1048
The core curriculum: defined?
can
it be
In 1980 the British General Medical Council recommended that the factual content of undergraduate courses should be reduced. Almost nothing has happened. Now a consultation paper to deans from the education committee of the GMC gives notice that next year will see further strong recommendations "to liberate the curriculum from the oppression of its factual overload". The difference this time is that medical schools will probably be obliged through an audit process to make changes. Whilst few disagree that factual overload must be dealt with, the unpacking of a medical curriculum is a daunting task. Especially in good basic-science departments and teaching hospitals the excitement of new knowledge, the presence of research units, and the curiosity of students to learn as much as they can of scientific medicine combine to pack curricula ever tighter. Who is to say what not to teach? Various solutions have been proposed, but one that now finds favour with many innovators and reform advocates is that of the core plus options, roughly in the ratio of 2:1 in the total course.1 This is not a new concept, and many medical schools already have an optional element in the form of electives and projectsin-depth. The optional part of an innovative curriculum is in reality the easier part to put in place, and most faculties should be able to muster the 30 or so projects that the GMC believes necessary to provide students with experience of learning in depth. It is in defining what should or should not be core material that great difficulties lie. The first step must be to define the objectives of the core curriculum-in other words, what sort of person the newly qualified doctor should be. Agreement even on this basic point may be elusive. The GMC that the suggests newly qualified doctor should have an understanding of health and disease, coupled with an attitude of learning based on curiosity and the exploration of knowledge. This is fine language but it does not define precisely what knowledge and skills are required by the preregistration house officer. Thus far, there have been few serious attempts to define the detailed content of a core curriculum, although several possible methods have been suggested.2 The first method (perhaps the only totally logical one) is to examine what is common to all branches of medicine. This common material must be the true core, essential to all undergraduates and relevant to their futures wherever they may be. Now imagine a group of doctors-let us say a psychiatrist, a urologist, a general practitioner, a public health officer, and a chemical pathologist-sitting down to discover their common essential core. After many hours this group might conclude that they shared only a vanishingly small amount of legal and ethical knowledge and communication skills-hardly sufficient to occupy a five or six year curriculum.
Clearly, long established doctors are going to fmd it difficult to define the core, having been shaped by years of postgraduate specialisation. What about asking junior doctors, lately qualified? Readers may like to try a straw poll amongst house staff asking whether certain specific items should be included in the core undergraduate curriculum. They may be surprised by the results. Central items such as acid-base balance are rejected by many young doctors. Few seem to value pathology. Even aspects often highlighted by educational reformists as being currently under-represented--communication skills, social medicine, rehabilitation-receive scant enthusiasm. What they want most in the undergraduate core is instruction in practical management, and who can blame them? But it is a far cry from the sort of curriculum envisaged by innovators. As regards the basic science element of the core, one suggestion has been to ask experienced practising doctors what they actually use in day-to-day clinical work from their cerebral databases.3Disappointingly the franker doctors will admit that precious little basic science is consciously rehearsed as they work, most of what they do being based on pattern recognition and experience. Maybe these experienced clinicians are likewise ill-equipped to reveal the core. Perhaps the best hope lies in an analysis of all the material needed to manage common clinical problems and critical incidents4,5-sore throat, abdominal pain, breathlessness, cardiac arrest, shock-and making this the basis of the core. This approach has the great virtue of relevance and it can be adapted to embrace much beyond the narrow scientific aspects. But where are the limits, and how can a keen selfmotivated student be kept within them? In no time a problem-solving student working on a case of abdominal pain could be lost in the biochemistry of porphyria. Should the library supply masking tape or warning notices to keep the student away from this minefield? To conclude, in the unlikely event of a detailed core curriculum being agreed locally, let alone nationally, how would it be put into effect? Teachers are hardly going to strike out paragraphs from their lectures or to stop in mid tutorial. Clinicians will not avoid showing their students rare conditions, which can often illuminate routine clinics and ward rounds. The core-plus-options curriculum is most likely to succeed if accompanied by a radical restructuring of the complete undergraduate course, which is what the GMC and many others are now talking about6(see p 1071). Henry James wrote, "experience is never limited, and it is never complete". This is exactly the philosophy we are trying to inculcate in our students: to erect fences and no-go areas is retrograde. 1. Towle A. Critical thinking: the future of undergraduate medical education. London: King’s Fund Centre, 1991.
1049
2. McManus IC, Wakeford RE. A core medical curriculum. Br Med J 1989; 298: 1051. 3. Charlton BG. Practical reform of pre-clinical education: core curriculum and science projects. Med Teacher 1991; 13: 21-22. 4. Editorial. Critical questions, critical incidents, critical answers. Lancet 1988; i: 1373-74. 5. Hayes DM, Fleury RA, Jackson TB. Curriculum content from critical incidents. Med Educ 1979; 13: 175-82. 6. Fraser RC. Undergraduate medical education: present state and future needs. Br Med J 1991; 303: 41-43. 7. Godfrey RC. Designing a doctor: all change? Lancet 1991; 338: 297-99.
Management of childhood fever Fever, a component of inflammation in all animals, is
now
coming
to
be understood
at
the molecular
leve1.1 Mammalian temperature is maintained by
a
self-regulating feedback mechanism that is present early in infancy: temperature rises throughout the waking hours and falls during sleep between the range of 36-5 and 37-5°C. The set point of this thermostat is raised by several activators including infective agents, immune complexes, and cytokines. That the febrile response has been preserved throughout evolution suggests a protective advantage; but, in children, antipyresis does not seem to prolong the illness or adversely affect outcome.2-6 Fever is a symptom not a diagnosis; it is important to diagnose the underlying condition promptly and not to over-investigate. The great majority of febrile children will have a non-bacterial upper respiratory tract infection and the widespread use of antibiotics is inappropriate, ineffective, and ecologically dangerous. The worry for parents is that, if uncontrolled, fever may spiral upwards to fatal outcome.’ Parents and professionals are also alarmed by the threat of febrile convulsions. Such convulsions are usually short-lived and self-limiting; they occur in 4% of all children and recur in one-third. There is no evidence that longterm anticonvulsant therapy reduces these figures8 nor that uncomplicated febrile convulsions lead to brain damage. It is severe uncontrolled febrile convulsions that cause brain damage and subsequent
epilepsy.9 In the absence of evidence that antipyresis is harmful, suggestions that febrile children should be left to get better and not be given antipyretics are not valid. They are as inappropriate in modem consumer society as the proposition that mothers should labour without pain relief. A child with a temperature of over 39°C will be uncomfortable, irritable, and anorectic. Physical methods of temperature control such as tepid sponging, fanning, or ice-water enemas are effective in the short term but increase the child’s discomfort and encourage temperature-conserving behaviour so cannot be recommended for children.1O The first pharmacological agents known to control fever were derived from willow and cinchona barkacetanilide, phenacetin, aspirin, and paracetamol (acetaminophen) were all synthesised before the turn of the century. Within the past 25 years all these drugs
have
shown to have toxic side-effects (nephrotoxicity with phenacetin; intestinal bleeding and Reye’s syndrome with aspirin; hepatotoxicity with paracetamol). Removal of aspirin from the paediatric pharmacopoeia in 1986 left paracetamol as the only antipyretic available for children. Accidental deaths from acute paracetamol poisoning have alerted pharmacists to ignorance among the general public about the widespread incorporation of paracetamol in proprietary remedies that are freely available over the counter Y Hepatotoxicity and fatal paracetamol poisoning in children are extremely rare, but recent scrutiny of Australian prescribing has suggested that chronic paracetamol poisoning is more of a danger.12 The margin of safety of frequent paracetamol dosing may be much lower than we thought. The main indication for prescribing an antipyretic is not to reduce the temperature but to relieve the child’s discomfort and thereby anxiety in the parents. Paracetamol is an analgesic antipyretic with little anti-inflammatory action. Propionic acid derivatives have both anti-inflammatory and antipyretic properties and have been increasingly used for childhood arthritis. Ibuprofen, the first of these drugs to be granted a product licence for treatment of childhood fever, has been administered in over 240 million doses to children without reported ill-effects13 and seems to have a high safety margin. It has a longer action than paracetamol (much appreciated by night nurses and mothers), rapid onset, and potent antiinflammatory antipyretic effects. Paracetamol can be given 4-6 hourly with a maximum of four doses in 24 hours. Many parents and nurses ignore this warning, giving 6-8 doses per day. At this level of dosing there is no cost difference between paracetamol and ibuprofen. It is unclear why ibuprofen suspension should cost twice as much as ibuprofen syrup per 100 mg and also unclear why the suspension initially needed sucrose and the azo-dye sunset yellow; a sugar and colour free preparation has now been made available. Thus the paediatric pharmacopoeia once again offers a choice in its range of antipyretics and it may be just a matter of time before other non-steroidal anti-inflammatory preparations are offered. It remains to be seen whether they will supplant paracetamol, or whether experience will temper enthusiasm. been
1. Dinarello CA, Cannon JG, Wolff S. New concepts on the pathogenesis of fever. Rev Infect Dis 1988; 10: 168-89. 2. Bennett IL Jr, Nicastri A. Fever as a mechanism of resistance. Bacteriol
Rev 1960; 24: 16-34. 3. Atkins A. Fever-new perspectives on an old phenomenon. N Engl J Med 1983; 308: 958-60. 4. Muzenberger JP, Royayo JR, del Valle J. Effect of antipyretics on the length of hospital stay of pediatric patients with bacterial infection. Am J Hosp Pharm 1981; 38: 861-63. 5. Doran TF, deAngelis C, Baumgartner RA, et al. Acetaminophen: more harm than good for chicken pox? J Pediatr 1989; 114: 1045-48. 6. Kramer MS, Naimark LE, Roberts-Brauer R, et al. Risks and benefits of paracetamol antipyresis in young children with fever of presumed viral origin. Lancet 1991; 337: 591-94. 7. Parks YP, Sunderland R. Sudden febrile infant death. Lancet 1986; i: 744-45.
The core curriculum: defined?
can
it be
In 1980 the British General Medical Council recommended that the factual content of undergraduate courses should be reduced. Almost nothing has happened. Now a consultation paper to deans from the education committee of the GMC gives notice that next year will see further strong recommendations "to liberate the curriculum from the oppression of its factual overload". The difference this time is that medical schools will probably be obliged through an audit process to make changes. Whilst few disagree that factual overload must be dealt with, the unpacking of a medical curriculum is a daunting task. Especially in good basic-science departments and teaching hospitals the excitement of new knowledge, the presence of research units, and the curiosity of students to learn as much as they can of scientific medicine combine to pack curricula ever tighter. Who is to say what not to teach? Various solutions have been proposed, but one that now finds favour with many innovators and reform advocates is that of the core plus options, roughly in the ratio of 2:1 in the total course.1 This is not a new concept, and many medical schools already have an optional element in the form of electives and projectsin-depth. The optional part of an innovative curriculum is in reality the easier part to put in place, and most faculties should be able to muster the 30 or so projects that the GMC believes necessary to provide students with experience of learning in depth. It is in defining what should or should not be core material that great difficulties lie. The first step must be to define the objectives of the core curriculum-in other words, what sort of person the newly qualified doctor should be. Agreement even on this basic point may be elusive. The GMC that the suggests newly qualified doctor should have an understanding of health and disease, coupled with an attitude of learning based on curiosity and the exploration of knowledge. This is fine language but it does not define precisely what knowledge and skills are required by the preregistration house officer. Thus far, there have been few serious attempts to define the detailed content of a core curriculum, although several possible methods have been suggested.2 The first method (perhaps the only totally logical one) is to examine what is common to all branches of medicine. This common material must be the true core, essential to all undergraduates and relevant to their futures wherever they may be. Now imagine a group of doctors-let us say a psychiatrist, a urologist, a general practitioner, a public health officer, and a chemical pathologist-sitting down to discover their common essential core. After many hours this group might conclude that they shared only a vanishingly small amount of legal and ethical knowledge and communication skills-hardly sufficient to occupy a five or six year curriculum.
Clearly, long established doctors are going to fmd it difficult to define the core, having been shaped by years of postgraduate specialisation. What about asking junior doctors, lately qualified? Readers may like to try a straw poll amongst house staff asking whether certain specific items should be included in the core undergraduate curriculum. They may be surprised by the results. Central items such as acid-base balance are rejected by many young doctors. Few seem to value pathology. Even aspects often highlighted by educational reformists as being currently under-represented--communication skills, social medicine, rehabilitation-receive scant enthusiasm. What they want most in the undergraduate core is instruction in practical management, and who can blame them? But it is a far cry from the sort of curriculum envisaged by innovators. As regards the basic science element of the core, one suggestion has been to ask experienced practising doctors what they actually use in day-to-day clinical work from their cerebral databases.3Disappointingly the franker doctors will admit that precious little basic science is consciously rehearsed as they work, most of what they do being based on pattern recognition and experience. Maybe these experienced clinicians are likewise ill-equipped to reveal the core. Perhaps the best hope lies in an analysis of all the material needed to manage common clinical problems and critical incidents4,5-sore throat, abdominal pain, breathlessness, cardiac arrest, shock-and making this the basis of the core. This approach has the great virtue of relevance and it can be adapted to embrace much beyond the narrow scientific aspects. But where are the limits, and how can a keen selfmotivated student be kept within them? In no time a problem-solving student working on a case of abdominal pain could be lost in the biochemistry of porphyria. Should the library supply masking tape or warning notices to keep the student away from this minefield? To conclude, in the unlikely event of a detailed core curriculum being agreed locally, let alone nationally, how would it be put into effect? Teachers are hardly going to strike out paragraphs from their lectures or to stop in mid tutorial. Clinicians will not avoid showing their students rare conditions, which can often illuminate routine clinics and ward rounds. The core-plus-options curriculum is most likely to succeed if accompanied by a radical restructuring of the complete undergraduate course, which is what the GMC and many others are now talking about6(see p 1071). Henry James wrote, "experience is never limited, and it is never complete". This is exactly the philosophy we are trying to inculcate in our students: to erect fences and no-go areas is retrograde. 1. Towle A. Critical thinking: the future of undergraduate medical education. London: King’s Fund Centre, 1991.
1049
2. McManus IC, Wakeford RE. A core medical curriculum. Br Med J 1989; 298: 1051. 3. Charlton BG. Practical reform of pre-clinical education: core curriculum and science projects. Med Teacher 1991; 13: 21-22. 4. Editorial. Critical questions, critical incidents, critical answers. Lancet 1988; i: 1373-74. 5. Hayes DM, Fleury RA, Jackson TB. Curriculum content from critical incidents. Med Educ 1979; 13: 175-82. 6. Fraser RC. Undergraduate medical education: present state and future needs. Br Med J 1991; 303: 41-43. 7. Godfrey RC. Designing a doctor: all change? Lancet 1991; 338: 297-99.
Management of childhood fever Fever, a component of inflammation in all animals, is
now
coming
to
be understood
at
the molecular
leve1.1 Mammalian temperature is maintained by
a
self-regulating feedback mechanism that is present early in infancy: temperature rises throughout the waking hours and falls during sleep between the range of 36-5 and 37-5°C. The set point of this thermostat is raised by several activators including infective agents, immune complexes, and cytokines. That the febrile response has been preserved throughout evolution suggests a protective advantage; but, in children, antipyresis does not seem to prolong the illness or adversely affect outcome.2-6 Fever is a symptom not a diagnosis; it is important to diagnose the underlying condition promptly and not to over-investigate. The great majority of febrile children will have a non-bacterial upper respiratory tract infection and the widespread use of antibiotics is inappropriate, ineffective, and ecologically dangerous. The worry for parents is that, if uncontrolled, fever may spiral upwards to fatal outcome.’ Parents and professionals are also alarmed by the threat of febrile convulsions. Such convulsions are usually short-lived and self-limiting; they occur in 4% of all children and recur in one-third. There is no evidence that longterm anticonvulsant therapy reduces these figures8 nor that uncomplicated febrile convulsions lead to brain damage. It is severe uncontrolled febrile convulsions that cause brain damage and subsequent
epilepsy.9 In the absence of evidence that antipyresis is harmful, suggestions that febrile children should be left to get better and not be given antipyretics are not valid. They are as inappropriate in modem consumer society as the proposition that mothers should labour without pain relief. A child with a temperature of over 39°C will be uncomfortable, irritable, and anorectic. Physical methods of temperature control such as tepid sponging, fanning, or ice-water enemas are effective in the short term but increase the child’s discomfort and encourage temperature-conserving behaviour so cannot be recommended for children.1O The first pharmacological agents known to control fever were derived from willow and cinchona barkacetanilide, phenacetin, aspirin, and paracetamol (acetaminophen) were all synthesised before the turn of the century. Within the past 25 years all these drugs
have
shown to have toxic side-effects (nephrotoxicity with phenacetin; intestinal bleeding and Reye’s syndrome with aspirin; hepatotoxicity with paracetamol). Removal of aspirin from the paediatric pharmacopoeia in 1986 left paracetamol as the only antipyretic available for children. Accidental deaths from acute paracetamol poisoning have alerted pharmacists to ignorance among the general public about the widespread incorporation of paracetamol in proprietary remedies that are freely available over the counter Y Hepatotoxicity and fatal paracetamol poisoning in children are extremely rare, but recent scrutiny of Australian prescribing has suggested that chronic paracetamol poisoning is more of a danger.12 The margin of safety of frequent paracetamol dosing may be much lower than we thought. The main indication for prescribing an antipyretic is not to reduce the temperature but to relieve the child’s discomfort and thereby anxiety in the parents. Paracetamol is an analgesic antipyretic with little anti-inflammatory action. Propionic acid derivatives have both anti-inflammatory and antipyretic properties and have been increasingly used for childhood arthritis. Ibuprofen, the first of these drugs to be granted a product licence for treatment of childhood fever, has been administered in over 240 million doses to children without reported ill-effects13 and seems to have a high safety margin. It has a longer action than paracetamol (much appreciated by night nurses and mothers), rapid onset, and potent antiinflammatory antipyretic effects. Paracetamol can be given 4-6 hourly with a maximum of four doses in 24 hours. Many parents and nurses ignore this warning, giving 6-8 doses per day. At this level of dosing there is no cost difference between paracetamol and ibuprofen. It is unclear why ibuprofen suspension should cost twice as much as ibuprofen syrup per 100 mg and also unclear why the suspension initially needed sucrose and the azo-dye sunset yellow; a sugar and colour free preparation has now been made available. Thus the paediatric pharmacopoeia once again offers a choice in its range of antipyretics and it may be just a matter of time before other non-steroidal anti-inflammatory preparations are offered. It remains to be seen whether they will supplant paracetamol, or whether experience will temper enthusiasm. been
1. Dinarello CA, Cannon JG, Wolff S. New concepts on the pathogenesis of fever. Rev Infect Dis 1988; 10: 168-89. 2. Bennett IL Jr, Nicastri A. Fever as a mechanism of resistance. Bacteriol
Rev 1960; 24: 16-34. 3. Atkins A. Fever-new perspectives on an old phenomenon. N Engl J Med 1983; 308: 958-60. 4. Muzenberger JP, Royayo JR, del Valle J. Effect of antipyretics on the length of hospital stay of pediatric patients with bacterial infection. Am J Hosp Pharm 1981; 38: 861-63. 5. Doran TF, deAngelis C, Baumgartner RA, et al. Acetaminophen: more harm than good for chicken pox? J Pediatr 1989; 114: 1045-48. 6. Kramer MS, Naimark LE, Roberts-Brauer R, et al. Risks and benefits of paracetamol antipyresis in young children with fever of presumed viral origin. Lancet 1991; 337: 591-94. 7. Parks YP, Sunderland R. Sudden febrile infant death. Lancet 1986; i: 744-45.
