Medical education is in a critical condition

Source: Nate Kitch

Should undergraduate medical education be based in universities? That the question should be posed at all may shock universities, many of which regard their possession of a medical school as their crowning glory, marking them out as “elite”.

But before the late 19th century, most people would be born, live and die without receiving any medical attention from a university graduate. Since then, increased understanding of disease arising from fundamental discoveries in pathology and bacteriology meant that a good grounding in biomedical science was seen as essential for all doctors, and that universities were best placed to provide it.

But medical schools seem different from most other university faculties. They are in universities but not wholly of them. The greater part of the course is delivered outside the university by NHS-based teachers who are not properly on the university staff and who are paid by a contentious process over which the university has little control. This NHS contribution to medical education is generally greater than the university funds that come directly into medical schools for teaching.

Recent changes in society have increased the differences. These changes include the realisation that to be in receipt of medical care is dangerous. Failures of systems and of individuals in the health service receive wide publicity and, as in many other fields, the response has been to replace trust with ever greater and ever more prescriptive regulation. The regulator, the General Medical Council, has, in addition, decided to introduce a national examination for those seeking to practise as doctors, and Health Education England, a non-departmental public body, has been mandated to become involved in both recruitment and curriculum design for the health professions.

Two educational developments also seem relevant. One is the modern emphasis on nationally defined “competencies”. The other is the realisation that medical professionalism is characterised not only by the rigorous application of scientific theory and technique but also by the use of tacit knowledge rooted in the workplace and related to the management of uncertainty and risk.

Much of this shift in emphasis towards the needs of the workplace is to be welcomed; it is perfectly reasonable for patients and NHS Trusts to expect their doctors to be competent and educated to a common high standard. However, the moves also mean that “ownership” of medical courses is now not with individual academics, departments or institutions. Increasingly, universities award degrees at the end of a course over whose syllabus, teachers, learning framework, assessment standards and financial arrangements they have limited control. This certainly diminishes universities’ historical freedom to admit those who they think will benefit, teach them what they see fit and award a degree to those who attain their standards. It might also be feared that – as is common where trust is replaced by regulation – it will increasingly disempower the academics involved, causing them to lose interest and cease to innovate or take responsibility.

But shifting medical education wholesale into the NHS itself would bring its own short-termist dangers. The emphasis would become even more narrowly focused than it already is on producing doctors who will not make (too many) mistakes in the current clinical environment. But this risks creating doctors “fit for purpose”; trained for today’s task but not educated for tomorrow’s. Educated people change themselves and, importantly, become change agents for those around them. Another way to put this is to say that training enables people to follow a protocol, while education enables them to know when it is best not to follow it. Competent doctors are more than collections of competencies: they need to be able to think for themselves, recognise what needs to be changed and possess the advocacy skill to bring about those changes.

This is precisely what is delivered by scholarship (which need not necessarily embrace research). Scholarship enables learners to become better able to weigh evidence, balance probabilities, reach conclusions and take appropriate action. Delivering such scholarship is clearly best done by universities. But they need to be free to do so. And if they are not, they need to lobby for the restoration of that freedom.

But, at the moment, it is not obvious to me that universities know or care that they are losing control of what they teach – or that the health service has been made aware that a short-term focus will cause long-term harm.

There are no easy answers but my worry is that there does not even seem to be a discussion taking place. Both universities and the health services are drifting into a situation which we may all eventually regret. Until universities rediscover their historical role, the answer to whether they should remain the deliverers of medical education can only be a qualified yes.