426 LEADING ARTICLES

surgical dressers or medical clerks the emphasis couldbe less on the subject of surgery or medicine and moreon clinical instruction. Systematic lectures in clinicalsubjects are surely superfluous : the facts are in ’thebooks, and it should be one of the main purposes ofa university (most medical students now belong toa university) to teach its members how to use books.If we attempt less specialised teaching, eliminate

systematic lectures, and blend preclinical with theclinical teaching, it may be possible to produce abasic rather than a comprehensive medical course.In an appendix to their report the College com-mittee outline such a plan. The theoretical know-

ledge lost would be offset by the practical gain in thepreregistration year. If it is to succeed, however,this revolution would have to include a firmmove towards simpler and less searching examina-tions at every stage. The College’s report speakssternly too about our present examinations :

" At all stages of medical education, examinations nowexercise an unhealthy dominance over the student’swork and thought ; but this is perhaps most damagingin the clinical years.... With a curriculum which wasno longer overloaded, and with reasonable examinations,the conscientious student, properly selected, could expectto pass, and would therefore avoid having his valuesdistorted and his programme of study disturbed byhaving to prepare repeatedly for some mental marathon."

These are some of the aims. What are the hin-drances ? As we have said, there is the understandablereluctance of teachers to reduce their own teachingtime while others seek to increase theirs. But the

College committee point to a more important bar toprogress-the belief that any substantial change inthe curriculum would have to be made in all medicalschools together. It is most unlikely that medicalschools could easily agree to a concerted change ; andthe General Medical Council would be reluctant to

urge an untried curriculum upon them. The firstneed therefore is for individual experiments promotedby the schools themselves. In the United States,medical teachers and administrators have beenexercised by much the same thoughts about overfullcurricula, and they have been able to do a great dealin the way of experiments. 6 7 For example, in oneof the most recent accounts of these American develop-ments, Dr. KARNOVSKY, of Harvard, has recorded 8how the elimination of departmental barriers has beenan enormous stimulus to both teachers and students.In this country there has been much less to report.This is perhaps because, as the College report suggests,the General Medical Council’s Recommendations as tothe Medical Curriculum have come to have the forceof regulations, and because the restriction which theyimpose on the diversity, freedom, and responsibilityof medical schools has, in fact, gone far beyond theiroriginal declared scope-" matters of general import-ance, such as the duration of study and the age atwhich the student should be permitted to practise."The Council are now considering whether changesshould be made in the current Recommendations,adopted in 1947 ; and we hope they will decide toencourage experiments in curriculum reform byreducing the range and precision of their instructions.Under the Medical Act, 1950, the Council have powersof inspection which would enable them safely to relax

6. Sinclair, D. C. Lancet, 1953, ii, 463.7. Pemberton, J. Ibid, p. 469.8. Karnovsky, M. L. J. med. Educ. 1955, 30, 15.

the control they now exercise by their Recommenda-tions. Such a step would do more than anything else,we judge, to break the seeming deadlock and helpmedical schools to examine at closer quarters someof the , possibilities about which they have been

thinking for so long.On the other hand, if the present rather paradoxical

situation continues, there is a danger that the cur.riculum will have to become very much worse beforewe are moved to make it any better. Nationallycautious, as a rule we make no change until greatpressure forces us into it ; and very rarely indeed dowe make a change because it would improve somethingwhich is not already unendurably bad, and which, inthis case, may even be called very good in parts.For once, we should break the rule or it may breakour students.

Commonwealth ProspectsON a later page we publish an article by Dr. MARTIN

and his colleagues which tells the prospective immi-grant doctor some of the things he will want to knowabout medical practice in Canada. For more informa-tion about qualifications, medical schools, and so onhe can turn to a recent issue of the Canadian MedicalAssociation Journal devoted to medical educationin Canada. But he should also take note of whatthe Editor of that journal has to say about the

prevalent idea that Canada is an under-doctoredcountry. The results of a survey of the situationundertaken last year have been issued by theCanadian Department of National Health and Wel-fare, and they show clearly that the supply of doctorshas certainly kept pace with the increase in popula-tion. The figure is 948 persons per doctor in Canada,compared with about 900 in England in 1953. Thereare good jobs to be won in Canada, in hospital,general practice, and elsewhere, by applicants fromoverseas ; but it is plain that they are not so manyor so easily attained, particularly in the cities, as

some suppose. And the competition is even keenerelsewhere in the Commonwealth. Discussing themedical prospects in Commonwealth countries, SirSTANLEY DAVIDSON 2 has noted the remarkableincrease during the past twenty years in the numberof practitioners registered in Australia, New Zealand,South Africa, and Canada. With the exception ofCanada, this increase has been out of all proportionto the increase in the population during the sameperiod. In Australia, for instance, there is evidence 3that before long there may be more doctors than canfind a livelihood. In our Students’ Guide this yearwe include some notes about the Colonial medicalschools, and it is clear that in many places the localschools will be able to supply an increasing propor-tion of the doctors for the medical services in their

part of the world. Only in the African Colonies isthe need for considerable numbers of doctors fromoverseas likely to continue ; and the splendid andexpanding work that the African schools are doingmakes it look as though it will not stay that way forvery long. No doubt the committee on medical man-power, which is at present considering the situation inthis country,4 will bear in mind these indications

1. Canad. med. Ass. J. July 15, 1955.2. Brit. med. J. 1955, i, 1171.3. Poate, H. Med. J. Aust. 1953, i, 714.4. See Lancet, 1955, i, 451.

427ANNOTATIONS

that the Commonwealth countries will be able to takean increasingly small proportion of doctors trainedin this country.

It is to Canada, then, that the young doctor looksmost hopefully (or with least discouragement, somemay say) when he cannot readily see the oppor-tunity he is seeking at home. And the news of thosewho have gone there from this country in the pastfew years is on the whole cheerful. A visitor justreturned says that those he met had settled downwell. The work is absorbing, hospital equipment isgood, and the chances of getting new capital for

necessary improvements or additions are better thanthey would be in this country. For a wife things maynot at first be easy : a new home with many unaccus-tomed features, little or no domestic help (not sucha striking change perhaps !), extremes of climate,and high housekeeping costs, may weigh more heavilyon her than her husband. An income that soundedwell on paper may during the early years proveinadequate to supply many of the things like refrigera-tors, dish-washers, television sets, and lakeside

cottages that Canadians have often come to regardnot as luxuries but essentials. These considera-tions will weigh more heavily with some familiesthan others; and many may judge that the oppor-tunities later on will make up for relatively humbleyears to begin with. It is certainly a very ill-advisedimmigrant doctor who expects to leap at once fromstriving insolvency at home to easy affluence inCanada. Canada does not offer that ; but she offersmuch to those prepared to work hard in a hard-working country.

Annotations

THE PREREGISTRATION YEAR

WHEN the Minister of Health spoke to the annualgeneral meeting of the British Medical Students’ Associa-tion last November he said that the time had come toconsider the results achieved by the regulations that cameinto force on Jan. 1, 1953, and provided for a year ofhouse appointments before full registration. And Mr.Macleod invited the association to give him its views.Accordingly, when information and opinions had beenrequested from all medical schools in Great Britain andNorthern Ireland, these were discussed by the executivecommittee of the association and the main points wereembodied in a memorial which was presented to theMinister.The results of the inquiry showed that the large

majority of medical students readily accept the pre-registration scheme ; but there were several criticisms.One was that some people have had real difficulty inobtaining preregistration appointments-a difficulty towhich we referred at this time last year.2 Few complaintswere received of unavoidable delay in getting a firstappointment, but second appointments were in generalless easily found ; it seemed that a considerable numberof doctors were taking two months or more to find asecond post. This, the B.1.S.A. suggested, could beavoided to a large extent if all medical schools were tofollow the progress of their graduates, to advise themwhen to begin to make applications, and to suggest suit-able posts. This advice could be based on cooperationwith local hospital boards, who could supply detailswhich would be helpful to graduates in making theirchoice of hospital. These details, together with the

1. Brit. med. Stud. J. 1955, 9, 4.2. Lancet, 1954, ii, 413.

advice of their dean, would perhaps enable graduates tomake a more confident approach to appointments innon-teaching hospitals. But, as the association points out,it is not always easy for a dean to keep close track of allhis students. Thus, one London dean said that he wasable to follow the progress of students who qualify withthe London M.B., but those who take Oxford or Cam-bridge degrees or the Conjoint diploma have to be signedup by their various registrars and easily lose touch withhim. He would prefer, he added, to sign up all hisgraduates for both their house jobs. He knew his gradu-ating students better than the registrar in, for example,either Oxford or Cambridge, and thus had a personalinterest in helping them.Most of the information that the association gathered

confirmed that approved posts provided the experienceintended by the Act. Teaching-hospital jobs may offerless responsibility, but many graduates considered thatthis was offset by the value of the teaching-indeed of theintrinsic value of a teaching-hospital testimonial. Butin some approved posts too much time was taken up byroutine administrative duties, and housemen were not ableto take full advantage of the clinical experience available.

In his reply to this clear and helpful document, theMinister pointed out that over the country as a wholethere were many more house jobs than people to fillthem. Wherever the Ministry had heard of graduatesbeing unable to find suitable posts, the regional hospitalboards had been notified. Mr. Macleod did not know of

any cases which had not been satisfactorily dealt with.It was important that applications for second postsshould be made well before the first post ended. TheMinister added that he was not aware of any proposalthat the length of the preregistration period be extended.

POSTGRADUATE STUDY FOR GENERAL

PRACTITIONERS

ONE of the conditions of membership of the College ofGeneral Practitioners is that a certain time be spentevery year on postgraduate study. As a result, many moregeneral practitioners are seeking opportunities for post-graduate training ; and there has been a big increase inthe variety of courses held, both in the teaching centresand elsewhere, during the past three years. The 24faculties of the College in the British Isles (includingSouthern Ireland) make it their duty to discover andstimulate the needs of members in this respect, and tomake contact with other members of the profession whocan help. Each faculty has its own postgraduate educa-tion committee, and cross-representation between thefaculty boards, the teaching staff of medical schools,committees of medical societies, and so on, is increasing,so that, by combining knowledge of the family doctor’seducational requirements and the ways they can be met,a suitable programme can be prepared for each region.The courses which have been most successful have beenthose designed with close cooperation between the Collegefaculties and the teaching bodies. New experimentalteaching methods are being developed. All courses inwhich the College has played a part have been open tonon-members. In London the hon. registrar of the

postgraduate education committee of the College councilenjoys the hospitality of the British Postgraduate MedicalFederation at their headquarters at 2, Gordon Square,ZT.C.l ; and here a record is kept of the doings of thefaculties, the medical schools, and societies all over thecountry.

This month a questionary has been sent to all membersof the College to discover their particular needs, whatplaces of study are within their reach, and what contribu-tion they can make to help their fellow practitioners inthis woik. Information is also being sought about theexperience and suggestions of members in the matter oftraining assistants and trainee practitioners.