interesting to compare the average size of the schools in which a clinical attachment to the specialty is available to all students with those in which it is not.
Table 2. Approximate percentage of students receiving a clerkship in neurology/neurosurgery when this is not available to all.
Percentage
Schools
10
Southampton Aberdeen
20
Wales
Manchester St Bartholomew's
30 40
-
50
UCHMS
60
Westminster
70
~
Bristol Birmingham
80
90
There is no significant difference between the two. Similarly, the average total reported amount of time devoted to teaching by staff in the two groups of schools is almost identical.
Figure 2 . Features of the clinical attachment in those schools where this is N O T provided f o r A L L students. (a) Duration of clinical attachment (F = full time, P = part time). (b) Approximate percentage of neurology in the clinical attachment (as compared with neurosurgery).
Manchestel" UCHMS' Bristor"
Wales"
Southampton"' Birmingham"'
a
Bristol Manchester Wales 100
Westminster UCHMS
80 70
60
-I
Southampton
50
I
40 Birmingham 30 St Bartholomew's 20 Aberdeen (Not known) 10
90
Medical Teacher Vol 1 No 2 1979
Elective Period
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T h e opportunity of spending an elective period in neurology/neurosurgery is available a t 14 clinical schools (Table 1, Column G ) . Such electives are usually undertaken by only a minority of students, late in the course; the length of these varies between one and 16 weeks, four weeks being the most common. T h e availability of a n elective period was reported as a particularly valuable component of the teaching programme by two schools and its lack of availability as a weak point by one school (St George’s), which reported that elective attachments were impossible at present. Experience of Neurological and Neurosurgical Emergencies Specific arrangements to give students experience of neurological and neurosurgical emergencies are only made in six schools (Table 1, Column H). T h e importance of this aspect of teaching may not be recognized everywhere and is difficult to resolve when it is. A period of residence in hospital for this purpose during the clinical attachment is exceptional. More commonly, students merely see all emergencies that occur during working hours during the period of the attachment. Alternatively, they may take part in an emergency rota in which students see all emergency admissions to hospital, some of which will be neurological or neurosurgical.
Standardization of Student Experience Twelve schools (Table 1, Column J ) issue students with checklists of conditions and procedures, to try to ensure comprehensive experience of the subjects. Students’ Responsibilities Respondents were asked to indicate on a pro-forma the extent of senior students’ normal permitted responsibility in their departments. They indicated for each of a number of responsibilities whether i t would ‘routinely’, ‘occasionally’ or ‘not normally’ be entrusted to students. T h e results are shown in Table 3 . Teaching Group Size T h e questionnaire then enquired into the size of student group typically present at neurological/neurosurgical teaching sessions. T h e number frequently differed between in-patient and out-patient teaching (Table 4). Teaching Methods Respondents were asked what use was made in their teaching of a variety of teaching methods, and how valuable they regarded these (Table 5 ) . Respondents would apparently like to make more use than at present of small-group tutorials, clinical teaching using out -patients, audiovisual materials and projects. Student Assessment T h e assessment of students in neurology/neurosurgery (Table 1, Column K ) is crucial in only one school, Ox-
Medical Teacher Vol 1 N o 2 1979
Table 3. Extent of senior students’ responsibility. Number of schools in which responsibilityis entrusted to students Responsibility
Not Routinely Occasionally normally
The students’ clinical notes form part of the patients’ records ‘
6
Students have the opportunity to act as locums in the absence of house officers, including: Talking to relatives’ Eking first contact in an emergency ’
4
18
13
8
8
13
8
13
Students have the opportunity to play a role similar to that of the house officer (but house officer present)
4
4
21
Students assist in neurosurgery theatre
3
3
23
’
( =Not all respondents replied to these items.)
Table 4. Size of student group present at in-patient and out-patient neurological/neurosurgical teaching sessions. Typical group size
Number of schools
In -patient teaching 1-5 6-10 11-15 16-20
7 16 4 2
Out-patient teaching 1-5 6-10 11-15 16-20
15 8 1 1
No out-patient teaching sessions
4
ford; crucial in the sense that a separate examination in these subjects must be passed as a prerequisite to qualification. I n eight more schools students are specifically assessed in neurology/neurosurgery by means of MCQ or other tests. These examinations d o not form part of the formal ‘critical’ assessment system in these schools, however, and would only possibly ’count’ in the case of a borderline student. In nine of the remaining 20 schools, neurologists record their general impression of students: again, this is unlikely to have any effect upon a student’s progress towards qualification, except in marginal cases. In the remaining 11 schools, no specific assessment whatsoever is made of students’ knowledge, clinical skills and attitudes in neurology a n d neurosurgery. T h e 91
Table 5 . Teaching methods used and their considered value. How much used Teaching method
A lot
Clinical teaching using in-patients Students’clerking patients Clinical teaching using out-patients Small-grouptutorials Large-groupdemonstrations Books
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Lectures Teaching by other specialists Audiovisual materials Projects Teaching by paramedical staff Teaching by general practitioners
Hardly at all (or not used)
Moderately
25 16
Value
3 6
High
0 6
27
1
18
7 3
15
7
7
24
11 5 4 3 2 1
14
4 13 4 11 17 16
21
25 6 8 2 3 6 4
19
1
28
0
11 16 15
8 10 6 9 0
1 0 0
Moderate
Low
3
0 0 2 0
10
10
15 15 7 10
1 10
10
13
5 8
9 4
13
8
Note: Not all respondents checked each item.
subjects simply form an unspecified examination of the parent specialties.
part
of the
Table 6. Particularly valuable features in the teaching of neurology and neurosurgery. Number of medical schools mentioning
Strengths and Weaknesses of the Teaching
Feature
The questionnaire asked neurologists and neurosurgeons to identify, if possible, particularly valuable features of their clinical teaching, and also weak points and difficulties (Tables 6 and 7: only features mentioned twice or more have been included).
Good integration between neurology/ neurosurgery/neuropathology/
neuroradiology Ability to teach in small groups Participationin preclinical teaching Good clinical material
5 5 4
4
Discussion We do not propose to comment upon the data in any detail: neurologists, neurosurgeons and curriculum planners may draw their own conclusions. We would like to highlight only three areas. Problems in optimizing the clinical attachment (e.g., making it long enough, full-time and available for all students) constitute the most commonly identified difficulty in teaching neurology and neurosurgery, emphasizing its importance. The preponderance of neurology over neurosurgery in the clinical attachment is probably appropriate for undergraduates, but the exclusion of neurosurgery, which occurs in at least eight schools (and which is regarded as a weak point of the teaching programme in five) cannot be satisfactory. Regarding teaching methods, there is some agreement that lectures are overused and that students would benefit from additional clinical teaching in small groups, especially using out-patients. Respondents who had achieved what they regarded as a well-integrated course, with neurologists and neurosurgeons (and often neuropathologists and neuroradiologists as well) teaching in a coordinated fashion, invariably reported it as satisfactory. Finally, no fewer than 10 returns reported dissatisfaction with the assessment arrangements. T h e general lack of formal assessment in the specialty means that students may not have the opportunity for selfassessment, and moreover, the incentive value of an examination is lost. The question of the desirability of students’ qualifying in medicine without having been
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Table 7. Weak points and difficulties in the teaching of neurology and neurosurgery. ~
Number of medical schools mentioning
Feature Something wrong with the clinical attachment (too short: ‘mixed’; not for all students) Not enough teachedtoo many students Curriculum problems (planners unsympathetic: overcrowded: curriculum too complex: out of control of professors) No neurosurgery Neurology and neurosurgery not integrated Lectures not a useful teaching method Neurology teaching too early in the course
12 11
11 5 3
3 3
formally and systematically assessed in neurology is one which needs further discussion. References General Medical Council, Basic Medical Education in the Brztirh Isles. Vols 1 and 2, The Report of the General Medical Council Survey, Nuffield Provincial Hospitals Trust, London, 1977. Health T r e n h , HMSO. London, August 1977. NHS, Staffing Figures, HMSO. London, 30 September 1971.
Medical Teacher Vol 1 No 2 1979
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CONFEKENCE REPORTS
The Great American Dream Shrinks a Little American Government thinking about the future of medical education was outlined by Joseph Califano, Secretary of the US Department of Health, Education and Welfare, addressing the American Association of Medical Colleges meeting in New Orleans. Health care is America’s third largest Industry. In 1978 it used some 180 billion dollars and almost six per cent of the national work force; by the year 2000 health costs are expected to reach one trillion dollars and 12 per cent of the entire gross national product. And the decisions taken by individual physicians account for 70 per cent of all such expenditure. Califano’s first message was clear-“The men and women you train today and tomorrow will make decisions governing several trillion dollars of our Gross National Product over the next two decades”.
Oversupply of Physicians Imminent The number of US medical school graduates has virtually doubled, from some 8,000 in 1963 to more than 15,000 in 1978, in response to concern during the early 1960s about an impending physician shortage. With the influx of foreign medical graduates, the number of doctors in active practice increased by 46 per cent between 1960 and 1975, the ratio of doctors to population increasing from 143 to 177 per 100,000 people. Califano stated that the first tenet of national policy in this area is that an oversupply of physicians is immi-
Medical Teacher Vol 1 N o 2 1979
nent. Depending on how one estimates need for physicians, an excess of 23,000 to 150,000 doctors is predicted by 1990, with 594,000 active doctors in practice, 242 per 100,000 of the population. The second major problem is that “we are producing too many medical specialists and subspecialists, such as surgeons, and there is a corresponding and disturbing decline in the proportion of primary care physicians”. Califano concluded, from a number of studies, that “as the number of surgeons rises in an area, the number of operations also goes up-with no clear evidence that all this extra surgery is necessary”. The USA has twice as many surgeons as England and Wales, for instance, and twice the surgery rate. In some parts of Maine where the ratio of surgeons to population is highest, the number of gall bladder operations is more than double the number performed in other parts of the State. Other studies suggest that the greater the number of surgeons in an area, the higher the surgeon’s fees. Califano voiced his concern about the decline in primary care. In 1931, fully 94 per cent of practising doctors in the USA were in full-time primary care. By 1975 that proportion had fallen to 38 per cent, compared with 72 per cent in West Germany and 60 per cent in Canada. Despite considerably greater efforts to reduce this trend in the last decade, it seems that only 35 to 40 per cent of doctors now in training in America are completing residency programmes in primary care fields. Distribution problems abound. Despite the “excess medical manpower”, more than 25 million Americans live in underserved areas with fewer than one doctor for every 2,000 people. The percentage of doctors practising in such areas actually fell between 1963 and 1976. In the areas with excellent doctor/ patient ratios (better than 1 to 300) the percentage increased sharply. So the rich get richer and the poor poorer. Britain, Germany, and Canada are experiencing similar problems. The next major problem Califano identified was the need for medical schools to be far more active in making physicians responsive to
demographic, social and economic changes -the ‘graying’ of America (the increasing proportion of the population over 65 years old); the need for greater emphasis on chronic and long-term rather than acute conditions, on palliative and rehabilitative rather than curative practice; the increasing importance of emotional and psychosocial problems; the need to learn to work with other varieties of health care personnel and to be more sensitive to ethical issues.
Action t o Deal with Problems Califano proposed action to deal with these problems. Federal funding and incentives will be realigned. Schools will be encouraged to reduce gradually the size of classes. It is extremely unlikely that new schools will be created, and strong opposition to the admission of foreign graduates will be continued. Efforts to increase the production of primary care physicians will gain more support, and Departments of Family Medicine can expect more funding and encouragement. Geographic maldistribution will be tackled by increased support and scholarships for the National Health Service Corps (an internal-service version of the Peace Corps); by encouraging the admission to medical school of students from underserved areas; and by clinical rotations in community health centres during training. Psychosocial, ethical and economic aspects of health care should receive more emphasis, too. Califano’s news may not have been uniformly welcome to all who heard him, but he is to be commended for his directness, his realism and his optimism. “We are approaching the day” he said “in health care as in the field of energy when we simply cannot sustain the costs of chromefinned, gas-guzzling, option-rich technology. ” At long last, it appears that we are talking about planning medical education on the basis of a realistic assessment of health care problems, apart from a few romantic rhetorical flourishes. 93
