To the Editor: In response to the recent column on medical education,1 I would like to point out that many of the medical schools in Australia have broadened the content of their curricula to reflect the expected demands of professional practice and to satisfy the objectives of the accrediting body.2 Medical schools involved in curriculum change have tended to favour a broad education that emphasised learning across four domains (basic and clinical sciences, clinical skills, population health and ethics, and professional development). Another principle influencing changes to curricula was the need to ensure that the students were competent to enter supervised practice as an intern and be equipped with the desire to pursue life-long learning. Remarkably, medical schools have tended to deliver similar curricula in response to these and other issues (eg, emphasis on communication skills, critique and clinical application of evidence, exposure to rural health issues).

Medical educators see a need to prepare medical students to cope with continuing changes in healthcare. Some of us would argue that many of the principles of such ongoing learning are fundamental to problem-based learning programs, and expect that graduates of such programs will be able to adapt to new continuing professional development programs. However, there is as yet no hard evidence that incorporating self-directed and problem-based learning techniques into medical curricula has any beneficial effect.

Although it is not yet possible to measure the long-term effects of the changes in medical curricula, in the short term objective measures are encouraging. Today’s Australian medical school graduates function well as interns and residents.3 However, many in the profession are concerned about the level of knowledge of current graduates, particularly (but not exclusively) about anatomy. Although knowledge of anatomy needed by doctors varies considerably between disciplines, the basic sciences, including anatomy, do need to be included in college training programs.

Clearly, the profession needs to measure the outcome of changes to medical school curricula.4 Ideally, as you say in your column, the outcome measures would be generally agreed by the profession.1 A debate in the Journal about the most appropriate outcome measures for medical schools would ensure that the concerns of many medical practitioners could be considered. Meanwhile, those involved in medical education need to develop and publish the outcomes that are measured in the medical schools.

To the Editor: In the lead-up to the description of events at a recent Royal Australasian College of Surgeons (RACS) conference,1 it appears that you do not fully agree with the changes in medical education in Australia and overseas in recent years. Firstly, it should be pointed out that problem-based learning has not “all but displaced didactic teaching”1 in Australian medical schools. Many schools have hybrid courses and a wide variety of teaching methods are used. Secondly, including outcomes such as “communication skills and compassion!”1 in the curricula can hardly be less than desirable. The desired outcomes of medical schools are driven by Australian Medical Council guidelines on the requirements for the safe and competent practice of clinical medicine by a generalised doctor in the intern setting before specialist training.

Individual surgeons, the RACS, and their United Kingdom counterparts2 have lamented the decline in medical students’ anatomical knowledge for generations, even when students were taught 500–700 hours or more of anatomy.3 There is nothing new in this call-cry.

A generalised doctor prepared for internship does not require much of the knowledge that some are lamenting has been lost from medical curricula. The “old” curricula were crowded with excessive amounts of topographical anatomy that was of questionable relevance and seldom taught within a clinical or medical context. The optimal time and context for students to learn detailed topographical anatomy is surely when the knowledge is most relevant and valuable. This is surely during basic and advanced surgical training programs, both administered through the RACS.

There is good evidence that detailed teaching of topographical anatomy in targeted postgraduate surgical training courses is of measurable benefit and greatly appreciated.4,5 Indeed, is it really very suprising that, for example, urological and gynaecological surgeons have a greater interest in the nine branches of the anterior division of the internal iliac artery and the detailed relations of the ureter in the pelvis than 18-year-old first-year or second-year medical students?

It is now the responsibility of surgeons and anatomists to deliver postgraduate programs that address the desired outcomes for RACS training (and the UK equivalent2). We at the University of Western Australia have launched a Graduate Diploma in Surgical Anatomy. A similar course has been in place in Melbourne for some years. Other states can only be encouraged to follow.

In reply: McMenamin reiterates the importance of the educational components of current medical curricula: problem-based and self-directed learning, along with the enhancement of students’ capacities for communication and compassion. Forbes agrees and advances that these changes are to prepare future doctors for life-long learning.

There are two issues at the centre of this discourse — what do medical students think of the curricular changes, and are these changes informed by scientific evidence? Anecdotal reports suggest that some medical students in the United Kingdom1 and Australia2 have concerns “that basic science does not get the priority that it once did”. Similar concerns have been raised in the popular press.3 Furthermore, UK academics fear that the dilution of basic sciences in current curricula may, in the long term, adversely affect medical graduates entering into research.1

Forbes concedes that the evidence underpinning these changes to medical education is wanting. And herein lies the rub. Despite continued calls for educational research that matters4,5 (and perhaps in keeping with opinions as to how difficult performing such research might be),6,7 the medical education community has yet to report solid evidence to support the intentions of these resource-intensive changes.8 The profession, hardened by the evidence-based movement, expects no less. This, I believe, was an undercurrent of the audience disquiet at the plenary session of the meeting of the Royal Australasian College of Surgeons in May this year.

As to McMenamin’s robust defence of the pruning of anatomy in medical curricula, this debate is more than 2 centuries old. An 18th-century guide to the training of apothecaries (the forerunners of general practitioners) stated that “he” should be “tolerably well acquainted” with Latin, be competent in “his” own language and “acquainted with botany chemistry, and pharmacy; and have studied anatomy and physiology”. But “the minutiae of anatomy are not necessary”9 [my italics].