447LEADING ARTICLES

Education v. The Curriculum

THE LANCETLONDON 30 AUGUST 1958

EARLIER this year TANNER 1 outlined a reorientationof preclinical studies which would, in his view, makethem more appropriate than they now are to the practiceof medicine, at present largely concerned with appliedhuman biology. At that time we forecast 2 small likeli-hood of such ideas being translated into action in Britishschools. The powers of resistance to change includethe fear of giving up what was once good, in favourof the new and unproven; and in the federation of

departments which makes a medical school, that fear caneasily be exploited by any unit which suspects that itsown interests can best be served by adherence to thestatus quo. But we added, " if all the older schools aretied to their dead past the same cannot be said of newschools, such as that of Western Australia "; and we arevery glad, therefore, that Prof. DAVID SINCLAIR haswritten the article on p. 430 describing the curriculumwhich, it has been agreed, shall at the moment be usedin Perth. The planning of the early years suggests thatthe aim accords to some extent with that of TANNER.The actual programme, however, also reflects manylocal and, it is to be hoped, temporary obstacles. Oneof these at present means that the first year is spent inisolated study of

" premedical " subjects. The second

year, on the other hand, will consist of a coordinatedcourse in human biology, with at its end a singleexamination which should act as a stimulus to thestudent to integrate his studies of anatomy and physio-logy. Dissection of the whole body will be requiredand will be carried out under the pressure of the tradi-tional viva system until the professional examination intopographical anatomy at the end of the second term ofthe third year. A term later the student will take oneexamination in biochemistry and another in

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physiologyand the general principles of pathology (with one

question on psychology) ". We hope that before longcircumstances will allow these two examinations to befused, so that the student may be encouraged to linkthe general principles of pathology with physiology,psychology, and biochemistry (and even anatomy)-asobviously he must.SINCLAIR points out that although the plan he

describes has been agreed to by all his colleagues someof them would place a different emphasis on the descrip-tion. This no doubt would apply to the clinical part ofthe curriculum, in which no mention is made of thatexceptionally important though technical part of medicaleducation-the introduction to clinical method. The

arrangement of the clinical years is, however, of suchsimplicity that at least it cannot be criticised for being

1. Tanner, J. M. Lancet, 1958, i, 1185.2. ibid. p. 1213.

diffuse. A first year in the wards (during the first halfof which the course and examinations in pathology willbe completed) should give the student that advantage oflong-continued practice in clinical method which hasbeen such a good feature of the traditional British

training. A second year consisting of four months’obstetrics and gynaecology, four months’ paediatrics, andfour months’ experience of specialties (with a carefullycoordinated course in preventive medicine) indicatesthat the University of Western Australia is at the outsetkeen to achieve that sense of proportion, in regard tospecialisation in undergraduate education, which charac-terises the best American schools. A final year " rela-tively free from formal classes " in which the studentmay gain experience and integrate his knowledge is, ofcourse, something to which almost every British schoolis vainly trying to return.As HALE HAM 3 has said, " The curriculum is the course

through which the student travels; it is a definition oflimitations as well as opportunity ". It closely resemblesa railway guide which shows the expected times ofarrival and departure, occasionally explains the localreasons for the route taken, and briefly indicates themain features of interest in each stopping-place. It doesnot state the degree of efficiency of the organisation, norreveal its standards or those of its employees. Some-times its avowal of close concern with the problems ofthe individual should not be taken too literally. Un-

fortunately in many medical schools in this countrythere are railway-guide teachers who still think ofmedical education primarily in terms of the curriculum.Unless a suggested improvement or reorientation is

expressed in time-table form it seems to them to be

hopelessly vague and diffuse-yet it cannot be translatedinto such form except by themselves in collaborationwith their colleagues. Thus, old curricula remain,annually becoming structurally more. "concrete" butfunctionally less successful: and some schools wait on,in agitated depression, for ready-made " concreteplans which will never come. For this reason, wesaid 2 two break the mould of the existing curriculumit may be necessary to start in Britain a new medicalschool ".As one means of solving our problems SCOTT 4

pleaded for restoration of the art of " great teaching "to its proper place. But the " great " teachers werelargely engaged in teaching what was known, while weare now equally concerned with teaching the best atti-tude to what is not yet kriown. " He teaches best," saidALAN GREGG in 1953,5

" who shows his students how tolearn: not what to think in 1953, but how to think andhow to learn to think in that long stretch of days (ahead)... till, let us say, the year 2000." We agree, however,

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with ScoTT and with WILSON 6 that there is a great needfor " teachers who take their responsibility as teachers asseriously as they take their research work or their clinicalduties ". We are particularly impressed, therefore, with3. Hale Ham, T. An Experiment in Medical Education at Western Reserve

University; p. 13. New York, 1954.4. Scott, J. H. Lancet, 1958, i, 1334.5. Gregg, A. For Future Doctors; p. 50. Chicago, 1957.6. Wilson, R. R. Lancet, July 5, 1958, p. 45.

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the principles which, as SINCLAIR records, were kept inmind during the planning of the Perth curriculum. " Aseries of weekly lunch-time meetings was instituted

among the professors, and it is proposed to continue thismost valuable practice indefinitely." " The second

principle was that the details of time-table arrangementsor teaching methods must never obscure the all-importantattitudes of both teachers and taught towards the processof becoming a doctor."

This augurs well for the future of Perth. Meanwhile,in this country, our best hope seems to lie in the Associa-tion for the Study of Medical Education,7 which willhold its first conference on Sept. 25 and 26. If it candraw together all the interested teachers from all

disciplines and all schools, it will not only provide themwith mutual strength and encouragement but will alsoenable them to work together to increase our know-ledge of education. The stimulus to progress therebygenerated cannot be ignored: it can produce that factualevidence of present weakness, and of the results of

change, which alone will convince the faint-hearted, andthe too easily satisfied, that change has to be made.

7. ibid. 1958, i, 1261.8. ibid. Aug. 2, 1958, p. 273.9. Williams, C. D. ibid, 1958, i, 863. 919

10. ibid. p. 951.

Tropical PracticeMEDICINE in tropical climates has always been a

challenging affair, and its enormous problems haveattracted outstanding men. Now that the perils ofmonsoon and insect have to some extent receded,doctors in the tropics are looking at matters which hadpreviously been masked by the daily drama and, perhaps,by the traditional approach to scientific medicine. Fromher wide experience, Dr. CICELY WILLIAMS 9 believesthat training in paediatrics for the tropics is not as goodas it should be-and we agreed Now, in this issue,Dr. JOHN WRIGHT puts forward some good ideas forovercoming present deficiencies and for helping thetropical neophyte. With increasing specialisation andcomplexity in Western medicine, training needs for the" home front " and for the tropics are always diverging.The doctor in veldt or jungle has no second opinion, andto " pass the buck" may involve a long journey bybullock cart and an expense that the patient’s familycannot afford. The doctor’s daily tasks may includedrawing a tooth, removing a uterus, taking an X-ray (ifhe is lucky enough to have a machine), and fitting a newhalf-shaft to the hospital van-cum-ambulance. Medicineof this calibre demands high skill and considerablemental stability.Among his proposals for meeting this challenge,

Dr. WRIGHT’S most interesting suggestion is a year’s"

internship " in a teaching hospital at the place wherea doctor intends to work. This seems such good sensethat we wonder why it was not introduced long ago:there are still too few suitable institutions, of course, andperhaps the small number of doctors has made the" waste " of a year impossible. But tropical medicine isnot just a specialty, it is a complex of specialties; and the

doctor in India will find himself dealing with a differentset of problems in different circumstances and in a

different culture from his colleague, say, in Africa orBritish Guiana-and therein lies the difficulty of teachingthe subject thousands of miles from where the studentswill finally work. It is a good idea, too, to ask tropicalpractitioners on furlough to help: home-leave is still,happily, on the grand scale, and many of them would bepleased to share their experiences and earn a little extramonev.

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Dr. WRIGHT treads on emotionally insecure groundwhen he suggests that new countries should scale downthe training of students to methods they can afford; but,as he points out, what is sauce for the British goose is notnecessarily sauce for the tropical gander, and medicalpractice will improve by adaptation to local circum-stances. Dr. WILLIAMS thought it wrong for developingcountries to put emphasis on large Western-style institu-tions ; and we believe that Western experts do a dis-service if they encourage such Governments to start

costly ventures of uncertain value. Likewise, as Dr.

JOHN B. GRANT has insisted,11 the undergraduate medicalcurriculum in the tropics should be devised, not to

reflect curricula in the U.S.A. or the United Kingdom,but to train an " undifferentiated physician ", com-

petent to undertake general practice in his own

community. Obscure investigations, all-day operations,complicated treatments may be out of perspectivewhen the average age of death is in the thirties andinfant mortality is twenty times as great as in Britain,This is not to say that research has no place in thetropics, but it should be devoted to the vast

unsolved problems of epidemiology and nutritionand to the relationship of disease to the wide culturaldifferences throughout the world. Many Westernriddles might be solved if we knew the answers to

the sort of questions that abound here. Why is appen-dicitis so rare in some primitive rural communities? 1Why is disseminated sclerosis almost never seen inIndia ? Why is syphilis so widespread in the tropics,yet affection of the central nervous system so rare? Ifthe difference is due to " autotherapy

" from attacks of

malaria, does the pattern hold for malaria-immune hillareas ? Facts emerging from careful work in the tropicscould radically alter ways of life in many other countries.How should the doctor fit into this changing pattern

of tropical practice ? Hitherto, effort has centred roundisolated overworked Government or mission hospitals,and it is tempting to follow a more thorough version ofthis plan. But large-scale curative and preventivemeasures, though very necessary, are of slight valuewhen unsupported by coordinated development projectstouching many aspects of life-economic, eugenic.educational, technical, domestic, and (many would add

. religious. Such plans are proceeding in India on a herou: scale,12 and the experience they are providing will be of’ the utmost interest to all who work in deprived countries: In this scene, the

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greater medical profession " includes

experts in many social and technical subiects, and the

11 See ibid, p. 1009.12. ibid. 1956, i, 491.