BRITISH MEDICAL JOURNAL
4 OCTOBER 1975
Firstly, there is a need for preventive medicine, which, because there is so much preventable disease in the tropics, requires a large body of people trained in preventive medicine (public health personnel). Secondly, some access to Western medicine is needed in remote villages. This requires men and women trained in family health who can make a few basic decisions such as when a patient should be referred to a larger hospital. A definite programme of training is needed for this and for the medical auxiliary" or "bare foot" doctor.9 The undisputed need for such people in developing countries should not have any affect on the training of a doctor. Lastly, doctors are needed for the diagnosis and treatment of disease. Disease and its complications are the same the world over. Tuberculosis and endocarditis present the same problems in diagnosis and management, carry the same serious prognosis, and have to be managed in exactly the same way in Britain, America, India, or Sri Lanka. The claim1 2 that undergraduate medical training in the developing countries should be altered is probably the result of an inability to recognise the need for these different groups of medical personnel. Attempts to produce one type of medical practitioner who is expected to satisfy these different functions
29
will only result in a lowering of the standards of curative medicine, preventive medicine and family health care. We are grateful to Dr K A Gunawardena and Dr Shanthi Thambipillai, research assistants, who made their data on the inpatient and outpatient studies and their views available to us, and to the Nuffield Foundation, London for a research grant to one of us (BS).
References IFendall, N R E, British Medical_Journal, 1975, 2, 190. 2Waterston, A J R, British Medical Journal, 1975, 2, 190. 3Senewiratne, B, British Medical Journal, 1975, 1, 618. 4World Health Organization: The Selection of Students for Medical Education, Regional Office for Europe, Copenhagen, 1973. 5Wijesinghe, C P, and Zarkovic, G, National Health Manpower Study in the Republic of Sri Lanka. Substudy B, Medical Education, Colombo, Ministry of Health, 1973. Davidson, S, Principles and Practice of Medicine, 8th edn, London, Livingstone, 1967. 7de Silva, W A B, et al, Interim Report on National Health Manpower Study in Republic of Sri Lanka, Colombo, Ministry of Health, 1974. 8Gisch, 0, Lancet, 1973, 1, 1251. 9 Health Care in China, Geneva, Christian Medican Commission, 1974.
Medical Education The Nottingham medical school J S P JONES British
Medical_Journal,
1975, 4, 29-31
An important milestone in British medical education was reached in July 1975, when the first students at the University of Nottingham Medical School graduated with the degrees of Bachelor of Medicine, Bachelor of Surgery. Planning for the first new medical school to be established in the United Kingdom this century was started in 1964, when the University of Nottingham appointed an advisory committee under the chairmanship of Sir George Pickering, FRS, then Regius Professor of Medicine in the University of Oxford. This committee produced their report-a blueprint for medical education of the future-in June 1965. In addition to setting down educational guidelines, the Pickering committee also recommended that a medical centre, consisting of a medical school and university hospital complex, should be sited adjacent to the existing university campus. Professor A D M Greenfield was appointed dean of the medical school in June 1966, and he brought together a team of professors and academic staff in the basic medical sciences and clinical subjects. This group, together with a newly created administrative and planning team, had the task of translating the Pickering concepts into reality. Coincidentally with the curriculum planning, the architects-Building Design Partner-
ship-drew up a design for the buildings to house the medical school and university hospital. They worked in conjunction with a planning team responsible to a local joint committee, which consisted of representatives of the University of Nottingham and the then Sheffield Regional Hospital Board. The first stage of the new medical school buildings comes into use this autumn, and in the meantime much of the medical school has been temporarily housed in new buildings on the university campus. Because of delays in the building programme the clinical undergraduate training to date has been provided entirely at the existing Nottingham hospitals, mainly at the City and General Hospitals. The Children's Hospital and Mapperley Hospital have been used for child health and psychiatric training respectively. The new University Hospital will open in phases over the next few years and will play an increasing, and eventually a major, role in clinical teaching as the student intake increases from the present 48 admitted each year up to 1974 to the 160, or even 192, expected at the turn of the decade.
The curriculum The first and second years of the five-year course consist of a basic medical sciences course, the third year of a special medical sciences course, and the fourth and fifth years of a clinical course.
BASIC MEDICAL SCIENCES COURSE
University of Nottingham Medical School, Nottingham NG7 2UH J S P JONES, MD, MRC PATH, Clinical Subdean
The two-vear basic course has been designed to encourage good habits of learning, to lead to a familiarity with the broad field of medical science, and to extend the student's curiosity. We hope that the
30 necessity of acquiring an excessive and unnecessary amount of factual information has been avoided. Students are shown how to apply scientific method to medicine, but they are also encouraged from the outset to develop a humane and sympathetic approach to patients and their problems. Initiation Course-In his first two weeks in the medical school the student views the whole range of medical care so that he may put the medical sciences course into perspective. Visits are arranged to general practitioners' surgeries, health centres, and patients in hospital. Lectures are given on such subjects as medical ethics and the organization of health care.
Basic medical sciences The basic medical sciences are taught mainly by the departments of biochemistry, human morphology, physiology with pharmacology, community health, psychiatry, and pathology. The two-year course consists of a series of joint programmes under three main themes(a) the cell, (b) man, and (c) the community-which aim to provide the student with an understanding of the structure and function of man, his response to the treatment of disease, his place in the community, his growth, development, behaviour, and emotions, and his response to the many forms of environmental stress. The relevance of the basic medical sciences course to clinical practice has been emphasized by introducing clinical and pathological aspects of the three themes at an early stage. The two main components of the behavioural sciences are taught by the department of community health (principles of epidemiology and medical demography, health education, and the sociology of medicine) and the department of psychiatry (the medical relevance of social and developmental psychology with some aspects of social anthropology and ethology). Teaching in pathology starts formally at the beginning of the second year, and with that of the departments of community health and psychiatry continues throughout the science and clinical courses. Close integration between the basic medical sciences and clinical subjects is encouraged; some examples are given below. During the first year the department of community health and the department of obstetrics and gynaecology run joint seminars on the problems of population control, including specific teaching on contraceptive methods. The second-year course on human reproduction is organized by the departments of human morphology and physiology, but the departments of biochemistry, obstetrics and gynaecology, paediatrics, psychiatry, and genetics all participate. The clinical relevance of surface and radiological anatomy is emphasized in the teaching of the department of human morphology. An introduction to the examination of the central nervous system is taught together with neuroanatomy. The physiology and pharmacology of the heart and blood vessels are linked up with the relevance to clinical investigations, as are the physiological tests of respiratory function. The student is introduced to the vocabulary of pathology by regular demonstrations, which may be attended during the first year, though the formal course does not start until the second year. Assessment-The system of intermittent assessment throughout the course has been designed to reward steady effort and to enable students to judge their own progress. The assessments relate to the three themes rather than to individual disciplines, and the results are cumulative. The methods of assessment range from short essays and viva-voce examinations to computer-marked "yes/no" questions.
BRITISH MEDICAL JOURNAL
4 OCTOBER 1975
CLINICAL COURSE
The 26-month clinical course, which encroaches on the last part of the third year, builds on the habits and methods acquired during the previous three years. The traditional practice of clinical "clerking" forms the foundation of acquisition of experience in taking histories and eliciting and interpreting physical signs. Each firm is made up of students who have studied different subjects in the honours year, so that each can contribute a special interest to the group. The outline of the clinical course is shown in the table. A two-week introductory course allows the students to settle into hospital life and be initiated in taking histories and examining patients. Structure of clinical course at Nottingham. Dates are those of first (1970) student entry Subject April 1973 November 1973 "The middle year"
November 1974 May 1975
July
1975
Length of Attachment
2 Introductory course 3 Junior medicine/surgery Part I examination 2 Obstetrics and gynaecology 2 Child health Part II examination 2 Psychiatry Anaesthetics, orthopaedic and 2 accident surgery, rheumatology Dermatology, ophthalmology, 2 otolaryngology 1 General practice 1 Elective 3 Senior medicine/surgery Part III examination 2 Additional hospital practice Part IV examination
weeks months each months months months
months months month month months each
months
Because of the geographical distribution of special units in Nottingham students undertake certain subjects in addition to general medicine and surgery. Thus, those at the City Hospital study chest medicine and surgery, geriatrics, plastic surgery, and urology, while those at the General Hospital study neurology, vascular surgery, and venereology. Each student spends a surgical and medical attachment (either junior or senior) at each hospital, so that all specialties are covered.
Jfunior medicine and surgery The main emphasis in junior medicine and junior surgery is placed on ward teaching, and students also attend small group seminars and central integrated teaching sessions. Pathology and community health form bridging disciplines throughout the course. Psychological aspects and psychiatric complications of medical and surgical conditions are discussed in small groups and the problems of communication and interviewing techniques are dealt with by the department of psychiatry. A particular feature of the course is the follow-up of patients after discharge by the students, under the supervision of the department of community health. In collaboration with the general practitioner the student visits the patient to observe the progress of the condition and is made aware of the effect of home and social background on convalescence, the importance of support from other professions, and the place of rehabilitation in training for alternative work. "The middle year"
SPECIAL MEDICAL SCIENCES COURSE
Because of the wide range of subject matter to be covered in the first two years there is only limited opportunity to dwell on any particular subject in depth. In Nottingham, therefore, each student spends nearly three terms pursuing a single basic medical science discipline. This course also allows him to make a critical study of principles, develop independence and precision of thought, and work closely with the staff of a department. Project work often involves members of clinical departments in hospital and general practices, as well as members of the basic medical sciences departments. The students provide a useful link between the personnel of several disciplines. This phase of the course provides a special and valuable opportunity for individual development. At the end of this year the students are awarded the degree of Bachelor of Medical Sciences (B Med Sci) with Honours.
The students, arranged in six groups, rotate through a succession of two-month attachments. While much of the teaching follows traditional lines the combined four-month course in obstetrics, gynaecology, and child health has several interesting features. Obstetrics and gynaecology-In addition to ward work students attend obstetric and gynaecology clinics, operating sessions, and family planning clinics. Beyond this point the pattern of teaching diverges from the traditional. A formal lecture course is replaced by a series of 25 slide-tape programmes with a printed protocol for each subject. Students make full use of teaching machines which are available during the eight-week residential attachment. Tutorials are given on pain relief in labour, radiology and ultrasonography, and the management and counselling of patients with sexual disorders. Child health-As well as acquiring the skills to approach and examine healthy and sick babies, infants, and children, students are
BRITISH MEDICAL JOURNAL
4 OCTOBER 1975
given lectures and seminars on medical problems in childhood and on the practice and responsibilities of the various branches of the health, social, and educational services concerned in the care of sick and handicapped children. A series of teaching packages is available for students on the child health attachment. A particular feature of the training at Nottingham is a combined course in the departments of obstetrics and child health on perinatal care. This course is held one afternoon a week during the four months' combined attachment. Psychiatry-At present based at Mapperley Hospital, the full-time clerkship includes half a day a week studying child psychiatry. Lectures and discussions make frequent use of videotape and closed-circuit television for students to study their own interviewing skills. Anaesthetics, orthopaedic and accident surgery, and rheumatology -Apart from attending the orthopaedic and fracture clinics and wards, students spend time "on call" in the accident department, in the intensive care unit, and on anaesthetic attachment. A course in bone and joint pathology is given, relevant to the clinical aspects of rheumatology and orthopaedics currently being studied. "Specials"-Students rotate through the outpatient clinics in dermatology, ophthalmology, and otolaryngology. Particular attention is paid to the way that diseases encountered in these disciplines can be part of more generalized illness. General practice-The practitioners to whom the students are attached have their surgeries in various districts of Nottingham, and they are also part-time lecturers in the department of community health. The students have an opportunity to see health care in the community, which helps to bring together domiciliary and hospital medicine. Elective-Students may pursue an approved subject of their own choice and are encouraged to work at a centre away from Nottingham to gain experience from different teachers in different surroundings.
31
Long-term assessments over the course are also made by the departments of community health and pathology. Formal tests of factual knowledge are based on multidiscipline multiple-choice question papers supplemented by problem-solving exercises, which present clinical situations requiring answers related to diagnosis, investigation, and management of clinical problems. The assessment system has so far shown a high degree of correlation between the different methods of evaluation and there has also been great consistency between the results of the clinical and basic medical science assessments.
Support for the future There are many problems involved in starting a new medical school, but the task has been made much easier by the immense goodwill of the University of Nottingham and by the help of the medical, nursing, and ancilliary professions and the hospital administrations at district, area, and regional level. Altogether 150 members of the hospitals' consultant staff have been appointed clinical teachers to the medical school, and their wholehearted involvement in teaching has greatly helped the integration of the school into Nottingham medicine. Much interest and goodwill has been expressed by the population of Nottingham and by local industry. These expressions of help and goodwill greatly encourage all those who are responsible for the future of the medical school.
Senior medicinie and surgery
While the first six months of the clinical course is directed towards acquiring skills in basic clinical techniques and a working knowledge of common disorders, the students on the senior attachments concentrate on the practical application of those skills and knowledge. Therapeutics and the management of patients are emphasized. The regular tutorials on psychological aspects and psychiatric complications of physical disorders continue. During senior surgery each student spends one week at the Derbyshire Royal Infirmary attached to the neurosurgery unit. Throughout the clinical course various aspects of community health, forensic medicine, pathology, and radiology are taught at the appropriate time.
Additional hospital practice
If a student's standard of work throughout the course has been satisfactory this final period may be used to pursue an approved clinical subject in a hospital in one of the cities or towns near Nottingham (Boston, Burton, Derby, Hull, Leicester, Lincoln, Mansfield, Stafford, Stoke). This attachment provides a short but valuable apprenticeship for the senior students before they take on the responsibilities of a preregistration house appointment. For those students who have had one unsatisfactory clinical attachment this period gives them the opportunity to repeat the weak subject, and if they redeem their weakness they may qualify without prolonging their course.
Assessments on clinical course Assessment is based on continuous subjective evaluation of each student plus intermittent tests of factual knowledge. The intention is to "defuse" the traditional style of final examination, but the onus is on the student to work consistently throughout the course. Continuous assessment also makes extra demands on the teaching and administrative staff, but the advantages of the system are considerable. At the end of each of the 12 clinical attachments a student evaluation report is completed by the teaching staff (who are encouraged to discuss the students' progress with members of the clinical team). The students are assessed on clinical skills, knowledge of subject, attitudes and ability to relate to patients, and attendance. In medicine and surgery an independent assessment of the student is also made by another clinical firm, based on a case presentation.
Are French cigarettes less
harm4ful to health than English cigarettes ?
Traditional French cigarettes contain fermented air-cured tobacco and give rise to a neutral or slightly alkaline smoke which becomes more alkaline as they burn down. English cigarettes are made of fluecured tobacco and give rise to acidic smoke. Nicotine is present as a free base in alkaline smoke and as such can be absorbed through the epithelium of the mouth and upper respiratory tract. The nicotine in acidic smoke is present in conjugated form which is not easily absorbed unless the smoke is taken into the lungs. Fewer French cigarette smokers claim to inhale than their English counterparts. It is arguable whether this is because they can obtain nicotine without inhaling the smoke or because the alkaline smoke of French cigarettes is more difficult to inhale. Cigarette smoking is associated mainly with three diseases: lung cancer; chronic bronchitis and emphysema; and coronary heart disease, and to a lesser extent with other diseases including cancers of the mouth and larynx. For cancers of the three sites mentioned and for chronic lung disease the association is only evident after many years' smoking. In France mortality from lung cancer in men is less than half that in England and Wales but mortality from oral and laryngeal cancers in men is over four times greater. It is not clear to what extents these differences reflect differences in inhaling habits, tobacco consumption during the 30-40 years before 1972, and differences in exposure to other factors such as alcohol. The Hunter Committee has recently recommended the use of a mouse-skin bioassay for comparing smoke condensates for carcinogenicity. There is no published report of a comparison of condensates prepared from typical English and French cigarettes for specific carcinogenic activity for mouse skin using the test procedures recommended by that committee. One comparison of condensates derived from air-cured and flue-cured samples of the same tobacco provided no clear indication that, after a difference in yield of condensate per cigarette had been taken into account, either curing process was to be preferred. There is no reliable information that would enable one to compare French and English cigarettes regarding their effects on the incidence of chronic bronchitis, emphysema, or cardiovascular disease. If nicotine or carbon monoxide, or both, are implicated in the effects of smoking on the incidence of cardiovascular disease, the risks would vary for different brands of cigarette, whether they are English or French, according to the concentrations of these substances in the smoke. In summary, there is no clear evidence that traditional French cigarettes are safer than British cigarettes or vice versa in terms of risk of any particular smoking-associated disease.
4 OCTOBER 1975
Firstly, there is a need for preventive medicine, which, because there is so much preventable disease in the tropics, requires a large body of people trained in preventive medicine (public health personnel). Secondly, some access to Western medicine is needed in remote villages. This requires men and women trained in family health who can make a few basic decisions such as when a patient should be referred to a larger hospital. A definite programme of training is needed for this and for the medical auxiliary" or "bare foot" doctor.9 The undisputed need for such people in developing countries should not have any affect on the training of a doctor. Lastly, doctors are needed for the diagnosis and treatment of disease. Disease and its complications are the same the world over. Tuberculosis and endocarditis present the same problems in diagnosis and management, carry the same serious prognosis, and have to be managed in exactly the same way in Britain, America, India, or Sri Lanka. The claim1 2 that undergraduate medical training in the developing countries should be altered is probably the result of an inability to recognise the need for these different groups of medical personnel. Attempts to produce one type of medical practitioner who is expected to satisfy these different functions
29
will only result in a lowering of the standards of curative medicine, preventive medicine and family health care. We are grateful to Dr K A Gunawardena and Dr Shanthi Thambipillai, research assistants, who made their data on the inpatient and outpatient studies and their views available to us, and to the Nuffield Foundation, London for a research grant to one of us (BS).
References IFendall, N R E, British Medical_Journal, 1975, 2, 190. 2Waterston, A J R, British Medical Journal, 1975, 2, 190. 3Senewiratne, B, British Medical Journal, 1975, 1, 618. 4World Health Organization: The Selection of Students for Medical Education, Regional Office for Europe, Copenhagen, 1973. 5Wijesinghe, C P, and Zarkovic, G, National Health Manpower Study in the Republic of Sri Lanka. Substudy B, Medical Education, Colombo, Ministry of Health, 1973. Davidson, S, Principles and Practice of Medicine, 8th edn, London, Livingstone, 1967. 7de Silva, W A B, et al, Interim Report on National Health Manpower Study in Republic of Sri Lanka, Colombo, Ministry of Health, 1974. 8Gisch, 0, Lancet, 1973, 1, 1251. 9 Health Care in China, Geneva, Christian Medican Commission, 1974.
Medical Education The Nottingham medical school J S P JONES British
Medical_Journal,
1975, 4, 29-31
An important milestone in British medical education was reached in July 1975, when the first students at the University of Nottingham Medical School graduated with the degrees of Bachelor of Medicine, Bachelor of Surgery. Planning for the first new medical school to be established in the United Kingdom this century was started in 1964, when the University of Nottingham appointed an advisory committee under the chairmanship of Sir George Pickering, FRS, then Regius Professor of Medicine in the University of Oxford. This committee produced their report-a blueprint for medical education of the future-in June 1965. In addition to setting down educational guidelines, the Pickering committee also recommended that a medical centre, consisting of a medical school and university hospital complex, should be sited adjacent to the existing university campus. Professor A D M Greenfield was appointed dean of the medical school in June 1966, and he brought together a team of professors and academic staff in the basic medical sciences and clinical subjects. This group, together with a newly created administrative and planning team, had the task of translating the Pickering concepts into reality. Coincidentally with the curriculum planning, the architects-Building Design Partner-
ship-drew up a design for the buildings to house the medical school and university hospital. They worked in conjunction with a planning team responsible to a local joint committee, which consisted of representatives of the University of Nottingham and the then Sheffield Regional Hospital Board. The first stage of the new medical school buildings comes into use this autumn, and in the meantime much of the medical school has been temporarily housed in new buildings on the university campus. Because of delays in the building programme the clinical undergraduate training to date has been provided entirely at the existing Nottingham hospitals, mainly at the City and General Hospitals. The Children's Hospital and Mapperley Hospital have been used for child health and psychiatric training respectively. The new University Hospital will open in phases over the next few years and will play an increasing, and eventually a major, role in clinical teaching as the student intake increases from the present 48 admitted each year up to 1974 to the 160, or even 192, expected at the turn of the decade.
The curriculum The first and second years of the five-year course consist of a basic medical sciences course, the third year of a special medical sciences course, and the fourth and fifth years of a clinical course.
BASIC MEDICAL SCIENCES COURSE
University of Nottingham Medical School, Nottingham NG7 2UH J S P JONES, MD, MRC PATH, Clinical Subdean
The two-vear basic course has been designed to encourage good habits of learning, to lead to a familiarity with the broad field of medical science, and to extend the student's curiosity. We hope that the
30 necessity of acquiring an excessive and unnecessary amount of factual information has been avoided. Students are shown how to apply scientific method to medicine, but they are also encouraged from the outset to develop a humane and sympathetic approach to patients and their problems. Initiation Course-In his first two weeks in the medical school the student views the whole range of medical care so that he may put the medical sciences course into perspective. Visits are arranged to general practitioners' surgeries, health centres, and patients in hospital. Lectures are given on such subjects as medical ethics and the organization of health care.
Basic medical sciences The basic medical sciences are taught mainly by the departments of biochemistry, human morphology, physiology with pharmacology, community health, psychiatry, and pathology. The two-year course consists of a series of joint programmes under three main themes(a) the cell, (b) man, and (c) the community-which aim to provide the student with an understanding of the structure and function of man, his response to the treatment of disease, his place in the community, his growth, development, behaviour, and emotions, and his response to the many forms of environmental stress. The relevance of the basic medical sciences course to clinical practice has been emphasized by introducing clinical and pathological aspects of the three themes at an early stage. The two main components of the behavioural sciences are taught by the department of community health (principles of epidemiology and medical demography, health education, and the sociology of medicine) and the department of psychiatry (the medical relevance of social and developmental psychology with some aspects of social anthropology and ethology). Teaching in pathology starts formally at the beginning of the second year, and with that of the departments of community health and psychiatry continues throughout the science and clinical courses. Close integration between the basic medical sciences and clinical subjects is encouraged; some examples are given below. During the first year the department of community health and the department of obstetrics and gynaecology run joint seminars on the problems of population control, including specific teaching on contraceptive methods. The second-year course on human reproduction is organized by the departments of human morphology and physiology, but the departments of biochemistry, obstetrics and gynaecology, paediatrics, psychiatry, and genetics all participate. The clinical relevance of surface and radiological anatomy is emphasized in the teaching of the department of human morphology. An introduction to the examination of the central nervous system is taught together with neuroanatomy. The physiology and pharmacology of the heart and blood vessels are linked up with the relevance to clinical investigations, as are the physiological tests of respiratory function. The student is introduced to the vocabulary of pathology by regular demonstrations, which may be attended during the first year, though the formal course does not start until the second year. Assessment-The system of intermittent assessment throughout the course has been designed to reward steady effort and to enable students to judge their own progress. The assessments relate to the three themes rather than to individual disciplines, and the results are cumulative. The methods of assessment range from short essays and viva-voce examinations to computer-marked "yes/no" questions.
BRITISH MEDICAL JOURNAL
4 OCTOBER 1975
CLINICAL COURSE
The 26-month clinical course, which encroaches on the last part of the third year, builds on the habits and methods acquired during the previous three years. The traditional practice of clinical "clerking" forms the foundation of acquisition of experience in taking histories and eliciting and interpreting physical signs. Each firm is made up of students who have studied different subjects in the honours year, so that each can contribute a special interest to the group. The outline of the clinical course is shown in the table. A two-week introductory course allows the students to settle into hospital life and be initiated in taking histories and examining patients. Structure of clinical course at Nottingham. Dates are those of first (1970) student entry Subject April 1973 November 1973 "The middle year"
November 1974 May 1975
July
1975
Length of Attachment
2 Introductory course 3 Junior medicine/surgery Part I examination 2 Obstetrics and gynaecology 2 Child health Part II examination 2 Psychiatry Anaesthetics, orthopaedic and 2 accident surgery, rheumatology Dermatology, ophthalmology, 2 otolaryngology 1 General practice 1 Elective 3 Senior medicine/surgery Part III examination 2 Additional hospital practice Part IV examination
weeks months each months months months
months months month month months each
months
Because of the geographical distribution of special units in Nottingham students undertake certain subjects in addition to general medicine and surgery. Thus, those at the City Hospital study chest medicine and surgery, geriatrics, plastic surgery, and urology, while those at the General Hospital study neurology, vascular surgery, and venereology. Each student spends a surgical and medical attachment (either junior or senior) at each hospital, so that all specialties are covered.
Jfunior medicine and surgery The main emphasis in junior medicine and junior surgery is placed on ward teaching, and students also attend small group seminars and central integrated teaching sessions. Pathology and community health form bridging disciplines throughout the course. Psychological aspects and psychiatric complications of medical and surgical conditions are discussed in small groups and the problems of communication and interviewing techniques are dealt with by the department of psychiatry. A particular feature of the course is the follow-up of patients after discharge by the students, under the supervision of the department of community health. In collaboration with the general practitioner the student visits the patient to observe the progress of the condition and is made aware of the effect of home and social background on convalescence, the importance of support from other professions, and the place of rehabilitation in training for alternative work. "The middle year"
SPECIAL MEDICAL SCIENCES COURSE
Because of the wide range of subject matter to be covered in the first two years there is only limited opportunity to dwell on any particular subject in depth. In Nottingham, therefore, each student spends nearly three terms pursuing a single basic medical science discipline. This course also allows him to make a critical study of principles, develop independence and precision of thought, and work closely with the staff of a department. Project work often involves members of clinical departments in hospital and general practices, as well as members of the basic medical sciences departments. The students provide a useful link between the personnel of several disciplines. This phase of the course provides a special and valuable opportunity for individual development. At the end of this year the students are awarded the degree of Bachelor of Medical Sciences (B Med Sci) with Honours.
The students, arranged in six groups, rotate through a succession of two-month attachments. While much of the teaching follows traditional lines the combined four-month course in obstetrics, gynaecology, and child health has several interesting features. Obstetrics and gynaecology-In addition to ward work students attend obstetric and gynaecology clinics, operating sessions, and family planning clinics. Beyond this point the pattern of teaching diverges from the traditional. A formal lecture course is replaced by a series of 25 slide-tape programmes with a printed protocol for each subject. Students make full use of teaching machines which are available during the eight-week residential attachment. Tutorials are given on pain relief in labour, radiology and ultrasonography, and the management and counselling of patients with sexual disorders. Child health-As well as acquiring the skills to approach and examine healthy and sick babies, infants, and children, students are
BRITISH MEDICAL JOURNAL
4 OCTOBER 1975
given lectures and seminars on medical problems in childhood and on the practice and responsibilities of the various branches of the health, social, and educational services concerned in the care of sick and handicapped children. A series of teaching packages is available for students on the child health attachment. A particular feature of the training at Nottingham is a combined course in the departments of obstetrics and child health on perinatal care. This course is held one afternoon a week during the four months' combined attachment. Psychiatry-At present based at Mapperley Hospital, the full-time clerkship includes half a day a week studying child psychiatry. Lectures and discussions make frequent use of videotape and closed-circuit television for students to study their own interviewing skills. Anaesthetics, orthopaedic and accident surgery, and rheumatology -Apart from attending the orthopaedic and fracture clinics and wards, students spend time "on call" in the accident department, in the intensive care unit, and on anaesthetic attachment. A course in bone and joint pathology is given, relevant to the clinical aspects of rheumatology and orthopaedics currently being studied. "Specials"-Students rotate through the outpatient clinics in dermatology, ophthalmology, and otolaryngology. Particular attention is paid to the way that diseases encountered in these disciplines can be part of more generalized illness. General practice-The practitioners to whom the students are attached have their surgeries in various districts of Nottingham, and they are also part-time lecturers in the department of community health. The students have an opportunity to see health care in the community, which helps to bring together domiciliary and hospital medicine. Elective-Students may pursue an approved subject of their own choice and are encouraged to work at a centre away from Nottingham to gain experience from different teachers in different surroundings.
31
Long-term assessments over the course are also made by the departments of community health and pathology. Formal tests of factual knowledge are based on multidiscipline multiple-choice question papers supplemented by problem-solving exercises, which present clinical situations requiring answers related to diagnosis, investigation, and management of clinical problems. The assessment system has so far shown a high degree of correlation between the different methods of evaluation and there has also been great consistency between the results of the clinical and basic medical science assessments.
Support for the future There are many problems involved in starting a new medical school, but the task has been made much easier by the immense goodwill of the University of Nottingham and by the help of the medical, nursing, and ancilliary professions and the hospital administrations at district, area, and regional level. Altogether 150 members of the hospitals' consultant staff have been appointed clinical teachers to the medical school, and their wholehearted involvement in teaching has greatly helped the integration of the school into Nottingham medicine. Much interest and goodwill has been expressed by the population of Nottingham and by local industry. These expressions of help and goodwill greatly encourage all those who are responsible for the future of the medical school.
Senior medicinie and surgery
While the first six months of the clinical course is directed towards acquiring skills in basic clinical techniques and a working knowledge of common disorders, the students on the senior attachments concentrate on the practical application of those skills and knowledge. Therapeutics and the management of patients are emphasized. The regular tutorials on psychological aspects and psychiatric complications of physical disorders continue. During senior surgery each student spends one week at the Derbyshire Royal Infirmary attached to the neurosurgery unit. Throughout the clinical course various aspects of community health, forensic medicine, pathology, and radiology are taught at the appropriate time.
Additional hospital practice
If a student's standard of work throughout the course has been satisfactory this final period may be used to pursue an approved clinical subject in a hospital in one of the cities or towns near Nottingham (Boston, Burton, Derby, Hull, Leicester, Lincoln, Mansfield, Stafford, Stoke). This attachment provides a short but valuable apprenticeship for the senior students before they take on the responsibilities of a preregistration house appointment. For those students who have had one unsatisfactory clinical attachment this period gives them the opportunity to repeat the weak subject, and if they redeem their weakness they may qualify without prolonging their course.
Assessments on clinical course Assessment is based on continuous subjective evaluation of each student plus intermittent tests of factual knowledge. The intention is to "defuse" the traditional style of final examination, but the onus is on the student to work consistently throughout the course. Continuous assessment also makes extra demands on the teaching and administrative staff, but the advantages of the system are considerable. At the end of each of the 12 clinical attachments a student evaluation report is completed by the teaching staff (who are encouraged to discuss the students' progress with members of the clinical team). The students are assessed on clinical skills, knowledge of subject, attitudes and ability to relate to patients, and attendance. In medicine and surgery an independent assessment of the student is also made by another clinical firm, based on a case presentation.
Are French cigarettes less
harm4ful to health than English cigarettes ?
Traditional French cigarettes contain fermented air-cured tobacco and give rise to a neutral or slightly alkaline smoke which becomes more alkaline as they burn down. English cigarettes are made of fluecured tobacco and give rise to acidic smoke. Nicotine is present as a free base in alkaline smoke and as such can be absorbed through the epithelium of the mouth and upper respiratory tract. The nicotine in acidic smoke is present in conjugated form which is not easily absorbed unless the smoke is taken into the lungs. Fewer French cigarette smokers claim to inhale than their English counterparts. It is arguable whether this is because they can obtain nicotine without inhaling the smoke or because the alkaline smoke of French cigarettes is more difficult to inhale. Cigarette smoking is associated mainly with three diseases: lung cancer; chronic bronchitis and emphysema; and coronary heart disease, and to a lesser extent with other diseases including cancers of the mouth and larynx. For cancers of the three sites mentioned and for chronic lung disease the association is only evident after many years' smoking. In France mortality from lung cancer in men is less than half that in England and Wales but mortality from oral and laryngeal cancers in men is over four times greater. It is not clear to what extents these differences reflect differences in inhaling habits, tobacco consumption during the 30-40 years before 1972, and differences in exposure to other factors such as alcohol. The Hunter Committee has recently recommended the use of a mouse-skin bioassay for comparing smoke condensates for carcinogenicity. There is no published report of a comparison of condensates prepared from typical English and French cigarettes for specific carcinogenic activity for mouse skin using the test procedures recommended by that committee. One comparison of condensates derived from air-cured and flue-cured samples of the same tobacco provided no clear indication that, after a difference in yield of condensate per cigarette had been taken into account, either curing process was to be preferred. There is no reliable information that would enable one to compare French and English cigarettes regarding their effects on the incidence of chronic bronchitis, emphysema, or cardiovascular disease. If nicotine or carbon monoxide, or both, are implicated in the effects of smoking on the incidence of cardiovascular disease, the risks would vary for different brands of cigarette, whether they are English or French, according to the concentrations of these substances in the smoke. In summary, there is no clear evidence that traditional French cigarettes are safer than British cigarettes or vice versa in terms of risk of any particular smoking-associated disease.
