Editorial Director: Dr Abraham Marcus Managing Editor: Anne Patterson Consultant Editor: Professor Michael A. Simpson
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Subeditor: Deirdre O’Flaherty
Editorial Department: Update Publications Ltd, 33/34 Alfred Place, London W C l E 7DP, England Tel: 01-637 4544 Subscription and Circulation Department: Update Publications Ltd, 2 High Street, Station Road, Petersfield, Hampshire, GU32 2JE, England Subscription Rates: Annual Subscription UK: E17.00 Overseas: €22.00 Air Mail: €27.00 Single Copies UK: E5.00 Overseas: €6.00
Contributions: Contributions are invited in the form of original papers, articles of discussion and comment on all aspects of health sciences education. Prospective contributors should write to the Managing Editor, Medical Teacher,Update Publications Ltd, 33/34 Alfred Place, London W C l E 7DP, England, before submitting manuscripts. Medical Teacher is published quarterly.
@ Update Publications Ltd, 1984 84
Too Many Applicants For Postgraduate Training Medical comparisons between the UK and the USA have a particular fascination because, as with language, we sometimes seem to be two nations separated by a common heritage and a common philosophy. Among the biggest of the problems we share are those of postgraduate training and medical manpower planning. The article “TOOmany applicants for available graduate medical education positions-are we on a collision course?”, by Richard Reitemeier of The Mayo Clinic provides a reaffirmation, from the American standpoint, of the inextricable relationship between training and manpower: ’ if you want to get medical manpower planning right, you must get the career structure right; and to get the career structure right, you must get postgraduate training right. You could just as well start from the other end, except it is no easier: if you get postgraduate training right, the career structure and everything else will fall into place. Either approach reveals that the interests of doctors, and those of the community, are not necessarily compatible nor well understood. Much of Reitemeier’s article is concerned with anxieties about placing US graduates in postgraduate training programmes of their choice. About 85-90 per cent of postgraduate training positions in the USA (first-year residency appointments) are arranged through the National Resident Matching Program. In 1983 there were 15,500 applicants for the matching programme, from medical schools in the USA, and only 8 per cent failed to match-not much of a problem for the doctors, in comparison to most countries, even though the number of US medical graduates has been rising while the number of available residency programmes has somewhat declined. Whether the specialty distribution of training opportunities for the doctors matches the best interests of society is another matter. Need is undefined, and demand is uncontrolled except through the market place. Graduates of medical schools not in the USA fared much worse in the 1983 matching process: only 51 per cent of US graduates from these medical schools succeeded, and only 25 per cent of foreign medical graduates. The article comments on quality control of foreign medical graduates, and of Americans who graduate outside the USA in ‘offshore’ schools, for example in the Caribbean. While 84 per cent of American and Canadian graduates achieve certification after postgraduate training in internal medicine, only about 25 per cent of foreign graduates do so. Attempts are made, notably in New York State, to find clinical clerkships for American students from offshore schools, but the procedures for ensuring adequate standards among these students clearly leave many loopholes and a great deal to be desired. Unsuccessful applicants seek training positions after the National Residency Match has been completed, and Reitemeier comments that “Some of the graduate medical education opportunities are in hospitals to which no US graduates apply and which, therefore, some Medical Teacher Vol6 No 3 1984
Med Teach Downloaded from informahealthcare.com by University of Alberta on 12/30/14 For personal use only.
members of the m e d i d education community suspect provide graduate medical education of a less than desirable quality”. He asks, “Should we set standards for entry into our graduate medical education programs that are the same for all candidates, accepting the fact that, as a result, many fewer foreign medical graduates will receive their training in the United States?”. But how would it be done? Who would set the standards for entry into a graduate training programme? How would the selection procedures be arranged, and who would monitor them? How well would individual specialists throughout the country comply with some form of national allocation procedure? The educationalists’ idealism has to meet the realities of providing a medical service. The qualifying doctor rapidly leaves the sheltered environment of personal surveillance, in which the weaker students get the best attention; even at the pre-registration stage he enters a market-world in which the best jobs tend to go to those who can best compete in their various ways. The ‘standard’ that will get a place in a residency training programme in internal medicine, or general surgery in a major teaching centre, is vastly different from that needed for the specialty that deals with mental subnormality or the many other specialties in the less favoured parts of the USA. This is the reality of the present day, as it has been on our side of the Atlantic-so what lies behind Reitemeier’s question? First, we need to re-examine our concept of more- and less-popular specialities; as competition builds up all round, postgraduate training becomes increasingly inflexible, and fewer people want to take other specialties’ dropouts. Second, we must set minimum criteria of quality, both in terms of training positions and applicants, and make it clear that if these criteria cannot be met the service must be provided in some other way than through a pretence at training. Other ideas from this article will be familiar to British readers, such as “Should we create some entirely different kinds of educational opportunities for those who need exposure and training only in special areas or techniques that they can take back to their native land?”. The most thought-provoking part of all Reitemeier’s rhetoric, though, goes far beyond the parochial interests of residency training in the hospital specialties: “Is the criticism valid that our residents see and know only what is done in tertiary care centres and have little knowledge of common medical problems?”. The future effectiveness of the medical profession in helping to solve the health problems of both our sophisticated communities, depends on taking a fresh look at what we want doctors for, what we expect them to do, and how much we think we can achieve through using high-technology services to try and cure or palliate problems that should never have been allowed to arise in the first place. Jamca PdthOUSe, M.SC. MA. MD,MB, CH.B. PFA, RCS,DA, Medical Careera ReMarch Group, Churchill Hospital, Hedington, Oxford
Bcfcrrnec lReitemeier R. Too many applicants for available graduate medical education positions-arc we on a collision eoum? Acblic Hlth Rcp 1984; 99: 47.
M&al
Twhn VoI6 No 3 1984
Medical Schools and the Community The need for medical schools to increase their involvement in the community was one of the wideranging recommendations of the Fifth Regional Meeting of Deans of Medical Schools convened by the Western Pacific Region of the World Health Organization. ’ Towards this end, each medical school should formulate a programme of faculty development, directed particularly towards change in attitudes of staff. The meeting also recommended that medical schools should be encouraged and helped to achieve curricula appropriate to the needs of WHO’S Health For All by the year 2000. Such curricular change would be facilitated if the involvement in community-orientated service and research by the school increased at the same time. The importance of research as an essential function of a medical school was underlined; this should include community-orientated projects as well as projects in social and behavioural sciences, including health care delivery systems and health care costs. There should be a balance between longand short-term projects, basic and applied research, and recognition of projects specific to the community, such as ageing. Research must be considered an integral part of the health area; its funding is therefore a responsibility of the government and should be included in allocations. The meeting additionally recommended that evaluation of all aspects of medical teaching, research and practice is mandatory. Research is required into developing improved methods of evaluation, as well as putting into practice known methods of evaluation. The meeting was convened by Ken Cox, Professor and Director of the School of Medical Education, University of New South Wales; Geoffrey Kellerman, Dean of Medicine, at the University of Newcastle, New South Wales; and Harmen Tiddens, Professor of Health Administration, National Aerospace Medical Centre, Soestberg, Netherlands. Bcfmnec COX K.N t ~ s h W, H O RcgMrUlr Tmcha Training Cntwfw Health Pcrsonnrl. School of Medical Education, University of Newcastle, NSE, February-March 1984.
Do You Subscribe to Medical Teacher? To ensure that you receive future copies, complete the form enclosed in this issue. 85
Med Teach Downloaded from informahealthcare.com by University of Alberta on 12/30/14 For personal use only.
Subeditor: Deirdre O’Flaherty
Editorial Department: Update Publications Ltd, 33/34 Alfred Place, London W C l E 7DP, England Tel: 01-637 4544 Subscription and Circulation Department: Update Publications Ltd, 2 High Street, Station Road, Petersfield, Hampshire, GU32 2JE, England Subscription Rates: Annual Subscription UK: E17.00 Overseas: €22.00 Air Mail: €27.00 Single Copies UK: E5.00 Overseas: €6.00
Contributions: Contributions are invited in the form of original papers, articles of discussion and comment on all aspects of health sciences education. Prospective contributors should write to the Managing Editor, Medical Teacher,Update Publications Ltd, 33/34 Alfred Place, London W C l E 7DP, England, before submitting manuscripts. Medical Teacher is published quarterly.
@ Update Publications Ltd, 1984 84
Too Many Applicants For Postgraduate Training Medical comparisons between the UK and the USA have a particular fascination because, as with language, we sometimes seem to be two nations separated by a common heritage and a common philosophy. Among the biggest of the problems we share are those of postgraduate training and medical manpower planning. The article “TOOmany applicants for available graduate medical education positions-are we on a collision course?”, by Richard Reitemeier of The Mayo Clinic provides a reaffirmation, from the American standpoint, of the inextricable relationship between training and manpower: ’ if you want to get medical manpower planning right, you must get the career structure right; and to get the career structure right, you must get postgraduate training right. You could just as well start from the other end, except it is no easier: if you get postgraduate training right, the career structure and everything else will fall into place. Either approach reveals that the interests of doctors, and those of the community, are not necessarily compatible nor well understood. Much of Reitemeier’s article is concerned with anxieties about placing US graduates in postgraduate training programmes of their choice. About 85-90 per cent of postgraduate training positions in the USA (first-year residency appointments) are arranged through the National Resident Matching Program. In 1983 there were 15,500 applicants for the matching programme, from medical schools in the USA, and only 8 per cent failed to match-not much of a problem for the doctors, in comparison to most countries, even though the number of US medical graduates has been rising while the number of available residency programmes has somewhat declined. Whether the specialty distribution of training opportunities for the doctors matches the best interests of society is another matter. Need is undefined, and demand is uncontrolled except through the market place. Graduates of medical schools not in the USA fared much worse in the 1983 matching process: only 51 per cent of US graduates from these medical schools succeeded, and only 25 per cent of foreign medical graduates. The article comments on quality control of foreign medical graduates, and of Americans who graduate outside the USA in ‘offshore’ schools, for example in the Caribbean. While 84 per cent of American and Canadian graduates achieve certification after postgraduate training in internal medicine, only about 25 per cent of foreign graduates do so. Attempts are made, notably in New York State, to find clinical clerkships for American students from offshore schools, but the procedures for ensuring adequate standards among these students clearly leave many loopholes and a great deal to be desired. Unsuccessful applicants seek training positions after the National Residency Match has been completed, and Reitemeier comments that “Some of the graduate medical education opportunities are in hospitals to which no US graduates apply and which, therefore, some Medical Teacher Vol6 No 3 1984
Med Teach Downloaded from informahealthcare.com by University of Alberta on 12/30/14 For personal use only.
members of the m e d i d education community suspect provide graduate medical education of a less than desirable quality”. He asks, “Should we set standards for entry into our graduate medical education programs that are the same for all candidates, accepting the fact that, as a result, many fewer foreign medical graduates will receive their training in the United States?”. But how would it be done? Who would set the standards for entry into a graduate training programme? How would the selection procedures be arranged, and who would monitor them? How well would individual specialists throughout the country comply with some form of national allocation procedure? The educationalists’ idealism has to meet the realities of providing a medical service. The qualifying doctor rapidly leaves the sheltered environment of personal surveillance, in which the weaker students get the best attention; even at the pre-registration stage he enters a market-world in which the best jobs tend to go to those who can best compete in their various ways. The ‘standard’ that will get a place in a residency training programme in internal medicine, or general surgery in a major teaching centre, is vastly different from that needed for the specialty that deals with mental subnormality or the many other specialties in the less favoured parts of the USA. This is the reality of the present day, as it has been on our side of the Atlantic-so what lies behind Reitemeier’s question? First, we need to re-examine our concept of more- and less-popular specialities; as competition builds up all round, postgraduate training becomes increasingly inflexible, and fewer people want to take other specialties’ dropouts. Second, we must set minimum criteria of quality, both in terms of training positions and applicants, and make it clear that if these criteria cannot be met the service must be provided in some other way than through a pretence at training. Other ideas from this article will be familiar to British readers, such as “Should we create some entirely different kinds of educational opportunities for those who need exposure and training only in special areas or techniques that they can take back to their native land?”. The most thought-provoking part of all Reitemeier’s rhetoric, though, goes far beyond the parochial interests of residency training in the hospital specialties: “Is the criticism valid that our residents see and know only what is done in tertiary care centres and have little knowledge of common medical problems?”. The future effectiveness of the medical profession in helping to solve the health problems of both our sophisticated communities, depends on taking a fresh look at what we want doctors for, what we expect them to do, and how much we think we can achieve through using high-technology services to try and cure or palliate problems that should never have been allowed to arise in the first place. Jamca PdthOUSe, M.SC. MA. MD,MB, CH.B. PFA, RCS,DA, Medical Careera ReMarch Group, Churchill Hospital, Hedington, Oxford
Bcfcrrnec lReitemeier R. Too many applicants for available graduate medical education positions-arc we on a collision eoum? Acblic Hlth Rcp 1984; 99: 47.
M&al
Twhn VoI6 No 3 1984
Medical Schools and the Community The need for medical schools to increase their involvement in the community was one of the wideranging recommendations of the Fifth Regional Meeting of Deans of Medical Schools convened by the Western Pacific Region of the World Health Organization. ’ Towards this end, each medical school should formulate a programme of faculty development, directed particularly towards change in attitudes of staff. The meeting also recommended that medical schools should be encouraged and helped to achieve curricula appropriate to the needs of WHO’S Health For All by the year 2000. Such curricular change would be facilitated if the involvement in community-orientated service and research by the school increased at the same time. The importance of research as an essential function of a medical school was underlined; this should include community-orientated projects as well as projects in social and behavioural sciences, including health care delivery systems and health care costs. There should be a balance between longand short-term projects, basic and applied research, and recognition of projects specific to the community, such as ageing. Research must be considered an integral part of the health area; its funding is therefore a responsibility of the government and should be included in allocations. The meeting additionally recommended that evaluation of all aspects of medical teaching, research and practice is mandatory. Research is required into developing improved methods of evaluation, as well as putting into practice known methods of evaluation. The meeting was convened by Ken Cox, Professor and Director of the School of Medical Education, University of New South Wales; Geoffrey Kellerman, Dean of Medicine, at the University of Newcastle, New South Wales; and Harmen Tiddens, Professor of Health Administration, National Aerospace Medical Centre, Soestberg, Netherlands. Bcfmnec COX K.N t ~ s h W, H O RcgMrUlr Tmcha Training Cntwfw Health Pcrsonnrl. School of Medical Education, University of Newcastle, NSE, February-March 1984.
Do You Subscribe to Medical Teacher? To ensure that you receive future copies, complete the form enclosed in this issue. 85
