Looking Inward
I don’t have to explain how hard you worked to get here. You are academically bright and after competing with thousands of aspirants, you finally made it to medical school. From the first year to final year, from one exam to another, there is only one thing you do, read huge medical books, if I am not wrong. There is hardly any time for life, the world or even sleep. You do not have any time for hobbies, fun, exercise, family or other enjoyable activities! You are mostly apolitical and at times rather asocial. Do you ever wonder what exactly it is that you are trying to become?
Having completed my MBBS a decade ago, I am sure nothing has changed except that your books must be even bigger than what I read. But that is not something unusual, if you talk to your professors, they would have a similar story. Nothing has changed when it comes to medical education, the same long answer questions, long and short case, quiz and viva. There is no curriculum and mostly teaching is based on guess work or what a standard book has in it. Even the subjects taught in various academic years are not based on any real evidence. The subjects are there purely by chance or because the person who was in charge then was from that very speciality. One spends months learning subjects which hardly matter once you pass the final year exam. Similarly, subjects that are essential for day to day clinical practice hardly find any space both in the classroom and in clinical experience.
Looking Out
The delivery of medical education has completely changed around the world. The teaching based on organ based system is nearly obsolete and has been replaced by systems based teaching, integrating the pre-clinical subjects like anatomy and physiology to the real world clinical work. Hence, students no longer study a limb or heart in isolation, but are taught systems like cardiovascular, respiratory etc. which makes more sense than studying anatomy and physiology of the heart in isolation. Students are not expected to amass knowledge significantly removed from clinical relevance. Instead they do more than just read thick books and pass exams. This would mean engaging in audits, research, charity work, sports, and other interests to give them a broader perspective and develop their overall personality. They are expected to undertake special study modules (SSM) wherein they may have to write a review essay every few months or do some work experience outside the hospital setting and present the work to their peers. This gives them a chance to work on the skills of writing, critical thinking and getting in touch with real life. Students undertake other degrees while doing MBBS like an intercalated BSc in some other subject. Some students spend time doing basic research and taster sessions in specialities to gauge whether they are interested in an academic career in the future. This helps them to build a strong portfolio and face any future challenges. Students are also expected to go on an elective to a different country in their final year which helps broaden their horizons and outlook.
Reflecting Back
Coming back to the situation of medical education in India, all I said above seems an alien concept and you may be thinking how can a medical student do all these things while studying for the hardest degree ever known? The reason they are able to do all these activities while completing a medical degree with all the competencies required to become a safe doctor is because the curriculum has been thoroughly reviewed and tailored. Students are not required to cram fat books, but to work around a syllabus which is clinically relevant. Exams are conducted mostly as multiple choices questions (MCQs) rather than long answer essays. The practical exams are conducted with the help of actors and are tailored keeping in view the essential practical skills which a doctor should have once they become an Intern. Teaching is aided with modern technology, simulation, professional actors and specialised aids. Students have to maintain a logbook in every clinical posting and learn prescribed skills and get them signed off once they have demonstrated that they are able to perform them safely. This can range from simple history taking; cannulation, blood pressure measurement, mental state examination, and catheterisation just to name a few.
With the delivery of health care changing worldwide simply knowing too much theory does not make good and safe doctors any longer. How many of us know the actual techniques once we have passed our final year? How many of us are mindful not to infect a patient while putting in a catheter? It can be argued that clinical skills examination is essential for a reason.
Rights for Patients and Doctors
In addition in other countries there is also an emphasis on human rights, dignity, privacy and confidentiality. I am sure we are very behind when it comes to these things and our patients often feel we do not treat them with respect and dignity. The fact of the matter is that we never learn any communication skills which form the core of medical training in the current age. Although we all become doctors to do good for humanity, it is not difficult to become mechanistic and lose that human touch if we are not mindful of our actions. There is an emphasis on building compassion and empathy and medical schools are supposed to inculcate such traits in budding doctors.
Many students struggle and find it hard to cope for various reasons once they join medical school. This may be due to work pressure, bullying, stress and we are aware how many leave and some even attempt to end their lives. Struggling is not a sign of weakness but a normal response to everyday life in medical school. It is high time that medical schools put in place measures to support such students and have close supervision. The culture of bullying needs to end and treating students with dignity would enhance their output and help make good and safe doctors.
Who to Blame, and How to Change?
The Medical Council of India (MCI) has proved a failure for various reasons and does not seem to be doing much when it comes to the reformation of medical education in the country. Technically, MCI is responsible for maintaining the standards of medical education and make it appropriate and relevant to the current times and demands. Unfortunately so many bright minds lose so many skills as they find themselves unsupported in a disorganised system. It is no surprise if you try to log on to the MCI website and fail to find what a medical student ought to know at various stages of training. Here again it is hard to fix the blame, is it the prevalent corruption in the country or the lack of interests from senior doctors? Students as the future of medicine will need to think long and hard, and try to bring about changes. There is no harm in approaching your teachers, asking for help, demanding to engage in research and teaching or attempting to do things beyond books and exams.
Finally with changing sociocultural values, doctors need to adapt accordingly. The paternalistic approach is no longer workable and people expect a service which is safe, collaborative and friendly. Many doctors find it hard to adjust to the real life practice once they leave the medical college and it becomes more imperative that they are trained with holistic skills so that their talent does not go waste. We have to be compassionate, responsible, safe doctors and treat our patients with respect and dignity. The relationship between teachers and students in college needs to be friendly though respectful and not based on fear and bullying. The faculty needs to work on such issues and unless the budding doctors’ work in a friendly learning environment, it is hard to expect any progress in the college working culture and academic excellence.
It is not impossible to bring the change but it needs some determination and toil, with channelling of effort and energy in the right direction. Never forget that you are the future scientists, researchers, teachers and leaders and that there is so much to do and explore. The future belongs to you so do not give up and be that change.
To give you a taster of how a medical student goes through the training in another part of the world, or more specifically in a developed setup, I am sure you will enjoy the excellent write-up by Dr Camilla Tooley. Here she describes her own experience of a medical curriculum within the UK in reflection of some wider comparisons. Developmental changes are necessary here too, but we can see that the approach may offer refinements in structure enabling greater breadth in personal and professional experience.
From the Dissection Table to Clinic;
A whistle-stop through the UK undergraduate Medical Curriculum
Dr Camilla Tooley
One size does not fit all
When asked to review the current medical undergraduate curriculum in the UK my first thought was which medical school and which course? Curriculum’s can vary dramatically across the country with differences ranging from the approach to learning, to the length of course and method of assessment. Currently taking a Postgraduate Certificate in Medical Education I have become even more aware how subtleties can shape an entire learning experience. My undergraduate medical school was voted last year to have the highest rated student satisfaction, so offers insights into a well-developed curriculum. I will in turn discuss the typical timeline of this undergraduate programme reflected to the commonalities and differences of other curriculum strategies that I am aware of.
Selection
The Selection process for medical school has changed throughout the years. Current requirement include three full A levels, examinations taken at 17-18, with at least one science subject, typically Chemistry, and occasionally two. UK applicants must also typically take one of three additional tests- the UK Clinical Aptitude Test (UKCAT), the Biomedical Admissions Test (BMAT) or the Graduate Medical School Admissions Test (GAMSAT). As competition is high it is also critical to show a widened perspective with work experience and evidence of other extracurricular activities. An interview will typically follow, which attempts to review whether an individual’s nature is fitting. Interestingly the terminology itself on selection panels has changed over the years from highlighting importance in conscientiousness and compassion to resilience, a highlight which is sure to match the changing NHS culture.
Early Days: Years 1 and 2
My medical school focussed on an integrated systems approach where the body was separated in to areas and essentially all detail in that region was discussed together. For example ‘Heart, lungs and blood’ where the anatomy, physiology and clinical cases were taught in unison. Learning experiences were shared between the lecture hall, the dissection room and small group work. Examinations taken at the end of each module to review knowledge acquired (every 4-6 months) combined with viva’s at the dissection table and written assignments. Clinical contact also started early with time spent in community family practice and projects focussed on this work.
Other medical school’s focus primarily on format of knowledge content in what many refer to as a ‘Traditional’ learning approach. While this may prepare the student with all information in one discipline (e.g. anatomy), the lack of contextualisation could hold this form of learning back. Equally at the other end of the scale where ‘contemporary learning style’ may be focussed on entirely student led practice with Problem Based Learning(PBL) the student can lose some of the detail required by contextualising too early. This is an example where a tool can be used well or be problematic and a balance of both approaches seems the most logical as was offered where I studied. Pure knowledge was integrated and contextualised with some problem based learning techniques.
Midway Exams and Intercalation: Years 3 and 4
Clinical practice took a jump in Year 3 when ward work began within the hospital setting and integrated system learning was built in to integrated management understanding. Student’s spend placements supervised by consultants and are assessed throughout on basic competencies from taking histories to undergoing physical examinations. At the end of this course year there are again set knowledge tests in addition to an Objective Structured Clinical Examination (OSCE), where the student is expected to carry out histories and examinations observed and marked by senior clinicians.
On passing this year the student will then have the option to intercalate, taking a degree or masters in a year before returning to the final years of the curriculum. I took this experience for the variety it offered me at the time, and as I was keenly interested in Psychology and wished to obtain a degree in this field. Other student’s took a range of other degrees from Ethics and Law to Neuroscience.
I believe anyone who was asked about this year would reflect positively about it, although it did come at a price to reengage in clinical practice in Year 4. This year in essence continued on clinical placements, together with a designated research project whereby students could begin to explore academic interests under supervision, and again as a marked component.
Finals: Year 5
A further year of clinical placements arranged around different specialities such as Paediatrics, Obstetrics and Gynaecology etc., for which student’s would be reviewed during ward assessments on completing certain skills and demonstrating clear competencies. Students would also be required to take written knowledge tests and a number of OSCE’s focussing on the different specialisms, split by Medicine and Surgery and subspecialties for example Elderly care and Psychiatry.
I noticed in reviewing other doctor’s experiences the variety of assessment methods at the end of the final year in different medical schools varied significantly. While I had a few written papers and up to 40 clinical stations in combination for my OSCE’s, students from other medical schools had significantly fewer. We could conclude from this variability that final OSCEs could fall a year earlier in other medical schools, or this assessment method may be replaced by other clinical review. Regardless this shows the disparity between learning experience and assessment throughout the UK.
Student Choice within the Curriculum
Electives and Student Selected Components (SSCs) form a platform to students exploring their own interests within medicine further, or experiencing areas that they may not otherwise encounter.
SSCs are held throughout different years and last around eight weeks. A small group meet for a few hours and discuss or explore different topics. For one of my more memorable SSCs I explored ‘The History of Medicine’ and went to a record office to review documents and identify if any epidemics may have existed from the middle ages according to information from church records. This work was again assessed by a written assignment.
In comparison the Elective tends to occur at the latter stage of medical school and offers the potential for travel together with in depth specialism for a two month period in the break between years (3 and 4) or at the end of finals (end of year 5 or 4 comparatively). While I took my elective in New Zealand others decided to take theirs across all continents including experiences in South East Asia, throughout Africa, the United States and Canada.
Societies and Extracurricular activities through medical school
Students are encouraged to continue extracurricular activities throughout their time at Medical School to broaden their learning experience. These additionally develop a student’s mind-set and build confidence outside of examinations and the evolving clinical setting. From my own personal experience I tried a variety of activities while at medical school from mountaineering to drawing classes and co-founded the Psychiatry Society there that continues to this day.
Pastoral Support and Advocacy
Students can experience difficulties throughout their studies, in their work or through emotional or financial pressures. In addition to considering the general curriculum it is noteworthy in considering the support services that are in place. Firstly students will have a consultant lead that they can approach if they are experiencing any problems on the ward in their later years.
There are also module leads, whom are other consultants within the faculty that can offer advice on the learning experience and direct students as needed to other staff. These may include generalised student support on the University campus that can offer financial and emotional advice.
Applying to the Foundation Programme
At the end of medical school students are ranked and apply for ‘foundation posts’ as junior doctors across the UK. Students apply for different regions according to a number of considerations such as geographical location, to specialisms offered by different regions or other opportunities. In my scenario I selected to work within Wessex, as it was both close to where I had studied and new friends I had formed. This area offered junior doctors the opportunity to travel abroad for work in their second year, which I applied for and acquired in New Zealand. Notably some new doctors do not get the opportunity to work where they may choose. This offers insights in to the first limits of autonomy at the start of one’s medical career.
Conclusion: Shorter stays and New Roles
On concluding my review of the undergraduate curriculum I thought it worthy to briefly discuss variants of the five year model. Firstly at many institutions mature students whom have taken a previously science based degree or profession enter many medical schools in a four year rather than five year programme. This shortening of the curriculum seems complimentary when someone has already compounded a wealth of knowledge around biochemistry. In medical schools with a more contemporary rather than traditional format however shortening the course length could result in vitally missed clinical experience.
A new breed of healer the Physician Associate has also been developed in the UK. These individuals essentially try to fit the entirety of medicine in to two years and complete their studies able to diagnose and assess patients, although remain non prescribers. In a system where the volume of knowledge covered is often considered to amass greatly it is worthy to consider how are these curriculums used to cover the same information? Could we be covering too much knowledge base still to UK undergraduates, or be repeating knowledge in too many formats? Should we consider a more ‘apprentice’ like craft again within Medicine?
On these points, as with all the changes thus far from traditional to contemporary styles the answer may lay somewhere in the middle. As great analysers the doctors who educate will review and get back to you on the next improvements.
The article was originally published in KASHMED, the yearly magazine published by Government Medical College Srinagar India.
http://www.indiamedicaltimes.com/2016/04/07/opinion-time-to-change-the-way-medical-education-is-delivered-comparisons-between-india-and-abroad/
http://www.indiamedicaltimes.com/2016/04/07/opinion-time-to-change-the-way-medical-education-is-delivered-comparisons-between-india-and-abroad/
