The uncertain future of medical education
Authors: Zoë Playdon, Abdol Tavabie
Publication date: 16 Feb 2011
Zoë Playdon and Abdol Tavabie look at the ongoing consultation on the future of medical education
In the aftermath of the Liberating the NHS: developing the healthcare workforce consultation and the Browne report on securing a sustainable future for higher education in England, the parallel worlds of postgraduate deaneries, universities, and medical schools seem set to converge. All three provide a crucial focus for improving patient care: universities through research, teaching, and social engagement; medical schools by preparing undergraduates to enter the profession; and deaneries by developing graduates into independent, career grade doctors. There are already obvious crossover points between the three, such as medical schools’ clinical placements for undergraduates, which use deanery local education providers in hospitals and general practices, and masters degrees provided by universities as an elective part of individual doctors’ postgraduate medical education. Given the high cost of maintaining three separate organisational bases to work towards similar purposes, our questions are: how might they collaborate to form a new community of practice; why haven’t they done so already; and what are the implications of the proposed changes?
Historic barriers to collaboration
To take the second part of our question first, beneath their surface similarities, the postgraduate deaneries, universities, and medical schools are historically different. Universities in the United Kingdom began with the foundation of Oxford in the 12th century. Medical schools, meanwhile, developed from real life clinical practice in charitable hospitals. So, the development of scientific medicine, from Jenner onwards, took place at one remove from the Victorian civic universities. For example, a college of medicine was established at Newcastle upon Tyne in 1834 in connection with the University of Durham, which was founded in 1832, but was not incorporated into Newcastle University until 1963. Separated by 900 years of different cultural development, even today most medical schools seem to be hosted by, rather than incorporated into, their universities.
Deaneries were founded within the NHS on the back of the Goodenough report, which recommended that universities should depute the organisation and supervision of postgraduate medical education. Since then, deaneries have acted as change agents for the NHS by creating collaborative partnerships with other parts of the national, regional, and local infrastructure for medical education. At present they are becoming part of the new skills networks proposed by the Liberating the NHS report.
These histories are reflected by a parliamentary separation, which locates universities in the Department for Business, Innovation and Skills and deaneries in the Department of Health. Universities, medical schools, and deaneries legitimately have different affiliations, networks of influence, roles, and responsibilities, which can stimulate creativity and diversity. However, they can also produce costly idiosyncrasies. For example, unlike every other part of the UK university system, medical schools do not have a uniform system for grading first degrees. Unlike other UK graduates, medical graduates cannot judge their career expectations from their first degree. Deaneries must therefore operate an expensive selection process for them to admit medical graduates to the first year of postgraduate medical education, so that the Department of Health seems to be paying for the inefficiencies of the Department for Business, Innovation and Skills.
Underlying these historical and organisational differences, and presenting a real danger to patient safety, is a philosophical division, between praxis and the academy. As Stanley points out, the “tradition of the academic mode” is to separate people from knowledge of their own experience and to re-locate knowledge in the academy. This is done by focusing “on propositional knowledge, or ‘knowing that,’ as the paradigm of knowing,” so that “‘knowing how,’ or skilled activity, is consistently subordinated.” Praxis, the knowledge that arises from practice, which is co-constructed through inter-subjective relationships between doctors and patients, is inferior in the eyes of the academy. Yet it is precisely praxis that comprises professionalism, the “psychosocial and humanistic qualities such as caring, empathy, humility, compassion, social responsibility, and sensitivity to people’s culture and belief,” which lie at the heart of a patient centred NHS. Without praxis, there is no professional judgment, no contextualised understanding of the complex needs of individual patients, and no way of managing change while maintaining patient safety.
Collaborating in medical education
To return to the first part of our question, how might new communities of practice emerge for medical education? A starting point, perhaps, is to reconceptualise the relationships between universities, medical schools, and deaneries. Medical schools are now part of a larger, wider academic body, with huge opportunities for drawing on a broader intellectual community. However, new requirements by the General Medical Council for accredited educational supervisors, a new focus on clinical leadership, and the emergence of medical humanities all provide routes for collaboration between medical schools and other specialist university departments.
This does not mean that universities should take over the function of deaneries, that the academy should subordinate praxis. Universities are locuses of academic qualification, whereas deaneries facilitate professional accreditation; universities have an effective “travel to teach” distance of about 30 miles, while deaneries must operate across a large region but within its boundaries; and deaneries, as NHS organisations, are indemnified against the legal and financial risks inherent in workplace based learning, whereas universities, as private organisations, are not. Nor does it mean that deaneries and universities should treat each other as cash points and convenience stores, with deaneries expecting universities to provide any kind of course instantly, and universities stalking deaneries to fund their favourite projects.
In other countries medical training is more centralised. It is important to note that the UK is relatively unusual in combining workplace learning and working in postgraduate medical education, as part of a conducive, decentralised learning environment. A new kind of partnership is required, therefore, in which clinicians and academics come together to develop new ways of improving medical education and increasing patient safety. Many deaneries have already made steps in that direction by employing non-clinical specialists in education, leadership, or careers to create new processes and programmes for learners within their region. Some deaneries have developed academic infrastructures in their local education providers to manage recruitment, retention, progression, and completion for postgraduate medical education, so that they operate on lines that are strikingly familiar to universities. These are clear directions towards ending the binary divide between undergraduate and postgraduate medical education, towards opening up a “third space,” where clinical and non-clinical specialists work together, and towards providing a curriculum in which workplace based learning and classroom based teaching count equally.
Who should lead improvements?
Who, then, should take the lead in transforming medical education for the new NHS? Universities are the only bodies that can award academic qualifications and they have unique academic expertise. But at the moment their focus must be on bringing medical schools into the mainstream of their organisations locally and into the UK qualifications structure nationally. At the same time, each university will need a considerable amount of time to understand their new financial equations post-Browne: medical schools are not necessarily the most profitable departments to run, and finding cost effectiveness for their present role will be a complex calculation. In addition, universities’ spheres of influence are both too local and too global, and their business too competitive, to make them credible leaders for regional change.
The medical royal colleges, which draw from the expertise of both local education providers and universities, clearly have a large agenda to review and implement their new national curriculums and be fit for purpose, for their role is highly specialist and national—each of them is a senior clinical curriculum authority for postgraduate medical education.
The main weakness of deaneries as change agents is their limited financial power, being unable to carry funding across from one year to another, without capital assets; funded as uniprofessional organisations; and highly vulnerable to economic pressures. However, these are weaknesses that have been addressed positively in the creation of foundation trusts, so they are clearly not insuperable.
Collaboration at Kent, Surrey and Sussex deanery
Deaneries provide a “third space” between universities and medical royal colleges, between national responsible bodies and local patient care. For example, at Kent, Surrey and Sussex we have created a regional network of local academic boards and local faculty groups within our local education providers. They are regulated to agreed contractual standards and managed by directors of medical education, who chair the local academic boards for their local education providers. To parallel this management structure, we have worked in partnership with the medical royal colleges to provide a strong leadership structure for specialty development, led by jointly appointed heads of specialty school who relate directly to the college tutors leading each local faculty group. Thirdly, we have formal partnership agreements with several universities to enhance the professional accreditation of postgraduate medical education by engaging with academic and research agendas. This includes a cadre of senior academic assistant deans for education seconded specifically to develop and implement new processes and partnerships.
In these ways, we seek to draw together the strengths of local education providers, medical royal colleges, and universities into an integrated, matrixed “learning organisation.” It is partnerships of this kind, built on a deep, mutual concern for better patient care, that we believe medical education will require to retain the best of its tradition and be fit for the 21st century: affordable, attractive, and academically rigorous.
Implementing government reforms
The new consultation paper envisions devolving education and workforce planning to local health providers. It emphasises skills and training for the whole workforce in order to deliver cost effective patient care. However, there is no mention of the necessary requirement for development of various professionals, including medical professionals, to act as change agents and risk assessors in delivering complex patient care. Furthermore, there is currently little expertise in the organisation of education at local health providers. We believe these omissions will carry an unintended high level of risks for preparing the next generation of professionals, including doctors, as critical, creative, and thoughtful practitioners who endlessly strive to develop their practice and who are therefore lifelong learners.
It is wholly appropriate to review education for professionals in partnership with local health providers, and we believe this should include service development planning, with integrated financial and workforce planning, as part of a medium to long term strategy. However, we urge policy makers to assess the level of risk for patients’ safety and cost benefit of the proposed organisational changes before their implementation.
Competing interests: None declared.
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Zoë Playdon head of education
Abdol Tavabie deputy dean director and GP dean Kent, Surrey and Sussex Deanery
Correspondence to: A Tavabie email@example.com