clinical practice scientific basis of medicine medical personal and professional development...

University of Adelaide Medical School

Clinical Practice

Scientific Basis of Medicine

Medical Personal and Professional Development

Factors affecting the outcomesof medical education

Dr E.G.Cleary

Assoc Dean for Curriculum

University of Adelaide


Clinical Practice



Alternative Title

The issues that have to be addressed

by an Assoc. Dean for Curriculum

(and the Curriculum Committee) in

meeting today’s (and tomorrow’s) needs

from medical education


Clinical Practice



My Background = Prejudices declared?

• Graduate Sydney Univ. Medicine 1955• 6 Years RPAH - physician training• MD Sydney (physiology)• 30 years research in basic science• 30 Consultant Physician (OPD) RAH• 40 years “teaching” pathophysiology• 32 years in medical education• Undergoing my 5th curriculum “revision”


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Lets go back to the ‘patient’• I agree, there is a crisis in medical education!

But I disagree with some proposed diagnoses, and especially with some proposed treatments.

• As with so many patients today, the aetiology of the problem is multifactorial and simple uni-dimensional “solutions” do not address the real issues.

• First, we need to define our models and introduce some ideas from modern research on how people learn.


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Basic Concepts

– Curriculum models

• Layer cake model of Flexner (1910) v • Integrated spirals of active learning


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Flexnerian Model?• Clinical Practice

• Clinical Training

• Paraclinical disciplines

• Basic Sciences


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Adelaide Medical School ModelClinical Practice



Vertical and horizontal integration, contextual

- basic science is still being learned in later years

and clinical work is introduced from beginning

The experience should be engaging and

enjoyable!


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Learning and Teaching models

Traditional: didactic, staff driven, rote learning

Modern: contextual, self-directed, ‘adult’ learning

v


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Assessment: Intermittent ‘cram-dump’ Model

• fact-rich,

• mostly rote,

• intermittent

• learning with view to ‘cram-dump’


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Assessment: Continuing Accumulative Model

• On-going • Formative and

summative

• Cumulative

• Directed to test learning for understanding


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Defining our objectives of Med Educn

• Preparing students for practice 10-12+ years ON– Need to envision future practice requirements

• Competent undifferentiated practitioner– Ready for internship

• Knowledge, skills and practice, attitudes– Personal and professional development

• Ethical, ‘equipped’ for life-long learning and self-care– Minimal competence assured

• Need to address causes of ‘adverse events’ in practice• Aware of own competence level, seeks help if unsure


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Some major issues to be addressed• Knowledge is increasing exponentially• Predicting, and training for, future needs• Students are different• Pressures on Staff and Medical Schools

– Teaching poorly valued in Universities– Time and service pressures in Hospitals– Administrative and fiscal pressures– Pressure groups and Media


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Chair of Clinical Senate’s wish-list• Ageing of population• Social and Economic determinants of health• Changing burden of disease (prevention and management)• Health inequalities• Changing governance and service delivery• Population health focus• Emphasis on primary health care

– (prevention, health promotion, health information, functioning in a multi-disciplinary team)

Dr M Rice


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Students are ‘different’• Secondary schools ‘driven’ by TER

– Forced-fed, rote-learning style imprinted• Principals: “We no longer teach students, we ‘teach curriculum’”• Reinforced now by training programs for selection to Medical School

• Television and computer games• Visual learners• ‘ER’ type TV programs influence student ‘entering view’ of medicine

• ‘Get-a-life’ affects students too! - further aggravated by:• Rising HECS, fee-paying students, living costs• High proportion of students work during term (up to 25 h/wk)• Challenges to assessment are an increasing burden for academic staff• Living away from home and international students - mentoring need


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Pressures from within University• Promotion mainly through publications

– Teaching is undervalued, so teachers are diverted

• Funds for teaching are being constantly squeezed– Reductions in government funding– Medical Faculties viewed as funding source - “socialization”– Pressures to take more fee-paying students– Universities have the centre-focussed ‘business model’

• SA Medical Schools are overrun with out-of-state students– We are not training enough students to meet present needs– Clinical staff ‘resent’ teaching students who will go elsewhere


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Changes in ‘teaching hospitals’ limit learning opportunities

• Patient related:– Bed numbers are being reduced to contain costs– Narrow spectrum of patients - age, diseases, trauma, very ill– Duration of stay is much reduced (3.5 - 4 days average stay v 14-21 days av.)– Effect of ODA surgery and overnight admissions – Patients are too ill and too busy to talk with (so many) students– Emphasis on patients rights, expectations, demands (this is good, but different)

• Staff related:– Increasing service load and bureaucratic burden on staff– Management do not value teaching– Advent of speciality units and reduction in general med/surg units– Effects of ‘cost shifting’ between Commonwealth and State Governments


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Effects of changes in teaching hospitals on staff

• Relative increase in number of students per patient• Lack of time to teach as before• No time, or incentive, to engage in staff development• Results in inability to teach students clinical skills• Major reduction in clinical student-assessment activities• No time to supervise ‘long-cases’ for students• Lack of time to provide feedback to students• Reluctance to fail students


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Effects of changes in teaching hospitals on staff -2

Consequences– Seems to generate false assumptions about ‘prior

knowledge’ students are bringing to wards at year 4– This leads to increased expectations/demands on earlier

teaching - ? a form of ‘blame shifting’, and often to denigration of students

– Diminishes relationships between staff and studentsQuestions?• Are major tertiary, acute-care (teaching?) hospitals still

appropropriate places in which to train medical students?• What mix of primary care training should be included in

the medical course and how can this be staffed and funded?


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Other factors• Factors related to general practice

• Rural training schemes

• Workforce issues

• Private hospitals

• Medical Boards

• AMC

• Governments and Depts of Health


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Some possible solutions• Need for more dialogue and to accept good intentions of parties• Understanding of issues and less ill-informed criticism

- feeds media ‘confrontation frenzy’• Willingness of medical community to provide effective,

modern, focussed, teaching and learning opportunities• Willingness to undertake staff development in teaching• Concerted approaches to help Governments to understand the

problems and to implement solutions• Actively engage in educating administrators regarding the

urgent need for change in their approach to training of THEIR future medical and health science staff members

• We must educate community attitudes with informed inputs


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Take Home Messages• We all agree: There IS a crisis in medical education!• This is a multi-factorial problem - unidimensional solutions will

do little to produce the outcomes required in the future• Modern curricula are being adapted to predictable future needs• It is our experience that students from our new curriculum

know AND CAN USE more of their basic science learning in clinical years than those from our older didactic curricula

• There are critical shortages of clinical learning opportunities• There are overwhelming pressures on clinical staff to divert

them from providing adequate training for medical students• We need a combination of critical analysis and creativity.• Our political and administrative “masters” must engage!

clinical practice scientific basis of medicine medical personal and professional development...

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