Reforming higher specialist training in the United Kingdom--a step along the continuum of medical education

OBJECTIVES: The requirement to align the arrangements for postgraduate training in the United Kingdom with those elsewhere in the European Community provided the opportunity to review and reform our arrangements for higher specialist training. This paper describes the case for change--the strengths and deficiencies of the traditional pattern of postgraduate medical training, demographic influences in the medical workforce and the need for a more structural or planned approach to training. CONCLUSIONS: Over the past 5 years substantial progress has been made: the introduction of new regulatory arrangements and a new higher specialist training grade; the development of a managed and flexible system for delivering training to standards set by the Royal Colleges and which can accommodate the needs of those pursuing academic and research medicine; and the opportunity for trainees' progress to be measured against published curricula. The significant programme of change has been underpinned by careful workforce planning and the publication of comprehensive guidance. Significant reform of higher specialist training has been achieved. This paper also makes the case for a more strategic approach to planning and developing medical education across the continuum, from entry to medical school until retirement, which can guide medical education and improve patient care into the next millennium.     

Specialist training and medical research in developing countries of tropical Africa: a case for the establishment of postgraduate medical schools

Developing countries like developed ones need highly skilled medical personnel, referred to as 'specialists'. In the case of developing countries, the training of these specialists abroad is expensive to the sponsoring governments, imposes a lot of hardship on the doctors and, above all, the coursecontent of such training takes little or no cognizance of the environment in which these doctors would later practise. The developing countries also cannot afford the loss of years in valuable services which the training abroad entails.
Attempts are now being made to train specialists wholly or partly at home, in some developing countries. The approach is still not much divorced from what obtains in Britain and North America, that is, one of being trained on the job, with the onus for self-education being placed on the prospective students. Such students in most developing countries of tropical Africa have little or no facilities for further education outside their places of work.
It is proposed that purpose-designed postgraduate medical schools may provide a temporary solution to specialist training in developing countries of tropical Africa. Such schools would in addition provide highly skilled medical service as well as obviate the need and the expense for the setting up of government sponsored medical research and training institutes.     

Medical doctors' attitudes and beliefs about diet and health are more like those of their lay countrymen (France, Germany, Italy, UK and USA) than those of doctors in other countries

The relation between diet and health has become a public health concern in Western/developed countries. Physicians are influenced in their views about health by their medical training and membership in a particular culture/nation to one extent or another. Their medical training is itself influenced by both a common body of accepted formal knowledge and practice and culture- or nation-specific influences on medical education. In this study, we compared physicians from different countries and physicians and lay individuals from the same country with regard to beliefs and attitudes about the relation between diet and health and other health-related issues. Telephone interviews about diet and health conducted with randomly sampled physicians and laypersons in France, Germany, Italy, the United Kingdom, and the USA revealed substantial cultural/national differences and few differences between physicians and laypersons of the same country. Three different measures of similarity converged in supporting the claim that in the areas of diet and health, physicians resemble their countrymen more than they resemble physicians from other Western countries. The degree to which differences in culture- and nation-mediated medical education influence these results is to be determined.     

Survey of the career experience and postgraduate training of the 1965 and 1970 graduates of the Scottish university medical schools

A survey of the career experience and postgraduate training of the 1965 and 1970 graduates of the Scottish university medical schools was carried out in 1975. The duration of training for the specialties of medicine and surgery and for obstetrics and gynaecology was in general longer than for anaesthetics, psychiatry and radiology; the implications of varying periods of training for postgraduate education are discussed. Attention is drawn to a number of factors which influenced career choice. The 1970 graduates who became principals spent longer in training for general practice than those of 1965. Some married women with children had difficulty in finding suitable part-time work; this may be a serious problem for those seeking accreditation of higher specialist training and for training for general practice. It was estimated that, of the British nationals, about 11% of the 1965 and 8% of the 1970 graduates had emigrated. General practice was the discipline most commonly chosen by doctors working overseas.     

Medical specialization in Europe: the way forward Promotion of educational quality

Summary. The medical specialties are being intensively reconsidered in the countries of Europe. The important need is for promoting improvement of educational training programmes. Evaluation and improvement of specialist training programmes is the priority and not the setting up of qualifying examinations. The first necessity is to safeguard 20 years of evolution in postgraduate training. Support for the educational process is essential, to a much greater extent than occurs at present, if standards are to be improved and the confidence of the public is to be retained. The EC medical education system is the only existing international structure in medical education which is controlled by law, and is on that basis alone of the greatest interest.     

The current status and future needs of education and training in family medicine and primary care in South Africa

South Africa is undergoing tremendous political and social change affecting every sphere of society, including medical education and the delivery of health services. The legacy of its history created a health system that in some respects can be compared to the best in the world, but one also characterized by inequity, discrimination and lack of access to even basic services for the rural and the poor. Its medical education system trails behind modern trends such as problem-based learning, community-based education and the utilizing of general/family practitioners as trainers. Vocational training in family practice is not compulsory for independent practice. The discipline of family practice has nevertheless developed the programmes and core infrastructure for such a future undertaking in the form of masters programmes in family medicine at all medical schools. The recently introduced system of compulsory recertification through continuous professional development provides a window of opportunity to develop locally relevant curricula and appropriate education and training methods for family practitioners. Challenges for family practice include the establishment of the role and value of the discipline in a developing country with a health system based on a nurse-driven primary care service and the re-orientation of family medicine teachers, trained in a biomedical paradigm, to the patient-centred approach. The aspirations of family practice are to define the core content of the discipline, establish and nurture a culture of research in primary care, and to develop and introduce appropriate under and postgraduate training programmes for the new generation of family doctors.     

Career destinations and views in 1998 of the doctors who qualified in the United Kingdom in 1993

OBJECTIVE: To report career destinations and views in 1998 of doctors who qualified in the United Kingdom (UK) in 1993. DESIGN: Postal questionnaire survey. SETTING: This study took place in the United Kingdom. SUBJECTS: All doctors who qualified in the UK in 1993. MAIN OUTCOME MEASURES: The percentage of doctors in each branch of medicine five years after qualification, and their views on their training and career opportunities. RESULTS: The NHS and universities in the UK employed 88% of respondents (men 90%, women 86%). UK general practice employed 24% of respondents (men 19%, women 28%). There were significant differences (P < 0.01) between the percentages of men and women working in the surgical specialties (men 28%, women 10%), paediatrics (men 8%, women 15%) and obstetrics and gynaecology (men 5%, women 10%). Respondents not in paid employment comprised 1.4% of men and 6.6% of women. 45% of respondents agreed that their postgraduate training was of a high standard, with 26% disagreeing and 29% unsure. 47% of specialist registrars felt their training was too short and 78% were concerned about the availability of consultant posts on completion. CONCLUSIONS: Although loss of doctors from the British workforce through emigration or unemployment is not increasing, our findings confirm a substantial shift away from careers in general practice. The number of home-trained GPs from this generation of doctors will be inadequate to meet service needs. GPs and hospital specialist doctors expressed concerns about quality of training, lack of careers advice, the shortness of specialist registrar training and availability of consultant posts on completion of training.     

Training for health care in developing countries: the work of the Tropical Health and Education Trust

The Tropical Health and Education Trust (THET) was established to strengthen medical education and training for health care in developing countries. The Trust responds to requests from training institutions with a wide range of activities and programmes. Projects to meet specific needs are planned in outline with the Deans or Directors of institutions, as a basis for a long-term link with a similar institution in the United Kingdom. These links are now the preferred method for meeting requests to develop skills, strengthen services and promote staff development. However, funding is always necessary for their support. THET has promoted students' community-based training by enabling students in a team-training programme in Ethiopia to make interventions in primary health care. A prize for the best students' community, clinical or laboratory projects in six African countries encourages enquiry by the students, promotes independent learning, and relates academic work to problems in health care. Work with Ministries of Health includes a continuing medical education programme for rural medical officers in Uganda, courses in basic and life-saving surgery for Ethiopian health and medical officers, and a programme to update the skills of laboratory technologists in rural hospitals in Ghana. The range of projects that THET supports is wide because the needs, defined by those who are working in, and responsible for, training in the health service are diverse.     

Flexible training opportunities in the European Union

This paper compares the opportunities for flexible (part-time) specialist training in the UK and elsewhere in the EU in the overall context of the rising numbers of women doctors across Europe. Few other EU countries appear to provide the same opportunities for flexible training as the UK, despite high percentages of women medical students and women medical graduates. There are important differences in training patterns across the EU and some reasons are proposed for why flexible training may be more difficult to implement or may not be required elsewhere in the EU. Reasons include less centralized health care systems and more rigidly structured training programmes. In the context of four main factors affecting medical manpower--medical unemployment, contracted working hours, maternity provisions and duration of training--both the health authorities' need to implement flexible training and the trainee doctors' demand for it would appear to be greater in the UK than in other EU countries.     

The place of primary health care in medical education in the United Kingdom: a survey

Primary health care has been held to be the foundation of any rational health system. The principle was fully endorsed by the Alma-Ata Conference in 1978, and has become the main policy of the World Health Organization. Important implications are involved for the education and training of doctors and other health care professions.
An enquiry was conducted by personal interviews of those most responsible for the teaching of primary health care in the United Kingdom, to enquire about the status of primary health care in the curricula of U.K. medical schools, and about the standing of general practice. The enquiry also explored the degree of awareness among medical educators about the Alma-Ata Declaration. The leading representatives of primary health care in the medical schools made it clear that the teaching of primary health care varied greatly in the importance accorded to it and the resources made available for it by medical schools. Almost half the respondents were unaware of the support for greater emphasis on primary health care that had been specified in the Alma-Ata Declaration.     

Home, training and work: mobility of British doctors

This study examines the locations of family homes, medical schools and places of specialist training, and work of doctors qualifying from UK medical schools in 5 calendar years between 1974 and 1993. The contribution of each UK region to the medical workforce relative to its population is assessed and trends over time are examined. The relationship between place of family home and medical school attended is examined for 14,108 doctors. Career appointment location and its relationship to medical school and family home loc‐ation are examined for over 4000 doctors. For the qualifiers of 1983, an additional analysis incorporating place of training is included. Large differences were found in the percentage of medical students from local family homes attending each regional medical school. In some cases differences reflected local populations but other cases had no obvious cause. Over all cohorts studied, 38% of respondents attended a medical school in the region of their family home (32% of 1993 qualifiers), 42% held a career post in the same region as their medical school, and 38% held a career post in the same region as their family home. Among the qualifiers of 1983, 65% had a career post in the same region as their postgraduate training, 34% also attended medical school in the same region, and 19% also came from family homes in the same region. More women than men took up a career post in the same region as their postgraduate training. The relationships to family home and medical school did not differ by gender. Consultants appeared slightly less likely than GPs to have stayed within a region, but this difference was not statistically significant.     

The difference between Japan and other countries, in particular the United Kingdom, in views regarding the teaching of geriatrics to undergraduate medical students

OBJECTIVES: To examine differences in views on geriatrics education at the undergraduate level between Japan and other industrialized countries, including the United Kingdom. DESIGN: We conducted a nationwide survey of professorial staff responsible for undergraduate education in all medical schools in Japan, and an international survey of 37 medical schools and geriatric institutes in other industrialized countries, including 16 medical schools in the United Kingdom. RESULTS: The results indicate that undergraduate education in geriatrics in Japan emphasizes the theoretical aspects of the aging process and the features of diseases in the elderly, and lacks attention to the practical aspects of care. In contrast, geriatrics education in the United Kingdom and other countries places emphasis on practical aspects of the care of the elderly. CONCLUSIONS: The introduction of practical aspects of management and care of the elderly to the undergraduate education programme in geriatrics in each medical school in Japan is strongly recommended. This is especially important to meet the needs of the rapid demographic shift towards an older population in this country.     

Public Health Medicine Training in the European Community: Is There Scope for Harmonization?

Harmonization of training in public health medicine has receivedlittle attention in the European Community compared with clinicalspecialties. Although most countries have a formal trainingprogramme, programmes recognized at a European level exist onlyin France, Ireland and the United Kingdom. This paper describesthe basis of mutual recognition at the European Community leveland the programmes in each country. Although there are someimportant differences including duration of training, thereare many similarities. Several existing programmes meet EuropeanCommunity standards or would do so with a little modification.If harmonization is to occur it is necessary for public healthbodies to make representations to their appropriate nationalbodies, and for public health to develop a much closer relationshipwith the relevant specialist committees of the European Commission.     

Medical teaching of the cultural aspects of ethnic minorities: does it exist?

The development of published material relating to the practice of medicine in multiracial and multicultural Britain is briefly reviewed. The utilization of such information in English medical schools is found to be absent or at a low level of priority. A more detailed study of one region demonstrates that junior hospital doctors believe from experience that they have a need for training in 'multicultural' medicine to serve their current patient load. Objective tests demonstrate the poor levels of knowledge and the role of practical experience. Responses from a survey of administrators and clinical tutors suggest interest or willingness to develop training in this field but a lack of coordination or resources. The paper demonstrates clearly that medical education has failed to keep pace with developments in the social and ethnic composition of the potential client population. Doctors who are practising in multiracial areas support this argument for changes in the undergraduate curriculum and extension of provision in postgraduate education. These improvements should not be confined to specific medical schools because of the career mobility of doctors, and by analogy could be extended to other medical professionals. Recommendations are made as a basis for a long-term strategy to ensure that medical education plays its part in combating racism in society.     

Support and faculty mentoring programmes for medical students in Germany, Switzerland and Austria

OBJECTIVES: To study what is being done at German-speaking universities regarding the counselling and tutoring of students, we carried out a survey among the deans of medical faculties in Germany, Austria and Switzerland. Our main concern was if any such projects were already available to the medical student or whether efforts to this purpose were under way. DESIGN: We focused in particular on faculty mentoring programmes, a continuous tutoring by designated members of the faculty on a person-to-person basis. SETTING: German, Austrian and Swiss medical faculties. SUBJECTS: Medical faculty deans. RESULTS: The return rate was 80%. While general student counselling is, if required, available at nearly all of the faculties, faculty mentoring programmes are offered by only 36.1% of the medical schools, and individualized career counselling by 30.6%. CONCLUSIONS: Compared to other countries, such as the United Kingdom or the United States, counselling and tutoring programmes, e.g. career planning or faculty mentoring, are not generally available to the German medical student. Regional differences are evident, which can be attributed to differences in the universities' legal and financial situation. The medical faculties at German-speaking universities should make it their priority to offer these services to the student on a permanent basis.     

Current practice patterns and training status of selected graduates at the King Abdulaziz University College of Medicine, Saudi Arabia

Graduate doctors are the primary output of medical education programmes. It is important for institutions to identify systematically the types of medical activities in which their former students are involved in order to determine the effectiveness of the curriculum, assessing academic standards and reviewing admissions policies. Information was obtained from a survey of men and women graduates from three of the early graduation classes of King Abdulaziz University College of Medicine in Saudi Arabia about postgraduate medical training, certification, practice patterns, and other curriculum issues. Information collected from 151 graduates (90%) indicated that 96% were practising medicine in a variety of medical specialties and subspecialties. Six were not practising at the time of the study. Significant differences were found in the specialties being practised when men and women were compared. Men tended to practise in medicine, surgery, dermatology, urology, ENT, ophthalmology and orthopaedics, while women concentrated in obstetrics and gynaecology and paediatrics. Certification beyond medical school was earned by 49% with no significant difference being found comparing men to women. Men earned the majority of their postgraduate certifications outside Saudi Arabia while most women earned theirs in Saudi Arabia. Graduates indicated that departments in the basic sciences were least helpful in preparing them as doctors, while selected clinical departments were most helpful. It was concluded from the study that the curriculum goals of the College of Medicine, namely a curriculum of international standards producing graduates to take leadership roles in both teaching and medical practice, were realized in part by the graduates surveyed.     

Higher fees paid to US physicians drive higher spending for physician services compared to other countries

Higher health care prices in the United States are a key reason that the nation's health spending is so much higher than that of other countries. Our study compared physicians' fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians' incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries' national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians' counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.     

乡村医生培训理论依据初探

从理论的角度探讨了乡村医生培训的依据,运用卫生法学、生命伦理学、社会医学与卫生事业管理知识得出如下结论：乡村医生培训是卫生法中保护公民健康原则的运用,是法律赋予乡村医生的权利和义务,是医德规范的要求,是以“农村为重点、依靠教育”为内容的我国新时期卫生工作方针的具体体现,是生物-心理-社会医学模式对医学教育影响的结果。     

Career choices at the end of the pre-registration year of doctors who qualified in the united kingdom in 1996

OBJECTIVE: To report the career intentions one year after qualification of doctors who qualified in the United Kingdom (UK) in 1996, and to compare their intentions with those of 1993 qualifiers at the same stage. DESIGN: Postal questionnaires. SETTING: United Kingdom. SUBJECTS: All doctors who qualified in the UK in 1996. MAIN OUTCOME MEASURES: Choices of eventual career expressed one year after qualifying. RESULTS: We report on detailed choices of long-term careers for all specialties. Only 20% of 1996 respondents chose general practice compared with 25.8% of 1993 respondents. The percentage choosing general practice fell more sharply among women, from 34.0% to 25.2%, than among men, from 17.5% to 14.1%. Choices for surgical specialties rose from 16.9% of 1993 respondents to 21. 4% of 1996 respondents. The percentage choosing the surgical specialties rose among women, from 7.8% to 11.6%, compared with a rise among men from 26.1% to 32.2%. The percentage of respondents who definitely or probably intended to pursue a long-term career in the UK was 77.7% compared with 75.7% of 1993 respondents. Most of the home-based respondents who had doubts about practising in the United Kingdom were considering practising abroad. Only 1% made an explicit first choice for a non-medical career. However, in all, 9. 4% said that there was a possibility that they might leave medicine. CONCLUSION: The substantial decline in intentions to enter general practice among newly qualified doctors, seen in the 1993 qualifiers, is continued in the 1996 qualifiers. A shortfall in recruitment of UK-trained doctors to general practice is the likely outcome. The rise in choices for the surgical specialties, particularly among women, may herald a renewed interest in hospital specialist training following the Calman changes. It is worrying that almost a quarter of respondents indicated some doubts about pursuing a medical career in the UK.     

The reform of medical education in Iran

In order to investigate the path of medical education in Iran, indicators of medical education were searched from 1970 to 1994. There have been rises in the number of educational institutions from 10 to 46; student admissions in programmes of medical sciences from 1387 to 18141; medical student admissions from 632 to 3630; teaching staff from 1573 to 7979; and teachingbed to student ratio from 1.05 to 2.08. The numbers of students in clinical specialty and MS degrees have increased, and various programmes in clinical subspecialty and PhD degrees have been initiated. The quality of medical education has improved with increasing field and ambulatory care training, with more emphasis on teaching preventive medicine and a significant rise in the research activities. Most qualitative and quantitative progress has been achieved following the establishment of a joint Ministry of Health and Medical Education in 1985. The results of this review demonstrate the success of Iran in upgrading medical education by the unification of health services and medical education in one ministry.