WORLD EEALTE OBGAK'41ZATION ORGANISATION MONDIALE D E LA SANTE

REGIONAL OFFICE BUREAU REGIONAL

FOR THE EASTERN MEDITERRANEAN POUR LA MEDITERRANEE ORIENTALE

SECOND CONFERENCE ON MEDICAL EmCkTION EH/scD.CONF.MED. ZWC. /BGD.MTL 3

Teheran, 12 - 18 Decemkr 1970 29 October 1970

ENGLISH AND FRENCH

FIRST CONFErnCE ON I rn ICAL r n C X T I O N I N

THE EASTERN MXDTPWFUi REGION, TFXERDJ, 1962

D[CEBE'S FR(61 THE RiPORl'

There were in the F i r s t Conference eight independent Committees, each

one discussing one different topic of the agenda.

Sane of these topics were closely related $0 subjects included in the

agenda proposed for the Second Conference, 1970. For infonostion of the

part icipanb in this Conference, the following were the ideas prevailipg in

1962, as shown in the discussions reported by Conunittees A, C, E and F.

Pages 15 through 18

OBJECTIVES OF Fr6DICA'L EDJCATIOW AND RWJRENENTS OF NEDImL mmrm m HOW TO EAKE UP THE DEFICIENCY ( C ~ I T T ~ "A*~)

The primary task of Ccamnittee llA'l was t o formulate a statemsnt, of the

objectims of medical education i n the Eastern Mediterranean Region. Once these

objectives were brought clearly in to focus, it became possible t o attack

specific pmblems such as the manpowpr deficiencymore rationally and, so-to-

speak, fran a well-prepared position. A t the outset of the Committee's

deliberation there was prompt agreement on a si@ficant point;

The objectives of medical education

are utLimately determined by the

health requirements o f t h e commmity.

With this important concept as guiding principle, the group preferred,

before maldng recommendations on ob.iectives, t o consider certain preliminary

questions, which re la te intimately both t o camrmnity health and t o medical

education. These canprised:

1 ) t h e physician shortage;

2 ) t h e maintenace of high educetin~lal standards;

3 ) the or ientat ion of 9,hysi~ians i n public he?.lM and preventive

medicine;

L) r u r a l health care; and

5 ) def in i t ion and u t i l i z e Lion of awdl ia r ies .

The discussion rrnged 7,ridely over a l l these problems and p r e c t i c d

experiences in various countrihs rrere described.

I ) The physician shortage

Two methods of ra i s ing t h e output of physicians were o u t l i n e d F i r s t , incr-

easing the size of t h e student body in exis t ing medical schools is t h e

most expeditious approach and h ~ s been required as an emergency measure

in some countries. Fxperience i n several schools of the Region indicates,

however, t h a t qua l i ty of medical education suf fe rs when facu l ty and

f a c i l i t i e s are overwhelmed by an excessive m t b e r of students.

Consequgntly, there i s a trend t o reduce enrolment in cer ta in of the la rge

schools. No cosclusion was drawn as tp the optimum s iae of a medical

school although one hundred students per c lass was mentioned a s acceptable,

The determiping f s c t o r i s the rg t io of f ~ r x l t y ~ n d physical p l an t f a c i l i t i e s

to students. It was f)tr$her noted t h a t t he cornunity resources a r e a l so

of w e a t hportance, e, g., a metropolitan area may be ablg t o support a

I 3 g e r school than feas ib le in a r e l a t i v e l y smaller city.

The majority of t he group seemed t o 2gree thnt, s ince production of

lsxger numbers i s l i a b l e t o lower t he qual i ty of the gractuates, it is

desirable t o concentrate on qua l i ty of the graduates ra ther than on

quan$ity in vim? of its e f f e c t on the standards of medical and heal th

work.

The seccnd, and probably preferable, means o f incregsing the y b e r

of 'physib$&is i s by establishment of nt%a medical schools. New medical

schools inevi tably demand f a c i l i t i e s a d faculty which overtax the supply.

The teacher shortage is most c r i t i c a l and may be met by t ransfer of t he

lower echelons of facu l ty from exis t ing schools t o provide staff f o r

developing schools. Recruitment of foreign teachers i s of def ini te , ~t

limited, value because of t h e i r shor t tenure and language d i f f icu l t ies .

Established univers i t i es or special i n s t i t u t e s may be expected t o

concentrate on preparing t e x h e r s for new schools.

The case of Pakistan, which was l e f t jn A947 w i t h one medical school

f o r a population of 75 million, was described. In addit ion t o the

t rznsfer of lower echelons of faculty, spec i a l i s t s were sen t abroad for

higher q u d i f i c a t i o n s and young graduates were selected f o r spec i a l i s t

t ra in ing and preparation as academic teachers. To expedite production of

basic science and c l in i ca l fecu l t ies , a post-graduate medicd centre h?a

been s e t up a s a tr-g i n s t i t u t e which up till now,has concentrated on

developing basic science teechers f o r the new schools.

Countries with no o r insuf f ic ien t medical schools rmrst look to outside

i n s t i t u t i o n s f o r t he t ra in lng of physicians and teachers. This type of

in te rna t iona l cooperz.tion i s q o h g on t o a l imited degree within the

Region 2nd shovld be encouraged. It was observed with sati&%ction tha$

the 1dHO fellowship programme fos t e r s constructive a c t i v i t y of t h i s kind.

In countries with undergraduate medical colleges 1.IHO assis tance i s given

to the ppsAwgraduate f i a l d with speci+l emphasis on the t ra in ing of

teachers.

.The statement was made t3at i n UAR 10% and i n *key 20% of places

in medical schools a r e reserved f o r foreign students.

Finally, the Committee recognized t h a t the doctor/population r a t i ? i s

an incopl~lete expression of the problem confronting soc ie ty and medical

schools. Numerous other f ~ c t o r s have, t o be tdcer- i n t o accaunt in

evaluating the shortage of physicians. These include the d i s t r i bu t ion and

categories of available heal th personnel (public health officers, general

pract i t ioners , spec ia l i s t s , nurses, auxi l imies , etc. ), t h e rap id ly

changing s o c i a l s tn -c tu re 2nd economic capacity of t h e conumnity t o absorb

medical care, t h e stage of development of the cpmunity, and t h e

organizational s tn lc ture of the heal th services.

EM/SCD, C O N F . ~ . mc. /B(ID.MTL.~ page 11

2 ) The maintenance of high educational standards

While pressure i s strong f o r increasing the supply of physicians,

t h e maintenance of standards i n exis t ing and developing medical schools

becomes a serious problem. Although scwp cor~promises may be required,

they should be considered only teworary. The greater effectiveness of

the better-trained physician was recognized. Standards of medical

education should be placed under the constructive suporvision of MedicCl

Councils or s imilar authorit ies.

There was general agreement t h a t t he educational system should create

only one basic c l a s s of physicians. Educational standards should take

i n t o account th?.t today's gradmate must serve tomorrow and be able t o

cope with the new problem of ten t o twenty years hence. In this,connection,

t h e growing importmce of basic science i n medicine was stressed. To

ensure b e t t e r grounding i n fundamentals a d t o avoid the t r ad i t i ona l and

d is t rac t ing tr?nsit ion,period, an integrat ion of pre-cl inical and c l i n i c a l

teaching was advocated.

3) The or ientat ion of physicians in public h e d t h and preventive medicine

Public heal th and preventive medicine receive inadequste emphasis i n

t h e curriculum of most schools. How,% improve teaching 2nd prac t ice in

these f i e l d s was considered a t length, It was suggested t h a t the subject

matter of preventive medicine and public heal th should be taught fran t he

first year of medicine, d i s t r ibu ted th rougho~~ t the medical course and, a s

much as possible, in tegrated with c l i n i c a l teaching by c l in i ca l teachers.

This mst no t be interpreted t o exclude t h e tepching pf preventive medicine

in separate courses, 2s a d i sc ip l ine i n i ts own right. Since learning by

doing i s most effective, the student should par t ic ipa te in appropriete

heal th programnes. Health, being p a r t and parcel of the soc ia l aspecss

of t he ccmmunit~., soc ia l tc.chniques should a l so fonn p a r t of teaching.

4) Rural heal th care

The C d t t e e $oak special cognieance of t h e urgent rural heal th

needs of t h e Region. The well-know urban concentration and r u m 1

deficiency of doctors was discussed. Physicians are re luc tan t t o s e t t l e

i n ru ra l areas because of poorer l i v ing conditions, l imited soc ia l and

educational opportunities, lower income, tendency to, professional

deteriorztion, and lack of professional sat isfact ion. One member drew

a t t en t i an t o t h e importance of good communications in rural heal th and

welfare.

Various means of inducing physicians t o prac t i se in outlying d i s t r i c t s

were described o r proposed. A number of governments require some years

of rural service before urban prac t ice o r special izat ion i s pemi t t ed .

Raising sa la r ies , providing heal th centre f a c i l i t i e s and housing f o r the

physician, and offer ing post-graduate courses i n regional medical centres

or health units were mentioned as p rac t i ca l inducements now on trial,

pa r t i cu l a r ly in UAB and Iran. A member suggested t h a t t he provision of

long-term i p s t a l l a t i o n loans t o doctora wishing t o pract ice in r u r a l areas

be explored.

The motivation and dedication of the physicians were touched upon as

poten t ia l s t iwiLi t o serve m a 1 communities. Suggestions f o r cultiv2tting

these qua l i t i e s in medical students included greater emphasis on,

preventive medicine, psychology, humanities, and s o c i a l sciences. The

example of medical teachers who a re thanselves w u i n g t o l i v e and work in the

r u r a l s e t t i n g was considered extremely important. It was f e l t t h a t t he

pres t ige and professional a t t r ac t ion of m r a l services can best be enhanced

b y the reor ientat ion of the &st ing systans o f medical education and c m e

through making them more ' t c o m i t y - c e n t r e d t ' and l e s s tthospital-centred."

This would mean t h a t not only would the m a 1 community receive high

q u a l i t y service,, but t h a t teaching f a c i l i t i e s would be extended t o a more

r e a l i s t i c sphere.

h i n g the discussion, r e f e r a c e was repeatedly made to t he

impor$ance of preventive medicine and public heal th measures in the mal

areas. Physicians and other workers assigned t o &ty in such areas should

therefore be adequately t ra ined along thes,e l ines. The implications of

t h i s for medical education were emphzsized.

The provision of rural service on a voluntary bas i s has n o t proved

successful in t h e Region. Assignment of doctors t o outlying d i s t r i c t s and

un i t s i s the only recourse a t present but measures designed t o a t t r a c t

physicians should be developed as rapidly as possible.

Pzgos 29 through 36

PEDICAL C U R R I C I ~ ~ I AID ~iZTHOE6 OF TEACHING (CMIITTEE "Cn)

The Cowi t tee defined its primary objective as the education of the

basic doctor. By t h i s is meant n doctor so educated in medical science,

s k i l l s ?ad community understanding snd respons ib i l i ty t h a t he i s capable

with appropriate post-graduate t ra in ing m d apprenticeship of preparing

himself f o r any branch of t he profession. It w i l l be noted that t h i s

objective assumes an organized aystem of post-graduate,preparation f o r all

branches of the profession, including general practice. It was real ized

t h a t the precise def in i t ion of t h e basic doctor would d i f f e r somewhat in

d i f f e r en t countries according t o the needs of the country 2nd the s tage

of d g v e l o p n t of i t s opportunit ies f o r organized poshgraduate apprentice-

ship. In 1;He education of t he basic doctor, it rms believed t h a t there

were three main objectives of great importance :

1. He should be educated as a sc ien t i s t . Not o d y does he require

t o know the basic s c i e n t i f i c f a c t s upon which modern mediczl knowledge i s

btrilt, but he must be able t o think s c i e n t i f i c a y and understand s c i e n t i f i c

methods i f he i s t o be able t o keep abrers t w i t h $he rapidly developing

Tield of medicine during h i s l i fe t ime of practice. The Comi t tee s t ressed

the need f o r h i s educz.tion t o enhance h i s capac$ty to think c r i t i c a l l y and

s c i e n t i f i c a l l y and to l e C m t o work f o r himself.

2. He should be ectuceted to be a comity-minded doctor. In many %rays th i s has provod the most d i f f icul t of the object$ves t o achieve.

Indeod, the C m i t t e e feels that in many countrias we are a t present

fai l ing d imi l ly t o achieve th is v i t a l objective. To meet this challenge

requires drastic re-thinking and radical action.

3. He should be educated t o be a skilful, sciontific, practical

and humane clinician. For this purpose he must grow up in en atmosphere

of the highest attainable standards of cl inical practice c v i e d on in

the &st environment which c m be provided fo r the purpose. The

Importance of creating tb best possible standards i n teaching hospi tds

cannot be over-emphasized.

The Connni%tee ponsidered the qurriculum.&d teaching methods in terms

of thei r objectiws. For convenience most of the points a b u t teaching

methods are dealt with separztely a t the ond of th is report.

Objective I - Education a s a sc ient is t

The CcPmnitteo f e l t that teaching in most of the secondary schools is

inadequate and unsatisfactory for the preparrtion of the future doctor,

as it &ponds greatly on the theoretical and didactic ~pproach snd learning

by rote. The student coming to the medical school is usually ignorant of

scientif ic methods. A transition period of one t o two years i s necessary

af ter leaving the secondary school and before embnrking on the pre-clinical

sciences. Tho pre-medicdl course should be directed t o orientating the

student,to a scientif ic at t i tude and an understanding of scientif ic

methods. In this phase he should be taught humanities, basic sciences

including s t a t i s t i c s and one of the more popular foreign languages, $he

teaching of which should be continued through the pre-clinical phase.

As t o whether the pre-medical course should be taught atr the medical

school or a t the university science facultg depends on the f ac i l i t i e s

available i n different countries. However, as the responsibility of

preparing bettor students for the medical school l i e s on the medical

faculty i t s e l f , the ?rc-medicd course can b t s t be done a t the medical

school, provided properly qwdified scientistsand adequate laboratory

f a c i l i t i e s w e ava ibble . On the other h a d , t he p r e a e d i c d course

under t~ken a t t h e un ivers i ty science f acu l ty has the advantage of delaying

t h e separation of t h e medical student from the generzl un ivers i ty atmosphere.

If the medical facul ty arrrnges the pre-medical course it i s r e s p n s i b l e

f o r selection f o r edmission t o th?.t covrse; but those who f&l t p cane up

t o t h e stcmdard within the mininnun prescribed period a re excluded. Thus

this s k g e becomes a stage of t r i a l . However, i f the un ivers i ty science

f acu l ty conducts pre-medical courses, the selection t o the medical s cNo1

comes a f t e r passing this t e s t , and those not selected can continue i n t he

f acu l ty of science.

Regarding the medical sc ience courees, t he C d t t e e f e l t t h e t it w a s

appropriate t o include anatorfiy, histology, embryology, news-anatomy and

neuro-histology in one course of s tudies and under one ch~irman. This

does not,prevent t he school from having a number of professors in these

branches. However, owing to the increased importance of biochemistry in

medicine, it was f e l t t h a t it shpuld have i ts special course ~ n d department

separate from that of physiology.

The period of study of these subjecss was discussed a t length;

suggestions rznged from one t o two years. The Corrmittee suggested one and

a ha l f academic years a s adequate; t he time t o be divided equally between

the three disciplines, anatomy, biochemistry and physiology.

Objective 11 - Education as a c o m i t y doctor

The f a c t must be facod t h a t ?t present rrmch, i f not most, of the

great e f f o r t pit i n t o medicrl education i s wasted; in most countries the

majority of students a f t e r graduation proceed t o pr iva te prac t ice where

they have l i t t l e i n t e r e s t in, or influence upon, t h e m a heel th problems

of t h e i r communities. This represents the grea tes t f a i l u r e a t t h e present

time in our mdhods of procbcing and u t i l i z i n g doctors. It is a problem

which will only be solved s a t i s f a c t o r i l y by a major e f f o r t of partnership

by meqcaJ. educ?.tors, heal th ndministrrtors, and t h e medical profession

i t s e l f . It w a s hoped t h c t t h i s outstanding problem could be solved through

the system which prevai ls in t h e Region of educating all b ~ s i c doctors in

the same pattern for this method has the potential advantage of creating

unified professiop and emouraging the close alliance of preventive and

curative medicine. If , however, a solution i s not found through our

existing unified system of medical education, it will become necessary

t o consider seriously the adoption of a separate system of education fpr

public health practitioners such as exists in USSR a t the present time.

In teaching the student about community public health and preventive

medicine two major tasks have to be accomplished:

1. The student must be motivated t o want to understand the health

problems of h is nation, and to devote his lifetime of practice $0 t he i r

solution, whstever his chosen f ie ld of professional work may be. This

objective i s oasy t o state, but d i f f icul t to accomplish; it postulates a

doctor drastically different from the c m o n image of the medical mzn, and

i t s attainment must lead t o amendpants of deeply ontrenched systems of

private practice and remuneration. Only the most vigorous a d imaginative

teaching stronglypractical i n i t s flavour w i l l help t o create the degree

of change required,

2. The student must be educated t o have a sc ient i f ic understanding

of the envirolfnental fcctors underlying i l l -hed th , wd the colmrmnity

structure =a@ behaviour which must be manipulated to bring about

improvsments. H i s teaohing of prevcn t ive medicine, epidmiology and

cummunity health organization must be presented w i t h the same high

standards of scientif ic content wd practical experimce which he finds

in the other aspects of h is ohcation.

Teaching i n commmity pllblic health and preventive medicine should

run through the whole course. It sho~rld be a major thane in the teaching

of a l l disciplines of medicine by giving m0r.e time and emphasis to the

preventive and social aspects of the subject. k c e l l e n t curriculum

programmes of this kind have been outlined i n WIO publications such as

the monograph by Grundy and Mackintosh on "The Tezhing of Hygiene and

Public- Health i n &ropen (A &view of Wends i n Undergraduate and p o s h

graduato Education i n Nineteen Countries - I6HO Monograph Series No. 34, 1957). It was suggested that, m e programe o f subjects peculiar t o public

health and spcial medicine, e.g., v i t a l s t a t i s t i cs , epidemiology, disease

cantrol, etc., should be distributed among dl years of the m e d i d Course.

The teaching should bc s t rongly p rac t i ca l i n i t s neture giving the

student o p p ~ r t ~ l t i e s t o work for himself with increasing respons ib i l i ty

under supervision, j u s t as he does in h i s clinic,al studies. Hezlth centres,

other community heal th services, a d disease s tudies in the f i e l d should

be 5741.i f o r this purpose. thatever resoilrces a r e used this experience

should be orymi.,ed t o ciiallenge the imagination of t he student. The

Comit tec instpnced an a c e l l p n t exmple of t h i s kind of work in the

opportunit ies to take p a r t i n endemic disease control schemes which have

been organized fo r medical students i n I ran by t h e I n s t i t u t e of Parasitology

and Malariology.

It follows from r.rhzt has been sa id t ha t t he ~ t ~ f f i n g , equipping and

financing of the Depar%ment of Prevnntive Medicine becomes a major

respons ib i l i ty in the medical school. It i s e s sen t i a l t h a t it should be

well ec:--ipped s ta f fed by vigorous, s c i e n t i f i c a l l y trained, conrmunity-

minded teachers who have t h e i r f u l l time available f o r teaching and

research,

Even i j i th such a strong depdmeci , it must be appreciated by all

who a r e conceriled with medical education and who teach in medical schools

t h a t inculcation of s c i e n t i f i c understanding of preventive medicine and

the community-minded a d preveiltive-minded a t t i t ude i n the medical student

i s a responsibilkty which belongs to t he whole medical school and evory

department i n it, The Department of Preventive Medicine has i % special

p a r t t o play, but in pa.~J;nerahip with dl t he other departments. Perhaps

more t h ~ n any other teacher in medical education the t ewher of preventive

medicine requires t h e f u l l suppoi-t of d l h i s colleagues. Without it he

i s a voice crying in Yne r~ i lderness and he i s bound t o fail. He w i l l only

succecd i f he i s teachifig students who, throughout t h e i r experience in

the medical school, have had t h e i r respons ib i l i t i es t o t h e i r c o m i t y

for t h e preventipn of disease and t h e promotion of heal th placed c l ea r ly

in f ront of them,

The Department of Paediatr ics has a special respons ib i l i ty i n t h i s

respect. Due t o t h e high proportion of tho population of t he Rogion who

a r c children, t h e j n p o ~ t ~ n c e of ch i ld care i n hea l th <and disease cannot

be over-emphasieed; The prac t i t ioner of medicine, regardless of his

speciality,, chould be fe.miliu. with t he preventive and c u r a t i w aspects of

paediatrics. This subjpct, therefore, must occupy a significant portior)

of the c l i n i c a l studies.

Objective 111 I Education as a clirkian

In cl inical teachin?, prolonged attachment of the student to the

c l in ical units is an essential; in each cl inical uni t he should be given

n gradually increasing responsibilitj for thc care of patients under the

supervision <md guidvlce of his tccchers. During th i s phase t he student

should have ample opportunity to develop contact with his teachers who

should be enthusiastic and haw adequatc time t o devote t o teaching. In

c l i n i c d education preaching has l i t t l e place, it is the practices which

he sees that provide the model the student will follow. It i s the mental

attitufle and the methods of the teacher which w i l l influence the future

doctor. For this, more th?m my other reasm, a very heavy burden of

responsibility rests on the c l in ical teachers.

The teaching hospitals should be regarded as the labor?.tories for

cl inical study, and proper tesching i s only possible i f the hospital

provides a proper atomosphere. Too often a t the present time, the teaching

hospit,a shows tho student hurriad medical care available only for brief

periods of the day, inadequate nursing and housekeeping, and laboratory

svpport which is inadequate i n q u ~ l i t y <md not elways %curate in results.

The teaching hospital, whether good or bad, -,be the model of

medical care which the student t ~ h s away i n h i s mind. It should be a

true model of excellence towards, which he can strive, i f l a t e r on he finds

himself in less ideal conditions. In this sense high smdards of nursing

are just as im>ortcmt as Egh standards of cl inical skill.

The teaching hospital is the place where the student learns t o apply

his scientif ic knorrledge t o the needs of his pctients. It is useless ilo

urge the student t o be a sc ient is t if he finds i n the teaching hospital

that the iaboratory i s not usod either because sane of his teachers are

not familiar w i t h its use or bec-use its resources are inadequate.

Ekcellent laboratory services are ?n ossentizl of the teaching hospital.

Owing to the shortage of teachin5 beds i n many uniyersity hospitals, good

use may bo made of other hospitals in the locality. This can create an

atmosphere of cooperation in the form of a university modical centre i n

which many individuals concerned with medical care, teaching and research

work for a ccraroon purpose.

Nost individuals seeking mcdical c?~re do no t need t o be hospitalised.

These anbulebry pa t ien ts provide excellent opportunities f o r c l i n i c a l

teaching, not only because of thc vss t c l i n i c a l mater ia l they provide, but

~ l s o because they are closer t o the nz tura l conditions of l i f e . By the

proper use of the ou t rpa t ien t department, therefore, t he student i s t r s ined

t o give medic21 cam under well-supcrvlsed conditions otherwise s imilar

t o what he w i l l meet in h i s fu ture prectice. The out-patient department,

therefore, should be adequately designed, equipped and orgmi50d t o provide

ample space, laboratories, diagnostic f a c i l i t i e s and oonierence rooms.

Senior s t a f f should regular ly par t ic ipa te there i n t h e teaching 2nd pa t ien t

care so that the student can observe how an experienced c l in ic ian e l i c i t s

t h e h i s to ry 2nd deals with the problem of h i s patient. Adequate numbers

of t ra ined para-meclicd. personnel, ihcluding nurses, social workers and

visijjing nurses shculd be available i n order t o give canprehensive medical

care.

The gap between the ide'd and the ac tua l i s probably wider, f o r present

outrpationt departments, than f o r other asp-cts o f the hospital. Too often

present-day out-patient depmtments are overcrowded and sevcr ly cramped

for space and in t h m the ri~ost junior st?ff have t o cope with a vast army

of t he s ick and t h e needy with ,great haste. Under such adverse

circumstances, t he out-patient department, so f a r from being one of the

bas t lecuning pleces for t he ,studant, i s a s i t ua t ion which is p o s i t i v d y

damaging t o the future doctor.

Curriculum plaming and teaching methods

A l l discussion on curriculum reforms i s mmningless unless it is

accompanied by 3 policy of s t a f f ing which allows the reforms to be car r ied

out effectively. Almost evory kflprovement which can be suggested, denlands

c loser contact between the teachers ~ m d the students md therefom requires

a much, higher teacher/student r z t i o than i s u s u . ~ J l y avai leble i n the

Region. The Conunittee was impressed with the urgent need to move a s rapidly

a s possible towards a t ru l2 full-time teaching staff and r ecmended a

teacher/student rr.tio of 1:10 of avzileble teachers per department c s a

reasonable g o d t o achieve, provided that such it embers of t he stdf work

m/scn.cOm.m.mc. /mD.mL.Y page 13

on a f i l l - t iune basis. It was recogtli~ed that .a true academic, atmosphere

cannot be created withoct a strong group of full-time faculty. However,

i n addition, suitably qudif ied and experienced practitioners i n the

comnunity could be encouraged t o participate in teaching duties and be

given faculty status.

In the opinion of the Cod t t eo , limitation of space for teaching and

proper laboratory work and shortage of, eq~dpnont are serious handicaps,

especi- in the out-paticnt teaching. Irrmedia,to and urgent attention t o

provide adequate space and equipnent is rquired.

With regsrd t o the question of the t o t a l duration of medical studies

af ter the pre-medical phme, it w'as the general opinion tha t with better

planning of the syllabus, removal of unnecesswy theoretical tssching,

introduction of coordinated tcaching, ovoidrnce of duplication, and a

higher teacher/student ra t io with c o n s e q ~ ~ t improved teaching methods,

it will be feasible t o reduce that period. A better ut i l ieat ion of the

studentls time can be effected by extendipg the working day t o 6 - 8 hours

and reducing the to ta l number of holidays. However, eash country must

work out the detai ls depending on 2% own circumstances.

The Connuittee considered that the c u r r i c d m i n most disciplines was

overloaded and should be lightened by cut$ing out unnecessa-y deta i l and

paying more attention to basic principles. For example, o reduction

could be made in the cmount of tecching in general and specizlized surgery

as the student does not real ly benefit by lcarning d e t d s of cpmplicatad

procedures or watching time-consuming major surg icd operations. The

student should be taught, only the principles of surgery a d common surgical

procedures a d practices.

The blpck system of teaching 3n the pre-clinical years was not viewed

with favour. It was, however, f e l t t ha t - i t m a y be of value, in the c l in ica l

yems.

Regarding the integrated system of teaching, the C-ttee f e l t that

it was unwise t o embark on too elaborzte an integrztion. However, the

integration of concepts and ideas of medicine i n the mind of the student

should be strongly encouraged 'c'zoughout his studies, by bringing teachers

%/SCD. CONF.lED.EaIC. /BGD.MTLo~ page 14

from the other d i sc ip l ines f o r w t i v e pmt i c ipa t ion in the ins t ruc t ion

of any subject whenever possible. The Euramination system shofld a l so be

planned to encmrage integrat ion in thc- minds of the students.

The student shpuld be encouraged t o do more f o r himself ?nd t o develop

a c l i t i c i a l =roach. Drast ic reduction in didact ic teaching i s e s sen t i a l

2nd closer personal contact between the student and the teacher should be

encouraged by small group discussions 2nd ac t ive p a t i c i p a t i o n of, the

students i n wmd a d 1aborr.tory a c t i v i t i e s as well a s i n r e s e w c h

Teaching of general pathology, bacteriology, pa-asitology ?nd of

phz.rm,?cology, as w e l l a s an introduction ho c l i n i c a l methods, should be

so mrznged t h z t the student has a sound bas i s of thesg subjects before he

embales on his c l i n i c s 1 apprenticeship in the hospital.

In the c l i n i c a l qezrs, the student shoulld spend near ly dl his time

in the hosp i t r l where he should be attached to each u n i t f o r a su f f i c i en t ly

long period, so t h a t he c2n fpllow his pa t ien ts uld learn t o take

respons ib i l i ty f o r t h e i r care.

Books m e f s s e n t i a l fo r the medic,d student, but the cos t of medicd

books is notoriously high vrith t h e r e s u l t th2.t m a y of the students i n t he

Region c m o t afford to buy them. Students c u l be issued books on loan

f r o m the librc.ry, o r P. coope r~ t ive system of purchase of books through

student bookshops will r e s u l t in a saving of 20% or more from t h e i r cost.

It w z s suggested tkt ~~j'HO be asked t o appronch publishjng firms with the

view of pmctucing cheap edi t ions of s t ~ n d a - d textbooks.

L i b r ~ r i e s a r e no t only usefu l f o r the ceachcrs, but also f o r t he

students who should be encour~.~:,:ed t o develop the hzb i t o f meking use of

the U b r s s y books and jourmls. The school l i b r a r y should therefore be

open f o r long hours and should have m open shelf system. The rocmenda t ions

of t he WHO consultsnt on the l ib r&es of t he medical schools of the

Region should be put i n t o pract ice .

In somc countries in the Region there a r e d i f f i c u l t i e s i n procuring

foreign books and jm.rn?ls due t o foreign exchmge W t ? t i o n s . A solution

of this d i f f i c u l t y i s nccessery t o bu i ld up proper l i b r d e s in medical

schools.

Audio-visug aids are welS organized as an integral part of modem

teaching methods. However, in the Region there is difficulty procurunent

of such aids and there i s insufficient experience of their use. The

Committee stmngly recommends that WHO and other similar,agencies should

give material assistance in dealing with this deficiency. It would be an

advantage immediately to have a t leas t one senior member of each medical

faculty especlally t r a h e d in the use of such %ids as adviser to h i s

colleagues.

With the tremendous increase of medical knowledge and t h e r e l a t i v e

limited period of medical education, it i s essentidl that medical school

teachers should have abi l i ty t o present thei r subject t o the student in

the most clear and lucid way; hence departments of pedagogy may be able

t o give valuable assistance to the medical faculty in improving their

teaching methods.

Each college should have an active curriculum cornnittee in which the

heads of all departments should participate, constzntly, and c r i t i ca l l y

evaluating thei r school- curriculum and teaching methods. The curriculum

comnittee should periodically invite all members of the staff t o discuss

the curriculum and their teaching methods.

Pages 42 through 46

SW?F ~~S (CI~IMITTEE "E")

Staff is the pivot of medical e&cation and a medical s0hool is ?s - good, and only as good, ea i t s staff. By his knowledge, reserxch,

enthusia-a w d dedication a medicd school teacher inspires his pnpXl.5, a d

by his attitude of mind end precept the teacher provides a model fo r his

students to follow. Without the correct atmosphere, which the teacher

Clone c~m provide in the medical school and the teaching hospitzl, the

future doctor cannot be expected t o have the right approach t o learning

and tho prop07 attitude towards h i s profession.

The medical school teacher has three main respnsibi l i t ies :

1. Teaching.

2. Research.

3. In the case of cl inicel teachers, p a t i a n h a m in the teaching

hoepital.

FM/SCD.CONF.MED.EDITC./ECID.~.~ page 16

Each of these three duties is t o be given due import?nce and t h e

required amount of t h e . Teaching without roseorch is barren, 2nd wsee.rch

i s e s sen t i a l f o r t he teacher t o remain a thinker and zn investigator. A

proper a t t i t u d e t o p n t i e n t - c ~ x e i s necessary for t he c l i n i c a l tea&er t o

be able t o give h i s pupi ls t he r i g h t type of apprenticeship which is

e s sen t i a l f o r t he future doctor.

These th ree respons ib i l i t i es can only be adequately discharged i f the

tea ther devotes us whole time and a t t en t ion to t h e medical school and the

te-ching hospital. It i s therefore t he opinion of the Committee ,that t h e

i d e a l i s t o have a f u l l y full-time f ~ c u l t y a t all medical schools. This

has been at ta ined i p t he depzrtments of basic medical sciences a t most of

t h e medical schools. Howeve--, in m a > countrios of t he Region, t h i s i d e a l

c ~ m o t b e immediately Fchieved f o r t he c l i n i c a l s u b j e ~ t s , but e f f o r t s

should be made f o r i t s attainment a s soon a s possible. The d i f f i c u l t y i n

providing f u l l y full- t ime staff f o r c l i n i c a l subjects i s the shortage of

su i tab ly qua l i f ied personnel who could be used entirej.y f o r t h e medical

school and the h o s p i t ~ l ?ad be adequately remuner:.ted. The Conrmittee f e e l s

t h a t l imit ing the z c t i v i t i e s of the number of highly q u d i f i e d s p e c i s l i s t

personnel who a r e all too few i n gome of t h e countries of t he Region, would

lead t o hardship t o t he community. Therefore the Conrmittee recommends as

a f i r s t s t ep t h a t in ezch c l i n i c a l subject the head of the depertment

should be f u l l y full- t ime but t h a t thorp i s also a place f o r geographical

f u l l - t h e , pert-time end honorary staff,

In t h e opinion of the Committee t he minimum teacher/student r a t i o

should be 1210 i n individual departments provided t h e s t a f f are full-time.

To t h i s should be added. pa t - t ime staff, especial13 i n t h e c l i n i c a l subjects.

The Committee d i m s s e d the ro le of non-medical teachers and cane to the

conclusion t h a t non-medical teachers have an importvlt place in the teaching

and laboyatory work et the medical school, especial ly in tho basic medical

sciences.

m~D.mNF.m.mc. /BCD.W page 1 7

Qualifications and experience

bnstra tor / regis t rar / res ident posts should be regerded as the f i r s t

stage i n specialization and the f i r s t rung of the,ladder i n the texh ing

profession and preparation for an academic career. The ~ a l i f i c a t i o n s

required for t h i s stage should be a basic medical degree ( M B B S ~ ) and $he

ab i l i ty and talent t o embark on a career of speciallaation and teaching.

For the lecturer, assistant professor and professor it i s the

opinion of the Committee that they should possess in their respect ive

subjects suitable post-graduate degrees of MD/%~S/P~D o r equivalent

qualifications recognized by the Medical Council or Upiversity concerned

with the s 'wadard of medical educztion i n the oountry. Besides the post-

graduate qualFfication the following additional minimum requirements are

recanmended for different catogorios:

Lecturer: Fivu pars' aperience a f te r graduztion, two years

of which should ha,w been s o m d as damnstrator/

registrar/resident.

Assistant Professor:

Fivo years1 experience as l ec twer and d d e n c e of

having psr%ibfcipatecl in rese?xch.

Associate Five years' experience as assist& professor and Professor and Professor: original published resc-arch work.

The above poriods e m only a guide. Some members of the Oommittee

were of the opinion that a lecturor could be d e s i m as assistant

professor when he has acquired research experience, and tha t for the

professorship f ive years1 experience as lecturer or assistent professor

was adequate. It was, however, the general opinion that selection t o the

vmious grades should be based on merit and not sonicr i ty alone.

Following a lengthy discussion as t o the method of selection and

promotion of the teaching staff, it was the general opiniota that selection

should bo based on mjnimum qualificetions and merit, following advertisanent

snd open canpetition, and thpt the mmunerntion shpuld be based on

responsibility rather than length of service zlone. It i s also suggested

that with a view t o encouraging teachers whose pranotion i s often blocked,

m/m. c0m.m. mc*/'EGam. 3 page 1 8

promotion from t h e lec turer t o e s s i s t an t professor and frm ass i s t an t

professor to associate professor be m?.de ,zfter t h e candidate has complpted

the period required and f u l f i l l e d the requirements of d i f fe ren t steges.

The professorship w i l l only be svailable when 2. vacancy occurs, though

the associate professor may s t a r t in the sca le of the professor, and the

lec turer i n the sca l e of a s s i s t ~ n t professor when quaYfied 2nd approved

i r respect ive of any f ixed number of posts. This w i l l a n i d frustra. t ion

due t o blocked p r m t i o n . Furthcr, t o oncourege teachers, the Conunittee

recommends the system of "merit ewardsu as in the Unitsd Kingdom, t o

cer ta in f acu l ty members f o r ciltstan&-g meri t and work.

The C?ommittee i s of the opinion t h a t the dean and the heed of the

medical school, as well as the heads of the departmonk should be

professors who are selected f o r t h e i r meri t and s u i t a b i l i t y t o the posts.

Terms of service

The d i f f i n d t y of a t ixact ing the r igh t type of teachers to medical

schools, especially i n t h e basic mcdical sciences, was discussed. It was

t h e unanimous opinion of the Ccamnlttee t h a t low remunerati~n which nei ther

corresponds d t h t h e long train'ng, por i s commensurate with the earning

capacity of the doctor, is t h e cause. It was therefore affirmed t h a t

adequate scales of pay, su i tab le f a c i l i t i e s f o r research 8nd fur thar

study, secur i ty of tenure, f r e e sui table r e s i d e n t i a l acconnnodation and a

retirement pmsion on which respecbble l i v ing i s possible arc the

e s s e n t m s required t o a t t r a c t sui tnble teachers to the medical schools

of the Region. The question of tenure w~s brought up by many members of

the Conanittee and, a f t e r careful deliberation, it was t h e opinion of the

Conanittee t h a t once t h e period of probation i s sa%isfac tor i ly completed,

no teacher, should be moved f r a n h i s post except f o r incanpetence o r

misconduct. Further, in tho opinion of the Conunittee, capensat ion f o r

t h e l o s s of pr iva te prac t ice should be, r e a l i s t i c and not l e s s than a

103 per cent increase i n the basic pay.

Research and progressive education

Research i s an e s sen t id and integral part of teaching and the

continued education of a teacher. Each teaching department should

therefore be provided with adequate funds, suitable working fatuities

and proper s teff for research, and the necessity of providing a secretaxy

to each deparhent i s most urgent. The role of "research f e l l o ~ s " in the

research progrgmo of ewh department cannot be over+mphasimd.

The question of defining resoarch in relation to teaching i s diff icult ,

but it was the opinion of the Committee that balance between the two is

necessary, depending on various factors i n different countries.

A p r o g r a e of continued educaticn of the teacher, senior as well as

junior, is essential. The following are the methods suggested:

1. Periodic conferences, teaching inst i tutes and workshops, seniners

and demonstrztions a t various levels -,college, intar-collegiate,

university, national and internaticnal. A suggestion was made for

teaching dEanonstre,tions i n pedagogy by d e n t educators who have studied

problem of medical teaching.

2. Regular v i s i t s t o other institutions in the country and abroad

t o attend conferences and seminars qnd to see teaching and resparch as

well as to keep contrct with those eng.?.ged i n similar problems. It is

f e l t essential that each s taff member should go abroad a t leas t once ewry

3 - 5 years. For these v i s i t s the national govonment or international

agencies l i ke WHO should pea- the cost as the teachers-cannot afford the

high e-nditure involv~d. A plea was mede fo r grearter use of

f ac i l i t i e s in the Region and it was suggested thatWH0 should poriodiczlly

prepare md ckcula te particulars of institutions of high merit.and

details of the research work effected i n various schools i n the Region

3. Periodic v i s i t s by eminent teachers fran abrod and exchange of

teachers between different coun3ries as visi t ing professors, especia3ly

between countries of the Region.

BM/SCD. M)NF.MED.EDUC. /BT;D.XTL3 page 20

Student preceptorship

The value of student p r r t i c ipa t ion i n the teaching progrvnme is

evident, not only t o c rea te i n t e r e s t among $he students, but a lso t o help

l imi ted f ccu l t i e s in the teaching programno. The Committee gonerally

supports the idea of senior students tenching t h e i r junior colleagues a s

teaching and learnings i s a two-way process, and rocommends c ~ r e f l i l

planning of such a progr~ame and encouragement of system.

A-iary s t a f f

Sui table g d i a r y stzff can not only l igh ten the heavy burden of

thc teaching s t a f f , but greetly enhance the eff ic iency and scope o f

teachfnlle, research and patient-care a t the medical school and the teaching

hospital. The Committee therefore recanmends the provision of an appropria.te

number of s u i t a b l l t ra ined technicians f o r t h e depmtments and l a b r e t o r i e s ,

t echnic ims f o r instrument repair shops and sec rc tmies f o r all departments.

In conclt~sion, t he Committee makes a plea t h a t i f t h e aims and

objectives of medical educ?.ticn a r e t o be achieved nnd the standards of

the fu tu re doctor is t o be improved, constant a t ten t ion is required t o

create an atmosphere of l ~ ? x n i n g , and research f o r t he stzff of t h e medical

school and the teaching hospit'al.

Pages b7 through 50

INTERNSHIP TRtZNING (CmiTIS'PTEE "F")

I General c ~ n s i d e r a t i o n s

The Committee ccnsiders t h a t t he success of internship and residency

programmes, depends to a great extent on the atmosphere and standards of

t he hospitnl, teaching in s t i t u t i cns , t r a in ing community heal th c a t r c s ,

etc., where these p r o g r m e s a rc carr ied out.

Certain standards m e needed i n thesc teaching and t ra in ing inst i tut ions , ,

which should be worked out for each co~mtry, kept up ~ n d surveyed continuously.

It i s highly desir?.ble t o have a ccmrmittee t o study these standards i n each

medical school and it i s sug?ested th.t a cunt rc l body on a nat ional l ove l

should be formed i n ea.ch corntry comprising representatLves of the medical

schools, health authorities an' other concerned agencies. Th i s body

should study end l ay down the standards needed, i n the above mentioned

institutions for the achievement of excellence. It should have the power

to s u m y these standards and t o gim, accreditation t o the, different

hospitals and centres chosen for these training progranmes. It should

also survay and follow up such institutions periodically t o ensure that

they are keeping t o the necessary standards. This body coulZ obtain

guidance frcm tho work done by s h i l a r organieations in other countries.

The Canrmittee also suggosts that the World Health Organization should,

Ff possible, ccnvene an Expert Cormnittee t o study and make recamendations

for acceptable standards i n hospitals and camunity h e a t h centres u t i l i sed

for the internship and residency training i n the Region.

These st-dmds should re la te t o such items as: si&e of the hospitd,

its oquirpilent, out-pationt department, medical and nursing staff,

laboratory faci l i t ies , systcm of medical records, l ibrary and osher

f a c i l i t i e s for scientif ic and educational act iv i t ies in general.

Hospitals and cmnniunity health centres, choscn for the internship and

residency progrmes, should comply w i t h the standards l a i d down by the

national body. The u l t h a b c-hoice of these hospitrls and contres as

w e l l a s the training progranmes, rests with the medical school concerned.

I1 Internship training

l. Necessity, type and duration

The h m i t t e ~ unanimously agreed that a ccanpulsory period of intern-

ship is essenti,d, The copcep$ of internship was accwted as defined in

Basie Document No, %N/COAIF.~. JUiC/7 (page 591, vis:

"Tho intern is the hcusoman with his duties but he is also the

subject of a controlled programme of learning, and the enphasis is

on the educatAve process both practical and cl inical as well a8

instructional. "

~/xD. CONF.MED. mc. ~3m.m.3 page 22

With t h a t ccncept, this perio6 of internship can be consi&red a s a

necessary continuation of the mescal c u r r i a l u n . For t h a t reason, the

Committee agreed t h a t t h i s period should be cmpleted i n a sa%isfactpry

manner, a f t e r t he f i n d exanination, but before receiving the degree.

Howevz cn opinion was expressed i n the plenary session that, t h e degree

should be grznted b ~ f o r e the cmpulsory period of internship.

The Committee considers t h a t the ro ta t ing internship is the most

usefu l type f o r the students i n t h i s Region.

With a progressive curriculum, laying emphasis on t h e importance of

c l i n i c d cJerkship, a period of twelve months should be adequzte f o r t he

internship. The internship i s a full-time job, necessi ta t ing the

contirmous presence of t h e intarn on the prLnisas while on duty and

complete dewtion t o h i s work. The schedule f o r t he interns should be so

a r r a n p d as t o o f f c r tho maimum pducational opportunit ies whilc maintaining

a proper standard of pa t ien t care. T h o off f o r t h e in te rn i s a pr ivi lege

and no t a r i g h t and should be tgrznted only ~ r h c n i t ,does no t i n t e r f e re with

pa t i en t care end proper functirning of the service. Tlus makes it essontisii in tho C m i t t e c ' s opinion, t h a t , i n t e m s should be lodged,

bosrdcd and paid a st ipend by tho hospital.

2. Hospital and community heal th centres selocted f o r t r a i n i n g

The standards of the h o s p i t d s md community health centrcs selected

to receive inttms, should be assessed by the nat ional bcdios suggcsted

above; these bodies grznt recognition of these hospi ta ls and may prescribe

t h e broad out l ines governing the rc lc t i rnsh ip between non-teaching

hospi ta ls md camunity heLdth ccntres chosen f o r trz"ining on $he one hand,

and t e x h i n g h 0 s p i ~ 2 . s on the other hrmd, i n regard t o intcrns. The

programme of internship should be tho respons ib i l i ty o f t h e medical school

which supervises i t s execution in the hoqi t5l .s end h e a t h ccntres ohosen.

When t he teaching h o s p i t d s cannot e.bbsorb all t h e yew ' s graduates,

t he consensus of opinion i n t he Committee was t h a t it i s b e t t o t o ro t a t e

all in te rns in both tho teaching ,md non-teaching i n s t i t u t i o n s ra ther than

se lec t ing the bust students f o r posts i n the kach ing hospitrils and

assigning others to non-teaching ins t i tu t ions .

3. Training programme

By i t s nature, internship training includes service and responsibility

i n patient care. However, mphasis should be placed on its educaticnal

aspects,and a satisfactory balance between octucaticn and service must be

reached. Teaching act ivi t ies such as conferences, lec twes and practical

exercises would fac i l i tg te the achievanent of t h i s goal. Mdactic

teaching should be kept t o the minimum and the intern should be trajned

t o learn by &self. Library f~.cj.lities for the house-staff should be

provided and their use encouraged. A proper ra t io of hospital beds per

intern, wopld help in keeping the balance between service and educational

activities. The Camtttee considers such a ra t io to be f i f teen t o twenty-

f i ve beds per inten

Creation of a c d t t e e , comprising representatives of interns,

residents, medical s taf f and hospital arlministratim authorities, would

secure batter worldng relationship among all the staff ccncerned. This

would also m o w constan$ evaluaticn of the results of different sorvices

and education activities. Furthermore, it would ensure an understanding

and willing participation of the interns a d residents in the hospital

activities, thus achieving higher standards.

This c d t t e e would be in an earcellent positicn t o pramote the

~ o c i a l and recreational ac t iv i t ies of the interns and residents and t o

help making them conmNnity-mindd.

Due t o the inqmrtance r f comuiunity health services, the Committee

considers it essential that every intern should spend a period of about

two months in community health centres, chosen by the medical school fo r

training purposes, under the supinrision of its toaching staff. Active

participation of the s taf f i n tho educational an6 training acti,xLties of

these centres, is essential for achim~~ment of the desired go&