How can we create a curriculum fit for tomorrow’s doctors and patients?
Authors: Davinder Sandhu
Publication date: 22 Jul 2015
Our outdated system of medical education needs to change to ensure it meets the country’s future care needs, says Davinder Sandhu
Doctors are training in a system that is outdated in terms of curriculum, patient expectations, and hospital structures. Public health and family medicine are at the heart of medicine and where most doctors practise, and yet they are largely ignored in the curriculum. Medical education and training of our future doctors are intimately related to the complexity of healthcare systems, as medical care is delivered within organisation structures. Better leadership and long term strategy are central to improving the quality of medical education.
Curriculum fit for purpose
The modern 21st century curriculum has to be fit for purpose, student centred, and patient focused, but it will also have to change beyond all recognition to deal with social changes. People are living longer with a greater burden of chronic disease; obesity rates are rising; consumption of alcohol and drugs is increasing; and there will be a huge impact on palliative and end of life care. Social pressures of unemployment and poverty are also placing a greater burden on health services, such that public health and prevention of disease will become a core activity. Health promotion, not sickness alleviation, is essential.
Demographic changes are driving more care into the community, yet in most medical schools primary care is a minor part of the curriculum, averaging 13% (range 2-30%) exposure during a five year course. Such low exposure means that trainees are reluctant to choose general practice as a career.
If we define education as the reorganisation of experience, then reflection is a serious part of education and learning. Educating medical students is not just about training but is also about development. We know that memory is flawed and simple regurgitation of facts and didactic lecturing do not work. Teaching has to be meaningful and contextualised correctly for students to be stimulated to learn.
Rather than the traditional split model of two years of basic sciences with token exposure to patients followed by three years of clinical training, an integrated curriculum is sounder and more relevant for students. A successful adaptive model is small group learning or inquiring learning, in teams of around eight students; in this model students are treated as unique learners with individual needs. Early exposure to patients is essential as this sets the scene of why doctors ask about symptoms (history taking) and look for abnormal changes to the body (physical examination), which leads to sensible differential diagnosis about disease (creating knowledge). It also underlines the need for knowledge of anatomy and physiology. Small groups of students in a healthy learning environment will learn to ask why, what, and how. This is different from being given lists to memorise.
All of this is affected by the knowledge explosion phenomenon. What students learn in the first three years of medical school will be just 6% of what is known by the end of 2020. Students will therefore need to shift their focus from what they know to how they can find out more to help their patients. The austerity culture also means that medical schools will need to adjust their education strategy within a business model which includes climate change and sustainable healthcare.
Technological advances are revolutionising teaching, and medical schools have to adapt to techniques such as simulation and simulated patients, clinical skills laboratories, long distance learning, webinars with recorded lectures, flipped classrooms, learning from expert patients, use of telemedicine, and peer learning. Students should also be treated as mature learners, responsible for their own learning but supported by a mentor.
Entry to medical school
Inappropriate selection to medical school is a disaster for the student, the university, society, patients, and the NHS. So how can we achieve effective selection? How much weighting should be given to academic and UK Clinical Aptitude Test scores, references, and non-academic achievements? And are personal statements valid?
A series of multiple mini-interviews may offer more validity. These are made up of 10, five minute stations with a mix of one to one discussions, communication and numerical skills tests, ethical scenarios, verbal and abstract reasoning, and a manual dexterity/practical test.
A key outcome is that it gives the medical school an opportunity to give objective feedback to students who are not selected. Some medical schools are now experimenting with situational judgment tests, which may add further evidence as we try to develop value based recruitment and widening participation.
Medical schools need to be part of the community: teaching staff and students should actively engage with their local schools and groups that are under-represented in the medical profession. This would be a potent force to break down the barriers of class and interprofessional working. Medical students could teach 13-14 year olds, acting as positive role models and helping to support work experience.
University staff development
Most university teaching staff have no formal teaching qualifications—they are appointed on the strength of their research, with teaching as an add-on. Every faculty member should be trained in how to teach and gain an understanding of educational theory. Well supported teaching staff breed enthusiasm and motivation in their students and set the culture of the medical school.
University research has a high profile and this contributes to its grant income. In England, funding comes mainly from the Higher Education Funding Council for England as part of the Research Excellence Framework. The Research Excellence Framework exercise takes no account of the direct contribution of teaching and faculty development; this attitude to teaching needs to be dealt with.
The General Medical Council expects the payment to trusts for teaching (service increment for teaching) to be used appropriately and for staff to be trained.  Teaching has to be part of the job plan and the appraisal process. This is how a community of teachers create a culture of empowerment, motivation, and enthusiasm and support each other.
It is clear that our current system of education needs to change. Students should be supported in small group collaborative learning with experienced tutors and with substantial use of modern technology and wise use of resources. Educators need to constantly develop and medical schools need to become organisations rich in ideas, encouraging creativity and curiosity. All this will help our students to become doctors who aspire to meet the needs of tomorrow’s patients.
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare that I have no competing interests.
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Davinder Sandhu head of postgraduate studies and research, Royal College of Surgeons in Ireland—Bahrain