East and Central African Journal of Surgery, Vol. 11, No. 1, April, 2006,
pp. 2-4
Rumbles in the Medical Schools?
John L Craven MD FRCS
York UK. Email: j.craven@btinternet.com
Code Number: js06001
I note disquiet among those who teach in the regions medical schools. Two recent articles in this journal report their unresponsiveness to the needs of the students and, even more importantly, to the needs of the populace who look towards them to provide the medical services the region sorely needs. The issue of this journal dated December 2004 has articles on the subject by Kakande1 and Kigonya2 who
both railed against declining educational standards. Kigonya noted ‘a decline in the standards of medical education in Uganda’,
and that ‘a significant number of house officers who are deficient in basic clinical skills, of taking a focused history and making a physical examination’; Kakande1 suggested
that the region’s medical schools had to give renewed emphasis
to ‘teaching and patient care’ and that the teacher ‘must
return to the bedside for teaching medical students’. They
both asserted, quite properly, that the primary role of the region’s medical schools, is to produce doctors competent in dealing with the common pathology of the region and that this was being threatened by the unresponsive bureaucracy of the universities. They criticized two developments which had significantly contributed to the decline; the growing tendency of the medical schools to appoint and give promotion and tenure to those clinical teachers who were research-orientated rather than those committed to teaching and, secondly, their tendency to impose new curricula, imported usually from the West, which lacked relevance to the countries’needs.
I hope that I, a retired surgeon, who has worked
in Uganda and has known its medical scene and
that of its neighbouring countries for nearly 40
years, may contribute to the debate that should
arise from these articles.
It is saddening to read these criticisms of the
region’s metropolitan medical schools but I am
forced to admit that they are appropriate. All of
them the first-formed medical schools, all of
them lodged in capital cities. The deterioration
of all is evident but the causes of their decline
rests in more factors, which I will return to later,
than the two quoted in the articles.
The writers are correct in saying that curricular
change should arise from within the school
though those who guide health policy must have
a voice. All who contribute to the debate must
accept that the goal of the medical school must
be to provide doctors knowledgeable of the
pathology of the region and competent in the
clinical techniques required for diagnosis and
treatment. A medical school administration
responsive to the needs of its country will adapt
its curriculum to those needs as articulated by
leaders in health policy and by its clinical
teachers. I have usually been impressed by the
knowledge possessed by recent medical
graduates but less commonly by his/her clinical
skills of diagnosis and clinical investigation. It
is the people of the rural areas whose medical
needs are greatest and it is on those areas that the policy makers must concentrate.
Therefore it
is to these regions that the young medical officer
must be sent and for his/her sake and for the
sake of patients there he/she must have the skills
to diagnose, investigate by simple means, and
treat the common disorders. The ability to test
urine and blood for sugar, to estimate the
haemoglobin, to perform a lumbar puncture,
wound toilet or drain an abscess, for example, is
essential.
Skills and techniques cannot be learned from
books. True enough, books describe the
methods to employ but the help of experienced
clinical teachers are needed to translate and
transmit the skills. They are learned from, and
practised under the eye of empathetic clinical
teachers at the bedside of patients. Here the
student is taught how and when to use them.
Diagnosis rests on the careful structured use of
history taking and examination but so varied and
subtle are the presentations of disease that only
repeated and supervised practice will produce
these skills. There is no substitute for clinical
instruction at the bedside. And so I agree with
Kakande’s contention that medical schools must
recognise that its clinical teachers must be, first
and foremost, clinicians with three qualities
above all others; a love of teaching,
accessibility to students, and a considerable
clinical experience. I say this not to exclude the
value of research but merely to put research, as
it were, in its place subordinate to that of
teaching.
The best of my teachers, Sir Ian MacAdam, performed little
formal research and wrote very few papers but he led a surgical department
that was second to none in its emphasis on teaching, most of it consultants – led but that department, under his leadership was also very productive of the best of clinical research in, for example, Burkitt’s
lymphoma, sigmoid volvulus, and osteomyelitis whilst at the same time
producing the best and most motivated young doctors I have ever seen.
Teaching and research are not incompatible; enthusiastic teachers will
also research but if research and numbers of publications are made the
paramount markers for university clinical staff then teaching may suffer.
As I wrote earlier I do believe that the malaise of the metropolitan medical schools lies in other deeply entrenched causes. Loefler3 has
written eloquently of the societal consequences that have developed
in the Africa’s post-colonial period, in which mimicry of the West have endowed the continent’s elite, the professions and the institutions with pretensions that have disengaged them from the burdens and concerns of their fellow citizens and he attributes some of the problems of the region’s older medical schools to these. I share his view that these medical schools have become too big. These bureaucratic structures, all of them housed in the capital city in over large, over specialised hospitals are failing to produce what their country needs –a
rural medical service. A visit to any of the poorly staffed and poorly
resourced health clinics or hospitals in the rural areas is proof
of this.
Fortunately the region’s health policy makers are
recognising this and in most countries of the region the ministries of
Education and Health have combined to establish new medical schools in
rural areas far from the capital e.g. Uganda, Ethiopia, Mozambique, Kenya,
Tanzania. That in Beira was established to address the medical needs
of the northern region of Mozambique and many kilometres distant from
Maputo, a region that had fewer than 10 Mozambiquan doctors. Its undergraduates
are all from the region. In every country the formation of these new
medical schools had been resisted by its established university.
I have visited several of these new medical schools and
without exception have found within them a vitality and enthusiasm so
often lacking in their elders. They have little of the grandeur of the
capital’s medical school or teaching hospital being usually based
on a regional hospital with adjacent small administrative and preclinical
departments. Their students are, in large part, usually bonded by family
ties and/or schooling to their area and it is likely that the majority
will graduate to work in the rural clinics or hospitals of the region.
I have noted several important distinctions between these new schools and the medical schools of the metropolis which offer the hope that the new schools will avoid the malaise referred to by Kakande1 and Kigonya2.
The new medical schools:
Finally, these new medical schools have an enthusiastic teaching staff, more committed to student teaching and to the production of good doctors. Their newness and smallness both contribute to their desire to demonstrate that they can produce results equal to, if not better, than their elder predecessors in the big city.
As for the metropolitan universities of which Kakande
and Kigonya wrote about, well I hope that they will recognise that
the challenges presented by the new schools rest on more than freedom
from an autocratic bureaucracy. The new schools possess a vitality
and enthusiasm which has been lost over the past few years by their
over-large metropolitan cousins, appropriateness for teaching that
an overspecialised hospital may lack and an effectiveness that
follows from their smaller class sizes. The metropolitan medical
schools need to adapt; rather than expanding their student numbers
they must reduce them; their curricula must be responsive to the
country’s needs and they need to re-emphasise that they exist
to provide appropriately trained doctors who are willing and able
to work in rural areas. The metropolitan schools must give much
more prominence to their links with rural health clinics and general
hospitals. They should illustrate the importance of rural medicine
by promoting clinical and social research into the problems of
its delivery.
The perceived deficiency in the graduate product of the metropolitan schools is not knowledge but clinical skills; the curriculum must contain a list of clinical skills which they will teach and test competency in before graduation. This list will only be well-taught if consultant ward teaching rather than occurring during a once-weekly, overcrowded business ward round of 60 patients is undertaken in the form of bedside tuition focussed on individual cases; the resource presented by teaching in outpatients
clinic is squandered if only delivered by an SHO –the
consultant should be present there.
Forty years ago in Mulago there was a consultant-led ward
round on the emergency ward each evening at which the surgical
firm students’ presence was mandatory. Patients’plans
were defined and student bedside teaching occurred; there
was no better introduction to the diagnosis, care and treatment
of the acute surgical patient. No amount of Grand Rounds,
lectures, internet searches or essays are substitutes for
bedside teaching.
I am hopeful that adaptation will occur for it will be driven by a healthy competitiveness between the new and the old. At present this competitiveness is driving the new schools to work harder and better to prove their worth. The gauntlet, figuratively speaking, has been thrown down by them but now is the time for the established schools to respond and they have the resources to do so. Only time will tell whether they have the will.