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Emerging problems with graduate medical education: An academic surgical perspective

Emerging problems with graduate medical education: An academic surgical perspective. John P Harris Professor of Vascular Surgery Associate Dean Surgical Sciences University of Sydney Chairman Division of Surgery Royal Prince Alfred Hospital. Aims of medical education Trends and outcome

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Emerging problems with graduate medical education: An academic surgical perspective

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  1. Emerging problems with graduate medical education:An academic surgical perspective John P Harris Professor of Vascular Surgery Associate Dean Surgical Sciences University of Sydney Chairman Division of Surgery Royal Prince Alfred Hospital

  2. Aims of medical education • Trends and outcome • Student assessment, ranking, honours • Implications of age • Suggested directions

  3. Australian Medical Council Goals and objectives of basic medical education Doctors must be able to care for individual patients by both preventing and treating illness, to assist with the health education of the community, to be judicious in the use of health resources, and to work with a wide range of health professional and other agents. They must possess a sufficient educational base to respond to evolving and changing health needs throughout their careers.

  4. Curriculum themes • Basic and clinical science • Community and doctor • Patient and doctor • Personal and professional development

  5. Dean SJ et al Preparedness for hospital practice among graduates of a problem-based, graduate–entry medical program. MJA 178:163-7, 2003

  6. Aims of medical education • Prepare young doctors to serve the Australian community as clinicians • Lesser but important aims: • The doctor as a social engineer • Patient/Doctor Society/Doctor(Public health) • The doctor as a scientist/researcher • PhD

  7. Medicine as vocational choice Pre-Med degree 3 years Enter Medicine 4 years USydGMP

  8. Medicine as vocational choice Pre-Med degree Miss out 3 years ?career options ?lost opportunity Enter Medicine 4 years USydGMP

  9. Move to Graduate Medical Education • Tutorial room • Self directed learning • Problem Based Learning • Non-clinician facilitator • Societal skills • Preparation for life-long learning • Clinician student • Didactic lectures • Basic sciences • Bedside teaching • Emphasis on history and • examination

  10. Move to Graduate Medical Education • Tutorial room • Self directed learning • Problem Based Learning • Non-clinician facilitator • Societal skills • Preparation for life-long learning • Now • <16% Ann Int Med 126:217-220, 1997 • Clinician student • Didactic lectures • Basic sciences • Bedside teaching • Emphasis on history and • examination • 1960’s • 75% clinical teaching at beside

  11. In ascendancy Medical educator Computer based resources Public health In decline Clinician based teaching Clinical content in the modern curriculum University clinical academic departments

  12. Anatomy formedical graduates • Traditional undergraduate dissection is no longer sustainable • Cost • Time constraints • Shortage of skilled staff • Innovative programmes • Self-directed learning, PBL, supervised practical classes • Option term dissection L Bokey & P Chapuis ANZ J Surg 71:781, 2001

  13. Anatomy teaching in ANZ medical schools Dissection in 3/16 19%

  14. Anatomy:Teaching in other courses ProgrammeHours Sydney Graduate Medical Programme 65 No dissection, prosected specimens, self directed Sydney Undergraduate Medical Programme 500 Science 6 unit science Anatomy (dissection) 91-98 13-14 week semester, Abdomen/Thorax, Head & Neck x2 1hr lecture, 1hr tutorial, 3hrs dissection/week Chiropractor 156 No dissection, 13-14 week semester Limbs, back & trunk, head and neck x4 hr/week x2 lectures, x2 hr practical with tutor ~15% of US hospital residents from osteopathic schools of medicine

  15. Implications? • 1995-2000 x7 fold increase in medico-legal claims based on anatomic error (UK MDU) • Future doctors may be proficient in the general and social aspects of medicine but it would seem that their knowledge of the basic facts of anatomy, physiology and pathology and their understanding of the mechanism of disease may be no better than that of a “medicine man”. R Magee MJA 179:224, 2003

  16. Getting the balance right

  17. Trends and outcome

  18. Student assessment, rank, honours • 5 yr Undergraduate programme • Honours based on cumulative success • Incentive to excel in each subject • USydGMP • Honours based on extra-project • Unrelated to core and distracting from the programme

  19. Student assessment, rank, honours • 5 yr Undergraduate programme • Honours based on cumulative success • Incentive to excel in each subject • USydGMP • Honours based on extra-project • Unrelated to core and distracting from the programme • No University Medal in Medicine • No Year Book 1997-2002

  20. Clinical surgery USydGMP • Graduate MB BS • Surgical content • 32 week block in Year 3 • 16 topics (1 lecture & 1 tutorial) • Integrated Clinical Attachment

  21. Formative assessment • Basic assessment of course • Attendance voluntary • 31 of 50 sat • Results anonymous • 11 of 31 unsatisfactory • Left up to individual to seek remedial preparation for barrier exam

  22. Absence of ranking • Satisfactory/unsatisfactory • How to sift out the poor student? • How to reward the good student? • Absence of objective criteria for: • Residency placement • Selection into specialty training • Award of honours

  23. Implications of age UGMP USydGMP High school 5 HSC 6 UGMP 6 PreMed 3 USydGMP 4 Mean age at graduation 29 +speciality training 4-7 Enters definitive vocation 33-36

  24. Implications of age • 14% >35 at graduation • Vocational choice • Length of specialty training • Short effective practice life • ?return to the tax payer • Life-style • Financial, housing, family • Learning hand/eye skills • Elite performance relates to age of first exposure and practice • Manturzewska in a sample of 190 elite musical performers found no individual who had started later than age nine Psych Review 100:363-406, 1993

  25. Medical education and hard science … And herein lies the rub. Despite continued calls for educational research that matters …, the medical education community has yet to report solid evidence to support the intentions of these resource-intensive changes. The profession, hardened by the evidence-based medicine movement, expects no less. Martin B Van Der Weyden, Editor letter in MJA 181:518, 2004

  26. The way forward…. • Emphasise clinical training • Base curriculum on feedback from students & doctors in practice • Universities & Colleges • Fusion of resources & skills • Apply AMWAC projections to plan medical school entry • Shorten medical education • Early streaming in medical training • New teaching tools • Surgical skills centres • Simulators, video-instruction systems • Consider the impending demise of clinical academic medicine Weedon D. Whither pathology in medical education? MJA 178:200-2, 2003

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