Emerging problems with graduate medical education: An academic surgical perspective

John P Harris Professor of Vascular Surgery Associate Dean Surgical Sciences University of Sydney Chairman Division of Surgery Royal Prince Alfred Hospital

     Aims of medical education Trends and outcome Student assessment, ranking, honours Implications of age Suggested directions

Australian Medical Council

Goals and objectives of basic medical education Doctors must be able to care for individual patients by both preventing and treating illness, to assist with the health education of the community, to be judicious in the use of health resources, and to work with a wide range of health professional and other agents. They must possess a sufficient educational base to respond to evolving and changing health needs throughout their careers.

Curriculum themes

1.

2.

3.

4.

Basic and clinical science Community and doctor Patient and doctor Personal and professional development

Dean SJ et al Preparedness for hospital practice among graduates of a problem-based, graduate–entry medical program. MJA 178:163-7, 2003

Aims of medical education

  Prepare young doctors to serve the Australian community as clinicians Lesser but important aims:   The doctor as a social engineer  Patient/Doctor Society/Doctor(Public health) The doctor as a scientist/researcher  PhD

Medicine as vocational choice Pre-Med degree 3 years Enter Medicine 4 years USydGMP

Medicine as vocational choice Pre-Med degree 3 years Miss out ?career options Enter Medicine ?lost opportunity 4 years USydGMP

Medical Science versus Arts background 40 35 30 25 20 15 10 5 0 1997 1998 1999 2000 2001 2002 2003 Medical Science Arts

Move to Graduate Medical Education •Clinician student •Didactic lectures •Basic sciences •Bedside teaching •Emphasis on history and examination •Tutorial room •Self directed learning •Problem Based Learning •Non-clinician facilitator •Societal skills •Preparation for life-long learning

Move to Graduate Medical Education •Clinician student •Didactic lectures •Basic sciences •Bedside teaching •Emphasis on history and examination 1960’s 75% clinical teaching at beside •Tutorial room •Self directed learning •Problem Based Learning •Non-clinician facilitator •Societal skills •Preparation for life-long learning Now <16% Ann Int Med 126:217-220, 1997

In ascendancy Medical educator Computer based resources Public health In decline Clinician based teaching Clinical content in the modern curriculum University clinical academic departments

Anatomy for medical graduates

  Traditional undergraduate dissection is no longer sustainable   Cost Time constraints  Shortage of skilled staff Innovative programmes   Self-directed learning, PBL, supervised practical classes Option term dissection L Bokey & P Chapuis ANZ J Surg 71:781, 2001

Anatomy teaching in ANZ medical schools

Medical School

Adelaide Auckland Curtin Flinders Griffith James Cook Monash Melbourne Newcastle NSW Otago Queensland Sydney Tasmania Wollongong Western Australia No No No

Yes Yes

No No No No

Dissection

No Elective

Yes

No No Elective No Elective No Elective No Dissection in 3/16 19%

Anatomy: Teaching in other courses

Programme Sydney Graduate Medical Programme No dissection, prosected specimens, self directed Sydney Undergraduate Medical Programme Science 6 unit science Anatomy (dissection) 13-14 week semester, Abdomen/Thorax, Head & Neck x2 1hr lecture, 1hr tutorial, 3hrs dissection/week Chiropractor No dissection, 13-14 week semester Limbs, back & trunk, head and neck x4 hr/week x2 lectures, x2 hr practical with tutor Hours 65 500 91-98 156 ~15% of US hospital residents from osteopathic schools of medicine

Implications?

 1995-2000 x7 fold increase in medico-legal claims based on anatomic error (UK MDU)  Future doctors may be proficient in the general and social aspects of medicine but it would seem that their knowledge of the basic facts of anatomy, physiology and pathology and their understanding of the mechanism of disease may be no better than that of a “medicine man”.

R Magee MJA 179:224, 2003

Getting the balance right

Trends and outcome

Student assessment, rank, honours

  5 yr Undergraduate programme   Honours based on cumulative success Incentive to excel in each subject USydGMP  Honours based on extra-project  Unrelated to core and distracting from the programme

Student assessment, rank, honours

    5 yr Undergraduate programme  Honours based on cumulative success  Incentive to excel in each subject USydGMP   Honours based on extra-project Unrelated to core and distracting from the programme No University Medal in Medicine No Year Book 1997-2002

Clinical surgery USydGMP

 Graduate MB BS  Surgical content  32 week block in Year 3   16 topics (1 lecture & 1 tutorial) Integrated Clinical Attachment

Formative assessment Basic assessment of course Attendance voluntary 31 of 50 sat Results anonymous 11 of 31 unsatisfactory Left up to individual to seek remedial preparation for barrier exam

Formative assessment Year 3 Surgery

10 8 6 4 2 0 1 3 5 7 9 11 13 15

Mark out of 20

17 19 21 2004

Absence of ranking

  Satisfactory/unsatisfactory   How to sift out the poor student?

How to reward the good student?

Absence of objective criteria for:  Residency placement   Selection into specialty training Award of honours

Implications of age

UGMP USydGMP High school 5 UGMP 6 HSC PreMed 6 3 USydGMP 4 Mean age at graduation 29 +speciality training Enters definitive vocation 4-7 33-36

Age on graduation

20 15 10 5 0 24 26 28 30 32 34 36

Age

38 40 42 44 47

Implications of age

    14% >35 at graduation Vocational choice    Length of specialty training Short effective practice life ?return to the tax payer Life-style  Financial, housing, family Learning hand/eye skills   Elite performance relates to age of first exposure and practice Manturzewska in a sample of 190 elite musical performers found no individual who had started later than age nine Psych Review 100:363-406, 1993

Medical education and hard science … And herein lies the rub. Despite continued calls for educational research that matters …, the medical education community has yet to report solid evidence to support the intentions of these resource-intensive changes. The profession, hardened by the evidence-based medicine movement, expects no less.

Martin B Van Der Weyden, Editor letter in MJA 181:518, 2004

The way forward….

      Emphasise clinical training  Base curriculum on feedback from students & doctors in practice Universities & Colleges  Fusion of resources & skills Apply AMWAC projections to plan medical school entry Shorten medical education  Early streaming in medical training New teaching tools   Surgical skills centres Simulators, video-instruction systems Consider the impending demise of clinical academic medicine Weedon D. Whither pathology in medical education? MJA 178:200-2, 2003