Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

Personal View: Medical Education in Sweden: Urgently Needed Reforms Erik Ask-Upmark To cite this article: Erik Ask-Upmark (1979) Personal View: Medical Education in Sweden: Urgently Needed Reforms, Medical Teacher, 1:3, 151-152 To link to this article: http://dx.doi.org/10.3109/01421597909023831

Published online: 03 Jul 2009.

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Date: 14 November 2015, At: 08:00

PERSONAL VIEW’

Medical Education in Sweden: Urgently Needed Reforms ERIK ASK-UPMARK

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Erik Ask- Upmark, MD,is retired Regius Professor of Internal Medicine, Svart backsgatan 37A, S- 753 32 Uppsala, Sweden. I have been licensed as a physician in Sweden for more than 50 years, working for most of this time at the Royal University of Lund, the Royal University of Gothenburg and the Royal University of Uppsala. My experience has been mostly as Professor of Medicine, but I have also had considerable experience in Anatomy, the most important preclinical subject. My researches have resulted in more than 300 articles and books. During the course of the last 50 years I have suffered from various ‘reforms’ of medical education. Three features are common to all these reforms: 1. They have been proposed, in most instances, by representatives of the theoretical (that is, preclinical) subjects. 2. They have aimed at shortening the duration of medical education, chiefly by means of abbreviation or deformation of clinical subjects. 3. They have been characterized by the introduction into the medical curriculum of topics alien to the education of physicians. For example, medical students are required to familiarize themselves with a myriad of enzymes that have no relevance to the practising physician.

Too Many Chairs? At the end of the 18th century it was resolved by the Faculty of Medicine in Uppsala that the faculty was to be limited to three Chairs ‘for all time’. This number has since been exceeded considerably, but in 1946 when I became Professor of Practical Medicine at Uppsala, the set of professorial Chairs was complete with one exception: we had no Chair of Hygiene (elsewhere often called Preventive Medicine). The Chair of Surgery has since been allowed to branch into professorships in General Surgery, Anaesthesiolggy , Orthopaedic Surgery, Neurosurgery, Surgery of the Thorax, Heart and Vessels, and Plastic Surgery. It is perfectly obvious that in a technical topic, such as surgery, this differentiation is perfectly reasonable. A long and much needed Professorship in Neurosurgery has

Medical Teacher VoL 1 No 3 1979

also been established (previously we had to send patients with such problems to Stockholm). As far as General Medicine is concerned (or Practical Medicine as the topic has been called since the days of Linne) it is, to my mind, essential not to allow any differentiation into various branches. Internal Medicine has to be kept intact as one subject, with the possible exception of a Department of Contagious Diseases (Epidemiology). True, there are some technical components of General Medicine, such as Cardiology and Nephrology, where some modest differentiation is permissible. At the University of Lund we were accustomed to having eminent neurologists as Professors in Medicine (e.g., Karl Petren and Sven Ingvar) and personally I can see no need for Neurology to be a separate topic unless the Professor of Neurology has insufficient knowledge about neurology. Necessary Reforms

I shall now enumerate the reforms of medical education that I consider necessary-as a matter of fact, urgently necessary- to improve the standard of medicine practised by Swedish physicians. 1. There are too many students (Figure 1). The number must be drastically reduced. Of course, this reform is likely to bring forth a cry of protest from those primarily concerned with quantity. But these individuals have caused so much harm to the standard and quality of doctors that their objections should be ignored. 2 . It is desirable, and indeed necessary, to introduce an examen rigorosum for everyone wanting to enter medical training. In my own student days we had such a course in Comparative Anatomy. This was de rigeur and anyone who did not satisfy the teachers was not allowed to pursue his medical studies. One does not necessarily have to use Comparative Anatomy as the subject, although this topic is far more important to the physician than many realize. General chemistry or physiology would serve equally well. 3. The preclinical studies have rightly been considered as the boundary that distinguishes a physician from a

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Year Figure 1. Number of students enrolled at Swedish medical schools, 1957 to 1976.

mountebank. Students must realize that, even if they are allowed to commence the medical curriculum, this is no guarantee that they will be allowed to continue their studies. It is essential that decisions based on the results in each subject should be made at the university where the student began those studies. I believe Anatomy should be recognized as the most important preclinical subject. Medical education should be devoted above all to those students who have the best qualifications, as is the case in France. The thoroughly unsound idea of equality should be thrown overboard, and the sooner the better. Only the best -suited students should be allowed to continue their studies. 4. Progress to clinical studies should be granted only to

those students who have performed well in their preclinical studies: no exception to this rule should be allowed in any circumstance. In the clinical curriculum, paramount importance should be placed on bedside medicine. Of course, laboratories should be attended as well, but they must not be allowed to encroach on the bedside clinical studies. The truly malignant, so-called ‘general service’ that has been allowed to develop in Sweden should be discarded and replaced with service as assistants in the principal clinical topics, such as medicine and surgery. 5 . There are some items that could be omitted from the 152

curriculum. Social Medicine is a good example. This was invented by politicians as a vehicle to get new notions into the Faculties. As a matter of fact, Social Medicine is already covered in other departments, such as Medicine, Surgery, Gynaecology, Ophthalmology, Ear Nose and Throat, etc. There is no need whatsoever for a chair in Social Medicine. As for Preventive Medicine, this too is to some extent covered by the other courses. However, a Chair of Hygiene is necessary. 6 . Each student must, during his clinical years, be allowed to study in detail a large number of patients. In recent years this has not been possible because there are too many medical students. 7. Some people have suggested that ‘medical psychology’ should be introduced into the curriculum as a special topic. No doubt this is to some extent a desirable antidote to the vast body of knowledge of the laboratory sciences with which students are burdened. However, psychology, in the medical sense, is already well covered by the other components of the clinical curriculum. Beware of psychologists who are not physicians! 8. The so-called multiple choice examinations should be discarded. Examinations should consist of an oral part conducted by the Professor himself, while the Assistant Professors may be relied upon to conduct the bedside part of the examination. Medical Teacher Vol 1 No 3 1979