Succeeding in Your Medical Degree

Simon Watmough, Simon Watmough

• Publisher: Learning Matters
• Year: 2011
• ISBN:
  9780857253989
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Education

Students may not be aware of it, but Tomorrow?s Doctors (2009) will have a significant impact on their undergraduate medical education. Aimed at new medical students, this book highlights the key themes in British medical education and how the recommendations in Tomorrow?s Doctors will affect their education and subsequent career. Covering topics such as professionalism, leadership, medical informatics and peer tutoring in addition to more familiar areas such as assessment, student-selected components, simulation and clinical attachments, this book will help medical students to understand the course they are embarking on and, ultimately, to succeed at becoming doctors.

chapter 1
The Role of the General Medical Council in UK Medical Education

Simon Watmough

Introduction

You will have heard of the General Medical Council (GMC) as you embark on your undergraduate degree in the UK. The GMC is frequently in the news, although this is often regarding disciplinary action against practising doctors, so some of you may think that the GMC is only relevant to qualified doctors. However, all UK undergraduate medical curricula have to conform to the recommendations made by the GMC on undergraduate medical education in their Tomorrow’s Doctors documents and medical schools have a statutory duty to prepare graduates to work and train as junior doctors in accordance with these GMC guidelines. This chapter will give a brief history of medical education in the UK, examining the role of the GMC in UK medical education and discussing why Tomorrow’s Doctors was written and the evidence behind it.

The role of the GMC in undergraduate medical education

The GMC is the regulatory body for medicine and medical education in the UK and has a statutory duty set out by law to set standards for medical education and decide who is fit to be a doctor registered with the GMC. No one in the UK can legally practise medicine unless they are on the GMC register. Although medical schools and undergraduate curricula in the UK are diverse and there is no ‘common curriculum’ by which all medical schools are guided, they are all required to comply with the recommendations issued by the GMC Education Committee.

There has been some kind of regulation in medicine and medical education in Britain for a long time. For example, in 1421 Parliament petitioned Henry V to pass a law determining that a medicine degree from a university was the only qualification granting the right to practise. In 1462 Edward IV gave a charter to the Company of Barbers allowing them to carry out surgery. In 1511 Henry VIII decreed that no person should practise as physician or surgeon within the City of London unless examined and approved by the Bishop of London or a Dean of St Paul’s Cathedral.

By the nineteenth century there were many different bodies regulating the medical profession and they all had different standards and interests. Prior to 1858 there were 19 separate licensing bodies in operation throughout the UK and none of them had a national jurisdiction. For example, an Edinburgh practitioner might not be able to practise legally in London or even Glasgow. In the mid-nineteenth century there were still a large number of charlatans, quacks, teeth pullers and bone setters with little formal training. There was a huge chasm between the ‘charlatans’ and those students who learned medicine, often at a great cost, through the universities or corporations, who inevitably felt cheated out of their educational investment (Stacey, 1992). As a result of this an Act of Parliament was passed in 1858 called The Medical Act, which established a national system of regulating medicine and medical education by creating the General Medical Council. The Act gave the GMC power to hold a register of practitioners and to set the standard for entrance to the profession by controlling the standards of medical education, and the GMC was made directly responsible to the Privy Council.

The GMC began to exercise its powers over medical education soon after the Act was passed. In 1867 the Council decided on the ten medical subjects that should be obligatory in terms of undergraduate teaching and examination: descriptive and general anatomy; physiology; chemistry; material medica; practical pharmacy; medicine; surgery; midwifery and forensic medicine. It was notable that that there was nothing in terms of communication skills, professionalism or practical skills! The first committee was made up of representatives of medical corporations, universities, colleges and six independent members nominated by the Crown. The GMC had the power to ask schools for information about current courses of study and the examinations. They did not have the power to stipulate a compulsory curriculum, just to say ‘sufficient’ or ‘insufficient’ regarding individual courses.

From 1867 to 1993 medical education and the content of undergraduate medical education largely followed similar patterns at universities. The first half of medical degrees involved intensive, didactic lectures in the sciences followed by clinical placements towards the end of the course so there were distinct preclinical and clinical sections. There was little, if any, formal communication or clinical skills training, few opportunities to experience general practice or opportunities to study topics that interested students in-depth. The publication of Tomorrow’s Doctors, however, was to bring about a major change in medical education and explains why the content of your medical curriculum looks as it does today.

ACTIVITY 1.1

Take a look at the GMC website and look at their role today. Search the internet for other regulatory bodies that regulate medical education elsewhere in the world. What similarities do you see between them?

---

Why reform undergraduate medical curricula?

There were a series of international pressures influencing medical education in the UK by the early 1990s. The World Federation for Medical Education (WFME) issued the Edinburgh Declaration of 12 principles for reforming medical education in 1988 (Parsell and Bligh, 1995). Also, many medical schools around the world, but in particular in North America, had radically altered their curricula with seemingly very few adverse effects (Albanese and Mitchell, 1993). For example, major reform with the introduction of problem-based learning (PBL) took place at McMaster University in Canada in 1962 and spread in the 1970s to other schools further afield, such as the University of Maastricht medical school (The Netherlands) and the University of Newcastle (Australia), so there were already precedents from outside the UK on managing curriculum reform away from traditional curricula.

There was also a growing feeling that too much ‘irrelevant’ knowledge was being taught to undergraduates and that in the preclinical part of the course students were learning biochemistry, anatomy and physiology which they would not need in their work as doctors. Having distinct clinical and preclinical sections to medical curricula seemed to exacerbate this and it was not always clear which was the most relevant knowledge for clinical practice.

Critics had been arguing for many years about the content of medical curricula and the didactic nature of medical education. Richard Davis wrote about the problem of excessive anatomy lectures in the 1750s. William Barrett Marshall, a student in the 1820s, felt the factual burden on students should be reduced and that thinking and reasoning should be encouraged instead. He also suggested that students should learn integrated anatomy teaching, long before it was introduced into UK medical curricula. In 1835 the London Gazette wrote that students should learn about public and private hygiene at the expense of pathology (Poynter, 1966). The opening pages of the original Tomorrow’s Doctors states that well over 100 years ago there were significant concerns that student doctors were not being given enough time for self-education and that there was far too much emphasis on gaining knowledge in medical curricula. The document quotes from Thomas Huxley in 1876:

The burden we place on the medical student is far too heavy, and it takes some doing to keep from breaking his intellectual back. A system of medical education that is actually calculated to obstruct the acquisition of sound knowledge and to heavily favour the crammer and grinder is a disgrace.

By the late twentieth century this was widely seen as being at the expense of learning the skills to work as a junior doctor.

ACTIVITY 1.2

• Why do you think it is important to have a regulator in medical education?
• Do you think medical education would be better or worse without a regulator?
• Do you think that regulation of undergraduate medical education will automatically lead to better doctors?

---

Medical education from 1945 to Tomorrow’s Doctors

After the Second World War and the introduction of the National Health Service (NHS) there were a series of Acts of Parliament and recommendations from the GMC which had further impact on undergraduate medical education and led directly to the publication of the original Tomorrow’s Doctors. The introduction of a preregistration year in 1953 was crucial to the development of undergraduate medical education as much as postgraduate medical education. The preregistration year was a direct result of the Goodenough Report (Goodenough, 1944) which for the first time recognised the need for further, supervised training after the undergraduate degree. The report also recommended provision for an increase in student numbers to produce extra doctors for the NHS which was introduced in 1948. The fact that the report recommended a preregistration year to ease the burden on undergraduate curricula highlighted the concerns even then about the preparedness of junior doctors for practice after graduation.

In 1957, the GMC (1957) advised a ‘lighter and more flexible’ curriculum, asking medical schools to consider experimenting with curriculum content and teaching methods. In 1962 the Porritt Report (Porritt, 1962) concluded ‘We cannot escape the conclusion that the medical facilities of British Universities are now lagging considerably behind those of many comparable countries in respect of research facilities, accommodation and available teachers.’ It also pointed out that students seemed to have a narrow experience of the range of clinical work with a lack of exposure to community medicine.

Before 1972, Parliament largely left the GMC to its own devices but a ‘revolt’ in the late 1960s over compulsory payments to enter the medical register forced Parliament to take a closer interest into the role and function of the GMC. As a result the Merrison Inquiry was set up to look at how the GMC was operating at that time. One of the recommendations of the Inquiry suggested that the GMC had to raise the standard of undergraduate and postgraduate education ‘to make a clinician out of the graduate’ (Merrison Report, 1975). Merrison also commented on what he saw as the failure of the educational component of the preregistration year. The Merrison Report was a big influence on the 1978 and then 1983 Medical Acts, which officially recognised that the aim of undergraduate medical education was no longer to produce a graduate who was competent in medicine, surgery and obstetrics (as it had been since the nineteenth century) but rather to create graduates capable of going onto postgraduate training and able to work as junior doctors.

Crucially, the 1978 Act reformed the structure of the GMC and created a semiindependent education committee, stating that the GMC should be responsible for co-ordinating all stages of medical education and promoting high standards. The Education Committee was given extended powers to visit universities and more control over the preregistration year. In the early 1980s the Education Committee started using its rights to visit medical schools to see how its recommendations of 1980 were being implemented. There was some anxiety about interfering in ‘university autonomy’ (Stacey, 1992) and at first only qualified doctors were included in the visiting parties. This set a precedent for more thorough visits which started in the 1990s following the publication of Tomorrow’s Doctors. As the 1990s approached, the GMC was taking a more active interest in undergraduate medical education which was indicated by making regular formal visits to medical schools.

The under-utilisation of general practice in undergraduate medical education was also contributing to the problems in medical education (Bligh and Parsell, 1995). By the 1990s over 90 per cent of NHS consultations took place in the community, yet many medical schools only had token short placements in general practice in their curriculum. Many generic medical skills could be learned in the community and it was suggested that this would also help students gain more of an insight into the social and emotional factors involved in medicine. There was a belief among medical educators in the need to include more public health medicine to enable doctors to deal with infectious diseases such as HIV or TB; a shift in emphasis from hospital care to communit...