The changed face of medical training

10 April 2013

Published in The Age

Doctors aren’t like they used to be. It all began in the liberal, educated 1970s, when a vast demographic trend to holistic healing began. Doctors weren’t going to stay in business if they remained aloof from their market. So a revolution was launched - one which, 30 years later, has transformed medical training and practice.

Today, Medicine’s new paradigm begins before enrolment: students are selected not merely for their HSC marks, but for their ability to manifest care, compassion and understanding for patients, to learn throughout their lives, to place less reliance on authority than before, and to practise in the face of uncertainty. Absorbing mountains of information is out.

In a growing trend, in three of Australia’s universities Medicine is an exclusively post-graduate degree. Graduate entry is lowering Medicine’s considerable dissatisfaction, drop-out and non-practising rates: whilst school-leavers may be pushed into Med by parents or headmasters, graduates are not so suggestible. So today’s doctors tend to enjoy their work more.

Associate Professor Susan Elliott oversees the development of the Medicine curriculum at Melbourne University. The entry criteria changes, she says, “mean you get a really nice diversity of students. That means you’re producing a more diverse range of doctors, to meet community expectations. It’s no longer the male private school boys who are the only people getting in.”

Degrees are getting shorter too: five years at Newcastle, and at Melbourne it’s four and a half for graduates and six for school-leavers.

Increasingly worldwide, the training approach is “problem-based learning” (PBL). PBL’s co-founder - and its foremost prophet -  is Emeritus Professor Howard Barrows of the Southern Illinois School of Medicine. He explained it to The Age:

“PBL as a distinct educational method started over thirty years ago at McMaster University [Canada]. The founding faculty, coming from other medical schools, decided they needed to do something about the way medical students universally disliked having to memorise endless amounts of facts from lectures...

“To the students this activity seemed to have little bearing on becoming doctors and caring for patients... The founding faculty noted that in contrast hospital residents in postgraduate training - overworked, under pressure most of the time - nevertheless loved the education they were getting.

“The new faculty decided that the motivation was working with patients. So they designed a curriculum based on work with patient problems, to motivate students, and overcome what seemed an irrelevant way to prepare for a career in medicine.”

Three decades later, a group of Australian first-year students will start with clinical scenarios, and work backwards toward learning anatomy, physiology and so on.

“Most schools,” says Susan Elliott, “use a paper case - the students are given successive pieces of paper with the case details - or use the university’s intranet. The case is often based on a real person. Students interact with patients in other contexts during their course.”

Professor Barrows says:

“Maastricht University in The Netherlands and the University of Newcastle in Australia started their problem-based learning new medical schools shortly after McMaster... I think the spread and development of PBL in Australia is particularly remarkable.”

Research suggests that the new school of PBL-trained doctors is not just more empathic, but more knowledgeable. Thus the change to problem-based learing is accelerating. Alison Verhoeven, who manages medical school accreditation at the Australian Medical Council, says:

“Currently there are eleven medical schools in Australia. Of these, six use PBL, with others using variations of the PBL approach, and some planning to introduce a PBL approach in new curricula being developed.”

Susan Elliott points out that problem-based learning dovetails with the other big revolution in medical training - integration:

“Horizontal integration is between disciplines at a particular level - say a body system. So instead of doing an anatomy subject, you’ll now do a block on the gastrointestinal tract and the liver. And in that block you’ll pull together all the anatomy, physiology, biochemistry, pharmacology, and so on that’s relevant to that body system. PBL is one of the vehicles for enabling that integration.

“PBL also provides vertical integration - between the basic and clinical sciences. So instead of doing a biochemistry course and having lectures on glucose metabolism and insulin, students will be given a problem of a patient with diabetes. And that’s how they will learn about glucose and insulin. In most universities, students start seeing patients from first year.”

To make things even more patient-based, says Elliott: “Students do a lot of their education in general practices and community health centres, often in rural locations - instead of just in the big hospitals.”

As well as being patient-based, Medicine is now also “evidence-based” - meaning doctors are expected to always know what is “best practice” for a particular illness. No longer can they rely on “the traditional treatment”, or their own experience. Indeed they can get sued for it.

The profusion of properly conducted clinical studies, and the Internet revolution, have made accurate, current information central to today’s medical training. University intranets, and electronic textbooks with external links, are common. Students track down studies through databases like PubMed, Current Contents or EMBASE. PubMed alone stores articles from 3,900 quality journals.

The much-used online Cochrane Collection contains thousands of systematic reviews of the primary literature - comparing, summarising and evaluating controlled trials against each other. Students and doctors alike may access these whenever they want the most accurate and up-to-date information possible for dealing with a case.

(The public can also access these digital goldmines.)

So for all its “patient-based” emphasis, Medicine hasn’t gone too touchy-feelie: students’ abilities to search and evaluate this literature - and grasp the scientific method which underwrites it - must be of a high standard.

Medicine’s new “McMaster Approach” combines patient skills and information skills to turn students into “life-long, self-directed learners possessing strong problem-solving and teamwork abilities”. It’s a world away from the rote, classroom learning of the past - which produced what’s now scornfully known as “cookbook medicine”.

It’s a different world for medical graduates now, too. They still go to a hospital as interns for a year. But after that, says Dr Paul Hemming, President of the Royal Australian College of GPs, those who wish to enter private practice either do specialist training, or a three-year “RACGP training program” for GPs.

The GP training is done in a general practice where a practsing GP will “mentor” the graduate. “There are in-training assessments throughout, so they have to keep up to scratch,” says Dr Hemming - then a final exam at the end. “The curriculum covers a broad range of skills,” he says. “Interpersonal skills are an important ingredient.”

And it doesn’t end there. After qualifiying as a “specialist GP”, says Dr Hemming, “graduates have to commit to a three-year cycle of continuing education - training programs, educational events, audit programs - and build up a series of points.” These three-year cycles, he says, “are a life-long thing”.

Medicine today is increasingly “holistic”: inclusive, mutual and accounting not just for patients’ bodies, but their cultures and their psyches.

The old school of patronising male demigods is fading into history. The change has occurred not by chance, or simply because times have changed, but because of a revolution which began in adventurous medical faculties - with Australian universities in the forefront - over three decades ago.