Tomorrow’s Doctors: Today’s Mistakes?W.S. MONKHOUSE* AND T.B. FARRELL

Department of Anatomy, Royal College of Surgeons in Ireland, Dublin, Ireland

Tomorrow’s Doctors, published by the General Medical Council of the UK in December 1993,has prompted far-reaching changes to medical education in Britain. We draw attention to someinconsistencies in the document and to those aspects of it that we maintain are undesirable. Wequestion the emphasis inTomorrow’s Doctorson change in view of the unchanging nature ofthe structure and function of the human body. We doubt the wisdom of exhorting students tolearn through curiosity and experiment, such methods being wasteful of time and resourceswhen used in the context of accepted core material. We do not accept that the informationoverload is an automatic result of traditional methods of delivering education, and we are by nomeans convinced that the university model is the right one for medical education. In the face ofexperts being unable to agree on or to define scientific method, we wonder if consideration ofthis is appropriate in an undergraduate medical course, and we doubt that ethics and criticismare rightly placed in the undergraduate curriculum. The drawbacks of systems-based teachingare considered in the light of the disease process, and we draw attention to the lack of evidencefor the document’s condemnation of departmental structures and its uncritical espousal ofintegration. Finally, we consider some of the ways in which these changes have affectedanatomy. Clin. Anat. 12:131–134, 1999.r 1999 Wiley-Liss, Inc.

Key words: medical education; integration; university model; systems-based teach-ing; anatomy

INTRODUCTION

Tomorrow’s Doctors was published by the GeneralMedical Council of the UK in December 1993. In itswake there have been far-reaching changes to the wayin which medical education is delivered in Britishmedical schools. At the time the document was pro-duced, the current orthodoxy was, as it still is, thatmedical education was deficient in certain ways andthat these deficiencies needed to be remedied bychanges that were dramatic, even revolutionary, innature. A gradual piecemeal process of alteration thatwould allow for assessment of the value of each changeand the rectification of newly introduced error was feltto be inadequate to the urgency and magnitude of thetask at hand. The GMC, swept up in this tide ofopinion and even contributing to it, as no doubt it feltit must be seen to do, produced Tomorrow’s Doctors inwhich it conveniently set out and supported thoseideas that were then, as now, so fashionable. It isincumbent upon those of us charged with the task ofeducating tomorrow’s doctors to attend carefully to thewords of the GMC—not, of course, in unquestioningacceptance, but, as their authors would wish, in a spirit

of critical inquiry, so much the better to appreciate thewisdom therein contained.

The task facing those who would advise us howbest to educate tomorrow’s doctors is no small one.They must construct, or at least provide guidelinestoward the construction of, a curriculum that retainswhat is worthwhile in the medical course of todaywhile preparing the trainee to cope with the advancesin medical science that accumulate at such a pace thatthe student has imposed upon him or her ‘‘a scarcelytolerable burden of information.’’

CHANGE

The authors of Tomorrow’s Doctors are concernedwith change: they percipiently observe that ‘‘we canbe certain that the doctors of tomorrow will beapplying knowledge and deploying skills which are atpresent unforeseen.’’ It seems to us that future devel-

*Correpondence to: W.S. Monkhouse, Department of Anatomy,Royal College of Surgeons in Ireland, St. Stephen’s Green, Dublin2, Ireland. E-mail: wsmonkho@rcsi.ie

Received 12 July 1998; Revised 29 July 1998

Clinical Anatomy 12:131–134 (1999)

r 1999 Wiley-Liss, Inc.

opments in medical practice will best be dealt with bythose who have a sound knowledge of the structureand function of the human body. These are both wellunderstood, and it is certain that neither has changedover several millennia, nor will change in the foresee-able future. It may be that modes of action of drugsmay change, that diagnostic technology may change,that interventional techniques may change, but it isabsolutely certain that the doctors of tomorrow will bedealing with patients whose bodies are in all respectsunchanged. We ask which is more important: thatdoctors understand the structure of the body, of somerelevance in the diagnostic and possibly even thetherapeutic processes, or that they learn today detailsof transitory things that tomorrow will be obsolete?The document apparently makes some concession tothis view by stating that ‘‘We must ensure that theessential elements remain embedded in our cur-ricula,’’ but yet it seems that in some medical schoolsthese essential elements of the course have been thefirst to disappear - almost without trace. We need to bereminded that in each discipline, new developmentsare built upon foundations well established by previ-ous generations, and there is a tendency to assume thatthose foundations are common knowledge. Professorssometimes choose to believe that students are innatelyfamiliar with fundamental material—material that inreality is acquired only with the expenditure of someeffort, often resented.

THE INFORMATION OVERLOAD

Let us next consider the ‘‘scarcely tolerable burdenof information that ... taxes the memory but not theintellect.’’ Our experience is that staff (faculty) do notimpose excessive demands on students. To qualify as adoctor, it has never been the case that students arerequired to know vast numbers of facts. We have foundourselves, however, unable to stop students learning ifthat is what they wish to do: we have been unwilling todampen their ardor or their curiosity. Strangely enough,it seems to us that it is more in postgraduate education,not undergraduate, that vast numbers of facts have tobe learned, and we cannot see the value of this either -except as hoops that the elders of the professiondecide that they must make aspirants jump through -these same elders who, presumably, have contributedto Tomorrow’s Doctors.

THE UNIVERSITY MODEL

Tomorrow’s Doctors advocates the university modelfor medical education as though there were a uniquedistinct activity proper to universities. If this means

the experimental approach to gaining knowledge, thenwe have no reason to think that the university model isright for training doctors given the essential unchang-ing nature of the function of the body. In one place thedocument recommends the university system as amodel for medical education, and yet in another itacknowledges that it is as a result of the increasingadoption of the university system (as opposed to whatmight be termed the polytechnic, vocational system)that ‘‘each part of the course has proliferated withoutthe moderating influence of the other,’’ referring inthis instance to the undoubtedly undesirable explo-sion in course content in some subjects that could notby any stretch of the imagination be regarded as‘‘essential elements.’’ This explosion was fueled bythe need for staff and departments to indulge interritorial behaviour in order to maintain funding andspace based upon student numbers, on course dura-tion, and on research profiles. It is the last of these thathas resulted in medical school staff interested inresearch being appointed as teachers with no notionwhatsoever of why the subject in question needs to betaught, or of why it is relevant to a patient seekingsuccour—if indeed it is. These staff, through no faultof their own, are required to place more emphasis onpublications than people, students becoming therebysubservient to test tubes. The enthusiastic adoption ofuniversity mores—publish or perish—has resulted inthere being ever fewer medically qualified specialistteachers of basic science who know what they aretalking about from a clinical standpoint. These are thefruits of the adoption of the university system.

Problem-based learning and self-learning are bothadvocated as examples of the university model. Theseare both excellent tools in education, but there isnothing new about them. They are not, as some wouldhave us believe, mystical elixirs. Self-learning in someplaces has become merely an excuse for staff toabrogate their responsibilities to students. Conclusiveevidence for the advantages of a problem-based curricu-lum, from any reading of the abstracts, is simply notthere: the most that can be said is that the results areequivocal. The authors of the document use thephrase ‘‘truly educational’’ without defining it. Theyexhort medical students to learn through curiosity andexperiment, thereby reflecting a popular sentiment.This seems, however, to ignore the fact that there is anaccepted body of knowledge that the student simplymust know and that, were it to be learned throughcuriosity and experiment, would waste valuable timeand resources. There is nothing more educational thanthe study of ancient Greek and Latin, and we are at aloss to see how this may be done by experimentation.

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SCIENTIFIC METHODAND CRITICAL SKILLS

The application of scientific method to medicine ismuch encouraged in Tomorrow’s Doctors. It is notewor-thy and perplexing that these comments encouragingmore scientific awareness come at a time when labora-tory-based components of basic science (e.g., labora-tory practicals) are increasingly being squeezed out ofundergraduate courses and when we are being encour-aged to drown the basic sciences, as scientific disci-plines, in a sea of so-called integration. There is a lackof cogency and logic in the document. The documentitself offers no insight into what scientific methodmight be. Is it some definite technique that thestudent can be taught, or is it something less tangiblethat it is hoped the student will acquire in the courseof study? Is there indeed any definite and distinctmethod that characterizes the sciences (was there evera more diverse group of disciplines?), or is the appealto such a thing merely a fashionable pious aspiration?The document suggests that scientific method may beexplored in the special modules, over and above theessential core, and both staff and students will be welladvised to make the most of these opportunities,previously available to those who undertook an interca-lated degree, or by those students at medical schoolswhere a few months were set aside for this purpose.The dangers of this are that many staff will favorspecial modules in which students can be used asresearch assistants at the expense of the essential coreand that the essential core, being essential, will cometo be viewed with the same kind of tedium as are allcompulsory components.

The document regards the acquisition of criticalskills as being vital for the continuing educationalprocess. These cannot be taught with universal suc-cess. They depend upon a student’s culture, upbring-ing, education, and inclinations and are not somethingto which all 17–25-year-olds are receptive. Would thisactivity not be better placed as part of postgraduatetraining? We ought not to fall into the trap of emptyingthe undergraduate course of one thing only to fill it upwith another that is much harder to acquire or evendefine. Similar comments apply to the teaching ofethics: one does not wish to have unethical doctors,but mores vary with culture and there are very few, ifany, absolutes.

SYSTEMS-BASED TEACHING

Systems-based teaching is now so widely admiredand adopted that to attack it, or even to point out itsdrawbacks, is regarded as the grossest immorality. Yet

it has to be done. Let us say first that systems-basedteaching is not new. It was prevalent in medicaleducation in Ireland in the eighteenth and earlynineteenth centuries until Abraham Colles pointedout that the topographical approach was more relevantfrom a medical point of view (cited in Widdess, 1967).A systematic approach may suit some metabolic disor-ders and the boundaries of knowledge of specialistphysicians, but disease pays no heed to systematicboundaries. How can a systems approach help with thediagnosis of an apical lung tumor that presents as a lackof manual dexterity? The danger of systems-basedteaching is that students no longer will acquire an ideaof the anatomy of the whole body. They are unlikely tohave been given this at school, and nowadays they arenot even expected to have it in postgraduate surgicaltraining. This is surely to be deplored. In neurologicaldiagnosis (segmentation, plexuses), vascular disease,and the spread of malignancy (to give but a fewexamples), an overall view of the body, undivided intosystems, is essential. It seems to us self-evident that adoctor should have a sound working knowledge ofhuman anatomy; at the very worst, a doctor will not bedisadvantaged by a knowledge of the parts of the body,their relationships to one another and to the surface ofthe body, and how they may be safely approachedwhen intervention is necessary.

INTEGRATION

‘‘We strongly favour true integration of the course,both horizontal and vertical, using the term in thesense of interdisciplinary synthesis and not simplycoordination or synchronisation of departmentally basedcomponents.’’ That statement may be of interest as apsychological report on the state of mind of themembers of the General Medical Council, but in theabsence of any argument having been adduced insupport of the types of integration that are recom-mended, one has no reason to attend to it as any morethan that. Vertical integration may have the merit ofhelping to ensure that only clinically valuable basicscience is taught. Horizontal integration may have itsown different benefits but is being advocated as if itwere a necessary concomitant of vertical integration.This is simply not so: the two notions are distinct andcan be introduced or rejected separately, as may bemost expedient for them.

DEPARTMENTS

Departmental structures are seen as being inimicalto the brave new world in that they hinder theintegrated and systematic approach to learning. It

Tomorrow’s Doctors 133

simply does not follow that departments are necessar-ily bad. It is perfectly possible to have a combinedapproach to vocational teaching within departmentalstructures: it requires that control be exerted byteaching supervisors who are competent, effective,and clinically knowledgeable. If traditional structuresare inadequate, it is because they have been ineptlyhandled, but they are no more intrinsically bad orrestrictive than are the less traditional structures thatsimply impose a set of different restrictions.

ANATOMY

What has been the effect on anatomy? As a result ofthe wholesale introduction of systems-based teaching,anatomy is likely to be taught in small bites with noregard to the whole organism. If car mechanics weretrained like this, how could they do their work? Someanatomists have found a role in the obvious linkbetween surface anatomy and the teaching of clinicalskills—an admirable role and one that emphasizes theimportance of structure. In some places, anatomyrooms (whether for dissection or not) have beenreplaced by clinical skills laboratories and computerlaboratories. This type of limited exposure to struc-tural science has yet to prove itself; anatomy staff areentirely justified in enthusiastically adopting clinicalskills and computer laboratories as a means of retain-ing a smattering of structural components in theprofessional medical course, but for those in charge ofthe course to imagine that this will be sufficient isbased upon nothing other than prejudice and a lack ofvision. Basic science curriculum committees are over-whelmingly populated by staff who are not medical,who put so-called scientific needs, as they see them,before vocational requirements, who see anatomy asmessy and expensive (e.g., embalming and funeralbills), and who wish, quite understandably, to get onwith their research with as little delay as possible.There can be few if any anatomists who can withstandthe advance of this tide, or the volume of hot air thataccompanies it. Their assertions that in order todiagnose disease one needs to know the big picture aremet with cries of parochialism, or of feathering one’s

own nest. That anatomists with clinical experiencemay be opining on the basis of good clinical practice isnot considered - or, if it is, it is brushed aside because,one suspects, of envy and begrudgery arising from aperception of inferiority in the denigrator because heor she does not also have a medical qualification. Thelogical course to pursue if systems- based teaching is tobe adopted would be to have a reasonably comprehen-sive plan of the human body taught first: body parts,language, segmentation, serous cavities, regions, pe-ripheral nerves, and a quick resume of the majororgans fitting together in their homes. This is not just awhim to satisfy anatomists—it is a diagnostic necessity.Clinicians have displayed little interest in basic sci-ence courses: some maintain that such courses areunnecessary (and some may well be so), others feelthat they, as clinicians, are omniscient and multital-ented (as well they may be) and therefore that theycan teach ‘‘all this stuff’’ themselves. Be that as it may,they don’t. Anatomy seems to us to be the equivalent,in primary school terms, of words, spelling, adding,and subtracting. And one is not born with a knowledgeof anatomy—it has to be acquired.

CONCLUSION

Primary education in Britain was propelled into alamentable state in the 1970s and 1980s by a series ofpresumably well-intentioned educationalists who as-serted that if children were allowed to be creative andexpress themselves, they would develop those criticalfaculties that would allow them to educate themselvesthrough a process of self-directed learning. The expe-rience, of course, was otherwise: the system failedthem in reading, spelling, adding, and ultimately inthinking for themselves. Are there not some lessons inthis story?

REFERENCESGeneral Medical Council. 1993. Tomorrow’s Doctors. Report of

the Education Committee. London: GMC. p 1–28.Widdess JDH. 1967. The Royal College of Surgeons in Ireland

and its Medical School 1784–1966. Edinburgh: Livingstone.

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