Environmental Studies: the Search for an Institutional Form 163

apocalyptic thunderings about the doom of mankind are accepted as'experts in fields in which they have no expertise.

Yours faithfully,

Monks Wood Experimental Station, KENNETH MELLANBu Huntingdon

TH E BALANCE OF RESEARCH, T E A C H I N G AND SERVICE IN

MEDICAL E D U C A T I O N

1 September, 1971

Sir,--Dr. Prywes' paper 1 gives an excellent account of attempts that are being made in many parts of the world to expand and improve medical education to meet the increased expectations of society. Perhaps because of i,ts internal cohesion, the medical profession has made more progress. thap any other in this field, and has even made scientific comributions to such general educational problems as the valida, tion of examinations and the relative virtues of instruction by teaching n~achines and .personal teachers for different types o,f student. In Britain at any rate this contras~ with the sketchy organisation of professional education for engineering, while legal education seems to be locked in fruitless controversy. However for some of us, obsessive ,preoccupation with ,the shape of the medical curriculum has gone too far. Scarcely a week passes without a conference being mounted somewhere between Calgary and Calcutta, 'at which medical deans and professors turned symposionauts preach the virtues of their particular educational recipe, instead of staying at home and doing some actual teach- ing. It is easy .to overlook the crucial fact that, whatever the pattern of the curriculum, the tone of a first-class medical school depends on haft a dozen truly outstanding clinical teachers able at the same time to evoke enthusiasm and to inculcate a scientifically critical outlook. Without these it will be a dead duck--whether~the teaching is departmental, interdisciplinary, horizontal, vertical or oblique. To find and keep the right staff is the critical factor.

After such an uneontroversial overture I .should like to unveil a few personal prejudices.

(1) There is no "solution" to the problems raised by Dr. Prywes. Controversy will .be interminable and progress pendular. Anyway there is great virtue in variety. I favour an even more integrated curriculum than we have so far achieved (influenced by the example of Case Western Reserve University Medical School) in Newcastle, and would like to abolish the separate pre-clinical phase by incorporating it into a curriculum centred romad the patient from the start, and making full use of the wealth of part- time teaching talem in the regional services. Three years of anatomy and physiology at Cambridge followed by all abrupt transition to the wards of St. Thomas's is certainly not the sort of curriculum that would be devised by anybody starting from scratch today. But nobody starts from scratch; even the new medical schools inherit an historically determined situation, especially i~ the matter of hospital facilities. And the remarkable' thing is that in the end there is little or nothing to distinguish the products 'of the different systems. There is little to choose professionally between the better medical graduates of Oxford, Harvard or Glasgow working in the: same line at the age of 30--except that the American is somewhat liable lo have had

1 Prywes, Moshe I " The Balance of Research, Teaching and Service in Medical Educa- tion ',, Minerva; IX, 4 (October, 1971), pp. 451-471.

164 Correspondence

less intensive personal clinical experience and responsibility, and that because of rigorous selexxion and the broad scope of American general education at its best he may also prove to have bo~h a higher IQ and a wider range of interests.

(2) What sort of physician are we seeking to t r a i n ? Can the general practitioner survive in Britain against the worldwide trend toward speeialisa- tion? Is the present revival of interest in family doctoring here and in the United States realistic, or just whistling in the dark? Can the developed countries really embark on a feldsher system that is gradually being phased out in the Soviet Union and is unacceptable to .the public even in Africa? There are so many uncertainties in the situation that I can see absolutely no alternative to the basic training of "mul.ti~potential" physicians with a view to varied and extended postgraduate vocational courses--with a large service component--after graduation.

(3) As one whose working life as a physician has been spen.t studying, interpreting and ,trying to influence human behaviour I remain highly sceptical about the possible contribution of the so-called behavioural sciences to medical education, and my scepticism is shared by most medical students so far exposed to them. Epidemiology and social medicine by all means, but exactly what has the contribution of the behavioural sciences been to medicine? In what way have sociology and its related disciplines actually influenced the daily practice of medicine? At this point the name of Durkheim is always darkly muttered. But shouldn',t we wait until there is a real contribution to offer before we load the student with yet another glossary of jargon?

(4) The Soviet system af dissociating medical education from the uni- versities and conducting it in academies or institutes under the Health Ministry has obvious disadvantages and has been unevenly .applied in Eastern Europe. It has, however, one overriding advantage. It means that the responsibility for training an adequate number of physicians .to man the health service sits fairly and squarely on the shoulders of .those responsible for rtmning it--and it is significant that the Soviet Union is the only major country in the world where the number of physicians is almost adequate to meet ,the needs of its popnlation. In the anarchy of the United States nobody is responsible. In Britain, medicine competes for a slice of the University Grants Committee's education cake with oriental studies, philosophy and traffic engineering. Meanwhile the Department of Health has no part in the exercise, and stands aside in Olymlaian detachment while its luckier casual,ty departments remain: open and partly manned by courtesy of .the Universities of Dacca and Madras. Does the tremendous intellectual dividend paid by educating medical students under the same roof as archae- ologists justify the social irresponsibility of such an arrangement?

(5) One final point. The potential benefits of modern medicine are enormous, and we all want them for ourselves and our families. But our politicians state quite baldly .that we are unwilling to pay taxes .to finance them. Curiously, I have never been asked whether I object to paying taxes to build nuclear submarines or to prop up Stormont, but this must be an oversight. The plain fact is .that the cos.t of a comprehensive health service is ,of an order that can be met only from public funds--i.e., by the healthy paying for the sick. If .this really is politically impracticable---and Mr. Jenkins' last financial projections suggest th~ this view is accepted even by ,the :Labour Party--then we may as well save our breath and paper.

Yours sincerely, University of Newcastle upon Tyne HENRY MILLER