AUTHORS: Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov
In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.
Here the subject is Professor Tim Lancaster, who is a GP and dean of King's College London Medical School. Professor Lancaster was previously the clinical dean at Oxford where he was also professor of primary care.
A podcast of this interview is available here:
How did you get to where you are today?
I initially studied English at university. Then I was very fortunate to be admitted to Guy's Hospital Medical School - they offered a transition course for people who'd done arts A levels or arts degrees into medicine. I was a student at Guy's and did junior doctor posts in London, mainly in medical specialties.
I then spent five years in the United States where I did a medical residency in internal medicine, and then a fellowship in internal medicine, where the main focus was on research methods for clinical epidemiology. I became interested at that time in what was then called ‘clinical epidemiology’. Subsequently, I became interested in the evidence base movement.
By the time I decided to come back to the UK I had done quite a bit of primary care as part of general medicine in the United States. I had to decide whether to go into a hospital-based specialty or to move towards primary care, and I chose general practice.
When I came out of my general practice training, I found that the skills I'd acquired in my fellowship were not as common then as they are now. I was able to move into a junior post within the academic department of primary care at Oxford - mainly in a research track, but subsequently more in education.
Then I became involved in organising the community-based education side of the Oxford Medical School. That took me to medical school, and I learned more about it. I worked closely with someone who was in the position that I subsequently held in the medical school, and when she decided to move on, she suggested I apply - and somewhat to my surprise, I was successful.
For the next 15 years, my main role was as director of clinical studies, responsible for the clinical years of the Oxford medical course. That takes me up to my arrival at King's, three-and-a-half years ago.
What made you give up on English and go into medicine instead?
It had always been an idea of mine to do medicine. I was better at humanities subjects at school, and that drove me to do English at university. It came down to going for a teaching research career in English, versus doing something different.
What swung it was wanting to do something where there was a teaching and potentially research element, but also the opportunity to do a job where there was a wider range of contact with society. That's what medicine seemed to offer, and the way it's worked out in the end.
What attracted you to general practice specifically?
I had done a lot of different specialties over quite a long period of time before entering general practice, and always found it quite difficult to settle on one that I would do to the exclusion of others, so the breadth of general practice was a great attraction.
I also realised I wasn't particularly good, or didn't particularly enjoy some of the procedural aspects of medicine. I knew that I was never going to go into a specialty where procedures formed a large part of the workload. I was more attracted to the cognitive aspects of medical practice, and general practice seemed the right specialty for me.
What did you learn doing your residency in the US?
I learned a lot. But the biggest lesson I learned was the value of the National Health Service and being able to work in the NHS. That was partly why I couldn't stay in the US, as I just didn't feel comfortable working in their health system. It really made me realise the great strengths of the NHS.
I had some wonderful opportunities while I was there - as well as the training and clinical epidemiology, I also had the opportunity to spend some time working in the Harvard system when its medical curriculum was being reformed. That gave me a lot of insights into medical education and how you shape curricula, which came in very useful later on.
Your webinars, where you teach specialties based on real patients, are famous. How did you develop this idea?
Most doctors find learning from their patients is the best way to learn, and I'd always enjoyed working through clinical problems, talking them through with colleagues and teachers, so that came quite naturally.
What turned into the webinar series began early on during my time as director of clinical studies at Oxford, when some of the students came to me in their final year and said: 'We're trying to work for finals, and we don't have a study group associated with our College.
Can you make any suggestions?' I said: 'Why don't you come along and we'll talk through a few cases together’. We started to do that, and then more and more people seemed to be turning up to the sessions, so I ended up opening it up to the year and doing it in a lecture theatre.
I realised the times when I was out of my depth, so I started to invite specialists to come along and comment on the cases - that was great learning for me and for the students. It seems quite popular.
Looking back, I realised that one of the things that medical students struggle with is: what do they need to know? Even if you have a highly-specified curriculum, people understandably struggle with the notion of: ‘How deep do I have to go, and what do I need to master in order to be a doctor?’.
What the sessions were really doing was interpreting the curriculum for the student body. We used to do this in the lecture theatre. People would work in teams and get a few minutes to talk about the problem, and then we'd ask someone to report back.
The problem we then started running into was that some people would not be on campus - they'd be in clinical placements elsewhere. So they were then coming back from their clinical placements elsewhere and saying: 'Will you repeat the session on ECGs?' or whatever it was.
I recognised that one of the challenges was trying to reach the whole student body without disrupting their placements elsewhere. It was obvious that the internet, or at least video conferencing, was a potential solution.
But at that time, video conferencing was very expensive and clunky, you had to have special equipment, and the expense just made it impractical. I asked our learning technologist, 'Is there a cheap internet program that would do this?'
There wasn't at the time. But a couple of years later, he came back to me and said: 'The university has signed a contract with this company called WebEx, and I think it might do what you want’. And it did indeed do exactly what I wanted.
You could project the material, you could have a discussion with people in remote sites, and it was cheap. So I started to do it that way - initially as a hybrid between broadcasting the lecture theatres so people could tune in elsewhere.
Then gradually it moved to being more online, just because the format worked very well. In some ways, the interaction was easier than in the lecture theatre because people could contribute in the chat box. What we lost from going online was face-to-face contact.
Actually being in the lecture theatre was a great social event. Students ended up getting to know other students in their year that they perhaps didn't know so well, and I got to know everyone, so it worked really well from that point of view. That's what I miss about online - I get to know people through their chat but perhaps not through their faces. So that's how it all evolved.
What changes have you seen within medical education?
The biggest change has been the systematisation and explicitness with which the outcomes are identified and talked to. Going back to my time at medical school, things like communication skills and procedural skills were not formally taught - it was assumed they would be picked up one way or another, and in many ways, they were.
It's all become much more formalised now as to what is expected in medical training, and teaching is more specifically oriented towards meeting those outcomes, which has many positive aspects to it.
Clearly, properly teaching clinical skills in a laboratory setting before we practise on patients is a big advance. Thinking about what really works in communication skills and trying it out in a simulated session - those are all strong positives, as are other forms of simulation.
The downside is it's become a little bit over-assessed and over-regulated in some ways. I don't just mean that at undergraduate levels. It's true at postgraduate and at CPD level.
One of the things that was very liberating for doctors - particularly GPs - about COVID, was that appraisal was suspended and we were told when it was reintroduced, that it was a ‘light-touch’ appraisal.
We didn't have to produce all the paperwork that we previously had to produce. It was extraordinary how liberating that was - just to be able to do some reading and think about it, and not enter it into your portfolio.
There is a challenge coming up to take the lessons we've learnt out of COVID and to try and reduce the burden on everybody of documenting every single thing they do in their learning.
Where do you see medical education heading?
I don't know. I don't suppose it'll change radically, but clearly you would think that advances in technology, in particular, will drive it. There’s a lot of talk about AI, virtual reality, all these technologies which clearly have great potential and could change the shape of medical practice.
Whether they're quite ready to do so yet, I don't know. I don't think they are at the moment. I guess there will be a gradual evolution. I don't see a revolution in medical education in the next ten years, but there will clearly be evolution, a lot of it driven by new technologies.
What challenges would you like to address?
I've always had a fairly simple view of this. We know largely what needs to be achieved in medical education, and the challenge is to do it. I've always felt that it's really about ensuring the right teaching and learning opportunities are in place, and that assessments are sensible and support the learning objectives.
There's going to be a challenge, because we've got increasing numbers of medical students - and that's likely to grow further in the future. We need to provide a safe and stimulating training environment for large numbers of students, perhaps where the clinical opportunities are less readily available. These are going to be challenges over the next few years.
What are your thoughts on the two types of medical curriculum - Oxford style, where pre-clinical and clinical are clearly split, and the King's curriculum, which is more integrated and clinical placements start from second year?
They're not quite as dissimilar as you might imagine. There is some early clinical contact in the Oxford course - it's not as extensive as in other medical schools.
My view is that it's good to have different kinds of medical schools because different people learn in different ways. I know a lot of the students who went to Oxford felt that they liked, in their terms, to ‘get a good grip’ of the theory and science of medicine before applying it.
Other people find it more difficult to motivate themselves without the direct link to clinical context. It's about finding a medical school that suits your personality. I think of Oxford in a way as a graduate entry medical course, and we've seen how enriched medicine has been by graduates coming in who have done other degrees and then do a shortened course.
In a way, that's what the Oxford course was. It was a science-based degree, and then a fully immersive clinical training. It can work well either way, but the crucial thing is that someone tries to go on a medical course that suits their own style of learning, and that they don't find themselves on a course which is not suited to the way they want to learn.
If you could create a medical curriculum from scratch, what would it be like?
I would like to create a medical school where there are no grades, no prizes. no exams and no fees. Where the emphasis is on teamwork, collaboration, developing your own interests, self-directed learning, and strong personal motivation.
The worst thing that's happened to medical education in this country during my involvement with it was the introduction of the Education Performance Measurement. Prior to then, there was a little bit of low-key competitiveness, but it was pretty marginal, and people were happy to find their own way through medicine, and didn't feel necessarily that they had to achieve top marks in every exam they did.
The EPM introduced a level of competitiveness, which really changed things. The first thing I would like to do is get rid of the EPM and move to a much more collaborative model. That may seem a bit of a pipe dream, but I have a friend who's involved in a small medical school in the States who has done this.
Of course, they've had to raise funds, but they've abolished tuition fees and there are no exams and no grades. They are highly selective - that's the downside - but their students are very self-motivated and it works well. So that's what I'd like to do.
How much influence does the dean of medical school have on the medical curriculum?
It varies. Clearly, if you are starting from scratch, as many medical schools have, then you have a lot of freedom to develop the curriculum. In the situations I've been involved in, there has already been a curriculum in place when I have arrived, and my approach has been to evolve it rather than to radically overhaul it.
It depends. It's a major thing to change a curriculum that already exists, it can be quite disruptive, and it’s something I've never done.
Do student doctors need to memorise all the theory when they can look it up on their phones any time they want?
In the past, there was too much emphasis on memorising large amounts of facts, and it's crazy to memorise things that you can easily look up. Particularly treatment pathways - that's something where you can have ready access, they can be changing all the time, and it's silly to memorise them.
In terms of clinical practice, you do need a certain amount of working capital. You can't take a good history from a patient unless you know something about the conditions that you're looking for, and how they feed into a differential diagnosis.
My view is that you should concentrate on learning the things that don't change very much and allow you to function on a day-to-day basis. From that point of view, the pathophysiology of disease and the symptoms and signs of disease are really important.
Learning precise diagnostic and treatment pathways - you can look them up pretty easily. It's possible that AI will change that concept of what working capital is, and you perhaps won't even have to learn so much about the symptoms and signs of disease. But we're certainly not there yet with AI and I can't ever see us getting to that stage.
It's important to know quite a lot of stuff. You need that in order to function. But it's a question of choosing the bits that really need to be learnt, and recognising the bits that can be looked up easily.
What was it like implementing a new curriculum at King’s?
It was challenging. Taking it one step back as to why I wanted to come to King's, the answer is that I had a wonderful time at Oxford, but had done most of the things that I wanted to do, and realised that I was treading water.
I wanted a new challenge, and I wanted in particular to see if some of the things that had seemed to work in a smaller medical school could work in a different environment. That was the interest for me. I must admit I didn't really focus so much on the new curriculum when I was exploring the possibility of moving to King's and it was a bit of a surprise to me when I arrived, how much there still was to do with that curriculum.
It was helped by the fact that the curriculum itself was good. It was one I could sign up to. So then it became mainly a challenge of implementation. The thing with change, I've always found, is that the change itself can be quite frightening to faculty, but particularly to students.
There is a huge, informal network among students where they learn from the years above what to expect, what they think, what's going to happen, what assessments are like, and if you take that roadmap away, it can be quite disconcerting and unsettling for the student body.
After my arrival, I identified that the most important thing was providing some reassurance to students about the experience they were getting and that they were going to meet the outcomes - that we were doing it in a different way but they would get there in the end. That was the main strategy.
King's is one of the largest medical schools in Europe. What are the challenges?
What I found - and this is what I really tried to test as a hypothesis - is that the same methods do work whatever the size of the school. My philosophy has always been that medical education, or education in general, is built on personal relationships.
These relationships are more challenging to nurture and develop in a larger student body, but it can be done. Coming back to the use of webinars and the internet - that's one way in which it's possible to bind together a much larger group of students.
Clearly, the organisation has to be much more complex in order to ensure that the aims and objectives are being delivered across a wide range of educational and clinical sites, and that the students in different places are receiving comparable experiences.
There's an organisational challenge, but if you can get the personal relationship side right, then the organisational side falls into place.
How have you managed to have those personal relationships?
It's been helped by having a very strong team who share the same sort of values and approach. It's not necessarily the case that I personally would need to have a personal relationship with each student - I'd like to - but that somebody has a personal relationship with them.
The educational supervisors' system has been a good part of the new curriculum, building that ongoing relationship. But that philosophy has also been shared with the stage leads and other team members of the educational team who have striven to make that personal. I like to teach and do a lot of sessions, and through this I feel I do get to know quite a wide range of the student body, although not all.
Oxford Medical School has come top for student satisfaction for about nine years running. How?
It’s about building personal relationships. When I was in the States, I was introduced to the ideas of continuous quality improvement in healthcare - mainly championed by Don Berwick. When I started at Oxford, I tried to draw on those principles in working out what needed to be done.
The first principle was trying to measure what you're doing. Although there was feedback, at that time it was quite unusual in university courses in general to try and measure the outcome. I experimented with using some questionnaires for graduating students - the course experience questionnaire, which really tried to get at student experience.
There were some quite surprising findings in those early measurements, and also in talking to students. They largely enjoyed the course, but they were not sure exactly what the aims and objectives were, what standard they had to reach, what they needed to do to get through our assessments.
These were questions where there was quite a lot of uncertainty. A lot of the work was around making the aims and objectives clear, reforming the assessments so that they lined up with the aims and objectives, and then trying to interpret the curriculum to the students - and that's where the case-based learning came in.
Again, a great team worked on this, so a lot of it was about encouraging innovation amongst your colleagues, giving them the space to try new things, and being patient, because it did take a while for things to change. Then, once you get to a certain point, it's self-sustaining.
A lot about developing an effective education institution is having a shared view and a shared sense of purpose between the student body, the faculty, and the administrative staff. Once things start going well, everyone likes that and takes pride in it, and wants to do better.
If you can make people feel that things are progressing, that things are working, then it tends to build on itself. Building the culture is what it's really about.
What was it like being dean of the largest medical school in the UK when COVID hit?
It was quite unlike anything I'd ever faced before, as it was for everyone in the country. Things moved at incredible speed, and when the news of what was happening in Italy started to come through, we said: 'We're going to need a contingency plan if things get bad here’.
We didn't, at that stage, envisage that it would involve closing down clinical placements. We thought we'd probably have to take some of the teaching online, but within a week of saying: 'We need a contingency plan’, we were facing a crisis in the clinical placements, and it was clear we were going to have to shut down.
This is where having a great team comes in. I said to our stage leads: 'We need to take the course online’, and they said: 'Give us a week and we'll do it’, and they did. We were helped by the fact that we had been developing online teaching for the previous couple of years and making use of Zoom, so that made it a bit easier.
It wasn't completely starting from scratch, but I was astonished how quickly they got an online programme up and running . Assessments were a big challenge, but again, I said to the assessments team: 'What do you think you can come up with?' And they said: 'Well, it's going to take us a bit of time but we'll sort it out’.
That was done very successfully - taking written exams online, even some OSCEs online. And then, over the summer, there was the great foresight from Professor Nicki Cohen who recognised there was a strong probability that with the second wave, we wouldn't be able to run conventional OSCEs.
And then there was the development of the concept that came to be known as the ‘CWE’ - effectively a long case in the clinical environment - which meant we were able to get all our final years certified before the second wave reached its peak.
The most difficult thing was not taking the course online, but getting it going again in the clinical placements. It took a huge amount of work to ensure that could be done safely with risk assessment, revamping of the curriculum for the final years, and trying to change the clinical placements so that clinical learning could be caught up on.
It was the hardest working year of my career, but we've learnt a lot and there will be many lessons which will carry on. And, as in clinical practice, it was strangely liberating to face situations where you didn't have to go through 16 committees to get approval to do something.
You just had to get on and do it, and that did encourage innovation. It's not something I'd choose to go through again, but we survived it!
What are the important qualities of a good leader?
There are different kinds of leaders, and it's important that you work within the limits and strengths of your own personality. I'll give you an example of someone who was a good leader. In the first post-war government in the UK, the Prime Minister was Clement Attlee, who was said to be self-effacing to the point of being dull, and really did not draw attention to himself.
He had a clear vision of where he wanted to go, and that vision led to the fabric of our modern society - the National Health Service, the welfare state as we know it, and the realignment of foreign policy following the war.
What he did was choose brilliant people to work in his cabinet, and gave them freedom and support. Allegedly, he chaired his cabinet meetings very effectively, so that people were focused on the vision and the targets. So without really drawing attention to himself, he created the culture which allowed some very clever and motivated people to rebuild our society.
I'm sensing that maybe Joe Biden is going to be that kind of leader, which is very welcome compared to the kind of leader that preceded him. That would be my ideal of leaders - the Attlee style rather than the style of Putin or Trump.
What are some of your proudest achievements during your career?
I can think about things that I hope I have achieved, or haven't achieved, but there's absolutely no way causality would be a testable hypothesis. What's made me most happy over the years has been when I've received a report from one of my students saying this particular doctor went out of their way to give us really good teaching, look after us, and help us.
Then I’ll see that the person they're referring to is someone I knew when they were a student. In those situations I try to write letters of thanks or congratulations to the teacher, and I often get a response back from them saying: 'We had a good experience in medical school, and we want to give back’.
That makes me feel that I'm part of a community across the generations of people who are passing things on and working to a common purpose. That's what's given me the greatest pleasure - seeing what my former students have gone on to do, in all kinds of fields, but particularly in terms of contributing to the education of the next generation.
How important is it to set goals?
Setting goals is very important but they need to be short-term. It's quite difficult to set very long-term goals. From an early stage in my career, I had an idea that I would like to be involved in shaping medical education in some way.
But for quite long periods of my career I thought that wasn't going to be a career path that was open to me. It was always a distant goal. In between, I focused on setting more short-term goals. And then things would happen and sometimes you would find you could move in different directions. So have an idea of where broadly you'd like to be in the future.
Are there any key lessons that you've learnt?
I'm reminded of Oscar Wilde's comment: 'There is nothing to do with good advice except pass it on, as it is never of any use to oneself’. I hesitate to give advice, but confronting your weaknesses is one of the most important things.
Your strengths probably come naturally, but it's your weaknesses you really have to work on. One of mine is procrastination - particularly with paperwork. I really had to discipline myself over the years not to push emails to the back of the tray, or not to leave letters until the last moment. So recognise where you're less strong, and try and improve in those areas, is my advice.
What advice can you offer students?
Everyone should be trying to achieve their potential, and people do need to work hard at medical school, and when they become doctors, to meet their potential. Each individual's potential is going to be different - something that is going to make one person happy in their career is not necessarily what another person wants.
My message is: do your best, but don't feel you necessarily have to achieve the trophies that other people regard as important. If you're happy in your work, and you're a good doctor, that's fine. You don't necessarily have to be publishing in Nature or leading a huge team. There are many ways to satisfaction.
I wish we could reduce that sense of competition, and make people feel happy with what they're achieving against their own targets, and not necessarily against what they perceive to be as other people's targets.
What's your favourite book?
My favourite book is War and Peace.
Who's your favourite character?
Pierre is obviously a very interesting character. But it's the breadth of the characters and the way they interact with history, which is so stunning about this book. I first read it in 1976, which for my generation was a mythical year. There was a wonderful summer where there was no rain for about three months.
I sat in the garden over a two-week period and completely immersed myself in War and Peace - and it's been associated in my mind with blue skies and youthful promise ever since. I’m looking forward to re-reading it over the next few years, when I have a bit more time.
Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.