THE NEW CURRICULA
The New Clinical Curriculum at the Royal Free Hospital School of Medicine
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NEIL McINTYRE Neil Mclntyre, B.SC, MD, FRCP, is Professor of Medicine and Clinical Sub-Dean, Royal Free Hospital School of Medicine, Rowland Hill Street, London NW3 2QG, UK.
In 1967 the General Medical Council published the document Recommendations as to Basic Medical Education, which encouraged flexibility in the planning of curricula. In the same year the University of London set up a Curriculum Committee to review the regulations governing the MB, BS course. It went on to approve new regulations which offered its medical schools a choiceeither to follow a new university-sponsored course and to use university examinations, or to submit proposals for a school-sponsored course with the additional option of setting school-based examinations. The School of Medicine at the Royal Free Hospital (Figure 1) decided to run its own course and to set its own examinations. A
Figure 1. The new Royal Free Hospital, London. @ H. Snock Photography @Associates.
curriculum was drawn up and approved by the University, and the first students subject to the new regulations began their studies in October 1974. In 1975 Dr Bruce MacGillivray was elected Dean of the Royal Free Hospital School of Medicine and he appointed two sub-deans-a Postgraduate Sub-Dean and a Clinical Sub-Dean. The main responsibility of the Clinical SubDean was to implement the new clinical curriculum (with effect from October 1976). The Dean also set up a new Curriculum Committee, with preclinical and clinical subcommittees. When the Clinical Subcommittee reviewed the curriculum planned for October 1976,they decided that it was unsatisfactory and that another would have to be produced, even though the first ‘new curriculum’ students were due at the hospital a few months later. The subcommittee met regularly and often in its early days. First, it defined a set of goals for the school, which were approved by the other relevant school committees, and drew up educational objectives to match several of the goals. It rearranged the timetable of the curriculum, and more importantly, drew up a series of recommendations on in-course assessment which had implications for methods of teaching during the first clinical year.
The School Goals The school goals spelled out the qualities which were considered desirable in newly qualified doctors. They formed the basis of subsequent discussions on the structure and content of the new curriculum. Not surprisingly they are similar to goals produced by other medical schools. At the end of the course our students:
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1. Should be able to collect, record and communicate clinical information (i.e. data obtained from history, clinical examination and special investigations) in a thorough and reliable manner. 2. Should be able to use such information to solve and manage clinical problems. Medical Teacher Voll No 5 1979
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3. Should have a core of knowledge and manipulative skills that will: a. facilitate their collection of clinical information, b. enable them to handle acute, life threatening emergencies promptly and effectively, c. allow them to deal efficiently with common clinical conditions, / d. give them an understanding of normal biological processes and how these are disturbed in disease states. 4. Should understand the potential influence of environmental and psychological factors on the patient’s illness. 5. Should be familiar with the resources and facilities available through health and social services and be able to use them effectivelyfor the benefit of their patients. 6. Should recognize the limitations of their own knowledge and abilities, admitting areas of ignorance and seeking help when necessary. 7. Should be familiar with scientific method and be able to apply scientific principles to the evaluation of published work. 8. Should be independent learners with attitudes to selfevaluation and self-education that will promote continuing improvement and adaptation to changes in medical practice, whether these result from the changing needs of the community or from advances in medical science. 9. Should be able to care for patients and their families; they should be able to reassure them, to allay their anxieties and to discuss illnesses and their treatment, prognosis and potential complications in terms which the patient and the family can understand. 10. Should be able to establish good working relationships with their medical colleagues and members of allied health professions. We used the term ‘goal’to describe a broad statement of intent and the term ‘objective’ for statements which describe more precisely what students must be able to do to indicate that they have achieved the relevant goals. We wrote one set of objectives to cover the whole of the first clinical year; they match the first three goals. They are concerned with basic clinical skills and with principles of patient care, and cover the knowledge required for the interpretation of symptoms, physical signs and abnormal laboratory investigations. These objectives spell out which clinical conditions are deemed particularly important by teachers and how much students should know about them. A separate set of objectives has been prepared for each of the more specialized subjects of the second clinical year. (Financial support towards the preparation of these objectives was generously provided by CIBA-Geigy Ltd.) The following are examples of our objectives. Objective 1 . Clinical Information Collection The student will demonstrate that he collects information thoroughly by recording for all his inpatients those details Medical Teacher Vol 1 No 5 1979
of history, physical examination and laboratory investigation which are routinely collected on the firm to which he is attached. The history should include a statement of the presenting complaint, the history of the present illness, the results of systematic enquiry and past, family, psychosocial and drug histories. The student should, when necessary, incorporate information obtained from sources other than the patient, such as the family or earlier medical records. The physical examination should describe all items stated in the data base for each firm. It should include: general description of the patient, skin examination, examination of cardiovascular system, respiratory system, abdomen, central and peripheral nervous systems, the musculoskeletalsystem and psychiatric examination. The laboratory investigations should include a note of all routine requests and results of these as they return. Assessment will be made throughout the post by inspection of a random selection of the student’s notes on current inpatients. Acceptable performance is the complete collection of the clinical information expected routinely by the teachers responsible for the individual firms. (The data base appropriate to each firm will be given to the students at the beginning of the post.)
Objective 2. Interpretation and Use of Clinical Information The student will demonstrate his ability to interpret and utilize clinical information. In his clinical notes on each inpatient he should: 1. Formulate from his data base a list of significant problems which require activity and attention. 2. Construct for each of these active problems a plan of action. This should include the collection of further information to help diagnosis and/or monitoring of patients. He should describe the treatment he recommends. He should write the names of drugs in block capitals and give the dosage and route of administration (as in a prescription). He should record how he would collaborate with other health care workers and with the social services: he should describe the advice he would give to the patient and record the patient’s fears about his illness and its consequences. 3. Record the progress of each problem, noting changes in symptoms and physical signs and the results of investigations as they return. If tests which he recommended were not carried out, he should indicate why these were not done (having consulted the medical staff). He should record his assessment of the status of problems as new information returns. He should write plans for further investigations or changes of treatment. He should monitor his patient for potential complications of therapy, including predictable hazards of drug usage, side effects and interactions. When monitoring intravenous fluid therapy, a cumulative chart of fluid and electrolyte balance should be recorded. The student’s performance will be acceptable if his 253
reasoning is clear in the notes and in discussion with his teachers, and if he can defend his statements and decisions on the basis of common sense, established practice or by reference to recent texts, journals, drug information leaflets, prescribers journals, and the National Formulary or pharmacopoeias.
Objective 3. Recognition and Initiation of Management
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The student should be able to describe, without recourse to books, how he would recognize and initiate the management of the following problems: Acute pulmonary oedema Pulmonary embolism Acute anaphylaxis and angioneuroticoedema Cardiac arrest Haemorrhage Shock Tension pneumothorax Laryngeal obstruction Hypertensive encephalopathy Hypoglycaemia Hyperkalaemia.
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The Timetable One of the most urgent tasks of the Clinical Curriculum Subcommittee was to arrange a new timetable (Figure 2). We were governed by many constraints and our eventual choice was a compromise with several obvious defects. We decided to reinstate the introductory course, which had been deleted from the original version of the new curriculum, and to follow this with a year in which students 'rotated through four three-month posts. There was broad agreement that general medicine, general surgery and psychiatry/neurology should be included in the first year, but we were left with one three-month period to be filled. Teachers from several disciplineswere unwilling to participate in a first year rotation because they did not want to teach students who might not have been on a general medical or surgical post. Eventually we filled the three-month period by introducing two new posts, geriatrics and nephrology, and by making up the rest of the time with anaesthetics and accident and emergency. At the end of this rotation all of the first cohort of new curriculum students joined a four-week post in clinical pathology (which included chemical pathology, haematology and microbiology, and immunology) before starting on another year-long rotation. During this second rotation students are attached to various clinical specialties, and to general practice, clinical epidemiology and histopathology. Six weeks of this year were initially allocated to a science elective, but after the first cohort of students had passed through this rotation the science elective slot was reallocated to clinical pathology (in place of the four-week post between the two rotations). This was done reluctantly, because the existing arrangements for clinical pathology teaching proved unacceptable to both teachers and students. 2 54
TktRblc
Figure 2. The timetable.
At the end of the second year rotation students begin a 24-week period during which they work very much on their own. Eight weeks are spent on a clinical elective. The remaining 16 weeks are given over to eight two-week periods; individual students are attached to clinical firms in medicine, surgery, paediatrics and psychiatry, and to general practice and accident and emergency. Students then begin a four-week period of revision before their final examinations. Educational Methods Much of the teaching in our new curriculum is conventional in that it takes place during ward rounds and outpatients, in tutorials and in a relatively small number of lectures. During these sessions the students tend to be passive participants. In our goals we emphasized the importance of learning (an activity of students) as opposed to teaching (activity on the part of teachers). We have tried to promote learning by providing students with appropriate educational activities and by giving them detailed and prompt criticism on their efforts so that they can correct deficiencies and redirect their learning. Medical Teacher Vol 1 No 5 1979
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Clearly, our greatest priority is that students should learn to care for patients. But caring for a patient is a complex process, and it is not enough that students should be able to handle constituent parts such as history taking and physical examination. They must be able to put them all together. Not only must they be able to formulate diagnostic hypotheses, but they must also learn how to monitor progress, how to treat patients and how to employ the services of nurses, physiotherapists, occupational therapists and social workers to best advantage. Students must learn how to explain to patients the implications of their illnesses and must learn how to answer their queries. For these several reasons we place great emphasis on the student’s clerking of the inpatients allocated to his care. Students are required to use the Problem Orientated Medical Record (POMR); this, because of its structure, promotes a disciplined approach to clinical problems (see Rendall 1979; Petri and McIntyre 1979). It guides students through all stages of clinical activity and ensures that they preserve the logic governing their actions. (Generous financial support for our efforts to teach students the use of POMR was given by the King Edward’s Hospital Fund, as part of wider support for the promotion of POMR within the hospital.) The record itself cannot ensure that a student does things correctly, but it does allow teachers to assess what he has done and to provide feedback on his performance. This feedback is given during ‘audit’ sessions, in which students and teachers meet on a one-to-one basis. The teacher goes over the notes kept by students on current inpatients and should point out deficiencies and praise good performance. Because students may not, on individual posts, clerk patients with all the common and important clinical conditions, we have prepared a large number of clinical presentations called ‘Problems of the Week’. These present a patient’s history, physical examination and details of special investigations. Students review these data and formulate a list of the ‘patient’s’problems. They write plans for each problem requiring action, and these plans cover diagnosis, monitoring of the problem, therapy and patient education. A teacher then goes over the case history with a group of students. A series of demonstrations of simple radiographs and ECGs are displayed outside the library. Initially, the radiographs are put up with no explanation and after 10
days or more, a period which allows most students to see them, comments and explanations are added by a radiologist or cardiologist. During clinical posts, sessions are held each week with clinical pathologists, who review with students the use of commonly used investigations and discuss with them the implications of the abnormal results found in their own patients. InCourse Assessment and Final Examinations In-course assessment of some kind is essential if poor performance by students is to be identified and corrected at a reasonably early stage. In our new clinical curriculum we have a system of in-course assessment designed to monitor the student’sprogress throughout the first two clinical years. Its primary purpose is to provide feedback to students and staff so that defects either of student performance or of teaching can be corrected. Some elements of our in-course assessment system are used only for feedback, e.g. audits of the student’s problem orientated records, the teacher’s review of ‘Problemsof the Week’, etc. Other elements are used for grading the performance of students on each post. At the end of most posts during the first year, and on some of the second year posts, the students are given a written paper which requires them to interpret symptoms, physical signs and abnormal laboratory data. Feedback is provided on their performance. Their scores contribute to an overall post grade, which also takes into account their skill at physical examination and their professional behaviour on the post (Figure 3). The latter assessment has been made largely on subjective grounds, but we are trying to improve the quality of this assessment by asking teachers to comment specifically on student’s motivation and determination, their relationships with their patients, teachers and colleagues, and their attitudes to learning. We hope that this will allow us to detect, and to correct, unacceptable professional behaviour. Four grades can be given to students at the end of a post: A-outstanding, B-good pass, C-pass and Dweak (and therefore unacceptable). No D grade can be awarded unless the teachers involved give an explanation for the grade, a recommendation for remedial action and state what the student must do in order to correct the grade. The grades and recommendations are reviewed
Figure 3. Part of theform usedfor assessment of professional behamour. & s a m n t . o f profnriorul behwiour
Dale
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Characteristics ltmr
Medical Teacher Vol 1 No 5 1979
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every three months by the Collegiate Committee of Examiners. This committee is made up of both internal and external examiners. It is hoped that our external examiners will be able to follow students through their incourse assessment and to officiate at their final examinations. Our students have to pass in-course assessment in order to be allowed to sit the final examinations, but no mark is taken forward to be added to the marks in finals. Incourse assessment grades cannot contribute to student failure in finals; they can only be used to help students on the borderline of failure. It seems sensible that students should ‘pass’in-course assessment before they are allowed to take the final examinations, because in-course assessment allows teachers to evaluate many qualities, such as clinical skills and sound professional behaviour, which are tested very poorly in conventional final examinations. (In the past we have paid lip-serviceto the importance of skills and appropriate behaviour but have only really tested the acquisition of factual knowledge. Students have responded by trying to remember facts and have neglected clinical skills and the development of sound professional behaviour .) Final Examinations Our final examinations take place at the end of the clinical course. Their timing is partly dictated by University regulations which specify the date by which the examiners’ results must be forwarded to the University. Our first examinations under the new regulations took place in June 1979. All subjects are to be taken during the same period. In pathology and in obstetrics and gynaecology there will be one paper, practical or clinical, and an oral examination. Medicine and surgery have been combined and include clinical pharmacology and therapeutics, psychiatry, clinical epidemiology, general practice and paediatrics. There will be two papers in medicine and surgery, one long case, some short cases and a number of oral examinations. Medicine and surgery papers will contain: 1. Short non-cued questions which will test the student’s ability to explain the likely cause of abnormal symptoms and physical signs and of abnormal laboratory results. For example, ‘A 20-year-old woman presents with a three-month history of loss of weight with an increase in appetite. Give two causes’. Such questions are similar to those used in the end-of-posttests. 2. Interdisciplinary questions that require short and relatively specific answers. For example, ‘Describebriefly the main clinical features which would lead you to suspect that an otherwise healthy 50-year-old man has suffered a myocardial infarct. What investigations would confirm your diagnosis? If the infarct appears uncomplicated how would you manage the patient? Give three likely complications that might arise and indicate how you would deal with these. What is the likely outcome in an apparently uncomplicated case? What factors place a patient at particular risk for the development of 256
ischaemic heart disease or from sudden death from this condition?’ The rationale behind the use of these two types of questions is that they call for performance similar to that required in clinical practice. In order to make a diagnosis, the student must first formulate diagnostic hypotheses to account for abnormal symptoms, signs and laboratory results. This skill is tested by the first type of question. He must then check whether the rest of the patient’s story matches the features of these hypothetical conditions. To do this, the student must know the clinical picture of these conditions. The second type of question tests the student’s knowledge of these clinical pictures, as well as his knowledge of clinical pharmacology, epidemiology and psychiatry. The ‘long case’ may be a patient with medical and/or surgical problems, or a child, or a patient with psychiatric problems. The student will be asked to list the patient’s problems and to write a plan of action for each active problem outlining: 1. Likely diagnoses and the information needed to confirm or refute each of these. 2. The information he would collect to monitor the patient’s progress. 3. Treatment. 4. Patient education, i.e. his explanation to the patient about his illness. The student will have 20 minutes to formulate these plans before presenting them to the examiners. Laboratory data will be available on request and during the examination the student will be allowed access to a list of normal laboratory values and to the Britbh National Formulary, Mims and the ABPI Datasheet Compendium.
Evaluation It was agreed initially that we should try to evaluate the effectiveness of our new clinical curriculum. Janet Gale, an educational psychologist then with the British Life Assurance Trust Centre for Health and Medical Education, and Liz Wyn Pugh, a gynaecologist and graduate of the Royal Free, were asked to undertake this evaluation. Recently they have been joined by Bo Nemcova, a sociologist. (Generous financial support for this evaluation has been received from the Royal Free Hospital Special Appeal Trustees and the Stanley ThomasJohnson Foundation.) Their method of enquiry has been largely b y interview and discussion with teachers and students. They have enquired into teachers’ and students’ opinions about goals and objectives, about problem orientated medical records and about audit. They have also asked about other methods of teaching and in-course assessment. Further topics have come up spontaneously during the course of the interviews. Space does not permit me to discuss the results of the evaluation in great depth. It would appear that the new curriculum has had an important, but limited, impact on clinical teaching. Many teachers have revised their Medical Teacher Vol 1 No 5 1979
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teaching programme to match the ideas behind the new curriculum while others do what they did before. As expected there have been criticisms of various aspects of the new curriculum, though in general these have been directed not at the basic principles of the new curriculum but at our failure to implement them properly. This failure is due mainly to poor education and to problems of organization and communication. We knew it would be difficult to inform teachers about the new curriculum before it came into effect because it was planned and implemented rapidly. Shortage of administrative staff made it inevitable that there would be problems of organization. But we did not anticipate how difficult it would be to communicate with many teachers. Meetings have been poorly attended and many teachers do not read the documents about the new curriculum which are sent to them. The problems of communication with students have been less serious, though still considerable, because there have been regular meetings with the Clinical Sub-Dean and representatives of students assigned to each post. To try to ensure that staff and students understand the principles underlying the new clinical curriculum we produced a small booklet, Everything You Have Always Wanted to Know About The New Clinical CurriculumBut Were Afraid To Ask! (This booklet and a selfinstructional booklet on the problem orientated medical record were prepared with the assistance of the Medical Sciences Liaison Division of Upjohn Ltd. Copies available on request.) Although this booklet has helped, communication is still a major problem. It seems that someone involved in the organization of the curriculum has to discuss matters personally with each person who needs to be informed. Unfortunately, this is timeconsuming and a great strain on the limited resources available for curriculum planning and implementation. Although there have been many difficulties, we feel that the introduction of the new curriculum has been a moderate success. A number of new ideas have been introduced into a school which previously had a very traditional clinical curritulum. These represent a systematic approach to medical education and we feel that with patience and cooperation, and with the determination of teachers and students to make it succeed, such an approach will lead to a gradual improvement in the quality of our graduates: we hope we will be able to monitor this quality and to continue to improve upon it!
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Barclaycard account for L............. References General Medical Council, Recommendatiom (L( to Basic Medical Education, London, 1967. Petri, J. C. and McIntyre, N., The Problem Orientated Medical Record: Its Use in Hospitals, General Practice and Medical Education, Churchill Livingstone, Edinburgh, London and New York, 1979. Rendall, M., POMR-The Case in Favour, Medical Teacher, 1, 147150.
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The New Clinical Curriculum at the Royal Free Hospital School of Medicine
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NEIL McINTYRE Neil Mclntyre, B.SC, MD, FRCP, is Professor of Medicine and Clinical Sub-Dean, Royal Free Hospital School of Medicine, Rowland Hill Street, London NW3 2QG, UK.
In 1967 the General Medical Council published the document Recommendations as to Basic Medical Education, which encouraged flexibility in the planning of curricula. In the same year the University of London set up a Curriculum Committee to review the regulations governing the MB, BS course. It went on to approve new regulations which offered its medical schools a choiceeither to follow a new university-sponsored course and to use university examinations, or to submit proposals for a school-sponsored course with the additional option of setting school-based examinations. The School of Medicine at the Royal Free Hospital (Figure 1) decided to run its own course and to set its own examinations. A
Figure 1. The new Royal Free Hospital, London. @ H. Snock Photography @Associates.
curriculum was drawn up and approved by the University, and the first students subject to the new regulations began their studies in October 1974. In 1975 Dr Bruce MacGillivray was elected Dean of the Royal Free Hospital School of Medicine and he appointed two sub-deans-a Postgraduate Sub-Dean and a Clinical Sub-Dean. The main responsibility of the Clinical SubDean was to implement the new clinical curriculum (with effect from October 1976). The Dean also set up a new Curriculum Committee, with preclinical and clinical subcommittees. When the Clinical Subcommittee reviewed the curriculum planned for October 1976,they decided that it was unsatisfactory and that another would have to be produced, even though the first ‘new curriculum’ students were due at the hospital a few months later. The subcommittee met regularly and often in its early days. First, it defined a set of goals for the school, which were approved by the other relevant school committees, and drew up educational objectives to match several of the goals. It rearranged the timetable of the curriculum, and more importantly, drew up a series of recommendations on in-course assessment which had implications for methods of teaching during the first clinical year.
The School Goals The school goals spelled out the qualities which were considered desirable in newly qualified doctors. They formed the basis of subsequent discussions on the structure and content of the new curriculum. Not surprisingly they are similar to goals produced by other medical schools. At the end of the course our students:
252
1. Should be able to collect, record and communicate clinical information (i.e. data obtained from history, clinical examination and special investigations) in a thorough and reliable manner. 2. Should be able to use such information to solve and manage clinical problems. Medical Teacher Voll No 5 1979
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3. Should have a core of knowledge and manipulative skills that will: a. facilitate their collection of clinical information, b. enable them to handle acute, life threatening emergencies promptly and effectively, c. allow them to deal efficiently with common clinical conditions, / d. give them an understanding of normal biological processes and how these are disturbed in disease states. 4. Should understand the potential influence of environmental and psychological factors on the patient’s illness. 5. Should be familiar with the resources and facilities available through health and social services and be able to use them effectivelyfor the benefit of their patients. 6. Should recognize the limitations of their own knowledge and abilities, admitting areas of ignorance and seeking help when necessary. 7. Should be familiar with scientific method and be able to apply scientific principles to the evaluation of published work. 8. Should be independent learners with attitudes to selfevaluation and self-education that will promote continuing improvement and adaptation to changes in medical practice, whether these result from the changing needs of the community or from advances in medical science. 9. Should be able to care for patients and their families; they should be able to reassure them, to allay their anxieties and to discuss illnesses and their treatment, prognosis and potential complications in terms which the patient and the family can understand. 10. Should be able to establish good working relationships with their medical colleagues and members of allied health professions. We used the term ‘goal’to describe a broad statement of intent and the term ‘objective’ for statements which describe more precisely what students must be able to do to indicate that they have achieved the relevant goals. We wrote one set of objectives to cover the whole of the first clinical year; they match the first three goals. They are concerned with basic clinical skills and with principles of patient care, and cover the knowledge required for the interpretation of symptoms, physical signs and abnormal laboratory investigations. These objectives spell out which clinical conditions are deemed particularly important by teachers and how much students should know about them. A separate set of objectives has been prepared for each of the more specialized subjects of the second clinical year. (Financial support towards the preparation of these objectives was generously provided by CIBA-Geigy Ltd.) The following are examples of our objectives. Objective 1 . Clinical Information Collection The student will demonstrate that he collects information thoroughly by recording for all his inpatients those details Medical Teacher Vol 1 No 5 1979
of history, physical examination and laboratory investigation which are routinely collected on the firm to which he is attached. The history should include a statement of the presenting complaint, the history of the present illness, the results of systematic enquiry and past, family, psychosocial and drug histories. The student should, when necessary, incorporate information obtained from sources other than the patient, such as the family or earlier medical records. The physical examination should describe all items stated in the data base for each firm. It should include: general description of the patient, skin examination, examination of cardiovascular system, respiratory system, abdomen, central and peripheral nervous systems, the musculoskeletalsystem and psychiatric examination. The laboratory investigations should include a note of all routine requests and results of these as they return. Assessment will be made throughout the post by inspection of a random selection of the student’s notes on current inpatients. Acceptable performance is the complete collection of the clinical information expected routinely by the teachers responsible for the individual firms. (The data base appropriate to each firm will be given to the students at the beginning of the post.)
Objective 2. Interpretation and Use of Clinical Information The student will demonstrate his ability to interpret and utilize clinical information. In his clinical notes on each inpatient he should: 1. Formulate from his data base a list of significant problems which require activity and attention. 2. Construct for each of these active problems a plan of action. This should include the collection of further information to help diagnosis and/or monitoring of patients. He should describe the treatment he recommends. He should write the names of drugs in block capitals and give the dosage and route of administration (as in a prescription). He should record how he would collaborate with other health care workers and with the social services: he should describe the advice he would give to the patient and record the patient’s fears about his illness and its consequences. 3. Record the progress of each problem, noting changes in symptoms and physical signs and the results of investigations as they return. If tests which he recommended were not carried out, he should indicate why these were not done (having consulted the medical staff). He should record his assessment of the status of problems as new information returns. He should write plans for further investigations or changes of treatment. He should monitor his patient for potential complications of therapy, including predictable hazards of drug usage, side effects and interactions. When monitoring intravenous fluid therapy, a cumulative chart of fluid and electrolyte balance should be recorded. The student’s performance will be acceptable if his 253
reasoning is clear in the notes and in discussion with his teachers, and if he can defend his statements and decisions on the basis of common sense, established practice or by reference to recent texts, journals, drug information leaflets, prescribers journals, and the National Formulary or pharmacopoeias.
Objective 3. Recognition and Initiation of Management
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The student should be able to describe, without recourse to books, how he would recognize and initiate the management of the following problems: Acute pulmonary oedema Pulmonary embolism Acute anaphylaxis and angioneuroticoedema Cardiac arrest Haemorrhage Shock Tension pneumothorax Laryngeal obstruction Hypertensive encephalopathy Hypoglycaemia Hyperkalaemia.
P 4
" .
c
The Timetable One of the most urgent tasks of the Clinical Curriculum Subcommittee was to arrange a new timetable (Figure 2). We were governed by many constraints and our eventual choice was a compromise with several obvious defects. We decided to reinstate the introductory course, which had been deleted from the original version of the new curriculum, and to follow this with a year in which students 'rotated through four three-month posts. There was broad agreement that general medicine, general surgery and psychiatry/neurology should be included in the first year, but we were left with one three-month period to be filled. Teachers from several disciplineswere unwilling to participate in a first year rotation because they did not want to teach students who might not have been on a general medical or surgical post. Eventually we filled the three-month period by introducing two new posts, geriatrics and nephrology, and by making up the rest of the time with anaesthetics and accident and emergency. At the end of this rotation all of the first cohort of new curriculum students joined a four-week post in clinical pathology (which included chemical pathology, haematology and microbiology, and immunology) before starting on another year-long rotation. During this second rotation students are attached to various clinical specialties, and to general practice, clinical epidemiology and histopathology. Six weeks of this year were initially allocated to a science elective, but after the first cohort of students had passed through this rotation the science elective slot was reallocated to clinical pathology (in place of the four-week post between the two rotations). This was done reluctantly, because the existing arrangements for clinical pathology teaching proved unacceptable to both teachers and students. 2 54
TktRblc
Figure 2. The timetable.
At the end of the second year rotation students begin a 24-week period during which they work very much on their own. Eight weeks are spent on a clinical elective. The remaining 16 weeks are given over to eight two-week periods; individual students are attached to clinical firms in medicine, surgery, paediatrics and psychiatry, and to general practice and accident and emergency. Students then begin a four-week period of revision before their final examinations. Educational Methods Much of the teaching in our new curriculum is conventional in that it takes place during ward rounds and outpatients, in tutorials and in a relatively small number of lectures. During these sessions the students tend to be passive participants. In our goals we emphasized the importance of learning (an activity of students) as opposed to teaching (activity on the part of teachers). We have tried to promote learning by providing students with appropriate educational activities and by giving them detailed and prompt criticism on their efforts so that they can correct deficiencies and redirect their learning. Medical Teacher Vol 1 No 5 1979
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Clearly, our greatest priority is that students should learn to care for patients. But caring for a patient is a complex process, and it is not enough that students should be able to handle constituent parts such as history taking and physical examination. They must be able to put them all together. Not only must they be able to formulate diagnostic hypotheses, but they must also learn how to monitor progress, how to treat patients and how to employ the services of nurses, physiotherapists, occupational therapists and social workers to best advantage. Students must learn how to explain to patients the implications of their illnesses and must learn how to answer their queries. For these several reasons we place great emphasis on the student’s clerking of the inpatients allocated to his care. Students are required to use the Problem Orientated Medical Record (POMR); this, because of its structure, promotes a disciplined approach to clinical problems (see Rendall 1979; Petri and McIntyre 1979). It guides students through all stages of clinical activity and ensures that they preserve the logic governing their actions. (Generous financial support for our efforts to teach students the use of POMR was given by the King Edward’s Hospital Fund, as part of wider support for the promotion of POMR within the hospital.) The record itself cannot ensure that a student does things correctly, but it does allow teachers to assess what he has done and to provide feedback on his performance. This feedback is given during ‘audit’ sessions, in which students and teachers meet on a one-to-one basis. The teacher goes over the notes kept by students on current inpatients and should point out deficiencies and praise good performance. Because students may not, on individual posts, clerk patients with all the common and important clinical conditions, we have prepared a large number of clinical presentations called ‘Problems of the Week’. These present a patient’s history, physical examination and details of special investigations. Students review these data and formulate a list of the ‘patient’s’problems. They write plans for each problem requiring action, and these plans cover diagnosis, monitoring of the problem, therapy and patient education. A teacher then goes over the case history with a group of students. A series of demonstrations of simple radiographs and ECGs are displayed outside the library. Initially, the radiographs are put up with no explanation and after 10
days or more, a period which allows most students to see them, comments and explanations are added by a radiologist or cardiologist. During clinical posts, sessions are held each week with clinical pathologists, who review with students the use of commonly used investigations and discuss with them the implications of the abnormal results found in their own patients. InCourse Assessment and Final Examinations In-course assessment of some kind is essential if poor performance by students is to be identified and corrected at a reasonably early stage. In our new clinical curriculum we have a system of in-course assessment designed to monitor the student’sprogress throughout the first two clinical years. Its primary purpose is to provide feedback to students and staff so that defects either of student performance or of teaching can be corrected. Some elements of our in-course assessment system are used only for feedback, e.g. audits of the student’s problem orientated records, the teacher’s review of ‘Problemsof the Week’, etc. Other elements are used for grading the performance of students on each post. At the end of most posts during the first year, and on some of the second year posts, the students are given a written paper which requires them to interpret symptoms, physical signs and abnormal laboratory data. Feedback is provided on their performance. Their scores contribute to an overall post grade, which also takes into account their skill at physical examination and their professional behaviour on the post (Figure 3). The latter assessment has been made largely on subjective grounds, but we are trying to improve the quality of this assessment by asking teachers to comment specifically on student’s motivation and determination, their relationships with their patients, teachers and colleagues, and their attitudes to learning. We hope that this will allow us to detect, and to correct, unacceptable professional behaviour. Four grades can be given to students at the end of a post: A-outstanding, B-good pass, C-pass and Dweak (and therefore unacceptable). No D grade can be awarded unless the teachers involved give an explanation for the grade, a recommendation for remedial action and state what the student must do in order to correct the grade. The grades and recommendations are reviewed
Figure 3. Part of theform usedfor assessment of professional behamour. & s a m n t . o f profnriorul behwiour
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every three months by the Collegiate Committee of Examiners. This committee is made up of both internal and external examiners. It is hoped that our external examiners will be able to follow students through their incourse assessment and to officiate at their final examinations. Our students have to pass in-course assessment in order to be allowed to sit the final examinations, but no mark is taken forward to be added to the marks in finals. Incourse assessment grades cannot contribute to student failure in finals; they can only be used to help students on the borderline of failure. It seems sensible that students should ‘pass’in-course assessment before they are allowed to take the final examinations, because in-course assessment allows teachers to evaluate many qualities, such as clinical skills and sound professional behaviour, which are tested very poorly in conventional final examinations. (In the past we have paid lip-serviceto the importance of skills and appropriate behaviour but have only really tested the acquisition of factual knowledge. Students have responded by trying to remember facts and have neglected clinical skills and the development of sound professional behaviour .) Final Examinations Our final examinations take place at the end of the clinical course. Their timing is partly dictated by University regulations which specify the date by which the examiners’ results must be forwarded to the University. Our first examinations under the new regulations took place in June 1979. All subjects are to be taken during the same period. In pathology and in obstetrics and gynaecology there will be one paper, practical or clinical, and an oral examination. Medicine and surgery have been combined and include clinical pharmacology and therapeutics, psychiatry, clinical epidemiology, general practice and paediatrics. There will be two papers in medicine and surgery, one long case, some short cases and a number of oral examinations. Medicine and surgery papers will contain: 1. Short non-cued questions which will test the student’s ability to explain the likely cause of abnormal symptoms and physical signs and of abnormal laboratory results. For example, ‘A 20-year-old woman presents with a three-month history of loss of weight with an increase in appetite. Give two causes’. Such questions are similar to those used in the end-of-posttests. 2. Interdisciplinary questions that require short and relatively specific answers. For example, ‘Describebriefly the main clinical features which would lead you to suspect that an otherwise healthy 50-year-old man has suffered a myocardial infarct. What investigations would confirm your diagnosis? If the infarct appears uncomplicated how would you manage the patient? Give three likely complications that might arise and indicate how you would deal with these. What is the likely outcome in an apparently uncomplicated case? What factors place a patient at particular risk for the development of 256
ischaemic heart disease or from sudden death from this condition?’ The rationale behind the use of these two types of questions is that they call for performance similar to that required in clinical practice. In order to make a diagnosis, the student must first formulate diagnostic hypotheses to account for abnormal symptoms, signs and laboratory results. This skill is tested by the first type of question. He must then check whether the rest of the patient’s story matches the features of these hypothetical conditions. To do this, the student must know the clinical picture of these conditions. The second type of question tests the student’s knowledge of these clinical pictures, as well as his knowledge of clinical pharmacology, epidemiology and psychiatry. The ‘long case’ may be a patient with medical and/or surgical problems, or a child, or a patient with psychiatric problems. The student will be asked to list the patient’s problems and to write a plan of action for each active problem outlining: 1. Likely diagnoses and the information needed to confirm or refute each of these. 2. The information he would collect to monitor the patient’s progress. 3. Treatment. 4. Patient education, i.e. his explanation to the patient about his illness. The student will have 20 minutes to formulate these plans before presenting them to the examiners. Laboratory data will be available on request and during the examination the student will be allowed access to a list of normal laboratory values and to the Britbh National Formulary, Mims and the ABPI Datasheet Compendium.
Evaluation It was agreed initially that we should try to evaluate the effectiveness of our new clinical curriculum. Janet Gale, an educational psychologist then with the British Life Assurance Trust Centre for Health and Medical Education, and Liz Wyn Pugh, a gynaecologist and graduate of the Royal Free, were asked to undertake this evaluation. Recently they have been joined by Bo Nemcova, a sociologist. (Generous financial support for this evaluation has been received from the Royal Free Hospital Special Appeal Trustees and the Stanley ThomasJohnson Foundation.) Their method of enquiry has been largely b y interview and discussion with teachers and students. They have enquired into teachers’ and students’ opinions about goals and objectives, about problem orientated medical records and about audit. They have also asked about other methods of teaching and in-course assessment. Further topics have come up spontaneously during the course of the interviews. Space does not permit me to discuss the results of the evaluation in great depth. It would appear that the new curriculum has had an important, but limited, impact on clinical teaching. Many teachers have revised their Medical Teacher Vol 1 No 5 1979
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teaching programme to match the ideas behind the new curriculum while others do what they did before. As expected there have been criticisms of various aspects of the new curriculum, though in general these have been directed not at the basic principles of the new curriculum but at our failure to implement them properly. This failure is due mainly to poor education and to problems of organization and communication. We knew it would be difficult to inform teachers about the new curriculum before it came into effect because it was planned and implemented rapidly. Shortage of administrative staff made it inevitable that there would be problems of organization. But we did not anticipate how difficult it would be to communicate with many teachers. Meetings have been poorly attended and many teachers do not read the documents about the new curriculum which are sent to them. The problems of communication with students have been less serious, though still considerable, because there have been regular meetings with the Clinical Sub-Dean and representatives of students assigned to each post. To try to ensure that staff and students understand the principles underlying the new clinical curriculum we produced a small booklet, Everything You Have Always Wanted to Know About The New Clinical CurriculumBut Were Afraid To Ask! (This booklet and a selfinstructional booklet on the problem orientated medical record were prepared with the assistance of the Medical Sciences Liaison Division of Upjohn Ltd. Copies available on request.) Although this booklet has helped, communication is still a major problem. It seems that someone involved in the organization of the curriculum has to discuss matters personally with each person who needs to be informed. Unfortunately, this is timeconsuming and a great strain on the limited resources available for curriculum planning and implementation. Although there have been many difficulties, we feel that the introduction of the new curriculum has been a moderate success. A number of new ideas have been introduced into a school which previously had a very traditional clinical curritulum. These represent a systematic approach to medical education and we feel that with patience and cooperation, and with the determination of teachers and students to make it succeed, such an approach will lead to a gradual improvement in the quality of our graduates: we hope we will be able to monitor this quality and to continue to improve upon it!
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Barclaycard account for L............. References General Medical Council, Recommendatiom (L( to Basic Medical Education, London, 1967. Petri, J. C. and McIntyre, N., The Problem Orientated Medical Record: Its Use in Hospitals, General Practice and Medical Education, Churchill Livingstone, Edinburgh, London and New York, 1979. Rendall, M., POMR-The Case in Favour, Medical Teacher, 1, 147150.
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