How should medical students be trained?

Tomorrow's Doctors, guidelines for training UK medical students, are being revised, explains Laura James

Lecturers observe a medical student practising on high teck manikin

Creating the model 21st century doctor is now a topic for discussion in the United Kingdom. Not just among the medical profession but for patients, the public, and, of course, medical students. Tomorrow's Doctors is the publication that gives guidelines to all UK medical schools for what and how students should be taught medicine. This includes knowledge, skills, attitudes, and behaviours. It is being updated because of advances in medical education and training in the past five years and is due to be published in March after months of debate.

Advances in education

The existing guidelines were published in 2003, which was the first update since the first publication in 1993. The General Medical Council has not waited another decade to create a new draft because of advances such as the opening of four new medical schools; the foundation programme for newly qualified doctors; and the new edition of Good Medical Practice, the GMC's principles of practice for doctors to ensure professionalism.

When Tomorrow's Doctors was first published in 1993 it meant a considerable change to the undergraduate medical curriculum. The GMC wanted to move away from predominantly factual based methods of learning to ones that would enable students to develop skills, evaluate data, shape attitudes, and integrate with patients and colleagues from early in training.

Medical school teaching in Australia and North America is now approached in a similar way. Their method is very much problem based, where learning is in context and team working skills are emphasised.

The question is what should change? Michael Farthing, chairman of the Tomorrow's Doctors review group, said that one of the main areas for discussion was “to ensure that medical students are better prepared for their F1 and F2 [foundation programme] years.”

The draft says that educational supervisors have expressed “deep concern about the knowledge base of new trainees.” In particular they thought that knowledge of basic sciences, anatomy, pharmacology, and prescribing was in short supply.

Joanna Fox, a foundation programme doctor at the Mater Hospital in Newcastle, Australia, and graduate of Cardiff University, said, “Pharmacology is an area of weakness for many doctors. The problem is that we learn about medications before we understand the disease process. We need more pharmacology teaching later in the course as well as early on.”

Student selected components

Another topic for debate is the student selected component (SSC). These were created as special study modules in the 1993 edition of Tomorrow's Doctors. They enabled students to study particular areas of medicine in more depth and, depending on the medical school, follow non-science based activities, such as foreign languages, teaching in local schools, or exploring art in medicine. The aim of the components are to give students choice. But some medical school teachers have concerns that the components occupy time at the expense of the core curriculum.

John Davis, a third year medical student at King's College London said, “If you want to do well you have to do a lot of research. I don't think they count for enough, for the time they take to do. Learning a language, for example, can take up to six hours a week.”

The 2003 Tomorrow's Doctors advised that the components form 25-33% of a five year course. The draft of the new guidelines however, does not give a minimum requirement.

The 2009 draft states that the component “should contribute to the development of a range of personal and professional skills, including team working, communication, time and resource management, teaching others, self reflection, and independent learning. They may also, especially in later years, provide opportunities to explore career options.”

John Rees, dean of undergraduate education at King's College London, said, “I would be in favour, personally, of keeping the proportion of time spent on SSCs more or less the same as now. The aims of the SSCs are expressed rather differently in the new draft. I think it is important that they are seen as a way of allowing students to explore areas that interest them.

Slight danger

“There is a slight danger that they may be used to deliver specific core tasks. However, there is also an emphasis on planning an individual's SSC experience across the programme, and I welcome this.”

One of the main purposes of Tomorrow's Doctors is to protect the patient and to avoid producing incompetent medical students and doctors. However, other than to produce a perfect doctor in knowledge, behaviour, and skill, the draft gives guidelines on how to make sympathetic ones. Medical school is not just a factory for producing parts for the NHS, so under ethical principles, as emphasised on the first page of the 2003 publication, the draft says that medical students should “be polite, considerate, trustworthy, and honest, acting with integrity, maintaining confidentiality, and respecting patients’ dignity and privacy and the importance of appropriate consent.” And they shouldn’t forget to smile.

Competing interests: None declared.

Provenance and peer review: Commissioned, not externally peer reviewed.

Anyone can take part in the consultation. Register at www.gmc-uk.org/tomorrowsdoctors until the end of March. The current guidelines and background to the consultation can also be found here.

See “Tomorrow’s doctors—the next decade” (Student BMJ 2001;9:221, http://student.bmj.com/issues/01/07/editorials/221.php).

Laura James intercalating student in medical journalismmedical student
sayuli_lsj@hotmail.com
Student BMJ 2009;17:037-080 . ISSN 0966-6494 | February 2009