Naeem A. Jafarey ( Dept. of Pathology,Basic Medical Sciences Institute, Jinnah Postgraduate Medical Centre, Karachi. )
Everyone is acutely aware of the explosion of new information (facts, concepts and techniques) that has taken place in the last few decades. All indications are that far from decreasing the pace of new information is likely to grow at faster and faster speed. This mounting burden of new information is leading to fundamental changes in the traditional concepts of medical practice and medical education. Some of these changes are well appreciated but some others have not drawn the attention of the profession in Pakistan.
The change that is most readily appreciated by the profession is that now it is impossible to keep up with new developments even in one chosen speciality. And yet, we must. This is a problem for which a solution has to be found. So far the medical education system has ignored this.
Another change brought about by new developments is the emergence of new specialities, often called as sub-specialities but the better term for them would be super specialities. This too is a trend which is likely to continue. This increase in the number of specialities has greatly influenced the nature of medical practice both in the hospital and in private practice-a fact which is well recognized. Its impact on Medical Education has however not been given much consideration.
For the undergraduate education it means that you can not teach everything, the programme just can not accommodate all specialities. It is unfortunate that some speciality groups have made this a prestige issue. They want the undergraduate programme to include their speciality. They also demand that they must be made an Examiner as well.
The repercussion of the emergence of newer specialities on the patients is also very far reaching and needs the urgent attention of the profession. Firstly, it has greatly increased the cost of treatment. Secondly, the patient confused and unhappy at being made to go from one physician to another. It is also dehumanizing. Instead of an entire individual he is being treated as a collection of parts.
What can we do to meet the challenges outlined above? Here I will only touch upon some of the issues where I believe the Medical Educators have to play the lead role.
The most important issue and which needs the most urgent attention of Medical Educators is that of the Curriculum. As it is impossible to teach everything, the selection of what is included and what left out should be made with due consideration and on rational rather than emotional grounds.
Before this question can be answered, the leaders of the community and the profession have to decide what should the undergraduate programme produce or what are the skills which we want the fresh graduate to have? The basic options are two. The first is to produce a graduate who is not capable of any independent professional work without further training in one of the specialities. The second is to pick up one speciality which is most needed and to tailor make the curriculum to produce them. Those wishing to take up other specialities then do so after graduation or in the final year of the undergraduate programme. Since the bulk of any graduating class wifi eventually specialize in Family Medicine this could form the basis of the undergraduate curriculum.
Both the options have some advantages and some disadvantages and the final decision to go for the one or the other should be made after a systematic and careful study. Decisions should not be made arbitrarily or on the whims of those in positions of control or defered in the hope that time will solve the issue. Much of the present mess in Medical Education is due to the fact that none of the regulatory agencies want to make the difficult decisions. Status quo is so much an easier decision to make.
Another important consideration for the Educators is the need for expansion of postgraduate training programmes and postgraduate training facilities. These two aspects of this demand for increase. The first is increase in the number of training positions to meet the expanding needs of the country. Since the undergraduate programme is only a preparation for eventual specialization all those wishing to become specialists have to have postgraduate training. The second aspect is that as! new specialities emerge we should simultaneously develop training programmes for them. Unless we do both of these things we will not be self sufficient in meeting all the health needs of the country.
At present there are only a handfull of institutions where postgraduate training is being done while the number of applicants for the limited number of seats is getting higher and higher. Some institutions have tried to acconthioate the increasing number of applicants by taking more trainees in the existing programmes without a parallel expansion of training facilities. This is having a damaging effect on the quality of the training. One way of decreasing this load on the extisting training institutions is to have part of the training done in smaller peripheral hospitals. Such a move will have the added benefit of providing training in different working conditions.
Yet another repercussion of expanding knowledge is that large parts of what is believed correct today will be proven wrong in a decade and will be replaced by new facts. What can be done to facilitate this process of unlearning and re4earning. The answer is firstly to inculcate the habit of self learning in the medical graduate.
The undergraduate programme must deliberately and actively train the students in assuming responsibility of learning on their own. There is very heavy emphasis in our educational system on learning by rote. This habit is further reinforced by examinations which are based on recall of information. These learning habits do not prepare a student to adjust to changing facts. To keep up with current developments requires unlearning some things and adding some other. A very open mind is needed to do this re-learning. It also requires a constant effort to keep abreast of current developments. The undergraduate curriculum must be designed to encourage the students to develop a critical open mind which can evaluate new information to be learnt. The present emphasis on didactic coverage of courses and selective reading does not provide them the training needed to meet the challenges of the future.
Another thing that Medical Educators have to do to meet the challenge of new information is to initiate and develop a comprehensive Continuing Education/training programme for all levels of health workers.
Pakistan Medical Association and its members are the opinion makers in matters relating to the profession. They are also the ones most concerned about the future of the profession and are its watchdog. Medical Educators can not do any of the things outlined above unless they have the support of the profession.