MEDICAL EDUCATION

  MEDICAL EDUCATION

INTRODUCTION

In several countries medical education, especially in the clinical context, has become part of a process of redesign and change. The redesign is based on current insights. However, probably a lot of insights still have to become apparent in the future. The process of redesign and change is an excellent opportunity to gain more knowledge and understanding of medical education in the clinical context. Concerning the art of medical education, in this article, an impressionistic picture is created lacking detail and lacking classical prime educational facts. An attempt is made to have a glance at future developments in clinical medical education.

Strategic planning

Medical education is done for a purpose: To serve health systems for the near future. What are the prospects of health systems for the future? What does society expect from medical personnel? Which pitfalls are recognized in daily medical care and which solutions for the future can be proposed? What is the right balance in several scales? For example, do we need generalists or specialized doctors? Do we need a focus on a certain group of patients like the elderly? Do we need a focus on certain technologies like information technology? Do we need very creative professionals that thrive in a world of ambiguity and relative chaos or do we need humble, adaptive and disciplined team members in a world where protocols and checklists bring us to optimal performance? The point made is that medical education should be recognized as an important tool in the governance of health systems. The goals for governance of health systems should be the main driving force for a medical school or a clinical learning environment. These goals may differ between high and low resource countries, between various cultures and even according to persons within one country . Moreover, these goals will change in time. The discussion about the goals for governance in health systems should be a continuously discussed matter.

Quality care

The quality of medical education is once more a matter of multi-perspectives. The quality could be regarded from the professional point of view on the care provided on the wards where the training is organised. This quality could be assessed by visitation of delegates from the professional society, but also last year trainees often are aware of the professional value of the content offered in different training sites. The quality could also be assessed from the point of view of educationalists. Measurements of educational climate, of educational performances of individual clinical teachers in combination with interviews of trainees at the end of their rotation would give sufficient information for an internal audit and improvement system. For feedback on educational structures an external appraisal like the EBCOG visitation system is suitable. Subjects are regional, hospital based and discipline based supporting structures for education. Examples are the availability of (e-learning) courses, skills laboratories, and a mentoring system and programmed communities of learners. Another point of view for quality assessment comes from society. It questions whether societal problems are addressed sufficiently in the training post. Examples are the care for the fragile elderly patients, training for cost effective care and safe care, dealing with ethical problems and so on. A final option for quality control is the use of patients as partners in training and patient care. A good system for quality control and an effective program for improvement are the crown on the achievement of mastery in the art of medical education.

Medical Education and Medical Council

The Medical Council of India and the Dental Council of India were set up under ACTs of Parliament with a view to regulate medical and dental education in the country. Under the provisions of Regulations of the two statuary bodies, no medical or dental college can be established or increase their capacity without prior approval of the Central Government. As per section 10A of the Indian Medical Council Act, 1956 and the Destistry Act, 1948, the Central Government’s permission to such colleges are granted initially for one year, i.e., for admitting only one batch of students in a calendar year. The permissions are to be renewed on yearly basis after verification of achievements of annual targets. This process is continued till such time the full required infrastructure is created and recognition is granted under the relevant Act.

The admissions made without the requisite permission from the Govt. of India shall be deemed as irregular. The degrees awarded to students admitted by the Colleges without obtaining the required approval/renewal shall not be recognised for registration to practice medicine/dentistry in India. Hence, the parents and students are hereby advised to verify the status of the colleges for admitting students for the academic year 2004-2005 from the Central Government and MCI/ DCI before seeking admission in MBBS/BDS courses. For the benefit of the public, the list of medical and dental colleges in India approved for conducting MBBS and BDS courses respectively with their current status for taking admissions for the year 2004-2005 is given alongside.

All the undergraduate and postgraduate medical degrees/diplomas awarded by various Universities and Medical Institutions which are recognised under section 11(2) of the IMC Act, 1956 along with the names of the Institutions approved for conducting each course are also indicated alongside. This does not include some of the postgraduate degrees/ diplomas awarded by some Universities which were started by the concerned institutions prior to the commencement of the IMC (Amendment) Act, 1993 with the approval of the State Governments/ Universities. The Institutions concerned are requested to apply to the Central Government for recognition of such degrees/diplomas under section 11(2) of the IMC Act, 1956 through the affiliating Universities at the earliest as until then theses degrees would continue to remain unrecognised for the purposes of the Act.

Medical education as a subject-didactic field

Medical education is also the subject-didactic field of educating medical doctors at all levels, applying theories of pedagogy in the medical context, with its own journals, such as Medical Education. Researchers and practitioners in this field are usually medical doctors or educationalists. Medical curricula vary between medical schools, and are constantly evolving in response to the need of medical students, as well as the resources available. Medical schools have been documented to utilize various forms of problem-based learning, team-based learning, and simulation. The Liaison Committee on Medical Education (LCME) publishes standard guidelines regarding goals of medical education, including curriculum design, implementation, and evaluation. 

The objective structured clinical examinations (OSCEs) are widely utilized as a way to assess health science students' clinical abilities in a controlled setting. Although used in medical education programs throughout the world, the methodology for assessment may vary between programs and thus attempts to standardize the assessment have been made. 

Health Policy

There is a growing call for health professional training programs to not only adopt more rigorous health policy education and leadership training, but to apply a broader lens to the concept of teaching and implementing health policy through health equity and social disparities that largely affect health and patient outcomes. Increased mortality and morbidity rates occur from birth to age 75, attributed to medical care (insurance access, quality of care), individual behavior (smoking, diet, exercise, drugs, risky behavior), socioeconomic and demographic factors (poverty, inequality, racial disparities, segregation), and physical environment (housing, education, transportation, urban planning). A country's health care delivery system reflects its "underlying values, tolerances, expectations, and cultures of the societies they serve", and medical professionals stand in a unique position to influence opinion and policy of patients, healthcare administrators, & lawmakers. 

In order to truly integrate health policy matters into physician and medical education, training should begin as early as possible – ideally during medical school or premedical coursework – to build "foundational knowledge and analytical skills" continued during residency and reinforced throughout clinical practice, like any other core skill or competency. This source further recommends adopting a national standardized core health policy curriculum for medical schools and residencies in order to introduce a core foundation in this much needed area, focusing on four main domains of health care:

 (1) systems and principles (e.g. financing; payment; models of management; information technology; physician workforce), 

(2) quality and safety (e.g. quality improvement indicators, measures, and outcomes; patient safety), 

(3) value and equity (e.g. medical economics, medical decision making, comparative effectiveness, health disparities), 

and (4) politics and law (e.g. history and consequences of major legislations; adverse events, medical errors, and malpractice).

However limitations to implementing these health policy courses mainly include perceived time constraints from scheduling conflicts, the need for an interdisciplinary faculty team, and lack of research / funding to determine what curriculum design may best suit the program goals. Resistance in one pilot program was seen from program directors who did not see the relevance of the elective course and who were bounded by program training requirements limited by scheduling conflicts and inadequate time for non-clinical activities. But for students in one medical school study, those taught higher-intensity curriculum (vs lower-intensity) were "three to four times as likely to perceive themselves as appropriately trained in components of health care systems", and felt it did not take away from getting poorer training in other areas. Additionally, recruiting and retaining a diverse set of multidisciplinary instructors and policy or economic experts with sufficient knowledge and training may be limited at community-based programs or schools without health policy or public health departments or graduate programs. Remedies may include having online courses, off-site trips to the capitol or health foundations, or dedicated externships, but these have interactive, cost, and time constraints as well. Despite these limitations, several programs in both medical school and residency training have been pioneered. 

Although it is difficult to identify the origin of medical education, authorities usually consider that it began with the ancient Greeks’ method of rational inquiry, which introduced the practice of observation and reasoning regarding disease. Rational interpretation and discussion, it is theorized, led to teaching and thus to the formation of schools such as that at Cos, where the Greek physician Hippocrates is said to have taught in the 5th century bc and originated the oath that became a credo for practitioners through the ages.

Later, the Christian religion greatly contributed to both the learning and the teaching of medicine in the West because it favoured not only the protection and care of the sick but also the establishment of institutions where collections of sick people encouraged observation, analysis, and discussion among physicians by furnishing opportunities for comparison. Apprenticeship training in monastic infirmaries and hospitals dominated medical education during the early Middle Ages. A medical school in anything like its present form, however, did not evolve until the establishment of the one at Salerno in southern Italy between the 9th and 11th centuries. Even there teaching was by the apprentice system, but an attempt was made at systemization of the knowledge of the time, a series of health precepts was drawn up, and a form of registration to practice was approved by the Holy Roman emperor Frederick II. During the same period, medicine and medical education were flourishing in the Muslim world at such centres as Baghdad, Cairo, and Córdoba.

Modern Way of medical education

As medical education developed after the Flexner report was published, the distinctive feature was the thoroughness with which theoretical and scientific knowledge were fused with what experience teaches in the practical responsibility of taking care of human beings. Medical education eventually developed into a process that involved four generally recognized stages: premedical, undergraduate, postgraduate, and continuing education.

Premedical education and medical school

In the United States, Britain, and the Commonwealth countries, generally, medical schools are inclined to limit the number of students admitted so as to increase the opportunities for each student. In western Europe, South America, and most other countries, no exact limitation of numbers of students is in effect, though there is a trend toward such limitation in some of the western European schools. Some medical schools in North America have developed ratios of teaching staff to students as high as 1 to 1 or 1 to 2, in contrast with 1 teacher to 20 or even 100 students in certain universities in other countries. The number of students applying to medical school greatly exceeds the number finally selected in most countries.

Requirements to enter medical school, of course, vary from country to country, and in some countries, such as the United States, from university to university. Generally speaking, in Western universities, there is a requirement for a specified number of years of undergraduate work and passing of a test, possibly state regulated, and a transcript of grades. In the United States entry into medical school is highly competitive, especially in the more prestigious universities. Stanford University, for instance, accepts only about 5 percent of its applicants. Most U.S. schools require the applicant to take the Medical College Admission Test, which measures aptitude in medically related subjects. Other requirements may include letters of recommendation and a personal interview. Many U.S. institutions require a bachelor’s degree or its equivalent from an undergraduate school. A specific minimum grade point average is not required, but most students entering medical school have between an A and a B average.

The premedical courses required in most countries emphasize physics, chemistry, and biology. These are required in order to make it possible to present subsequently courses in anatomy, physiology, biochemistry, and pharmacology with precision and economy of time to students prepared in scientific method and content. Each of the required courses includes laboratory periods throughout the full academic year. Student familiarity with the use of instruments and laboratory procedures tends to vary widely from country to country, however.

The number of good medical teachers has hardly increased to keep pace with the number of colleges. Most of the new colleges, including government ones, have shown a complete disregard for the seriousness of the process of medical education and training.

Almost every warning against this numerical obsession has been confirmed in inspections by the National Medical Commission (NMC). A news report quoted officials saying that a large number of medical colleges had “inadequate and poor infrastructure, absence of faculty during teaching hours, deficiency in clinical material [e.g., shortage in the number of cadavers for anatomy classes], and student grievances on issues such as ragging, inadequate hostels, and poor student-teacher relationship”. Despite these findings, the NMC has refused to make its college assessment reports available to the public.

Considering the ground realities of India’s highly compromised education quality, it is clear that not many of the thousands of new medical graduates annually will contribute to public welfare. Will they find jobs or opportunities for specialisation (and then employment)? Or as the Himachal Pradesh Chief Minister plainly said a few months ago, will the new doctors “find themselves in the unemployment queue”?

WHO Recommendations 

Doctors are only one part of a region’s healthcare infrastructure, and health outcomes depend upon a host of socioeconomic, political, and environmental factors, in addition to the numbers of other healthcare practitioners like nurses, midwives, and community health workers. It is therefore quite impossible to conduct specific public health studies on how many doctors it would take to help a community or a country reach a pre-determined optimum level of health overall.

Careful studies have avoided prescribing targets. When an international group of public health researchers based at Harvard University in 2004 published the Human Resources for Health: Overcoming the Crisis report, they “quantified  health worker shortages not to seek numeric precision but to offer a sense of the scale of gaps. We use an arbitrary minimum worker density threshold of 2.5 workers (doctors, nurses, and midwives) per 1,000 population” . Their ratio was derived from a choice to focus on two services as surrogate markers for adequate healthcare: immunisation   and skilled attendance at birth. After comparing countries across the world, they found that the prospects for achieving 80% coverage of these goals “are greatly enhanced where worker density exceeds 2.5 workers per 1,000 population”.

Conclusion

The art of medical education will become apparent in an environment where teams of clinicians and educationalists try to bring in a multi-perspective on teaching. They should give lots of attention to setting the goals for future health care, to the process of change and to the way educational science is optimally brought in to the learning places. Quality care should bring in the ongoing drive for innovation and continuous improvement of the system.