2015, 37: 394–396
PERSONAL VIEW
Do we really want a revolution in medical education? KIERAN WALSH
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 04/15/15 For personal use only.
BMJ Learning, UK
There has been much recent commentary about a revolution in medical education or indeed the need for such a revolution. The calls for revolution come in different forms and sometimes in different words. Other words besides revolution that are used include transformation and wide scale change – however their essential meaning is the same. (Benner et al. 2010; Frenk et al. 2010; Lueddeke 2012) Some dictionary definitions of revolution include ‘‘a sudden, complete or marked change in something’’ or ‘‘an overthrow or repudiation and the thorough replacement of an established government or political system by the people governed’’ (Dictionary.com 2002). Thus the calls for radical change broadly fit with the dictionary definitions of revolution. However I question whether these calls for a revolution in medical education are right or whether they will have beneficial consequences. Whilst it is impossible to look into the future and see whether a revolution might bring positive outcomes, it is possible to look at the past - and sometimes to learn lessons from the past. There have been few genuine revolutions in medical education that would fit the true meaning of the term – however one such revolution occurred in Russia in the first half of the twentieth century. It followed in the aftermath of the political revolution. It had pervasive effects on medical education in that country. And not all effects were those that were intended. In 1924, Gantt wrote a descriptive review in The BMJ describing the medical education revolution that concurred with the communist revolution in Russia (Gantt 1924). The medical education revolution brought with it human costs, educational costs, and also financial costs. In this short article I have conducted documentary research on Gantt’s review and analysed it from a positivist perspective. As the financial costs are most tangible and quantifiable, I have concentrated on them. I have adhered closely to what can be objectively viewed and quantified. As with any documentary research the first step is establishing that the document is genuine – here there is no question but that this is a genuine document retrieved from the archives of The BMJ. However as is often the case in documentary research, establishing the reliability of the
document is more subjective. The document is written from perspective of an American educator – Horsley Gantt who had worked in the medical section of the American relief administration in Petrograd. Even though Gantt specifically states that ‘‘there is no conscious political tendency or bias in the mind of the writer’’, there still may have been unintended or unconscious tendencies. The author quotes Russian academics quite liberally in the piece – however all quotes are anonymised. As is often the case with historical documents in medical education, the voice of the learner and that of the patient is conspicuously absent. This is a weakness in many medical education documents of the past. The paper commences with a short description of the early years of the Russian revolution. As the author states medical education does not happen in a vacuum – it is very much dependent on the country in which it is based, and this state was wracked by ‘‘war, revolution, famine, and disease.’’ The paper then progresses to discuss the state of medical education in Russia prior to the war and revolution. The account is reasonably well-balanced, albeit possibly affected by the predisposition of the author. According to the author, prior to 1914 medical schools were well supplied with funding and equipment, and were often supported by individual members of the Czarist regime. The downside was that they did not produce sufficient numbers of graduates to meet Russia’s needs. Even before the revolution in 1917, the advent of the First World War meant that funding of the medical schools reduced to approximately 50% of pre-war levels. According to the author after 1917 things were to get a lot worse. The main driver behind the deterioration was lack of funding. This lack of funding meant no new supplies or materials, and no repair to existing materials. And earning was impossible as ‘‘trading was abolished’’. The lack of funding affected all stakeholders – from professors down. Senior faculty spent time doing manual work and queuing for rations – which left them precious little time to perform their duties. By 1921 the New Economic Policy of the government relaxed the strict application of Marxist economic doctrine to the Russian state. However this policy was applied largely to
Correspondence: Dr. Kieran Walsh, BMJ Learning, BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR, UK. Tel: 0207 3836550; Fax: 0207 3836242; E-mail: [email protected]
394
ISSN 0142-159X print/ISSN 1466-187X online/14/040394–3 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.957662
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 04/15/15 For personal use only.
Does medical education require revolution?
individuals and to business and offered little relief to the government controlled sector – i.e. the medical schools. However by 1923 investment in the medical schools started to increase and so the situation improved once again. The paper discusses medical education in the wider context of general education. The narrative is relatively straightforward – before the revolution, the wealthy minority received a good education but left ‘‘the mass of the population entirely uneducated’’. The new system offered ‘‘elementary instruction’’ to all. A problem affecting general education, however, was that many of the intelligentsia had emigrated. According to the author, the medical education curriculum in itself changed relatively little over the period of the revolution. The few content changes were the introduction of instruction in communism and in public health. The main change was that the schools struggled due to drastic cuts in funding. This was exacerbated by an accompanying increase in student numbers and in the percentage of students who had an inadequate basic education and so were ill equipped for medical school. Criteria for admission changed so that preference was given to people from lower classes and from the communist party. A majority of the unprepared students were unable to pass the medical schools exams and to progress and so they left the schools early in their courses. According to the author there had long been a shortage of doctors in Russia – however the government had tried to fill this deficit too quickly. The economic challenge facing the schools was stark – they had to educate three times as many students with one quarter of their former income. However there were apparently some benefits to the wide scale changes – there was more emphasis on public health within the curriculum and some of those who could not complete the full medical course were able to qualify as medical assistants. According to the author, some features did not change. The five-year-duration of studies remained the same, as did the division of the curriculum into preclinical basic science studies and then clinical studies. Before the revolution state examinations were in place for final year students, in the immediate aftermath these exams were abolished, but then subsequently re-established. After the revolution all grades and titles were abolished. However a form of postgraduate training and assessment remained in place. Faculty was selected centrally and sometimes by political apparatchiks. However, according to the author this did not make such a great difference – previous post-holders largely remained in place albeit without their former title. The author claimed to ‘‘have never known of any efficient man ejected unless he were suspected of being counter-revolutionary.’’ What is striking about the document is the marked emphasis on cost. Much of the emphasis relates to costs for students. After the revolution, fees were abolished. However also abolished were grants to the students and students’ kitchens. Overall this led to a net deterioration in conditions for the students. Most ended up having to work in order to continue their studies. By 1923, fees were reintroduced as were grants, student kitchens and student accommodation.
Many students got subsistence from voluntary organisations such as the European Student Relief Committee. Many more grants were reintroduced than existed before, however their administration was means-tested and also influenced by the political affiliations of the students. Some of the emphasis relates to faculty costs. Before the First World War, medical school faculty were reasonably well paid. Then salaries dropped progressively during the war. Immediately after the revolution no salaries were paid – faculty received rations. From 1921 onwards salaries were reinstituted. According to the author, salaries were sufficient to support an individual but there was not enough to support a family or to purchase books. So what themes can be drawn from this document? There are a number of such themes. Firstly many changes within medical education will have unintended consequences. There was massively increased access to medical education in the immediate aftermath of the revolution – but this largely resulted in the admission of unqualified students. Secondly some actions were chaotic – within six years students fees were first present, then abolished, then rapidly reintroduced. Thirdly in some circumstances there was the superficial appearance of change – and no real change underneath. For example immediately after the revolution all grades and titles were abolished and yet previous post-holders largely remained in place albeit without their former title. Fourthly and finally many of the changes were inextricably linked to funding streams and to costs. Cost is an unmissable leitmotiv in the document. Sometimes changes to funding drove changes in the provision of medical education. Sometimes changes in the medical education system affected costs and caused drastic shortages of funding. Most of the changes that related to costs were unforeseen, unintended and had adverse consequences. Within a few years the widespread transformation that had been attempted had gone wrong and the changes that had impoverished the system had to be rapidly reversed. And what lessons can the current generation of medical educators draw from the document? I would suggest that we should beware of wide scale and rapid changes to our systems – even if these changes seem to be to the good. If wide scale changes are implemented, then there should be adequate funding to see them through (Walsh 2010; Walsh et al. 2013).
Notes on contributor Kieran Walsh, FRCPI, is Clinical Director of BMJ Learning.
Ethical approval This was not sought as this was not a trial.
Acknowledgements The author would like to thank The BMJ for making its archive freely available.
395
K. Walsh
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.
References
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 04/15/15 For personal use only.
Benner P, Sutphen M, Leonard V, Day L. 2010. Educating nurses: A call for radical transformation. Stanford: The Carnegie Foundation for the Advancement of Teaching. Dictionary.com. 2002. [Accessed 7 August 2014] Available from http:// dictionary.reference.com/browse/revolution.
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Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, et al. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376(9756):1923–1958. Gantt WH. 1924. A review of medical education in Soviet Russia. Br Med J 1(3311):1055–1058. Lueddeke GR. 2012. Transforming medical education for the 21st century. Oxford: Radcliffe. Walsh K. 2010. Cost effectiveness in medical education. Radcliffe: Abingdon. Walsh K, Levin H, Jaye P, Gazzard J. 2013. Cost analyses approaches in medical education: there are no simple solutions. Med Educ 47(10):962–968.
PERSONAL VIEW
Do we really want a revolution in medical education? KIERAN WALSH
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 04/15/15 For personal use only.
BMJ Learning, UK
There has been much recent commentary about a revolution in medical education or indeed the need for such a revolution. The calls for revolution come in different forms and sometimes in different words. Other words besides revolution that are used include transformation and wide scale change – however their essential meaning is the same. (Benner et al. 2010; Frenk et al. 2010; Lueddeke 2012) Some dictionary definitions of revolution include ‘‘a sudden, complete or marked change in something’’ or ‘‘an overthrow or repudiation and the thorough replacement of an established government or political system by the people governed’’ (Dictionary.com 2002). Thus the calls for radical change broadly fit with the dictionary definitions of revolution. However I question whether these calls for a revolution in medical education are right or whether they will have beneficial consequences. Whilst it is impossible to look into the future and see whether a revolution might bring positive outcomes, it is possible to look at the past - and sometimes to learn lessons from the past. There have been few genuine revolutions in medical education that would fit the true meaning of the term – however one such revolution occurred in Russia in the first half of the twentieth century. It followed in the aftermath of the political revolution. It had pervasive effects on medical education in that country. And not all effects were those that were intended. In 1924, Gantt wrote a descriptive review in The BMJ describing the medical education revolution that concurred with the communist revolution in Russia (Gantt 1924). The medical education revolution brought with it human costs, educational costs, and also financial costs. In this short article I have conducted documentary research on Gantt’s review and analysed it from a positivist perspective. As the financial costs are most tangible and quantifiable, I have concentrated on them. I have adhered closely to what can be objectively viewed and quantified. As with any documentary research the first step is establishing that the document is genuine – here there is no question but that this is a genuine document retrieved from the archives of The BMJ. However as is often the case in documentary research, establishing the reliability of the
document is more subjective. The document is written from perspective of an American educator – Horsley Gantt who had worked in the medical section of the American relief administration in Petrograd. Even though Gantt specifically states that ‘‘there is no conscious political tendency or bias in the mind of the writer’’, there still may have been unintended or unconscious tendencies. The author quotes Russian academics quite liberally in the piece – however all quotes are anonymised. As is often the case with historical documents in medical education, the voice of the learner and that of the patient is conspicuously absent. This is a weakness in many medical education documents of the past. The paper commences with a short description of the early years of the Russian revolution. As the author states medical education does not happen in a vacuum – it is very much dependent on the country in which it is based, and this state was wracked by ‘‘war, revolution, famine, and disease.’’ The paper then progresses to discuss the state of medical education in Russia prior to the war and revolution. The account is reasonably well-balanced, albeit possibly affected by the predisposition of the author. According to the author, prior to 1914 medical schools were well supplied with funding and equipment, and were often supported by individual members of the Czarist regime. The downside was that they did not produce sufficient numbers of graduates to meet Russia’s needs. Even before the revolution in 1917, the advent of the First World War meant that funding of the medical schools reduced to approximately 50% of pre-war levels. According to the author after 1917 things were to get a lot worse. The main driver behind the deterioration was lack of funding. This lack of funding meant no new supplies or materials, and no repair to existing materials. And earning was impossible as ‘‘trading was abolished’’. The lack of funding affected all stakeholders – from professors down. Senior faculty spent time doing manual work and queuing for rations – which left them precious little time to perform their duties. By 1921 the New Economic Policy of the government relaxed the strict application of Marxist economic doctrine to the Russian state. However this policy was applied largely to
Correspondence: Dr. Kieran Walsh, BMJ Learning, BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR, UK. Tel: 0207 3836550; Fax: 0207 3836242; E-mail: [email protected]
394
ISSN 0142-159X print/ISSN 1466-187X online/14/040394–3 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.957662
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 04/15/15 For personal use only.
Does medical education require revolution?
individuals and to business and offered little relief to the government controlled sector – i.e. the medical schools. However by 1923 investment in the medical schools started to increase and so the situation improved once again. The paper discusses medical education in the wider context of general education. The narrative is relatively straightforward – before the revolution, the wealthy minority received a good education but left ‘‘the mass of the population entirely uneducated’’. The new system offered ‘‘elementary instruction’’ to all. A problem affecting general education, however, was that many of the intelligentsia had emigrated. According to the author, the medical education curriculum in itself changed relatively little over the period of the revolution. The few content changes were the introduction of instruction in communism and in public health. The main change was that the schools struggled due to drastic cuts in funding. This was exacerbated by an accompanying increase in student numbers and in the percentage of students who had an inadequate basic education and so were ill equipped for medical school. Criteria for admission changed so that preference was given to people from lower classes and from the communist party. A majority of the unprepared students were unable to pass the medical schools exams and to progress and so they left the schools early in their courses. According to the author there had long been a shortage of doctors in Russia – however the government had tried to fill this deficit too quickly. The economic challenge facing the schools was stark – they had to educate three times as many students with one quarter of their former income. However there were apparently some benefits to the wide scale changes – there was more emphasis on public health within the curriculum and some of those who could not complete the full medical course were able to qualify as medical assistants. According to the author, some features did not change. The five-year-duration of studies remained the same, as did the division of the curriculum into preclinical basic science studies and then clinical studies. Before the revolution state examinations were in place for final year students, in the immediate aftermath these exams were abolished, but then subsequently re-established. After the revolution all grades and titles were abolished. However a form of postgraduate training and assessment remained in place. Faculty was selected centrally and sometimes by political apparatchiks. However, according to the author this did not make such a great difference – previous post-holders largely remained in place albeit without their former title. The author claimed to ‘‘have never known of any efficient man ejected unless he were suspected of being counter-revolutionary.’’ What is striking about the document is the marked emphasis on cost. Much of the emphasis relates to costs for students. After the revolution, fees were abolished. However also abolished were grants to the students and students’ kitchens. Overall this led to a net deterioration in conditions for the students. Most ended up having to work in order to continue their studies. By 1923, fees were reintroduced as were grants, student kitchens and student accommodation.
Many students got subsistence from voluntary organisations such as the European Student Relief Committee. Many more grants were reintroduced than existed before, however their administration was means-tested and also influenced by the political affiliations of the students. Some of the emphasis relates to faculty costs. Before the First World War, medical school faculty were reasonably well paid. Then salaries dropped progressively during the war. Immediately after the revolution no salaries were paid – faculty received rations. From 1921 onwards salaries were reinstituted. According to the author, salaries were sufficient to support an individual but there was not enough to support a family or to purchase books. So what themes can be drawn from this document? There are a number of such themes. Firstly many changes within medical education will have unintended consequences. There was massively increased access to medical education in the immediate aftermath of the revolution – but this largely resulted in the admission of unqualified students. Secondly some actions were chaotic – within six years students fees were first present, then abolished, then rapidly reintroduced. Thirdly in some circumstances there was the superficial appearance of change – and no real change underneath. For example immediately after the revolution all grades and titles were abolished and yet previous post-holders largely remained in place albeit without their former title. Fourthly and finally many of the changes were inextricably linked to funding streams and to costs. Cost is an unmissable leitmotiv in the document. Sometimes changes to funding drove changes in the provision of medical education. Sometimes changes in the medical education system affected costs and caused drastic shortages of funding. Most of the changes that related to costs were unforeseen, unintended and had adverse consequences. Within a few years the widespread transformation that had been attempted had gone wrong and the changes that had impoverished the system had to be rapidly reversed. And what lessons can the current generation of medical educators draw from the document? I would suggest that we should beware of wide scale and rapid changes to our systems – even if these changes seem to be to the good. If wide scale changes are implemented, then there should be adequate funding to see them through (Walsh 2010; Walsh et al. 2013).
Notes on contributor Kieran Walsh, FRCPI, is Clinical Director of BMJ Learning.
Ethical approval This was not sought as this was not a trial.
Acknowledgements The author would like to thank The BMJ for making its archive freely available.
395
K. Walsh
Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.
References
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 04/15/15 For personal use only.
Benner P, Sutphen M, Leonard V, Day L. 2010. Educating nurses: A call for radical transformation. Stanford: The Carnegie Foundation for the Advancement of Teaching. Dictionary.com. 2002. [Accessed 7 August 2014] Available from http:// dictionary.reference.com/browse/revolution.
396
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, et al. 2010. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376(9756):1923–1958. Gantt WH. 1924. A review of medical education in Soviet Russia. Br Med J 1(3311):1055–1058. Lueddeke GR. 2012. Transforming medical education for the 21st century. Oxford: Radcliffe. Walsh K. 2010. Cost effectiveness in medical education. Radcliffe: Abingdon. Walsh K, Levin H, Jaye P, Gazzard J. 2013. Cost analyses approaches in medical education: there are no simple solutions. Med Educ 47(10):962–968.
