Challenging medical education

Greg Baxter spoke to Prof Geraldine MacCarrick, about the introduction of outcomes-based medical education.
The principles of medical education that dominated the 20th century, proposed in 1910 by Abraham Flexner, stated that future doctors ought to spend years listening to lectures, working in labs and memorising textbooks before immersion in a clinical setting largely divorced from scientific study. These have been slow to disappear from Ireland.

That’s not necessarily a bad thing, according to Prof Geraldine MacCarrick, the Vice Dean of Medical Education at the Royal College of Surgeons in Ireland (RCSI), since many experts complain that pedagogical modernisation has gone too far in places.
Future doctors were learning about the social implications of medicine and becoming skilled problem solvers, but lacked a basic knowledge of anatomy, she told Irish Medical Times.
Prof MacCarrick was born in Ireland but emigrated to Australia at the age of 10. She did her undergraduate and postgraduate training in Australia, worked as Medical Officer for the Royal Australian Air Force and as a GP, then moved to hospital administration, and finally to education.
From 2002 to 2007, she was the Foundation Director of Medical Education at the Tasmanian School of Medicine. In her position with the RCSI, she’s charged with implementing and maintaining best practice in education at the College, and securing re-accreditation from the World Federation for Medical Education (WFME). The Medical Council plans to officially adopt the WFME standards shortly, though it has used them to accredit medical schools already.
The RCSI officially adopted them in 2005 – it is the only institution to have sought, unprovoked, external accreditation, and this shows the RCSI’s unique commitment to outcomes-based medical education, she said.
She called outcomes-based medical education – which has become the new global standard – the ‘new Flexnerian revolution’. “We are defining the end of the journey in advance. We want to know what our medical graduates will be able to do when they complete the programme,” she said.
h4. Obsolescence
Healthcare delivery is undergoing a major transformation. There’s an ever-increasing amount of knowledge doctors need to know, an increasing number of therapies, issues around cost-effectiveness, reduced lengths-of-stay in hospitals and reduced training time for interns. All these factors and more are leading the old approach – hammering expertise into passive brains – toward obsolescence, according to Prof MacCarrick.
“Medical schools have to think creatively about the best way to deliver training. The traditional divide between didacticism and disciplined scientific work followed by hospital activity did not prepare clinicians for their profession. It created an artificial divide,” she said.
A United States study in the 1980s undermined the Flexner approach by recommending that basic sciences and medical education be better integrated. “A lot of medical schools around the world are introducing patient bedside teaching much earlier in the programme, and have it in parallel with the basic teaching of sciences.”
h4. Nine standards
There are nine WFME standards that must be met to receive accreditation. Prof MacCarrick said when she arrived, the RCSI was struggling with the two standards with which all medical schools struggle most – programme evaluation and student assessment.
“How do you know your curriculum is delivering the goods? How do you know your graduates are fit for purpose? It is increasingly the responsibility of medical schools to ask those questions. Where do our graduates go? What contribution are they making to the workplace? How fit do they feel they are for clinical practice when they emerge?” she asked.
“We are starting to do that research at RCSI, where I have to say it’s more challenging because a significant number of graduates move overseas. Tracking them can be daunting.”
The area of student assessment is the focus of a great deal of research and debate.
“How do we make sure students require the requisite learning along the way? How do we assess their problem-solving skills, their history-taking and clinical skills?”
h4. Valid and reliable
“The challenge in all medical schools is that the assessment methods that are chosen must be valid and reliable – they measure what they intend to measure, and you can reproduce the same results over time,” she said, adding that while a lot of work has been done in post-graduate assessment, there has been an increase in interest in undergraduate assessment.
Another area that presents a challenge for all medical schools globally is the decreasing lengths-of-stay in hospitals. “We can’t rely on opportunistic learning on the ward rounds for medical students. We have to create learning opportunities for them,” she said.
The way to approach this is through simulation – manikins, models, computer simulation, standardised patients who are trained to deliver a history and physical examination findings to students for teaching purposes, said Prof MacCarrick.
“These are resource-hungry activities,” she said, and the RCSI is pursuing leading-edge simulation models.