The major problem in the quality and effectiveness of
medical education stems from the mismatch between the
health needs of the public and what is concentrated upon,
demonstrated and taught in our academic medical centers.
The educational program is dominated by the choices
made in research and patient care, which reflect the
interests of the many specialized individuals and groups
that make up the faculty. Though each of these choices has
some relevance to health and disease, when taken together,
they rarely match the health needs of the population as a
whole. Geriatrics and alcoholism, for example, present
massive problems which get little, if any, attention in the
academic medical center. The emphasis is on acute and
unusual conditions, leaving chronic disease grossly neglected.
The focus is generally on the unusual rather than the
common problems. Prevention and rehabilitation are
given lip service. Tertiary care is preferred over primary
care. The patient in bed is deemed to be more interesting
than the one who is ambulatory. The patients in the
teaching hospital, where student experience is concentrated,
represent a tiny fraction, less than 1 percent, of the
total number of patients who seek medical care at any
point in time. How can this experience be thought to
prepare students adequately for medical practice?
....................Causes of postgraduate training problems
The causes are not obvious. Perhaps the single
most important one is the absence of control and
coordination of the total complement of funded
positions and their allocation across specialties and
training sites. Even a cursory look at the statistics
provided by CAPER'2 reveals numerous examples of
duplication and of small programs.
However, there is a deeper issue. The need for
control and coordination seems widely acknowledged
and appreciated; thus, their virtual absence
must be attributed to a failure of political will, at two
levels. First, despite the ample opportunity for coordination
in some provinces no agency has stepped in
to take a leadership role (although the Council of
Faculties of Medicine in Ontario is trying). Second,
at the time of our report there had been few serious
attempts to develop interprovincial arrangements.*
This same lack of political will underlies the
misalignment of the mix of funded positions with
population needs. Provincial ministries have always
been keenly interested in the overall numbers of
positions they fund but apparently not in their
specialty mix. As one senior ministry official noted,
"We know it's a problem, and we know it's a
problem about which we could do something.
Somehow it never seems to be quite important
enough amidst the competing political and fiscal
priorities." Certainly, medical educatQrs have no
interest in seeing governments involved in the
"micromanage[ment of] postgraduate training."'9
There is ample evidence of similar problems at
individual institutions. As Maudsley'3 noted, "in
many programs the issue is not too few trainees but,
rather, too many CTUs [clinical teaching units]."
The causes are pressures from clinical teaching units
and potential clinical supervisors who would stand
to benefit personally from the establishment of
programs and affiliations.'3 This conflict between the
service needs of teaching units and the educational
needs of a mix of residents that matches population
requirements should be resolved in favour of the
educational interests (legitimate service needs being
met through other means).
Of course, it is not always (or ever) that easy.
For example, a province's subspecialty service needs
may be met only through the offer of an academic
affiliation and a residency program during recruitment.
To meet such needs a province may end up
training people it has no use for.
Reply With Quote
Originally Posted by Yurt
