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We interviewed the Deans of our medical schools, who told us "Deans live in interesting times"

Kerrie A Lawson, Ruth M Armstrong and Martin B Van Der Weyden

Peter Brooks (Queensland) said that "delaying the decision to do a course that prepares you for a lifetime career can be justified. Such a decision is extremely hard when you are 17 or 18, with no experience of the world or life in general. The graduate students are more mature, very good at questioning and very good at working in groups -- dealing with group dynamics and setting priorities." Stephen Leeder (Sydney) lauded the greater diversity among graduate-entry students: "Our students have done a wide variety of things. A tutorial group I took this year included a trained physiotherapist, a person completing a PhD in biochemistry, one with a PhD in molecular biology, another with a nursing background and an American student who had studied liberal arts and anthropology."

The issue of graduate entry is on the agenda at two other medical schools -- Monash and New South Wales. Nick Saunders (Monash) was Dean at Flinders during the move to graduate entry. He recently circulated a discussion paper on graduate entry which will be debated at Monash at the end of this year. Bruce Dowton (New South Wales) said that his school "is just about to launch into significant reformulation of the medical course." Although this will almost assuredly involve changed selection criteria, he believes that "the question of graduate or school-leaver entry is not important at the outset. I am encouraging the faculty to begin by defining the sort of medical graduate they wish to produce before debating what sort of program will best produce that graduate".

On a national scale, a consequence of graduate entry in some medical schools has been migration of students to the school-leaver programs in Western Australia and Tasmania. According to Lou Landau (Western Australia) the number of interstate students at his medical school has increased over the last five years to 10%, and includes particularly Queenslanders, who now have no school-leaver program in their home State. Robert Sanson-Fisher (Newcastle) felt no pressing need for all medical schools to adopt the same entry policy, saying that "variation is needed between medical schools. There should be choice for applicants -- the consumers -- about what or how they want to specialise. And we want different sorts of people produced or encouraged in different sorts of medical schools."

According to Frewin, "the effect in Adelaide has been to almost double the number of feeder high schools (from about 20 to 35) and to more than quadruple the number of country students (from 5% to 22% in 1998). Students are also more socially interactive and more collegial in approach." Melbourne and Tasmania are also in the process of introducing UMAT to complement the TER-equivalent for school-leaver entrants.

In contrast, current selection criteria at Monash are TER (97.5 or above), appropriate prerequisite subjects (eg, chemistry) and a structured interview. However, these are under review. Similarly, the University of NSW, according to Dowton, will almost assuredly change its selection criteria during any potential restructuring of its course.

Most Deans recognise the need for positive discrimination for rural and disadvantaged students and many schools have targeted-access schemes. Newcastle was the pioneer in targeted access for Aboriginal and Torres Strait Islander people and has produced 11 of the 26 indigenous medical graduates nationwide between 1989 and 1995. Although most other schools have put effort into providing access and support for indigenous students, many have had difficulty attracting applicants -- Newcastle seems to have "cornered the market" (Wing).

Most schools also have targeted-access schemes for rural students, partly in the hope of increasing the number of rural pracitioners. In support, Larkins reported that "a 15-year survey of Melbourne graduates found that 40% of those from a rural background were practising in rural areas, compared with only 10% of those from a non-rural background." Furthermore, Landau asserted that providing opportunities to rural people is important in itself: "You won't get people living in the country if they don't believe their children have the same opportunities as urban students."

With the move to graduate entry, Flinders, Sydney and Queensland medical schools have also adopted curricula based on the above principles. At Sydney and Queensland, this was a major change from the traditional curriculum -- basic sciences taught in individual disciplines in the early years, followed by clinical exposure. Flinders had always had a systems-based curriculum, but has now moved to problem-based learning. The curriculum, similar at the three schools, was explained by Leeder: "We've organised students' learning not according to disciplines but according to four themes -- basic and clinical science, community and doctor, patient and doctor, and personal and professional development. We also introduce students into the clinical context from Week 1, and students work in groups on clinical problems."

According to Larkins, Melbourne medical school will also have a "totally new curriculum" from 1999. It will be organised similarly to the curricula of other graduate-entry schools, but "a unique feature for school-leavers is an intercalated year of advanced medical studies with a significant research component. This may be chosen from about 30 different areas, ranging from Aboriginal health, rural health, health in their own country (for international students) and medical history through to bench-based medical research."

Western Australia, Adelaide and Tasmania are also breaking down the discipline barriers and adopting problem-based learning. This was seen by several Deans as a key to active learning. Frewin said: "We are moving away from 'teaching' to 'active learning', because it enhances retention and allows students to see the material in the context of its applications, leading to lifelong learning."

Both Monash and NSW are actively exploring the need for curriculum change. Saunders felt that "given the changes over the last two years with provider number legislation and the increasing length of postgraduate training, Monash may be best to stay with high school entry, to reduce the course to five years, and to find an innovative and creative way of allowing graduates to do a four-year course within the same curriculum envelope". This will be debated within the faculty.

Several of the Deans spoke of multidisciplinary education. According to Brooks, "Queensland is looking at ways of having medical students train with students in other health sciences -- pharmacy, rehabilitation sciences and dentistry." Sanson-Fisher says the Faculty of Medicine and Health Sciences at Newcastle is also moving in this direction. "There are core competencies needed by all clinical healthcare providers -- communication skills, ability to critically interpret literature, ethical issues, some basic science. Next year, we will be introducing the idea that our students learn these with other professional groups, not just in a big lecture theatre, but actually working together. That's really important, because if you don't train them together how can you expect them to work together when they graduate?"

Many Deans talked of the need to recruit general practitioners (GPs) as teachers and highlighted the difficulty of recompensing them appropriately; teaching reduces the number of patients GPs can see and consequently their incomes. Saunders said: "The easy things are to give GPs a proper clinical title and some tangible benefits -- links with the university community, access to the library, and information technology -- but the difficulty is to get real dollars out there . . . The Australian public hospital system -- mainly the teaching hospital system -- is subsidising medical education to the tune of at least $50 million per year."

This ease of communication has also allowed for lengthy rural placements. For example, at Flinders all students go to the country for a week in Year 2, two weeks in Year 3 and six weeks in Year 4, while a cohort of students spends all of Year 3 in a rural environment in the Riverland. Students at Queensland can opt to spend Years 3 and 4 at the northern clinical school in Cairns, Townsville and Mt Isa. "All clinical problems are available on the Intranet and next year we are planning to provide any campus-based tuition to these sites through telemedicine-telehealth links," said Brooks. According to Carmichael, rural rotations are also particularly important in Tasmania, the most rural State: "A lot of educational support is provided via the Internet during these rotations. Students either provide their own laptop computer or can borrow one from the school."

Most agreed with Larkins that "one of the challenges for our graduates will be to steer patients through the morass of information on the World Wide Web and allow them to discriminate between scientifically based and non-scientifically based information." Many Deans emphasised the need for medical students to learn how to access and critically appraise information and the value of the new curricula and methods of teaching in meeting this need. According to Wing, the paradigm shift in the doctor-patient relationship is "one of the main reasons Flinders has gone to problem-based learning. The students are not just presented with information as though it is the universe of information, they're presented with a problem and have to go and seek the information. We are trying to encourage them to learn how to access and appraise information and fit it into their everyday use, skills that will underpin their continuing education."

Larkins added that "it is important for graduates to have an understanding of alternative/complementary medicine -- Melbourne students are exposed to a variety of different beliefs about health in their study of the social aspects of medicine. Graduates also need the skills to listen to the views of their patients, to communicate their own views and to help patients use all their sources of information to come to a sensible decision about their health. A doctor can no longer make a statement about what's best for the patient and expect it to go unchallenged."

Landau agreed, but felt that, despite the necessary emphasis on evidence-based medicine, "the community still wants an individual to talk to and discuss the options . . . The increasing need for evidence-based criteria has removed a lot of the magic from medicine, but people still want some of that magic. We have to combine the magic with the evidence-based information, so that we can give both."

General practice teaching and training was a priority for Brooks: "I'd make sure we have a very active postgraduate medical school that runs training programs in the first three years of hospital training. These could be linked into the college programs. We would work with the colleges to see how the universities could add value to their programs."

Boosting research was also often mentioned. For example, Saunders would "invest in 'blue sky' strategic, applied research and encourage cross-disciplinary research. The really interesting research into delivery of medicine and the practical nature of medical care is at the intersection of disciplines; it needs to bring in economics, sociology and epidemiology. At the moment it is enormously difficult to get funds for this sort of research because it looks too foreign, too risky." Similarly, Dowton felt that "Australian universities have begun to lose the edge in medical research, and that's the part of medicine that society still needs from medical schools and research institutes. While we are no longer the archives of information -- that's out in the public domain, as it should be -- we should be the engines of producing new knowledge, not just in biological sciences but in sociopolitics, ecology, sociology of medicine and so on." Dowton also identified a need for research into "information management or informatics -- the whole area of how to harness knowledge to improve healthcare. We have amassed the so-called evidence about how to treat diseases, but we can't get it into practice because we have paid too little attention to how human beings use information and knowledge to alter behaviour. We're just starting to scratch that surface in Australia."

Almost all Deans felt staff were a priority, with several mentioning the need for more staff development, appropriate remuneration for academics (academic salaries may be considerably lower than salaries in teaching hospitals), rewards for teaching merit and "a good holiday because it's very hard at the moment" (Saunders). For Landau, staff were the highest priority: "I would get more good people and pay them better to teach. Technology is good and we can use it, but individuals are still the most important resource. I would try to provide the best teachers, clinicians and scientists to be role models for students. You need a mixture of people in your faculty -- those good at teaching, the charismatic, the good researchers and the good clinicians."

The special difficulties of the smaller, newer medical schools were apparent. Wing told us that "One of the problems about being a new school at a young university is that we don't have good endowment money, so we don't have any reserve pots to dip into. I would love a development pot so that we can actually kick off our own initiatives and not chase every government grant." Carmichael would like to "better equip his staff, including the clinical teachers, in the new educational methods -- problem-based and self-directed learning -- and developing new curricula, and give them more time for research."

No reprints will be available from the authors.
Correspondence: Dr K A Lawson, Medical Journal of Australia, Private Bag 901, North Sydney, 2059.

©MJA 1998
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