Journal of the Royal Society of Medicine Volume 71 May 1978
373
Evidence from other countries would suggest that externally imposed continuing education, even if in the guise of a carrot such as the maintenance of seniority awards, is not really effective. Real personal motivation is necessary for new material to have the biggest impact and for it to be most effectively retained. Group activity, generally speaking, by examining what is done within the group, can throw up problems which each member of the group feels he would like to have answered. 'Audit' is the current word for this sort of activity, but it is much easier for a group to start by setting up its own series of professional objectives; then each member can determine whether he or she reaches them - if not, why, and what should be altered? Nearly always this type of audit consists in an examination of the process of medical care, not of the outcome. Ideally, in my view, we should be developing methods of assessing outcome, of comparing outcome results between individuals or teams, and of ascertaining whether any significant differences occur and if so why. Doctors who expose their activities and results to this sort of inspection - not for any censorious reason, but in order to improve their professional performance - are bound to find from time to time that in whole areas of medical knowledge they need updating. If it is a simple matter the updating can be done in the library, but it would often entail a literature search which would be too time-consuming. If a body like the Open University were to develop packages which dealt specifically with growing areas of medical knowledge (one package, one subject) and the implications in diagnosis and therapy, it might provide a ready and effective means of filling the gap which the individual has perceived. I have no idea whether this sort of development would be sensible or practicable but, with the growing importance of updating, and with all the calls on a doctor's time, ways must be found to enable him to keep abreast of new developments with the least amount of effort. I would conclude, therefore, by suggesting that the OU could in principle be of considerable help to existing medical schools, and that involvement in this way in undergraduate medical education would be more efficient than by an attempt to organize the whole of an individual's undergraduate medical education through its own medical school or faculty. In the postgraduate field it could help immensely in the field of basic sciences, and it might well be able to extend its sphere of activities beyond this. The development of learning packages for the purposes of updating might be useful and financially feasible. The expenses are great. Start with what seems to be the most likely to be successful and, if it is, build on that. The Open University: teaching laboratory medicine
Professor D L Gardner MD FRCPath Department of Histopathology, University of Manchester The purpose of this paper is to examine the possibility that the methods of the Open University can be used to teach the preclinical and paraclinical subjects that, it is widely accepted, comprise the early part of the European medical student curriculum. Whether there is a need for this new approach to medical education, whether the present structure of the Open University permits such an approach, and whether it is politically and financially expedient for the country to embark on this experiment - these are matters that have been dealt with by other speakers in this symposium. In this paper I shall deliberately set on one side the problems of clinical teaching and of the access to hospitals that are central to medical and dental education and I shall concentrate wholly upon the question of pre- and paraclinical teaching where solutions are more easily obtained. Obviously, none of us has experience of teaching within the Open University itself- for our present purpose we must argue from the practice that we have obtained in more conventional media. In most British medical schools up to 150 students attend a six-year (or in a growing number of instances a five-year) medical course in which years 2(1) and 3(2) are largely nonclinical. The 0 1 41-0768/78/0071-0373/$O 1.00/0
((7) The Royal Society of Medicine 1978
374
Journal of the Royal Society of Medicine Volume 71 May 1978
introduction to patients and their problems is begun methodically early in year 3(2); year 4(3), in many British schools, is an integrated paraclinical/clinical period; and years 5(4) and 6(5) are divided between the minor and major clinical specialties, with practical time widely divided between different teaching hospitals. Pathology and microbiology are presented as an intrQductory general course in the second and third terms of the 3rd(2nd) year in which lectures and practical classes are combined. The systematic study of the organ diseases in the 4th(3rd) year, coordinated by committees that cross departmental barriers, employs a balance of lectures, small group tutorials, practical classes and demonstrations, and clinicopathological conferences. Seeking to improve and amplify the impact of current clinical problems on this conventional programme, a new series of discussion groups were begun in the Queen's University of Belfast in 1972. On the basis of the long experience of the Royal Postgraduate Medical School with 'lunchtime' post-mortem demonstrations, we offered daily, voluntary presentations of a similar kind. The student response was slight, the effect of the demonstrations minimal. We then borrowed two cheap black-and-white TV cameras and three monitors and used them to discuss X-rays, electrocardiograms, gross morbid anatomical specimens and cryostat sections from cases of current diagnostic importance. Teacher, class and material were together within the old mortuary amphitheatre of the Royal Victoria Hospital. The results exceeded our expectations: interest was intense, attendance very high and rapport excellent. For four years, an average of 150 clinical cases was discussed publicly each year. For two years, the total capital costs amounted to £1372, with no payment of salaries for audiovisual staff. Subsequently, a further £17 000 was invested in colour cameras, monitors and videorecorders. The central University audiovisual unit was able to maintain and repair equipment and no special departmental audiovisual staff proved necessary. There is no doubt from this experience that television programmes can present the teaching of systematic undergraduate pathology and microbiology in an acceptable way. There is no reason to doubt that, with equal facility, they can be used to present the theoretical aspects and practical demonstrations that form the core of the other preclinical and paraclinical subjects of the medical and dental curricula. To provide an entire course, albeit supplemented for learning and revision purposes by tape, slide and textbook methods, calls for much live, practical experience and for more student/teacher contact than can be provided by the present form of Open University course. Anatomy, for example, is of limited value to the surgeon unless learnt, in part at least, by dissection. The growth and behaviour of microorganisms, central to clinical diagnosis, can best be understood by making blood agar plates and testing antibiotic sensitivities. The response of the vascular system to catecholamines and to inflammatory agents can be understood when displayed by closed circuit TV, but can only properly be translated to the patient when tested personally in a live situation. How can these requirements be reconciled with the limitations of the Open University? 'Don't speculate - try the experiment!' Surely this dictates the next step in the debate that prevails today. Let us conduct a controlled trial to see whether an amalgam of Open University technology with contemporary classroom methods can be used to allow effective medical learning. In place of the TV monitors that relay our own classroom experiments, let us install monitors to transmit the central programmes prepared by the Open University. In place of our own lectures, let us relay the lecture/demonstrations of the Open University medical faculty. In place of our textbooks, let us use those prepared by the Open University. Many of the classrooms of all British medical schools lie idle for much of the day, and for many weeks in the year. Let us find an existing medical school, solicit help, offer payment and use a classroom to teach in this way. A medical school where the large classes are already divided or where classes must already be repeated, offers the most ready site. An existing student group, perhaps one year of a large school, will be divided into two parts by a method that avoids bias but which ensures that participation in the experiment does not mitigate against subsequent academic progress. One half of the class will learn, say pharmacology, by current teaching methods; the other half will be taught with the media of the Open University.
Journal of the Royal Society of Medicine Volume 71 May 1978
375
At the end of a semester, or year, the results of the trial will be assessed by the most appropriate examination methods. Alternatively, a cohort of students will be divided into four groups: one to attend the whole conventional teaching programme in a preclinical subject; one to attend the whole programme of the Open University; and the remaining two groups to attend one half of each programme, combining, for example, conventional lectures with Open University classroom demonstrations. The choice of the participating medical school would rest upon the successful outcome of negotiations between the Open University, the UGC, the General Medical Council, and the vice-chancellor and medical dean of a receptive established medical school. The cost of an experiment of this kind would be small compared to the cost of building a whole Open University medical faculty and curriculum. As a way of resolving the debate on the role of the Open University in medical education, and perhaps of securing the strongest possible support for a future comprehensive medical or dental programme, it appears possible that the Department of Education and Science (DES) would welcome the opportunity such an experiment could offer. The political issues that lie behind this paper and its proposals are beyond the sphere of my influence. I can do no more than draw the attention of this symposium, of the Open University and of the DES to the practicability of determining, by experiment, the feasibility of using the resources of the Open University to establish a medical faculty, to teach medicine and to supplement the country's existing resources in undergraduate and postgraduate medical and dental education. Using existing techniques it would seem that the Open University could teach the anatomy, physiology, biochemistry, psychology, genetics, immunology, pathology, pharmacology and microbiology necessary for a conventional European preclinical medical (and dental) curriculum. The theoretical presentations (lecture-demonstrations, tutorials, seminars) of the Open University would require more practical work in support than is customary in an Open University course. The practical facilities could be obtained by the use of the classrooms of existing medical and dental schools, most of them at present grossly under-used. The best approach to the solution of an educational or scientific problem is to conduct an experiment. I therefore propose that the Department of Education and Science persuade a large medical school to divide one cohort of its students into two or into four parts for a period of one semester or one year, comparing the efficacy of the present curriculum with that of a curriculum wholly or partly provided by the Open University. The experiment might require repetition over a three- or five-year period and would have to be without detriment to a student's progress in the remainder of the medical curriculum. There exist in the UK medical schools sufficiently large to sustain the experiment that is proposed: some have already divided their classes in the manner necessary for this trial, or could do so. The completion of this experiment, and the experience obtained would help to answer the question: 'Has the Open University a role in medical education?' The answer may prove to be as important for postgraduate as for undergraduate teaching, as relevant to underdeveloped as to European communities. It cannot fail to be of interest.
Acknowledgments: I am most grateful to Dr J McClure of the Queen's University of Belfast, who greatly helped with early experiments on the use of closed circuit television in medical education. My investigations have been supported by the Nuffield Foundation and I am glad to acknowledge their invaluable help. References Gardner D L (1975) Proceedings of the Association of Clinical Tutors Gardner D L & McClure J (1976) Proceedings of the Pathological Society of Great Britain and Ireland, p 30, paper 42
373
Evidence from other countries would suggest that externally imposed continuing education, even if in the guise of a carrot such as the maintenance of seniority awards, is not really effective. Real personal motivation is necessary for new material to have the biggest impact and for it to be most effectively retained. Group activity, generally speaking, by examining what is done within the group, can throw up problems which each member of the group feels he would like to have answered. 'Audit' is the current word for this sort of activity, but it is much easier for a group to start by setting up its own series of professional objectives; then each member can determine whether he or she reaches them - if not, why, and what should be altered? Nearly always this type of audit consists in an examination of the process of medical care, not of the outcome. Ideally, in my view, we should be developing methods of assessing outcome, of comparing outcome results between individuals or teams, and of ascertaining whether any significant differences occur and if so why. Doctors who expose their activities and results to this sort of inspection - not for any censorious reason, but in order to improve their professional performance - are bound to find from time to time that in whole areas of medical knowledge they need updating. If it is a simple matter the updating can be done in the library, but it would often entail a literature search which would be too time-consuming. If a body like the Open University were to develop packages which dealt specifically with growing areas of medical knowledge (one package, one subject) and the implications in diagnosis and therapy, it might provide a ready and effective means of filling the gap which the individual has perceived. I have no idea whether this sort of development would be sensible or practicable but, with the growing importance of updating, and with all the calls on a doctor's time, ways must be found to enable him to keep abreast of new developments with the least amount of effort. I would conclude, therefore, by suggesting that the OU could in principle be of considerable help to existing medical schools, and that involvement in this way in undergraduate medical education would be more efficient than by an attempt to organize the whole of an individual's undergraduate medical education through its own medical school or faculty. In the postgraduate field it could help immensely in the field of basic sciences, and it might well be able to extend its sphere of activities beyond this. The development of learning packages for the purposes of updating might be useful and financially feasible. The expenses are great. Start with what seems to be the most likely to be successful and, if it is, build on that. The Open University: teaching laboratory medicine
Professor D L Gardner MD FRCPath Department of Histopathology, University of Manchester The purpose of this paper is to examine the possibility that the methods of the Open University can be used to teach the preclinical and paraclinical subjects that, it is widely accepted, comprise the early part of the European medical student curriculum. Whether there is a need for this new approach to medical education, whether the present structure of the Open University permits such an approach, and whether it is politically and financially expedient for the country to embark on this experiment - these are matters that have been dealt with by other speakers in this symposium. In this paper I shall deliberately set on one side the problems of clinical teaching and of the access to hospitals that are central to medical and dental education and I shall concentrate wholly upon the question of pre- and paraclinical teaching where solutions are more easily obtained. Obviously, none of us has experience of teaching within the Open University itself- for our present purpose we must argue from the practice that we have obtained in more conventional media. In most British medical schools up to 150 students attend a six-year (or in a growing number of instances a five-year) medical course in which years 2(1) and 3(2) are largely nonclinical. The 0 1 41-0768/78/0071-0373/$O 1.00/0
((7) The Royal Society of Medicine 1978
374
Journal of the Royal Society of Medicine Volume 71 May 1978
introduction to patients and their problems is begun methodically early in year 3(2); year 4(3), in many British schools, is an integrated paraclinical/clinical period; and years 5(4) and 6(5) are divided between the minor and major clinical specialties, with practical time widely divided between different teaching hospitals. Pathology and microbiology are presented as an intrQductory general course in the second and third terms of the 3rd(2nd) year in which lectures and practical classes are combined. The systematic study of the organ diseases in the 4th(3rd) year, coordinated by committees that cross departmental barriers, employs a balance of lectures, small group tutorials, practical classes and demonstrations, and clinicopathological conferences. Seeking to improve and amplify the impact of current clinical problems on this conventional programme, a new series of discussion groups were begun in the Queen's University of Belfast in 1972. On the basis of the long experience of the Royal Postgraduate Medical School with 'lunchtime' post-mortem demonstrations, we offered daily, voluntary presentations of a similar kind. The student response was slight, the effect of the demonstrations minimal. We then borrowed two cheap black-and-white TV cameras and three monitors and used them to discuss X-rays, electrocardiograms, gross morbid anatomical specimens and cryostat sections from cases of current diagnostic importance. Teacher, class and material were together within the old mortuary amphitheatre of the Royal Victoria Hospital. The results exceeded our expectations: interest was intense, attendance very high and rapport excellent. For four years, an average of 150 clinical cases was discussed publicly each year. For two years, the total capital costs amounted to £1372, with no payment of salaries for audiovisual staff. Subsequently, a further £17 000 was invested in colour cameras, monitors and videorecorders. The central University audiovisual unit was able to maintain and repair equipment and no special departmental audiovisual staff proved necessary. There is no doubt from this experience that television programmes can present the teaching of systematic undergraduate pathology and microbiology in an acceptable way. There is no reason to doubt that, with equal facility, they can be used to present the theoretical aspects and practical demonstrations that form the core of the other preclinical and paraclinical subjects of the medical and dental curricula. To provide an entire course, albeit supplemented for learning and revision purposes by tape, slide and textbook methods, calls for much live, practical experience and for more student/teacher contact than can be provided by the present form of Open University course. Anatomy, for example, is of limited value to the surgeon unless learnt, in part at least, by dissection. The growth and behaviour of microorganisms, central to clinical diagnosis, can best be understood by making blood agar plates and testing antibiotic sensitivities. The response of the vascular system to catecholamines and to inflammatory agents can be understood when displayed by closed circuit TV, but can only properly be translated to the patient when tested personally in a live situation. How can these requirements be reconciled with the limitations of the Open University? 'Don't speculate - try the experiment!' Surely this dictates the next step in the debate that prevails today. Let us conduct a controlled trial to see whether an amalgam of Open University technology with contemporary classroom methods can be used to allow effective medical learning. In place of the TV monitors that relay our own classroom experiments, let us install monitors to transmit the central programmes prepared by the Open University. In place of our own lectures, let us relay the lecture/demonstrations of the Open University medical faculty. In place of our textbooks, let us use those prepared by the Open University. Many of the classrooms of all British medical schools lie idle for much of the day, and for many weeks in the year. Let us find an existing medical school, solicit help, offer payment and use a classroom to teach in this way. A medical school where the large classes are already divided or where classes must already be repeated, offers the most ready site. An existing student group, perhaps one year of a large school, will be divided into two parts by a method that avoids bias but which ensures that participation in the experiment does not mitigate against subsequent academic progress. One half of the class will learn, say pharmacology, by current teaching methods; the other half will be taught with the media of the Open University.
Journal of the Royal Society of Medicine Volume 71 May 1978
375
At the end of a semester, or year, the results of the trial will be assessed by the most appropriate examination methods. Alternatively, a cohort of students will be divided into four groups: one to attend the whole conventional teaching programme in a preclinical subject; one to attend the whole programme of the Open University; and the remaining two groups to attend one half of each programme, combining, for example, conventional lectures with Open University classroom demonstrations. The choice of the participating medical school would rest upon the successful outcome of negotiations between the Open University, the UGC, the General Medical Council, and the vice-chancellor and medical dean of a receptive established medical school. The cost of an experiment of this kind would be small compared to the cost of building a whole Open University medical faculty and curriculum. As a way of resolving the debate on the role of the Open University in medical education, and perhaps of securing the strongest possible support for a future comprehensive medical or dental programme, it appears possible that the Department of Education and Science (DES) would welcome the opportunity such an experiment could offer. The political issues that lie behind this paper and its proposals are beyond the sphere of my influence. I can do no more than draw the attention of this symposium, of the Open University and of the DES to the practicability of determining, by experiment, the feasibility of using the resources of the Open University to establish a medical faculty, to teach medicine and to supplement the country's existing resources in undergraduate and postgraduate medical and dental education. Using existing techniques it would seem that the Open University could teach the anatomy, physiology, biochemistry, psychology, genetics, immunology, pathology, pharmacology and microbiology necessary for a conventional European preclinical medical (and dental) curriculum. The theoretical presentations (lecture-demonstrations, tutorials, seminars) of the Open University would require more practical work in support than is customary in an Open University course. The practical facilities could be obtained by the use of the classrooms of existing medical and dental schools, most of them at present grossly under-used. The best approach to the solution of an educational or scientific problem is to conduct an experiment. I therefore propose that the Department of Education and Science persuade a large medical school to divide one cohort of its students into two or into four parts for a period of one semester or one year, comparing the efficacy of the present curriculum with that of a curriculum wholly or partly provided by the Open University. The experiment might require repetition over a three- or five-year period and would have to be without detriment to a student's progress in the remainder of the medical curriculum. There exist in the UK medical schools sufficiently large to sustain the experiment that is proposed: some have already divided their classes in the manner necessary for this trial, or could do so. The completion of this experiment, and the experience obtained would help to answer the question: 'Has the Open University a role in medical education?' The answer may prove to be as important for postgraduate as for undergraduate teaching, as relevant to underdeveloped as to European communities. It cannot fail to be of interest.
Acknowledgments: I am most grateful to Dr J McClure of the Queen's University of Belfast, who greatly helped with early experiments on the use of closed circuit television in medical education. My investigations have been supported by the Nuffield Foundation and I am glad to acknowledge their invaluable help. References Gardner D L (1975) Proceedings of the Association of Clinical Tutors Gardner D L & McClure J (1976) Proceedings of the Pathological Society of Great Britain and Ireland, p 30, paper 42
