N. A. Jafarey ( Department of Pathology, Basic Medical Sciences Institute, Jinnah Postgraduate Medical Centre, Karachi. )
Before priorities can be assigned to different aspects of medical education it is necessary to first list what medical education is supposed to accomplish. Education is planned change in behaviour. Medical education should therefore bring about in the fresh entrant such improvements and modifications as will make him or her capable of performing the desired functions at the end of their stay in the College.
What are the desired functions which we wish the graduate to perform ? There will be no dispute about the answer to this question, ‘the graduate should be able to provide health care to the population’.
The problem arises in translating this into action. First of all we have to define what is health care ? Is it restricted to those who are ill and seek the services or should it cover the entire population, both ill and healthy at the moment ? Secondly, the list of all the attitudes, skills and knowledge required to provide health care to the community- the ultimate consumers-is formidable. No one individual can single handedly provide all the services required; medical science has become too big ‘for anyone to master it all. Health care can only be provided by a team-consisting of various categories of medical as well as paramedical personnel. The different categories of medical manpower that are needed includes amongst others Family Physicians, Medical Officers, Administrators, Consultants and Teachers. The job requirement and expertise required by each of the major categories is widely different. A single educational programme cannot provide all the categories of medical personnel needed by the community. The answer that has been found is to divide the training programme into two parts one which is common to all categories. of medical manpower and the other specially designed for the particular speciality i.e., Family Medicine, Administration etc.
The immediate concern of medical education is to define the attitudes, skills and knowledge that all categories of medical manpower should have. That becomes the undergraduate curriculum. A point to note is that a very large part of the list will be relevant throughout the world but parts wifi be relevant for specific communities since their health needs are different. An specific example would be that for Sind Snake bites are an important health problem, when the health problems of travel in outer space are not of immediate importance in Pakistan. The undergraduate curriculum therefore has to be designed to meet the needs of the population that the graduates of that College are expected to serve. There is no standard ready to use curriculum that can be adopted in toto. Again as the health needs change with time the curriculum needs to be reviewed continuously.
The undergraduate curriculum then is that subset Of the complete list of all the attitudes, skills and knowledge needed to provide comprehensive health care to the entire population of a community or country. Such a curriculum usually means introduction to the fundamentals-structure and function of the human body, factors which adversely affect it and the changes brought in thereby, how to prevent these adverse changes and lastly how to cure them. Details required by different specialities are covered in the postgraduate training programme. This is the point which is usually least understood by advocates of different specialities. For them the inclusion of their own speciality particularly in the examination has become a prestige issue. The only reason for inclusion in the curriculum of anything should be its relevance for the majority of the students.
An undergraduate curriculum confined to what is relevant to all categories of medical person: nel is likely to be shorter than the present course in Pakistan. The major drawback of such a curriculum is that the graduate is not fit to join the health services immediately. All graduates of such a programme need postgraduate training in the speciality of their choice before they become useful to the community. In fact the present house jobs are a step in that direction for those who wish to specialize in hospital based work. It is largely irrelevant to those wishing to work Outside the hospital set-up.
An alternate strategy for undergraduate curriculum is to determine which category of medical worker is needed most by the health services of the country and then design the under. graduate curriculum to produce that category. Other categories of medical manpower can then do the remaining training in their speciality programme. If this strategy is adopted then the graduate is ready to enter the health services right away. If this strategy is chosen for Pakistan at this moment then the category of medical person most required is a Family Physician/Primary Care Physician. In this case the undergraduate medical curriculum in Pakistan should be designed to produce Primary Care Physicians. As a matter of fact this is what the preamble of the PMDC describes, but then the PMDC document fails in converting it to defined instructional objectives.
An important issue facing medical education is the rapid expansion of medical sciences. Firstly it has made it impossible for anyone to master everything, which problem has been solved by development of specialization and postgraduate training. The implications of this have already been discussed earlier. The second impact has been brought about by better understanding of the causes of diseases. Once we learn the cause of the disease we can plan its prevention. This has led to a change in emphasis from curative to preventive, from Medicine to Health. The task expected from the profession is to keep the people healthy not just cure the ill. In Pakistan both the undergraduate as well as postgraduate education has failed to take note of this change. It is stifi preoccupied with hospital based medicine. Around the world many new teaching institutions are being called Health Sciences Colleges and not Medical Colleges. The third major influence of expanding knowledge is that many of the things which are taught today, will in the next 5 to 10 years become obsolete and often wrong. Our present reliance on facts and note learning is totally misplaced. It is at times dangerous. What can be dOne to solve this problem ? One thing is to develop Continuing Education Programmes, but such programmes can only be developed for those who are interested in continuing their own education. One of the prime objectives of education in any scientific discipline particularly Medicine should be to train its disciples to be life long self learners. Our present educational methods specially examinations are not designed to stimulate critical self learning. They are only emphasising on memmorization of facts which is dangerous.
Lastly attention needs to be drawn to perhaps the most difficult of all the problems that confront medical education. How to inculcate the required attitudes? Imparting Knowledge as part of the curriculum is the easiest thing to do. Lectures, notes and textbooks do the job adequately. Training of skills is harder as it involves personal contact and supervision. The present programmes provide some opportunities to learn skills. They may not be completely satisfactory nevertheless attempts are made to teach the skills. What is left by default is teaching of attitudes. Yet the public who is the ultimate consumer of our services and pays for it in one form or other, mostly judges us by our attitudes. There is no ready made formula for solving this problem.
To sum up, what has been done is to high. light some ground rules and guiding principles which are essential for designing a programme of medical education. Without such guiding principles medical education is a hit and miss proposition and not a carefully thought of planned activity, which is what it should be. This then is the priority for Medical Education in Pakistan. It is recommended that the PMDC which is the statutary body responsible for the quality medical education should examine the entire process of medical education keeping in view the health needs of the people and principles of education.