Reform of undergraduate medical teaching in the United Kingdom: Unfunded reform always ends in reaction

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7469.799 (Published 30 September 2004) Cite this as: BMJ 2004;329:799
  1. Julian T Hart, research fellow
  1. Department of Primary Care, University of Wales, Swansea SA2 8PP

    EDITOR—Williams and Lau seem to have overlooked an important factor common to all attempts to make education more effective by making it more humane and less industrialised.1 Humane educational methods are always far more labour intensive and always require higher teacher to pupil ratios.

    I visited Albuquerque medical school in the 1980s in its first years of introducing problem based learning, modelled on experience at Case Western Reserve and McMaster. The programme was then experimental, with educational results compared in two cohorts, one continuing the traditional didactic programme. Problem based learning won hands down on all counts, including popularity with students—so much so that the experiment had to end because so few wanted to stay in the traditional programme.

    Watching problem based learning in action, I was struck by the huge new demands placed on one to one tutoring and on far more imaginative teaching, which made it impossible to rely on teaching routines and material changing little from one year to the next. Problem based learning would demand a huge expansion in staff and per capita costs.

    Problem based learning for medical students resembles the teaching methods applied throughout Wales and in most parts of England from the late 1960s, which were eventually enormously successful compared with past methods of more didactic teaching. In 1970 nearly half of all children left school without qualifications; by 2000 this had fallen to 10%. In the early 1960s only 10% of children went on to any kind of higher education, but by 2000 this reached nearly 40%.2

    These new, more humane, more pupil oriented methods required much higher teacher to pupil ratios, and per capita funding, at levels comparable with those in private sector education. These they never received. The result has been a reactionary counterattack ignoring all these advances, and blaming differences between public and private education on progressive teaching methods based on evidence rather than gut beliefs, instead of the parsimony of a state still serving minority interests.

    Williams and Lau present a plausible warning against any trust in magical effects of problem based learning compared with rote learning, with an underlying assumption that teacher to pupil ratios and per capita funding are bound to fall. The key issue is not how students are taught, but how they learn. That has an inescapable material base in sufficient university funding from the nation as a whole through taxation—the growing social product devoted to growing social purposes. There is no alternative.


    • Competing interests None declared.


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