Reform of undergraduate medical teaching in the United Kingdom: a triumph of evangelism over common sense
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7457.92 (Published 08 July 2004) Cite this as: BMJ 2004;329:92All rapid responses
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I find it interesting that the debate has centred on PBL versus
'traditional' medical teaching (though consensus on what people mean by
'traditional' I think would be quite difficult!) when in fact the article
by Williams and Lau criticises numerous factors. They raise issues
including PBL versus didactic lecturing, expert tutors versus non-expert
tutors, replacing basic science content with communication skills, and
allowing students some leeway to study non-medical topics for up to 10% of
the course.
Remember that the 'traditional' approach that the authors cherish
itself grew from dramatic critiques of current practice by people such as
Flexner at the turn of the century. The educational movements that grew
from that era, including the 'progressive' movement that rejected the rote
memorisation and large group recitations that were the primary approach to
teaching at the time, did not have randomly-controlled, nicely packaged,
unequivocal evidence, but as time went on resulted in a radical change to
schooling, including the professionalisation of medicine. PBL grows out
of that same movement that aims to teach through experience, contextualise
facts, connect to previous knowledge, and give learners some control over
their own growth.
PBL is _not_, as some respondents imply, about letting students study
only what interests them. While there are many methods under the umbrella
term PBL, most approaches include being specific about the ultimate
outcomes that are expected to be achieved. What is not specified is a
single path for achieving that outcome.
PBL is _not_ about sacrificing the basic sciences. For instance,
Hull York requires a great deal of anatomy, physiology and pharmacology
from our students, in some areas more than some 'traditional' schools.
But it is also about bringing in aspects of _all_ the knowledge and skills
needed by doctors. Our external examiners were very impressed at the level
of basic science questions that HYMS students were expected to answer in
the 1st year exams, and equally were very impressed with communication and
consultation skills, noting an impressive level of performance in OSCEs.
Likewise, many SSCs allow students to delve more deeply into basic
sciences such as biochemistry and we hope will encourage some to choose to
pursue these areas.
I won't go here into the evidence 'for or against' PBL, though some
has been presented by other respondents, because I think that it is too
simplistic a question to begin with, given the multiple factors that go
into any curriculum change. However, there is certainly plenty of
evidence that active learning results in better retention than passive
learning, that placing responsibility on students for directing their own
learning is more effective (and more enjoyable) than goosestepping
everyone down a single path, and that integrating knowledge with
application is better than teaching isolated facts. It is also clear that
students who are used to being led along at every step, as happens with
much A-level teaching, are often unable to deal with being dumped directly
into PBL from Day 1. This is why our (very talented) students have
developed a mentoring scheme and induction to PBL delivered to our new
students by existing students, to ease that transition.
As Lynch says, any teaching approach can be done well or badly. I
would hope that the authors might take it upon themselves to visit some
schools where it is being done well with an open mind.
Competing interests:
Physiologist and cognitive scientist working at a PBL school
Competing interests: No competing interests
Dear Sir
Re: "Reform of Undergraduate Medical Teaching in the United Kingdom :
A Triumph of Evangelism over Common Sense”
Authors: Gareth Williams and Alice Lau. BMJ volume 329 p92-94 10 July 2004
I write as a product of a pioneering new style undergraduate medical
education course dating from the 1970’s at the University of Nottingham.
Gareth Williams has expressed a view that educational revision of
undergraduate medical teaching in the UK has swung to a level where the
priority of teaching attitudes amongst educationalists has reached a point
where they overshadow the importance of teaching clinical knowledge and
skills for those training to be doctors in the United Kingdom.
As a graduate of the University of Nottingham Medical Faculty in
1977, I was one of a group of students who were subjected to the
experience of an educationally driven new course based upon novel
principles of education at that time. The course identified themes, the
cell, man and community, used a diverse range of educational techniques,
lectures, seminars, tutorials, problem based learning, early clinical
teaching, integrated courses, programme text learning, streamlined
practical classes, continual assessment and formative assessment with the
aim of producing an educated and highly trained House Officer capable of
taking their professional training further within their personal ambitions
for the rest of their lives. The central component of the course was to
include training in research, with every student undertaking an
individualised research project with appropriate supervision and achieving
a BMedSci degree within the 5 year time slot.
At the time of graduating as a Houseman and working around the
country amongst others from the more traditional courses, it was apparent
that there was an emphasis in my training that meant that I had a reduced
body of clinical knowledge compared to my colleagues from other Faculties.
However, I had a comparable level of scientific knowledge and a higher
level of research and communication skills training compared with my
colleagues from other Faculties.
This contrast in the late 1970s was noticeable and the lack of
clinical knowledge, in particular, did impact, to some degree, upon my
ability to achieve in postgraduate training in medicine and paediatrics.
This has not proved insurmountable as I now work as an academic in
paediatric oncology.
It is my view that the problems identified by Williams and Lau are an
exaggeration of the same situation that I found myself in in the late
1970s with the more extreme forms of educational course being experimented
upon in the new Faculties that are springing up around the country. The
difference is that they are, in general, not laying emphasis upon the
importance of research training as an integrated skill for the modern
doctor.
As a multi-system specialist physician working with children, I would
challenge the wisdom of down playing the importance of basic science in an
undergraduate education and I would also challenge the safety of too
greater emphasis being placed upon a limited core of knowledge with
disregard to its breadth.
It is impossible as an undergraduate to predict your future career
course. The end of your medical training is a time when you have acquired
your metaphorical set of basic tools for the rest of your career. To have
a bag of tools that are so light in basic science and clinical knowledge
that you need to buy new tools throughout your professional training, does
mean that the choices open to you will be unacceptably constrained before
you have even earned your first salary.
I would therefore, support Williams's and Lau’s view that extremes of
educational fervor in the area of problem based learning, and an excessive
focus on attitude is to our disadvantage. Modern clinical practice
cannot disregard the importance of scientific, as well as clinical
training, if this highly valued national workforce with the country’s
health service budget at their disposal is to meet the expectations of
their patients and employers.
Yours sincerely
Dr David A Walker BMedSci.BM.BS.FRCP.FRCPCH
Reader in Paediatric Oncology / Honorary Consultant
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
I was disappointed to read the recent article by Williams and Lau
(1), which appeared to be critical of modern teaching methods and in
particular, problem-based learning (PBL). They suggest that students
taught through problem-solving may be put at a disadvantage when compared
to those taught by more traditional, didactic methods including lectures
and tutorials. Indeed, the authors cited the examples of McGill and
McMaster Universities in Canada, and stated that overall, PBL did not
produce doctors with better knowledge levels than traditional courses.
What is more, they also appeared to imply that British undergraduates were
less likely to fare as well as their Canadian counterparts, due to them
being ‘less mature and motivated’.
I must say that I disagree with them on both counts.
Problem-based learning is by no means a perfect teaching tool and the
authors gave some evidence to this effect. However, other studies-
including large meta-analyses have shown that PBL students may take a
deeper approach to learning and manage to retain their knowledge for
longer periods of time (2,3). Students and clinicians perceive PBL as
more clinically relevant and rate these courses more highly (4). This is
indeed borne out in teaching practice.
Although, it is clear that some students are less mature than others,
they are usually highly motivated- at least initially. I provocatively
suggest that any fall in their motivational levels are not wholly due to
the distractions of student life, nor to a loss of inherent drive- but
partly the fault of antiquated teaching methods. If we insist on a rigid,
Victorian classroom-style approach to higher education- we will by
definition, encourage well-mannered but ‘infantile’ practitioners. A 21st
century NHS doctor needs 21st century, mature learning skills to actively
keep abreast of the pace of change. That, to me, is the problem.
Word count 299
1 Williams G, Lau A. Reform of undergraduate medical teaching in the
United Kingdom: a triumph of evangelism over common sense. BMJ 2004;
329:92-4.
2 Albanese M, Mitchell S. Problem-based learning: a review of
literature on its outcomes and implementation issues. Acad Med; 68(1): 52
-81
3 Schmidt H, Dauphinee W, Patel V. Comparing the effects of problem-
based and conventional curricula in an international sample. Med Educ; 62:
305-15.
4 Smits P, Verbeek J, Buisonje C. Problem-based learning in
continuing medical education: a review of controlled evaluation studies.
BMJ; 324: 153-56.
Competing interests:
None declared
Competing interests: No competing interests
Williams and Lau imply that there has been undue haste in reforming
the medical curriculum (1) . However the GMC as far back as 1863 was
pointing out that there was “overloading of the curriculum of education …
with results that are injurious to the student” (2). Such comments were
reiterated in the GMC Recommendations on Basic Medical education in 1980.
The Royal Commission on Medical Education 1965-68 (Todd Report paragraph
197) commented that “We cannot emphasis too strongly that the
undergraduate course should be primarily educational … We must postulate
that what is taught should be taught in such a way as to promote the
powers of the mind”. The Royal College of Physicians Committee on Medical
Education in 1944 and Pickering in 1978 (3) were also damming of the state
of British Medical Education. Maybe the surprise is that it is only by the
1990s that we see British universities moving with any rapidity towards
change.
I wonder if an essential point has been overlooked in the discussion
so far. The primary outcome for undergraduate medical education seems to
be the adequate preparation of doctors able to perform as pre-registration
doctors in hospital. The surrogate marker that informs the decision as to
whether someone is indeed competent to progress, is the exam system. In my
day (twenty plus years ago) the pass mark was 50% - giving a clear message
that much of what was taught and assessed was irrelevant. This encouraged
superficial and tactical learning. If one can develop clear core
competencies and knowledge, develop exams which actually test those skills
with high specificity and sensitivity (pass mark say 90%), then maybe how
one learns – PBL, didactic or both becomes less relevant. (4)
I wonder if the current divide between post graduate and
undergraduate medical education has more to do with bureaucracy, finances
and power, than the genuine needs of our health system. In their final
year, medical students spend significant time shadowing pre-registration
doctors. Following this the newly inserted Foundation year 2 will
consolidate and develop skills that were acquired the previous year, a
process which seems repetitive. Core medical skills which were stoutly
defended in the past ( for instance, phlebotomy and ECGs by pre
registration doctors, and more significantly, being the point of first
contact and specialising in undifferentiated illness by GPs) have been
taken on with surprising ease by other professionals.
I think medicine is at a pivotal point and the next decade will see
exciting changes. Hopefully our education system will adapt with greater
speed than is has in the past!
(1) Williams G, Lau A Reform of undergraduate medical teaching in the
United Kingdom: a triumph of evangelism over common sense. BMJ 2004;
329:92-94
(2) Quoted in GMC Tomorrow’s Doctors 1993 para 10
(3) G. Pickering “Quest for Excellence” 1978
(4) Shumway J, Harden R, The Assessment of learning outcomes for the
competent and reflective physician. Medical Teacher Vol 25 No 6 pp569-584.
See also Biggs J, Teaching for Quality Learning at University, Second
Edition 2003
Competing interests:
None declared
Competing interests: No competing interests
Sir,
The most concerning and important point to emerge from this
discussion is that there is any need to be having it at all.
As Williams and Lau say:
"The training of doctors is too important an activity for bold
experiments to be conducted without discovering what really happens."
Surely this is the most fundamental point? Failings in Medical
Education/Training jeopardise both patient and practitioner welfare. It
does concern me that, in 21st Century Britain (and indeed the 21st Century
Developed World), doctors (who by definition should be well-educated
people) seem to be so confused about how they should be educated and how
they should educate others. It is quite absurd, for example, that content
cannot be defined properly and that assessments are so frequently invalid.
Competing interests:
None declared
Competing interests: No competing interests
As a recent graduate of the type of program in question, I have been
following this debate with some interest.
I think PBL has become a catchy marketing pitch to draw attention
away from the real issue of quality in medical education. (In my
experience, assessment was a complete joke.)
In "The PBL Debate is a distraction", Watts illustrates the current
misplaced emphasis.
"However, debates over problem-based learning are a distraction.
Different methods of teaching should not define the quality of medical
education. Equal measure should be given to rigourous definition of
content, effective delivery matched by valid assessment. Medical schools
worth their salt give equal weight to all three."(Watts)
Sometimes, it seemed more like acting school than medical school.
There was an early emphasis on developing a slick bedside manner. Coupled
with just the right amount of arogance, would the patient be deterred from
asking questions to which you wouldn't know the answers. Acting would be a
fun career, though.
So, I was intrigued by McCoubrie's letter, "Sucessful PBL?".
"Sir Recently, I had occasion to be a medical advisor to a tv drama.
For one episode, I had to teach an actor how to perform a complicated
medical emergency procedure on a prosthetic patient. We were given an hour
to have a one to one tutorial, and the training was sucessful enough for
the actor in question to perform the procedure competently under the
scrutiny of a camera (and ultimately the tv viewing public)on the first
take; and then to repeat this several times during the day. The teaching
centred only upon the problem (how to do the procedure "for real" on a
dummy), and not the anatomy, physiology or pathology of the supposed
underlying diagnosis (although the actor was at liberty to study these
himself at a later time). I subsequently read publicity interviews for the
show where the actor talked about the medical status of one of his
relatives, and how he felt competent enough "to have a go" if a medical
emergency arose." (McCoubrie)
For those of us who have endured this type of education, what now?
Competing interests:
MBBS Sydney University 2004
Competing interests: No competing interests
I read the recent article with interest - on two accounts. One as a
doctor trained the traditional route and now working in Undergraduate
Education and the other as the mother of two daughters who have just
qualified as doctors this summer...... one went to a PBL school ,the other
to a school which has taken on the changes advocated by Tomorrows Doctors
with a 'hybrid curriculum'. I will produce a definitive paper with my
control study of two!
Many UG teachers have wondered like Willaims and Lau,whether all the
suggested GMC changes are indeed the way forward -especially as one reader
also suggested .. the emphasis on Student Selected Components. It was
interesting to note the differences between the girls medical schools in
which type of SSC was expected and what was achieved!!!!
My daughters greatly enjoyed many of the SSCs but it was only coming up to
finals that they suggested that this important 30% of the course could be
better spent seeing patients and gaining clinical experience.
I do not wish either of my daughters to feel short changed by their
medical education and epecially not as Williams suggested - damaged by
the 'new ideology'. At present they do not know the answer to this - the
'outcome' may be apparent after differing experiences in PRHO years.
However, I would suggest that the typical UK entrant to medicine can use
differing methods to attain the skills, knowledge and attributes necessary
to become good doctors but, more than a fixed type of curriculum, they
need the enthuasiam and support of the NHS staff to teach and act as role
models. Also Universities must start putting the 'school' back into
Medical school and reward teachers - avoid the research vs teaching dilema
which has driven many good academics out of the profession.
Transparency into the SIFT (in NI SUMDE) monies which the government gives
the Trusts is essential to support the NHS teachers. Tens of millions of
pounds is going to individual Trusts to deliver Undergraduate teaching but
this money is not releasing the NHS staff to do so. This must be addressed
before the argument on the reform of Medical teaching goes much further
and to me is more important than having 'a rigorous comparison of
traditional vs new curricula' carried out.
Competing interests:
None declared
Competing interests: No competing interests
I would love to be a fly on the wall when the GMC QA team visits
Bristol! Like the content of medical undergraduate curricula, about half
of what Williams and Lau (1) say is probably true, but it is difficult to
know which half until further data emerge. There is no specific mention of
problem based learning (PBL) in Tomorrow’s Doctors (2) and it is
misleading to suggest that this is an essential component of the GMC
reforms. Stimulated by Tomorrow’s Doctors and the establishment of new
medical schools, medical education has become a dynamic area for
educational research and a legitimate area of sub-specialisation. It
would be unfortunate if the amateurism of the “old” school e.g., teaching
by humiliation, detailed factual overload, subjective and unreliable
assessment, did not continue to be replaced by a professional approach.
Increasingly there is an evidence base in medical education, but the
absence of significant funding to support research is a major problem, as
highlighted in the recent Calman Review in Scotland (3). The frustration
of the proponents of PBL that their case has not yet been proven is
evident (4,5).
Any curriculum, whether PBL, systems or specialty based, should cover
an agreed core of knowledge, skills and attitudes and there should be no
presumption that adopting PBL precludes students from learning facts, any
more than there should be the presumption that students on non-PBL courses
are unable to think for themselves. We should welcome the vitality and
diversity that the reforms have brought and defend education from the real
problems – the pressures brought to bear by other factors such as the new
consultant contract and the Research Assessment Exercise. Whatever the
pedagogic approach, PBL or otherwise, the single most important factor
that shapes the undergraduate educational experience is the quality with
which that approach is implemented.
References
1. Williams G, Lau A. Reform of undergraduate medical teaching in the
United Kingdom: a triumph of evangelism over common sense. BMJ 2004;329:92
-94.
2. General Medical Council. Tomorrow’s Doctors. Recommendations on
undergraduate medical education. London:GMC, 2002.
3. Calman K, Paulson-Ellis M. Review of Basic Medical Education in
Scotland. http://www.scotland.gov.uk/library5/health/rbmes-00.asp, June
2004.
4. Dolmans D. The effectiveness of PBL: the debate continues. Some
concerns about the BEME movement. Med Educ 2003;37:1129-1130.
5. Farrow R., Norman G. The effectiveness of PBL: the debate continues. Is
meta-analysis helpful? Med Educ 2003;37:1131-1132.
Competing interests:
None declared
Competing interests: No competing interests
Editor -
I welcome Gareth Williams’ and Alice Lewis’s timely intervention
about modern medical education and respect their wish to hark back to a
more traditional view of medical training. It is well recognised that many
share their views. However, the contention that “traditional medical
training produces doctors with a sound knowledge base that allows them to
practise across a broad spectrum of medicine” is stark in the face of the
demand for evidence of positive outcomes from modern curricula. Indeed,
the recent headlines about scandalous doctor behaviour reflect those who
undertook a conventional training. What evidence is there that the new
ideology may actually damage medical training in this country as suggested
by the authors? None is included within their paper.
The authors do not argue against the GMC’s principle of ensuring that
undergraduate medical training is a platform for lifelong learning but
they do fall into the trap of considering the first five years in
isolation from learning (and training) that follows. The continuum of
education is the justification for focusing on core elements of knowledge
and skills, and encouraging undergraduate students to broaden their
interests through selected study modules – an opportunity that is
difficult to realise after graduation. Medicine is such a vast subject
that it is impossible for students to learn every detail (as was expected
in the past). The many additions, rather than deletions, to undergraduate
training is what is recognised by the GMC as “curriculum overload”. There
is no justification in blaming modern curricula as being responsible for
the difficulty in recruiting to certain disciplines – the present day
shortage of pathologists reflects a lack of interest from graduates taught
along traditional and didactic lines that so often divorced pathology from
the clinical setting. Moreover, shortage of anatomists and the abolition
of anatomy demonstrators as part of postgraduate surgical training were
the major factors that influenced the system- based methods for teaching
anatomy in modern curricula.
It is disappointing that Williams and Lewis do not analyse how
students best learn medicine and the difficulty faced by many, although
academically talented, in bridging the step up from a more superficial and
rote system taught in secondary education to higher education’s need for
deeper learning. They make no mention of the importance of contextualising
medical learning and teaching to emphasise the relevance to clinical
practice – just one of the underlying principles promoted by the GMC and
reflected in modern medical curricula. It is crucial for good doctoring
for the future that our doctors understand the deeper principles about
good practice rather than obtain a superficial knowledge learnt by rote
and taught through lectures.
Good medical curricula must recognise the importance of a balance between
old and new methods and allow students to learn rather than be taught.
Evangelism is a term inappropriate to modern curricula as Puritanism is to
the traditional courses – British medicine has a firm tradition of
innovation and progress in medical education that is clinically based. The
new courses attempt to take this forward in a considered way in a
challenging environment – I agree with the authors’ suggestion that change
and adaptation must be built on an evidence base, something that the
traditional courses of the past sorely lack.
Competing interests:
None declared
Competing interests: No competing interests
Validation for Problem Based Learning: a comparison of student perceptions.
In 1993, the GMC recommended that Medical Schools should develop
student-centred curricula, to discourage memorising detail in favour of
information gathering and problem solving (1). In response, most UK
schools (2) have adopted a form of problem-based learning (PBL), which
when compared to traditional courses, at best produces graduates with only
marginally better diagnostic acumen (3). This has recently raised concerns
about the cost effectiveness of introducing new learning formats without
significant validation (4), a situation which is confounded by uncertainty
as to whether PBL courses conform to the GMC guidelines.
To ascertain whether PBL can deliver on these recommendations, 86
traditional, and 246 PBL course graduates were asked to quantify on a 5
point Likert scale (1 – small amount, 5 – large amount) the extent to
which memorising detail and gathering and analysing information featured
in their courses. Statistical analysis was performed by Chi-square test
and effect size.
Over 90% of traditional-course students considered memorising details
a prominent part of their course (grade 4/5 - Figure 1a), whereas only 40%
of the PBL students thought this a significant feature of theirs
(p<_0.000001 effect="effect" size="size" _-1.56.="_-1.56." by="by" comparison="comparison" gathering="gathering" and="and" analysing="analysing" information="information" was="was" a="a" major="major" characteristic="characteristic" for="for" _75="_75" of="of" pbl="pbl" students="students" course="course" grade="grade" _4="_4" _5="_5" _-="_-" figure="figure" _1b="_1b" whereas="whereas" only="only" _22="_22" traditional="traditional" considered="considered" it="it" relevant="relevant" in="in" their="their" curriculum="curriculum" p0.00001="p0.00001" _1.6.="_1.6." p="p"/> PBL is reported to stimulate life-long learning (5), but curriculum
change followed education and psychology theories with only a limited
evidence base that it improves clinical performance. These data show
compelling, comparative and objective proof that students perceive that
the GMC objectives are being attained through PBL, because it has altered
their learning techniques. This therefore provides further justification
for its assimilation into Medical School curricula.
Corresponding Authors
J Burke*
D Lloyd+
R G Matthew*
M Field* (Corresponding Author)
Affiliations
*Wolfson Medical School Building
University of Glasgow
University Avenue
Glasgow G12 8QQ
+The Business School
The Open University
Milton Keynes
REFERENCES
1. General Medical Council, (1993),
Tomorrow’s Doctors: Recommendations on undergraduate medical education
London: GMC
2. Christopher DF, Harte K and George CF.
The implementation of Tomorrow's Doctors.
Med Educ. 2002; 36: 282-8
3. Colliver JA.
Effectiveness of problem-based learning curricula: research and theory
Acad. Med. 2000; 75: 259-266
4. Williams G and Lau A.
Reform of undergraduate medical teaching in the United Kingdom: a triumph
of evangelism over common sense.
Brit. Med. J. 2004;329:92-4.
5. Newble DL and Entwistle NJ.
Learning styles and approaches: implications for medical education.
Med. Educ. 1986; 20: 162-175.
Figure 1a/b
Student perceptions of the extent to which each parameter
characterised the traditional (blue) and PBL based course (burgundy).
Competing interests:
None
Competing interests: No competing interests