Report of the Royal Commission on Medical Education 99

future. One would feel that, unless the family physician finds an attractive and challenging role available to him after such a period of training, he will be increasingly frustrated by this lengthy requirement.

The recommendations concerning undergraduate education are very similar to those being proposed in t h i s country. The move towards increasing flexibility in the curriculum is everywhere apparent. There is a generally accepted move towards ‘streaming’ by means of electives, as opposed to the creation of a number of formal pathways through the final years of the undergraduate experience. The downgrading of the formal test in favour of an on-going day-to-day evaluation of the student is surely long overdue in both countries.

Of great interest to a Canadian educator was the recommendation that all medical schools be made part of multi-faculty universities. On this continent the Flexner Report of xgro made such a strong recommendation to this end that, within a very few years, every medical school was part of a general university. However, although associated

with universities in an administrative sense there was, for many years, very little functional relation- ship between the two. Medical schools were almost foreign bodies on university campuses. They contributed little or nothing to the university and received little or nothing in return. It is only in the past two decades that the interests of medical schools and those of other university disciplines began to merge. Now the ties are strong and steadily be- coming stronger. We have shared interests with the engineering schools, the behavioural’ sciences, the economists, the urban planners and, to some degree, with most disciplines represented on a university campus. The wisdom of this recommendation is strikingly clear in Canada where we have begun to taste the rewards of union with the university.

The ferment in medical education at all levels and the concern about the future patterns of health care are very widespread phenomena today. A Canadian reading the Commission’s Report cannot but be impressed with the similarity of our prob- lems and the generally similar approaches toward their solution which are being accepted in the two countries.

Postgraduate Education

H E N R Y M I L L E R University of Newcastle

Medical education is a controversial subject on which our opinions are mildewed by tradition, prejudiced by personal experience, and for the most part insecurely based on inadequate evidence. For these reasons it is unlikely that any commentator will agree with the views of the Royal Commission in every detail. I regard its Report as an edightened document, and its recommendations for reform as a valiant attempt to achieve a compromise between what .would be ideal and what is feasible if the will is there. I applaud especially the logical incorporation of the teaching hospital within the regional frame- work as a university hospital; the realistic and excit- ing concepts of the larger hospital and medical school; the liberalization of student entry require- ments, even if they may in the end imply some lengthening of the course; and the recognition of postgraduate professional training as an obligatory sequel to academic undergraduate education. In the matter of primary medical care the Com-

mission follows the Ministry of Health and the B.M.A. in accepting the obligation to furnish a

personal doctor as well as a specialized service based on the hospital, and envisages salvation in revivified and rationalized large-group general practice run from purpose-built health centres. The fact that the provision of primary care through a system of specialist .polyclinics is anathema to most of the profession in Britain presumably excluded it from serious consideration, which is not unreasonable. Ideally, it is perhaps difficult to fault the Commis- sion’s recommendations in this connection, but the suspicion remains that they may be overtaken by events. An overall shortage of doctors will be with us for many years, and under present conditions at any rate only a minority of students regard practice centred round the domiciliary care of minor illness and the adjustment of ‘personality disorders’ as a first professional choice. In medicine as elsewhere some jobs are more Faxing than others, and even in an age of egalitarianism I iind it difficult to envisage real parity of esteem between the skilled neuro- surgeon and the skilled general practitioner - unless of course his practice happens to be in Mayfair.

I 0 0 Report of the Royal Commission on Medical Education

In general the section of the report that deals with postgraduate education is excellent, and with one exception criticism is minor.

Except in the case of those already committed to a laboratory career on graduation there can be no two opinions about the necessity of a three to four year period of progressive and varied clinical respon- sibility after qualification. Even the embryo labora- tory worker should at least complete his intern year. Professional ambitions and directions may change with the years, and the man or woman who has completed an internship is in a position easily to resume general professional training even after an appreciable laboratory interlude.

The Commission’s recommendations about the preregistration year would be supported by any medical Dean, though the extent to which such employment has in fact been subject to academic supervision that is more than nominal varies remark- ably from region to region. Arid in the urgent and vital matter of furnishing married quarters for junior medical staff at all levels our record is in- excusable. For the most part such accommodation has been provided only where appointments were so desperately unattractive that there was no other conceivable method of attracting applicants. If the Minister is seriously concerned to improve hospital staffing he should ask every hospital authority for a statement of its present position and a time-tabled plan in this connection - and publish the results.

With regard to hospital training, the necessary provision of time for part-time or full-time post- graduate study demands an increase in staff, and not the irresponsible procedure . of ordering release without augmenting establishment, and unloading the resultant difficulties on hospitals often already dangerously undermanned.

Among other aspects of the Commission’s recom- mendations that must be wholeheartedly supported are included more organized arrangements for advice about the choice of a career. It is not easy to tell a man that he is unlikely or unfit to become a consultant, and more comfortable to let him find Out for himself through a succession of failed appli- cations for appointment, but the provision of more formal machinery for the administration of such unattractive advice would be both kinder and more economical.

The Postgraduate Institutes The contention that for some unspecified reasons undergraduate and postgraduate teaching are best conducted in separate institutions enjoys no support in medical circles in the provinces or overseas, or for that matter in other fields of scientific activity here. It has always struck me as a piece of special pleading related to the metropolitan situation, and to the

multiple hospital appointment system that is so inimical to sustained professional application. The recommended affiliation of the various postgraduate institutes with appropriate undergraduate teaching hospitals must therefore be regarded as a step in the right direction. But nothing can be done until building can begin. Why not be more radical, and replace the institutes by viable academic and service specialist units in each of the new enlarged teaching- hospital complexes ? The existence of autonomous departments disseminating specialist expertise throughout the general hospital environment, and each in a position to make a distinctive contribution to some particular aspect of the specialty would surely be preferable to the perpetuation of a mono- lithic pattern based on nothing more logical than the historical accident of the nineteenth-century special hospital ?

The Royal Colleges The Commission’s strictures on the proliferation of postgraduate diplomas make heartening reading, and it was fortunate that its deliberations were guided by so eminent an exponent of a discipline that main- tains the highest academic standards without the aid of this rickety superstructure. I must admit to some ambivalence of view on the subject of examinations, sharing Oscar’s view that while they are to be abhor- red, those who can’t pass should be regarded with some suspicion. However, a situation in which an Edinburgh Fellowship is a more than adequate qualification for a chair of surgery in any British university but disqualifies an applicant for the post of assistant surgeon at St. Ananias’s Hospital, East Cheam, is lunatic rather than merely indefensible.

The trouble is, of course, that ever since serious medicine in Britriin became decentralized, .and flourished in universities and teaching hospitals up and down the country, the Royal Colleges have been, to paraphrase Pirandello, Institutions in search of a Function. In this connection the Com- mission’s Report offers little solace. The universities are unlikely to abrogate responsibility for organking and supervising their postgraduate training courses, or for undertaking the continuous assessment of trainee progress that will mercifully devalue the examination lottery, while the Report confirms that it is the General Medical Council that will be charged with maintaining the specialist registers and supervising their standards. Within the general pattern of postgraduate training considerable variation will continue to operate between different schools as it operates today - despite the appearance of uniformity imposed by the diploma system - and it should surely be encouraged. But the universities will be at least as jealous of their accolade as the Royal Colleges, and since it will be based on intimate

Report of rhe Royal Commission on Medical Educarion I01

knowledge over a period of years rather than on a brief encounter in. the artificial situation of an examination room it is likely to prove a more valid measure of clinical ability. Furthermore the Colleges have always been examining rather than educational institutions and seem likely to remain so: they have no facilities for undertaking a serious educational function. The universities will undoubtedly need to accept inspection in relation to the efficient per- formance of their educational duties in the post- graduate field, but it is difficult to envisage much enthusiasm for the improbable suggestion that this function might be allocated to the Colleges rather than the G.M.C.

If the Royal Colleges are to find a real place in the medicine of the future they would be well advised to begin by agreeing on complete reciprocity here and now, scotching the aetiology of multiple diplomato- sis to free the energies of aspirant consultants for more productive activities. At the present time the acquisition of two memberships is all too often the signal for an eagerly awaited withdrawal from all forms of intellectual professional activity.

Psychiatry Psychiatry is the most important, the most exciting, and the most difficult branch of medicine, but it is emphatically medicine and not a thing-in-itself. In this connexion it is with regret that I must describe the Commission’s approach and recommendations as thoroughly deplorable. This is certainly not due to any failure to accord adequate space to the subject. Indeed the amount of attention devoted to educa- tion in psychiatry suggests that as far as other branches of medicine are concerned the educational situation is either so unimportant as to escape notice or SO perfect as to require no improvement, both of which contentions are demonstrably false. Psychiatry scores 32 index entries (as against two for neurology and one for cardiology), while no less than 19 para- graphs are devoted to a very pedestrian account of the mysteries of undergraduate and postgraduate education in the subject - as against nil for general medicine and surgery, to say nothing of the special- ties mentioned above. Not only the extent but the style of these sections of the Report contrasts with the remainder; the crisp relevance of the rest of the Report gives place to psychiatric cliche muttered

lip-service to the tarnished dogma of psycho- analysis, and tacit acceptance of psychological determinism as the mainspring of psychiatric dis- order. However, the fashion for ‘psycho-dynamic’ (sic) psychiatry is not entirely limited to the glossy magazines, and psychiatry and prolixity are in- separable bedfellows. What is more ominous for the future is that this disproportionate treatment con- iirms the existence of the chasm that some psychia- trists seek to maintain between psychiatry and medicine, or between illness w l h and illness without mental symptoms, which is after all the only difference between the two disciplines.

Psychiatry is a symptomatic specialty. The Report however, seems for the most part to envisage not a clinical discipline firmly based on medicine, but one floating uneasily on a swamp of such intangibles as psycho-dynamics, sociology, and learning theory. It betrays an unjustified emphasis on the role of psychological factors in the aetiology of illness with psychological symptoms. I find it staggering to read the ‘consolidation of general medical experience by spending six months or a year in general medicine (either in hospital or in general practice), should. . . be regarded as optional’ in the training of a psychiatric specialist; and frankly alarming to observe that six months’ part-time instruction in neurology is considered an adequate safeguard against the prolonged treatment of raised intracranial pressure with psychotherapy.

I hope I am right in believing that th is approach to psychiatry is unlikely to be shared by responsible British psychiatrists, who are well aware that before a man can set about becoming a competent psychia- trist, he must already be a safe and effective physician.

In conclusion I am deeply impressed by the Report of the Royal Commission on Medical Education, by its view of the probable future, and by the radical changes it proposes in the administra- tive organization of British medicine. I believe that its assessment of undergraduate education as a general introduction to the subject, its concentration of professional vocational training in the post- graduate phase, and its devaluation of the diploma examination system are excellent. I am sure that its apparent acquiescence in the separation of psychia- try from medicine (and neurology) will be ignored by history.

Postgraduate Training for General Practice P. S . B Y R N E General Practitioner

The therapy demanded by major illness may not be would like. The serious malaise of general practice as quick-acting nor as acceptable as the patient is international and climactic. The measures