Medical education

Objective: To compare preparedness for hospital practice between graduates from a problem-based, graduate-entry medical program and those from other programs (undergraduate problem-based and traditional).Design: Survey of graduates (by mailed questionnaire) and organisers of clinical training (by semistructured interview); results were compared with published results of surveys of graduates from other programs.Setting and participants: All graduates of the first intake of the University of Sydney graduate-entry medical program were surveyed at the end of their first intern year (2001), along with the director of clinical training or intern manager at each of the New South Wales hospitals that employed the graduates.Main outcome measures: Graduates' self-reported level of preparedness in the eight domains of the Preparation for Hospital Practice Questionnaire; and organisers' opinions of their strengths and weaknesses.Results: 76 of 108 graduates from the graduate-entry program (70%) and organisers of clinical training at all 17 hospitals participated. Graduates from the program felt more prepared than did those from other programs in five of the eight domains assessed (interpersonal skills, confidence, collaboration, holistic care, and self-directed learning) and no less prepared in any domain. Organisers rated the graduates highly, especially in clinical competence, confidence, communication and professional skills. Opinions of interns' knowledge of basic sciences conflicted, with strengths and weaknesses mentioned with equal frequency.Conclusion: Graduates from the graduate-entry, problem-based program are at least as well prepared for their intern year as graduates from traditional and undergraduate problem-based programs.

Sarah J Dean BA(Psych Hons) · Alexandra L Barratt PhD, FAFPHM · Graham D Hendry BA(Hons), PhD, GradDipEdStud · Patricia M A Lyon MEd, PhD

Teacher-clinicians are not always adequate role models In 2000, the Australian Medical Council highlighted the place of clinical ethics in the education of medical students.1 A similar appreciation of its relevance has grown in the UK, North America and Europe.2-4 Recently, a working group of the Association of Teachers of Ethics and Law in Australian and New Zealand Medical Schools (ATEAM) produced a core curriculum for the subject5 that encompasses the knowledge, skills and attitudes required for students to appreciate the range and complexity of ethical issues permeating medicine and the moral principles required to deal with them. Who should teach ethics to medical students remains debatable, with some advocating a role for ethicists and others seeing the clinician as more appropriate. ATEAM argued that an optimal program embodies "multiple perspectives and multiple teachers".5 As the working group put it: "Teachers of ethics can play an important role in modeling the very nature of ethics: the teaching process should be perceived as being emotionally supportive and academically encouraging, should be tolerant of multiple perspectives, should be interdisciplinary and should actively involve clinicians as code-instructors and as role models for students. This also underscores the responsibility of teachers to develop as an ethical community and be alert to, and respond to, unethical behavior among themselves."5 Clinicians who are specifically recruited to teach clinical ethics are invariably selected on the basis of their sensitivity and commitment to the ethical dimension of the doctor–patient relationship; they are likely to serve as appropriate role models. Regrettably, during the course of their training, students may encounter other clinicians who lack sensitivity and manifest a disregard of ethical principles. In a survey of Canadian medical students, half reported pressure to act unethically and 60% had observed unethical conduct in a clinical teacher.6 Moreover, they had felt impotent in the face of these circumstances because of the teacher's intimidatory attitude. Having taught clinical ethics for almost three decades and on three continents, I have compiled a body of evidence of clinicians demonstrating wholly undesirable qualities and behaviour to medical students. In the context of case-centred teaching programs in ethics, students are requested to observe ethical aspects of practice during their attachment to a medical or surgical unit and then select an experience which has provoked their curiosity, generated concern or affected them in some way. The narrative of this experience is shared with a group of fellow students, one of whom serves as a scribe. As a result of this process, I have files containing dozens of ethically challenging scenarios (Box 1). The student dilemmaA recurrent theme in these scenarios is the students' powerlessness either to challenge the clinician or to intervene on the patient's behalf: "How can I, when placed at the very bottom of the hierarchy, voice my disapproval?" . . . "How can I come to the aid of patients when I am not directly responsible for them and this could be construed as acting beyond my remit?" . . . "How can I inform the Dean given that my quandary may well be divulged to the clinician himself?" Although these sorts of questions have been posed many times, I have always found it difficult to provide a rational response. After all, any advice to take action could well place students in professional jeopardy.7 When asked what factors inhibit students from speaking out, fear heads the list. Teacher-clinicians exert a strong influence over the student's future. They may be examiners or a source of references. Another commonly cited factor is the dominance of a professional culture which makes it taboo to question the clinical or professional conduct of a senior colleague. Mention is often made of an ethos whereby doctors should protect one another, especially in the face of a censorious environment and a siege mentality regarding the legal profession. Students note that "whistle blowing" is frowned upon and that the discloser of "medical secrets" is often ostracised.8 Students may not always feel confident that their critical reaction to an unethical clinician is justified: "Perhaps I am not able to tease out all the aspects?" . . . "Surely consultants with much more clinical experience and knowledge than myself must know what they are doing." . . . "Perhaps it is the best way of dealing with the situation." Other factors are probably rationalisations to justify retreating from a potential confrontation. For instance, are students justified in levelling criticism when they themselves may act unethically in the future, whether deliberately or inadvertently? Leeway is also given to the common plight which doctors, especially junior staff, face — working under great pressure with limited resources. Is it not understandable that a doctor may sometimes, in a state of frustration or fatigue, fail to maintain optimal ethical standards? Finally, questioning a consultant's clinical decision is akin to a student asking a teacher to clarify an objective position, but raising questions about an ethical judgement may penetrate more deeply and imply an attack on the personal qualities of the clinician. In minor instances, issuing this challenge may not seem worth the offence it may cause. In extreme cases, where a student surmises that a teacher is habitually unethical by dint of inherent deficiencies, the corollary may follow that "Such doctors unfortunately do exist and we have no choice but to tolerate them". If a series of teachers fail as ethical role models, students may well become disillusioned with their chosen profession. Instead of having an eager, energetic approach to medical life, they may become cynical and embittered. If insufficient good role models are available, students may miss the opportunity, at a formative period in their development, to enhance their own ethical capabilities. Students are well placed as members of an observant, intelligent peer group to contribute to the promotion of ethical standards by raising issues with their teachers. By not speaking out, avoidable patient distress may persist. The distress may be amplified by a sense of disillusionment that the "next generation" of doctors merely imitates the undesirable behaviours of their seniors. Students' acquiescence could be seen to maintain the status quo. James Dwyer7 captures the essence of the problem: "... the failure to speak up in certain situations is a failure of learning and caring." Moreover, the risk prevails that moral sensibility becomes eroded. Suggestions for changeGiven the adverse repercussions of negative ethical role modelling, I have sought the views of student groups over recent years as to how they may act. What follows is the product of these discussions. The cardinal change required is to remove the taboo on students "speaking up". Dwyer7 encapsulates this appositely by calling on students to subscribe to the Socratic maxim primum non tacere ("first, do not be silent") to fulfil their responsibilities to patients, colleagues and the medical profession. Abolishing the taboo depends on a number of overlapping factors. Altering the nature of the teacher–student relationship is paramount. The traditional hierarchical character of not only that association but of all the tiers of medicine embodies so many limitations that it ought to be ditched at the earliest opportunity. A more equitable link, similar to a partnership, is bound to be much more rewarding to both parties by permitting everyone to learn from each other's perspective.9 Here, the teacher must obviously modify well-entrenched habits and come to regard students as creative and curious. The learning process can be so much richer when it encompasses this interactive quality. The host environment, whether it be a hospital, a clinic or general practice, is another crucial variable in enabling the student to raise ethical questions. An institution whose ethos encourages ethical enquiry and is open to the challenge of optimising clinical care will listen carefully to the student's voice. The student may contribute to this spirit of ethical openness in at least two ways. Firstly, questions about ethical aspects of a clinical situation should be raised respectfully, avoiding judgementalism or personal denigration. Secondly, students should take care to broach delicate matters, which may well involve patient care, in a suitable setting. Thus, if distressed by an encounter between doctor and patient, they should refrain from questioning the teacher until in the private surroundings of the tutorial room. In proposing these two requirements of students, we have depicted them as individual protagonists. They may hesitate to raise an issue lest they are "out on a limb", their views stemming from an idiosyncratic source. Students would therefore do well to ventilate their concerns to their fellows and then share the task of questioning the clinician. The advantage of fellowship can be reinforced by reference to a code of ethics. A draft code for medical students published in 2002 by the Australian Medical Students' Association is an exemplary document comprising eight principles (Box 2), each of which is elaborated upon and clarified in a series of annotations.10 In the event of an experience with a negative role model, students can readily compare what they have observed with corresponding principles in their code. This comparison can then embolden them to challenge the teacher. If students experience difficulty because the teacher resists their enquiry they may feel helpless. The third annotation of Principle 6 of the AMSA code anticipates this by stipulating that: "When medical students experience difficulty with staff, they should discuss this with their academic mentor or supervisor." This is sound advice, although the student may be reluctant to follow it lest he or she be labelled a "whistle blower". Again, the notion of "security in numbers" applies. Fellow students who share a concern would no doubt find it easier to raise this as part of a group with a clinical dean or clinical supervisor. ConclusionNo matter how comprehensive and systematic the teaching of medical ethics, the acquisition of relevant skills and the cultivation of desirable attitudes will take place mainly in the clinical arena and be influenced by doctors who model an appreciation of the myriad ethical questions that pervade medical practice. Role models of good ethical conduct will always loom large in guiding the student to acquire a sense of moral integrity.11 Clinician-teachers share a duty to do all they can to expedite the process. Negative modelling is a destructive force which has no place in the learning environment. We all have a responsibility to confront and eradicate it. 1: Examples of ethically challenging situations faced by medical students The jocular doctor: In an effort to introduce each patient in a clinic to the observing students, a consultant either joked about them or referred to an amusing quality in them. Although the content and tone were not malicious, the students wondered whether this did not undermine the principle of respecting the dignity of the person. The students were sensitised given their experience not long before of a pair of surgeons talking indelicately about an anaesthetised patient under their joint care. The slanging match: A group of students were unnerved when witnessing a feud between a consultant and a ward sister, conducted in the passage and well within earshot of the patients. The pair had virtually come to blows over the issue of truth-telling. The nursing staff were convinced that a patient with advanced cancer sought the truth about her prognosis, whereas the consultant was of the view that she would be emotionally harmed if given an explicit prognosis. The students felt immobilised in the face of the increasingly acrimonious exchange. The scolding doctor: During the course of a consultation, a patient complained of a burning sensation in her legs. The clinician briefly reassured her that this was of no consequence. The pain appeared to worsen, the patient becoming tearful and distressed. Expecting further reassurance by the doctor or cessation of the examination, the students were staggered to hear his litany of criticisms of the patient for her not exercising or eating adequately. Later in the staff office, the doctor complained further about the patient, seemingly insensitive to her suffering. "All must palpate": Having examined a patient with an abdominal mass who was obviously in severe pain, the doctor instructed all eight students in the tutorial group to palpate her abdomen after the ward round. Half the group felt so intimidated by the clinician's "overbearing personality" that they examined the patient despite her request for the process to cease. The others felt it disrespectful to impose on the patient, but then had to lie to the teacher that they had "felt the mass". The "difficult" patient: The patient screamed out in pain when the doctor examined her pelvis. The observing student was startled to hear the doctor then reprimand the patient for acting "hysterically" and losing control. Later, but still at the bedside, he explained to the student that she was a "difficult personality" and had always responded in this "exaggerated" way. 2: Principles from the Australian Medical Students' Association Code of Ethics — preliminary draft Medical students should: respect the needs, values and culture of patients they encounter during their medical training; never exploit patients or their families; hold clinical information in confidence; obtain informed consent from patients before involving them in any aspect of training; appreciate the limits of their role in the clinical setting and in the community; respect the staff who teach and assist them in their clinical training; when involved in clinical research adhere to the ethical principles in the appropriate national and international guidelines; maintain their personal integrity and well being.

Sidney Bloch PhD, FRANZCP

Before I visited the Department of Forensic Medicine in Glebe, my concept of an autopsy lacked insight. I now realise that autopsies have many roles and affect us at as many different emotional levels. My first impression was that a very strong "impersonal" aura prevailed in the autopsy suite. Two rows of cold, steel tables laden with bodies were surrounded by uniformly dressed pathologists and technicians — opening bodies, removing organs, examining organs, replacing organs, restoring bodies. As I observed this routine, I became aware of the social chatter, similar to the conversation that takes place in operating theatres. Here, the chatter seemed to trivialise the situation. The emotional spectrum then shifted dramatically when I focused, not on the body, but on the person that the body represented. Each person has a history and it was at this level that the concept of death became very personal. I found myself studying their facial expressions and becoming immersed in the circumstances surrounding their death. For people who had died by suicide, I tried to comprehend the terrible anguish and hopelessness they must have felt before taking their own lives. For those who died in accidents, I realised that they would not have expected to die that day. The face of a motorcyclist killed in an accident did not show pain, although the reports indicated that death was not instantaneous. Did he have any last thoughts or reflections as he lay dying on the side of the road? Then I wondered how the families would deal with the devastating news of these deaths. I witnessed a young man who had survived surgery and then died of a massive pulmonary embolism at home. I reflected on the pain that his family, girlfriend and friends must have been feeling. The fact that he was well loved was obvious from all the graffiti on his plaster cast and the tattoo of his girlfriend's name on his abdomen. These incidents impressed on me how precious and unpredictable life is and how I so readily take it for granted. I found that what disturbed me most was not, as I had anticipated, that a person was "dead", but rather the emotions involved in death. I found that I could not detach myself from the profound feelings of sadness that the deceased person's family would be feeling. A powerful compounding factor was the short time frame between death and autopsy. In most autopsies, the person had died in the past 24 hours. I would go home each night knowing that someone alive right now would die, and I would see them in the morgue in the morning. At the end of each day I was exhausted. I had moved through a kaleidoscope of emotions, from sadness to helplessness, from anger to frustration. I became aware of the extent to which I was personalising each case and of the toll this was taking on me. I needed to detach. It was at this point that I began to understand the "impersonal aura" that I had initially felt was inappropriate. The social chatter and humour provided protection from a narrow focus and draining emotions. On a daily basis, one could not survive this high emotional intensity without such a coping mechanism. Even knowing this, I still found it difficult to stay detached, especially during an autopsy. The body is opened by a series of incisions in the head, neck and trunk, then the internal organs are removed for dissection and examination. I felt this intermediate presentation of the body (with empty chest, abdominal and cranial cavities) to be a violation of that person. I imagined the distressing reaction of the family if they could see what was happening to their loved one. I asked the questions "Was it not enough that they had already lost their loved one? Was an autopsy really necessary? How do we justify this added pain?". These questions played on my mind all through the week. I learnt that family consent is not needed for a coronial autopsy in New South Wales, although a family does have a legal right to object to the examination. The pressure of having to make such a decision at a time of great emotional distress and vulnerability doesn't seem fair. This decision could also conflict with the family's religious or other beliefs. On the other hand, an autopsy is clearly a valuable procedure. Determining whether a person died of natural causes, or as a result of unnatural interference by others, is necessary both for the emotional recovery of family members and the maintenance of justice in our society. Autopsies also provide information about diseases that may directly affect relatives, and, cumulatively, aid in the prevention of future deaths. I learnt a lot during my week at the morgue — particularly about my "personal and professional development". I had never experienced death on a personal level, and my reactions to death were not what I expected. I had experienced a similar inability to detach during hospital rounds. I realise now that it is a trait that I must confront, particularly if I want to remain sane in the medical field. I need to find a balance between becoming what I perceive as too impersonal and becoming too involved.

Tina Kastowsky BSc (Biomed)

Medical Education The rise and rise of academic general practice in Australia The Heads of General Practice are excited about partnerships with GPs and the community Kerrie A Lawson, Mabel Chew and Martin B Van Der Weyden MJA 1999; 171: 643-648 Introduction - The struggle for identity - Standing as an academic discipline - Role of academic general practice - Divisions of General Practice - Evidence-based medicine - Improving GP morale - The way forward - Authors' details - - More articles on General practice and primary care

Kerrie A Lawson · Mabel Chew

Medical Education A sea change in Australian medical education 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 MJA 1998; 169: 653-658 Introduction - Graduate entry - New selection criteria - Curriculum changes - Clinical exposure and information technology - Medicine and our changing society - Where should medical education be going? - Conclusion - Authors' details - - More articles on Education Introduction On the brink of the new millennium, we are beset by change -- social, technological, scientific, economic; the list continues. These changes have affected all areas of life, including medicine, and the medical schools have had to respond. The past year has also seen new Deans at eight of Australia's 10 medical schools. We spoke to these eight Deans and to their two longer-serving colleagues to find what has been happening in medical education, and their visions for the future. Graduate entry Perhaps the most dramatic change in the last few years has been the adoption of graduate-entry medical programs at Flinders University and at the Universities of Queensland and Sydney. At Flinders, where "mature" entry has always been encouraged and has led to a lower student drop-out rate, it was "part of the natural evolution of the medical course", explained Lindon Wing. 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." University of Melbourne Medical school established: 1862 Course: Entry from school, 6 years; plus (from 2000) graduate entry, 4.5 years 1998 intake: 170 Australian, 70 overseas fee-paying (mostly from South East Asia) Outstanding graduates: Frank Macfarlane Burnet (Nobel laureate), Edward "Weary" Dunlop (war services) Richard Larkins Position: Dean, Faculty of Medicine, Dentistry and Health Sciences Graduated: Melbourne medical school (1966) This time last year: James Stewart Professor of Medicine, University of Melbourne Books and discs for a desert island: Cairo Trilogy by Naguib Mahfouz; Beethoven's Eroica symphony; Smetana's Má Vlast Book with most impact in past year: Nelson Mandela: a biography by Martin Meredith The University of Melbourne will move to graduate entry for a third of its intake from the year 2000. Richard Larkins explains: "This is because of the very strong arguments in favour of both undergraduate and graduate entry. Students who've done extremely well at high school and know exactly what they want to do should not have to study things they're not really interested in for three years, and then do a four-year concentrated course in medicine with little chance for lateral extension during that time . . . but there are also lots of students who miss the opportunity to go straight into medical school through educational disadvantage, or because they they are "late developers" or decide only later to go into medicine. They also deserve a realistic opportunity of getting into medicine. Mixing the two groups of students from different backgrounds will provide mutual support and benefit." The dual program will also allow the school to compare the two types of students -- evidence-based education! 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". University of Sydney Medical school established: 1883 Course: Graduate entry, 4 years 1998 intake: 137 Australian, 13 overseas fee-paying (mostly from North America) Outstanding graduates: Gus Nossal (former director of the Walter and Eliza Hall Institute of Medical Research), Paul Torzillo (Aboriginal health) Stephen Leeder Position: Dean, Faculty of Medicine Graduated: Sydney medical school (1966) This time last year: Pro-Dean of Faculty of Medicine, University of Sydney Books and discs for a desert island: The god of small things by Arundhati Roy; Killer plants by Gordon Cheers and Julie Silk; Wallace and Gromit fun pack; Triple J - hottest 100 (volume 5) Books with most impact in past year: Fugitive Pieces by Ann Michael; Lovesick by Angeles Mastretta The other four medical schools have considered graduate entry, but plan no immediate changes. Derek Frewin (Adelaide), Chair of the Committee of Deans of Australian Medical Schools, explained that "Adelaide would first need evidence that the product of graduate-entry programs is at least as good or better than that of school-leaver programs." Furthermore, a disadvantage of graduate entry is that "with time added for the first degree, graduate-entry programs take at least a year longer. There is concern that this longer duration may influence the decision to pursue lengthy specialist training and particularly disadvantage women. According to Allan Carmichael (Tasmania) "one of our briefs is to provide for the medical workforce needs of the State, and graduate entry would disadvantage Tasmanians". Further, "the small size of our school would make reorientation to graduate entry more difficult". 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." University of Adelaide Medical school established: 1885 Course: Entry from school, 6 years 1998 intake: 90 Australian, 35 overseas fee-paying (mostly from Malaysia) Outstanding graduates: Howard Florey (Nobel laureate), Aubrey Lewis (first Professor of Psychiatry at London Institute of Psychiatry), Hugh Cairns (first Nuffield Professor of Surgery at Oxford) Derek Frewin Position: Dean, Faculty of Medicine, and Head, Division of Health Sciences Graduated: University of Colombo medical school (1965) This time last year: Same position (appointed Dean in 1991) Books and discs for a desert island: books by Robin Cook and Jeffrey Archer; middle-of-the-road music - Celine Dion, Cliff Richard, Harry Belafonte New selection criteria Whereas once all medical schools relied on the Tertiary Entrance Rank (TER) or equivalent, now only the University of NSW retains this as the sole criterion for entry, but even there it is under review. Changes to selection procedures were pioneered at Newcastle in the 1970s. Sanson-Fisher explained that "the TER is a necessary but not sufficient criterion for entry. If you believe both technical competence and the 'care dimension' are important, then you should select for both -- ability to acquire and regurgitate information in set formats, but also ability to work and talk with people." This philosophy led Newcastle and, more recently both Adelaide and Western Australia, to use a broad-based hurdle -- TER of 90 or above -- followed by psychosocial assessments -- the Undergraduate Medicine and Health Sciences Admission Test (UMAT; a psychological test that includes problem-solving, creative thought and ethical reasoning), followed by a structured interview. 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. University of Queensland Medical school established: 1936 Course: Graduate entry, 4 years 1998 intake: 228 Australian, 1 overseas fee-paying Outstanding graduates: Reginald Withers (Professor of Radiotherapy, UCLA, US); Ralph Doherty (Emeritus Professor of Social and Preventive Medicine and Emeritus Pro-Vice Chancellor, University of Queensland) Peter Brooks Position: Executive Dean, Faculty of Health Sciences Graduated: Monash medical school (1967) This time last year: Professor of Medicine, and Head of the Medical Professorial Unit, University of New South Wales at St Vincent's Hospital Books and discs for a desert island: The awakening by Bruce Chatwin; Bach cantatas; Handel's Water Music Book with most impact in past year: The unconscious civilisation by John Ralston Saul The change to graduate entry has also involved new selection criteria. All four graduate schools (three current and one planned -- in Melbourne) use the same criteria: academic performance in any undergraduate degree; score on the Graduate Australian Medical Schools Admission Test (GAMSAT); and a structured interview with a selection panel which may include community representatives. GAMSAT, in contrast to UMAT, is a test of knowledge, communication and intellectual skills gained through prior experience and learning which specifically assesses reasoning in humanities and social sciences and in biological and physical sciences, as well as written communication. 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." Curriculum changes All the medical schools are undergoing major curriculum changes. "Curricula need to be dynamic and to adjust and adapt to the circumstances," said Frewin. All the Deans spoke of vertical and horizontal integration of curriculum content, problem-based, self-directed and computer-assisted learning, and early clinical exposure. Newcastle was first to espouse these principles when it was given a mandate by the Karmel Committee to bring a fresh approach to medical education. 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." University of Western Australia Medical school established: 1956 Course: Entry from school, 6 years 1998 intake: 125 Australian, 11 overseas fee-paying (mostly from South East Asia) Outstanding graduates: Barry Marshall (co-discoverer, with Robin Warren, of Helicobacter pylori), Fiona Stanley (child health) Louis Landau Position: Executive Dean, Faculty of Medicine and Dentistry Graduated: Melbourne medical school (1965) This time last year: Same position (appointed 1996) Books and discs for a desert island: Complete works of Shakespeare; A dictionary of modern thought; Mozart's Marriage of Figaro; The glory of Gershwin (with Larry Adler) Book with most impact in past year: The Reader by Bernard Schlink 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. Monash University Medical school established: 1959 Course: Entry from school, 6 years 1998 intake: 145 Australian, 7 overseas fee-paying (mostly from South East Asia) Outstanding graduates: Michael Wooldridge (Federal Minister for Health), John Murtagh (Professor of General Practice), Tan Sri Dato Dr Abu Bakar Suleiman (Malaysian Director General of Health) Nicholas Saunders Position: Dean, Faculty of Medicine Graduated: Sydney medical school (1970) This time last year: Dean, School of Medicine, and Head, Faculty of Health Sciences, Flinders University Books and discs for a desert island: Border trilogy by Cormac McCarthy; a book by John Grisham; Mozart's serenades; Toni Childs Book with most impact in past year: Memoirs of a geisha by Arthur Golden Landau and Carmichael want to offer students more options. According to Landau, these may be in medical subjects not well covered in traditional medical courses (eg, psychology, sociology), but may also be from outside the medical school (eg, music or a foreign language). Carmichael explained: "Our students are mainly school leavers who have studied a fairly narrow range of prerequisites, and we wish to broaden their horizons." NSW may take this even further; part of Dowton's vision for the school is to enhance the flexibility of its programs. "There are opportunities for medical graduates in more diverse areas than traditional clinical medicine -- law, advocacy, ethics, business, economics and so on. I would like to see our students able to take subjects from other schools and faculties -- Arts, Engineering, the Graduate School of Management," he said. 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?" Clinical exposure and information technology Not only does clinical exposure now come earlier in most medical courses, it is moving out of the teaching hospitals into smaller hospitals, general practice and the community. According to Brooks, "The major quaternary referral teaching hospitals are inappropriate for young students. A third- or fourth-year medical student in the undergraduate course should not be interviewing someone who is waiting for a double lung or heart transplant." 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." University of New South Wales Medical school established: 1960 Course: Entry from school, 6 years 1998 intake: 160 Australian, 30 overseas fee-paying (mostly from South East Asia and Norway) Outstanding graduates: Robert Lusby (youngest appointee to Chair of Surgery in Australia), Bob Graham (Director, Victor Chang Cardiac Research Institute) Bruce Dowton Position: Dean, Faculty of Medicine Graduated: Sydney medical school (1980) This time last year: Associate Vice-Chancellor and Associate Dean for Medical Education, Washington University, St Louis, US Discs for a desert island: Verdi's Gianni Schicci; Mozart's Così fan tutte Books with most impact in past year: A time to keep silence by Patrick Leigh Fermor; The measure of our success by Marian Wright Edelman The move out of major teaching hospitals has been facilitated by advances in information technology, enabling both supervision and delivery of the curriculum. For example, Landau explained that "the academic GP who looks after the general practice elective programs is in regular electronic contact with the supervising GP and the student, which ensures she can get involved if the experience is not optimal." 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." Medicine and our changing society Until very recently, doctors were the custodians of information that was not readily available to the general community. Now, with medical information easily accessed on the Internet and popularised in the media, our community is becoming more sophisticated about healthcare. In addition, there seems to be a growing anti-science sentiment and interest in alternative medicine. We asked the Deans how they are preparing their graduates for these changes in society and in the doctor-patient relationship. 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." University of Tasmania Medical school established: 1963 Course: Entry from school, 6 years 1998 intake: 50 Australian, 5 overseas fee-paying (mostly from Malaysia) Outstanding graduates: Peter Stanton (first Tasmanian graduate appointed professor in the Tasmanian medical school), Tim Flanagan (rural GP and Censor-in-Chief of the RACGP) Allan Carmichael Position: Dean, Faculty of Health Science Graduated: Monash medical school (1970) This time last year: acting in same position, and Director of Women's and Children's Services, Royal Hobart Hospital Books and discs for a desert island: The Bible; Lord of the rings by J R R Tolkien; Bach's Brandenburg concertos and Mass in B minor Book with most impact in past year: The Bible Another factor important in preparing graduates for the changes in their role is, according to Leeder, "adequate real contact with patients." Many agreed that this contact should be in general practitioners' surgeries and in the community -- patient questioning of doctors "is not the sort of behaviour you see in horizontal patients in teaching hospitals", said Saunders. "Students need role models who can say 'I don't know, but I know how to go and find out and let's do that together' . . . we have to work on staff development in this area," he added. 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." University of Newcastle Medical school established: 1973 Course: Entry from school, 5 years 1998 intake: 68 Australian, 20 overseas fee-paying (mostly from Norway) Outstanding graduates: Sandra Eades (first Aboriginal graduate; now researcher at the WA Institute of Child Health), Ian Kerridge (medical ethicist) Robert Sanson-Fisher Position: Dean, Faculty of Medicine and Health Sciences Graduated: B Psych Hons (1967), PhD (1978), University of Western Australia This time last year: Director, National Institute of Cancer Control Books and discs for a desert island: Lord of the rings by J R R Tolkien; the poetry of John Donne; Luka Bloom; Verdi's Tosca Book with most impact in past year: The fatal shore by Robert Hughes Where should medical education be going? We asked the Deans for their wishlists if funding were unlimited. Educational issues figured highly in their answers. Sanson-Fisher saw "a need for more evidence-based educational knowledge. We need to know in a cleaner, clearer and more precise way what works and what doesn't, and we need mechanisms for monitoring student and staff perceptions of the faculty, educational issues and curriculum modules. We also need much more multidisciplinary education and greater flexibility in our educational system." Saunders said he "would experiment in self-directed learning and flexible delivery, turning the teaching programs into learning programs, which is expensive because you need physical facilities, multimedia development and good training for your staff." In contrast, Dowton would like "to maximise the contact between the faculty and individual students or small groups in a physical environment conducive to rich, deep learning, not superficial learning. This would involve a lot of individual tutorials and informal networking between faculty and students." 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." Flinders University of South Australia Medical school established: 1974 Course: Graduate entry, 4 years 1998 intake: 58 Australian, 25 overseas fee-paying (mostly US nationals or graduates from the US college system) Outstanding graduates: Steve Wesselingh (new Professor of Microbiology at the Alfred Hospital, Victoria), Chris Baggoley ("first" graduate of Flinders medical school; President of Australasian College for Emergency Medicine), Brendan Nelson (Federal MP and former President Federal AMA) Lindon Wing Position: Dean, School of Medicine Graduated: Sydney medical school (1967) This time last year: Professor of Clinical Pharmacology, Flinders University, and Director of Clinical Pharmacology, Flinders Medical Centre Books and discs for a desert island: Complete works of Shakespeare; Chopin's and Beethoven's piano sonatas Books with most impact in past year: The god of small things by Arundhati Roy; Fugitive pieces by Anne Michaels, Captain Corelli's mandolin by Louis de Bernières Investment in information technology (IT) was another high priority to facilitate decentralisation of teaching. Larkins saw a need for "proper academic teaching and research departments at dispersed sites, properly linked by IT to the central site. With the ultraspecialisation of central teaching hospitals and the shorter bedstays in those hospitals, a huge challenge is the disjunction between where we have our clinical academic departments and where we need to teach. We need to develop significant academic departments at decentralised sites, with research concentrating on clinical and population health and with really effective IT communication." Frewin mentioned the importance of "a state-of-the-art network and intranet facility to deliver the curriculum and for use in hospitals." In Tasmania, Carmichael would also like to "upgrade our information technology network, with access to the Internet, videoconferencing facilities and links to the State Telehealth network at all our teaching sites, which are widely dispersed around the State." 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." Conclusion Twenty-five years ago, there were the traditional medical schools and then there were Newcastle and Flinders. Now the medical schools are enormously diverse, in their entrants, length and structure of curricula and the range of opportunities for clinical exposure. Programs have changed to meet the evolving needs of society and, if the Deans of today have their way, many more changes are to come. Authors' details Medical Journal of Australia, Sydney, NSW. Kerrie A Lawson, PhD, Copy Editor; Ruth M Armstrong, BMed, Editorial Registrar; Martin B Van Der Weyden, MD, FRACP, Editor. No reprints will be available from the authors. Correspondence: Dr K A Lawson, Medical Journal of Australia, Private Bag 901, North Sydney, 2059. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Kerrie A Lawson · Ruth M Armstrong

Problem-based learning: its rationale and efficacy Paul M Finucane, Steve M Johnson and David J Prideaux For editorial comment see Schmidt Problem-based learning (PBL) in medical education uses clinical cases as the context for students to study basic and clinical sciences. Its possible advantages over traditional approaches include its greater relevance to the practice of medicine, its ability to promote retention and application of knowledge, and its encouragement of self-directed life-long learning. Possible disadvantages include higher costs, both in resources and staff time. Although its efficacy is difficult to evaluate, the current enthusiasm for PBL seems justified and its use is likely to increase further. (MJA 1998; 168: 445-448) Introduction - What is PBL? - Rationale for using PBL - Is PBL effective? - Advantages of PBL - Disadvantages of PBL - Future directions in PBL - Acknowledgements - References - Authors' details - - ©MJA1998 Introduction Medical schools [which fail to implement educational reform] will continue to graduate doctors who are, on the whole, largely adequate, but who could be so much more. Max Kamien1 After much criticism and calls for reform in medical education,2-4 several Australian medical schools have made fundamental changes in student selection processes, curricula, teaching strategies and assessment methods. The Karmel Report in 19735 -- which concluded that Australian medical school curricula were too science- oriented, not innovative and neglected primary care -- stimulated changes in existing medical schools. It also led to the establishment of a new medical school in Newcastle, in 1978, with a mandate for innovative approaches to medical education.6 Among its many innovations, the Faculty of Medicine at Newcastle emphasised learning through the study of clinical problems (ie, problem-based learning [PBL]).7,8 Although new to Australia, PBL was by then well established at overseas institutions, most notably McMaster University in Canada, where PBL was introduced in the medical curriculum in 1969.9,10 The PBL "experiment" has been endorsed as an educational strategy by the World Federation of Medical Education11 and the World Health Organization.12 By 1991, some 100 medical schools in the United States had embraced PBL to varying extents,13 and PBL is now an entrenched component of medical school programs in Canada, the United Kingdom, the Middle East and Asia.14 PBL is widely accepted in Australia, and the three medical schools with recently developed graduate entry programs (Flinders University of South Australia, the University of Sydney and the University of Queensland) have based their new curricula on PBL.15 Other Australian medical schools are also adopting PBL. By the year 2000, more than 50% of Australia's doctors will have graduated from schools with PBL-based curricula. While PBL has been developed primarily for the early years of medical education programs, there is increasing interest in PBL in the clinical years.16-18 What is PBL? Definitions of PBL vary, but a comprehensive example would be "an educational method characterised by the use of patient problems as a context for students to learn problem-solving skills and acquire knowledge about the basic and clinical sciences".19 Students usually meet in small groups two or three times a week for PBL tutorials. They are presented with a clinical problem (eg, a patient with chest pain), and, in a series of steps, they discuss possible mechanisms and causes, develop hypotheses and strategies to test the hypotheses, are presented with further information, and use this new information to refine their hypotheses, finally reaching a conclusion. A tutor usually acts as a facilitator, guiding students in this group-learning process. In the course of this exercise, students identify both their existing levels and gaps in their knowledge. These gaps form the basis for independent learning outside the PBL tutorials. The identification and pursuit of these so-called "learning goals" is a key element of the PBL process. Rationale for using PBL The PBL approach is based on principles of adult education20 and cognitive psychology.21 It differs fundamentally from traditional curricula, in which students acquire "background" knowledge of the basic sciences in the early years of the course and in the later years apply this knowledge to the diagnosis and management of clinical problems. This traditional approach has been criticised for a number of reasons:4,22,23 It creates an artificial divide between the basic and clinical sciences; Time is wasted in acquiring knowledge that is subsequently forgotten or found to be irrelevant; Application of the acquired knowledge can be difficult; The acquisition and retention of information that has no apparent relevance can be boring and even demoralising for students. Theoretically, PBL, with its educational objectives24 (Box 1), can avoid many of these problems.25 Various disciplines, particularly the basic and clinical sciences, are integrated throughout the curriculum. As students attempt to understand and solve clinical problems, they learn about normal bodily structure and function, and apply this knowledge to their search for a solution. Learning occurs in context and builds on what students already know. In theory, this process can aid retention,10,21,26,27 add interest14,19,21 and increase motivation to learn.21 Students (with initial help from tutors) determine both their own learning needs and the strategies they need for learning (eg, the efficient accessing of library resources or the formation of study groups). Is PBL effective? The efficacy of PBL is difficult to evaluate,28 as it is generally introduced together with other changes in the curriculum and along with changes in student selection, staff development, and assessment procedures. With so many confounding variables, it is hard to determine the extent to which PBL contributes to any detected change in outcomes. Many of the early claims for its effectiveness were based on the anecdotal evidence of enthusiasts. Empirical research often consisted of small and highly specific studies from single centres, and the ability to generalise from such findings is uncertain. Pooling information to gain an overview of the advantages of PBL is difficult and may be misleading. For example, there are considerable differences in what individual medical schools even consider to be PBL.29 Conclusions about the effectiveness of PBL are thus tentative, and the methodological and logistical problems which constrain educational research make it very difficult to conduct randomised controlled trials. Indeed, few such trials have been, or are ever likely to be, undertaken. Advantages of PBL The justification for PBL lies in its compatibility with modern theories of adult learning, together with evidence of efficacy in some areas. Recent reviews highlight the aspects of PBL generally agreed to be effective and those aspects whose efficacy is controversial19,21,28,30 (Box 2). Most students enjoy the active participation which PBL fosters and consider the process to be relevant, stimulating and even fun,19,31 while teachers tend to enjoy the increased student contact.19 Students and teachers report that the learning environment created by PBL is more convivial as traditional barriers between students and faculty are lowered.14 There is convincing evidence that PBL fosters self-directed learning skills10,21,26,27,32 and this may help medical school graduates to be life-long learners.32-34 PBL activities also bring together faculty from different disciplines, initially in planning and developing the curriculum and later in teaching and assessing students -- promoting interaction between basic scientists and clinicians. This can have important spin-offs in fostering collaborative research, improving the delivery of clinical services and enhancing the work environment. In other areas, however, PBL seems not to have lived up to expectations. There is no evidence that PBL curricula are any better than traditional curricula in achieving one of their prime aims -- the fostering of clinical reasoning and problem-solving skills. Also, while there is both theoretical support and anecdotal evidence that PBL enhances motivation and helps in the development of interpersonal skills, these effects have never been proven.30 Disadvantages of PBL The criticism most often voiced is that PBL is costly, in demands of staff time and teaching materials and other physical resources (Box 3). Both initial and on-going costs should be considered -- considerable energy and resources are needed over several years to develop the curriculum and to train tutors and students in the PBL process. Most schools need to import expertise to help initiate, develop and sustain PBL. Once up and running, a PBL curriculum can be demanding of staff time; Des Marchais estimated that the introduction of PBL at Canada's University of Sherbrooke increased the teaching load by 30%.31 However, at the University of New Mexico, PBL increased the contact time between students and staff without increasing the overall teaching load.35 The demand on teaching staff is largely determined by class size. Compared with the costs of lecture-based curricula, the relative costs of PBL-based curricula increase with increasing class size. The "break-even" point (ie, the point where the costs of PBL and conventional curricula are the same) appears to be with annual student intakes of about 4030 or 50.33 Other necessary resources for PBL include properly furnished and equipped tutorial rooms. For successful PBL, ready access to first-class library and computer facilities is a necessity rather than a luxury. Accordingly, PBL may not be economically viable for medical schools whose annual student intake exceeds 100.19 However, some large medical schools have recently introduced PBL-based courses. For example, the University of Queensland, with a medical student intake of 240, introduced a PBL-based graduate entry medical program in 1997 (D Price, Senior Lecturer in Medical Education, personal communication). It is probable that technological advances, particularly in computing and telecommunications, have enhanced the ability of large medical schools to deliver PBL-based curricula. Another possible disadvantage of PBL is its relative inefficiency -- some research suggests that PBL curricula cover about 80% of what might be accomplished in a conventional curriculum in the same period.19 There are particular concerns about students' grounding in the basic sciences, with some evidence (although confounded by uncontrolled variables, including the effects of admission policies) that students from PBL-based schools do less well than those from traditional schools in the basic science component of the US National Board Examinations.28 However, it is argued that, as much of the basic science content in traditional curricula lacks relevance and is quickly forgotten,22 it matters little that PBL students fail to learn or remember such material. PBL can also be stressful for both students and staff, at least until they become familiar with the process.30 Most students come to PBL from educational backgrounds where teachers direct learning. By contrast, PBL does not limit what students may choose to learn, and the process may provide little guidance on the best ways of achieving learning goals. Students may be concerned that their learning strategies are misdirected or inefficient. These concerns should be anticipated and addressed within PBL tutorials where students develop and refine the necessary skills. Yet one study which compared levels of student stress in a traditional and a PBL curriculum found that PBL was less stressful.36 Some teachers find that PBL is unduly demanding of their time and some are uncomfortable in small-group situations and with their role as facilitators. Tutor training is needed to address these issues. Finally, as accounts of PBL have come mainly from medical schools where it was implemented in the context of major curricular reform, with much enthusiasm and investment in the process, the "Hawthorne effect" -- where enthusiasm per se influences the outcome -- may have been operating, and it may be difficult to differentiate enthusiasm for the new curriculum from real gains in student learning. The introduction and maintenance of PBL in less fertile educational environments may be more problematic. Future directions in PBL The pendulum of educational reform is swinging away from traditional approaches and towards PBL with such momentum that further emphasis on PBL seems inevitable. Yet PBL and traditional curricula are far from incompatible, and Berkson argues that the two will gradually merge.30 As commitment to the principles of adult learning and the creation of a more stimulating and supportive learning environment become more common goals for both students and teachers, traditional curricula will face pressure to become more integrated and interactive. Resource limitations and other constraints may force some medical schools with PBL-based curricula to revert to traditional learning methods. Yet advances in educational technology (eg, teleconferencing, computer-assisted learning) may well lessen the resource demands of PBL and make it more attractive to larger institutions. PBL is not a panacea for all the current ills in medical education.34 Of the three major variables in learning -- students, teachers and curriculum -- the latter is probably the least important.37 Nevertheless, the effect of a well designed curriculum in facilitating learning should not be underestimated. The current level of enthusiasm for PBL in Australia's medical schools seems well justified. Acknowledgements The authors acknowledge the staff and students of the School of Medicine at Flinders University of South Australia for providing the context for the writing of this paper. References Kamien M. The reform of medical education. Med J Aust 1993; 158: 226-227. World Health Organization (1973). Training and preparation of teachers for schools of medicine and of allied health sciences. Geneva: World Health Organization Technical Report Series, No. 521. Muller S. Physicians for the twenty-first century: report of the project panel on the general and professional education of the physician and college preparation for medicine. J Med Educ 1984; 59: 1-208. Lowry S. What's wrong with medical education in Britain? BMJ 1992; 305: 1277-1280. Expansion of medical education: Report of the Committee on Medical Schools to the Australian Universities Commission. Canberra: AGPS, 1973. Clarke R. The new medical school at Newcastle, New South Wales. Lancet 1978; I: 434-435. Maddison D. A medical school for the future: the Newcastle experiment. World Health Forum 1980; 1: 133-138. Leeder SR. An Australian approach to medical education -- The Newcastle experiment. Med J Aust 1984; 140: 158-162. Neufeld VR, Barrows HS. The "McMaster Philosophy": an approach to medical education. J Med Educ 1974; 49: 1040-1050. Barrows H, Tamblyn R. Problem-based learning: an approach to medical education. New York: Springer, 1980. Walton HJ, Matthews MB. Essentials of problem-based learning. Med Educ 1989; 23: 542-558. Fulop T. Setting the stage: Problem-based learning in the mirror of the great social target -- health for all. In: Schmidt HG, deVolder ML, editors. Tutorials in problem-based learning: a new direction. Assen, The Netherlands: van Gorcum, 1984: 1-5. Jonas HS, Etzel SI, Barzansky B. Educational programs in US medical schools. JAMA 1991; 266: 913-920. Blight J. Problem based, small group learning: an idea whose time has come. BMJ 1995; 311: 342-343. Geffen LB. The case for graduate schools of medicine in Australia. Med J Aust 1991; 155: 737-740. van der Vleuten C, Wijnen W. Problem-based learning: perspectives for the Maastricht experience. Amsterdam: Thesis Publishers, 1990. Tosteson D. New pathways in general medical education. N Engl J Med 1990; 322: 234-238. Barrington D, Wing L, Latimer K, et al. Evaluation of a change from traditional case studies to patient-based, problem-based learning: a case study. Med Teach 1997; 19: 104-107. Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med 1993; 68: 52-81. Knowles M. The adult learner: a neglected species. Houston: Gulf Publishing Company, 1990. Norman GR, Schmidt HG. The psychological basis of problem-based learning: a review of the evidence. Acad Med 1992; 67: 557-565. Schmidt HG. Problem-based learning: rationale and description. Med Educ 1983; 17: 11-16. Des Marchais JE, Bureau MA, Dumais B, Pigeon G. From traditional to problem-based learning: a case report of complete curriculum reform. Med Educ 1992; 26: 190-199. Barrows HS. Problem-based, self-directed learning. JAMA 1983; 250: 3077-3080. Schmidt HG. Foundations of problem-based learning: some explanatory notes. Med Educ 1993; 27: 422-432. Blumberg P, Michael J. Development of self-directed learning behaviours in a partially teacher-directed problem-based learning curriculum. Teach Learn Med 1992; 4: 3-8. Dolmans DHJM, Schmidt HG. What drives the student in problem-based learning? Med Educ 1994; 28: 372-380. Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med 1993; 68: 550-563. Wolf FM. Problem-based learning and meta-analysis: can we see the forest through the trees? Acad Med 1993; 68: 542-544. Berkson L. Problem-based learning: Have the expectations been met? Acad Med 1993; 68: S79-S88. Des Marchais JE. A student-centred, problem-based curriculum: 5 years' experience. Can Med Assoc J 1993; 148: 1567-1572. Shin JH, Haynes RB, Johnson ME. The effect of problem-based, self-directed undergraduate education on lifelong learning. Can Med Assoc J 1993; 148: 969-976. Donner RS, Bickley H. Problem-based learning in American medical education: an overview. Bull Med Libr Assoc 1993; 81: 294-298. Headrick L, Kaufman A, Stillman P, et al. Teaching and learning methods for new generalist physicians. J Gen Intern Med 1994; 9: S42-S49. Mennin SP, Martinez-Burrola N. The cost of problem-based vs traditional medical education. Med Educ 1986; 20: 187-194. Moore-West M, Harrington DL, Mennin SP, et al. Distress and attitudes toward the learning environment: effects of a curricular innovation. Teach Learn Med 1989; 1: 151-157. Sinclair D. Basic medical education. London: Oxford University Press, 1972: 1-19. Finucane P, Allery LA, Hayes TM. Comparison of teachers at a "traditional" and an "innovative" medical school. Med Educ 1995; 29: 104-109. Vernon DTA. Attitudes and opinions of faculty tutors about problem-based learning. Acad Med 1995; 70: 216-223. Dolmans D, Schmidt H. The advantages of problem-based curricula. Postgrad Med J 1996; 72: 535-538. Newble DI, Clarke RM. The approaches to learning of students in a traditional and in an innovative problem-based medical school. Med Educ 1986; 20: 267-273. Engel CE. Problem-based learning. Br J Hosp Med 1992; 48: 325-329. (Received 10 Jan, accepted 4 Sep, 1997) Authors' details School of Medicine, Faculty of Health Sciences, Flinders University of South Australia, Adelaide, SA. Paul M Finucane, FRACP, Professor of Rehabilitation and Aged Care; Steve M Johnson, PhD, Senior Lecturer in Clinical Pharmacology; and David J Prideaux, PhD, Associate Professor of Medical Education, and Head, Office of Education. Reprints will not be available from the authors. Correspondence: Professor Paul M Finucane, Department of Rehabilitation and Aged Care, School of Medicine, Flinders University of South Australia, Bedford Park, SA 5042. E-mail: sfinupmATrgh.sa.gov.au ©MJA 1998 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1998 Medical Journal of Australia.

Paul M Finucane · Steve M Johnson · David J Prideaux

Healthcare and the information age: implications for medical education Simon Carlile and Ann Jervie Sefton The information age, combining rapidly developing information technology and massive growth in biomedical and clinical data, is placing special demands on healthcare workers. Further, radical changes in access to information in our society are affecting the doctor-patient relationship. These changes necessitate a new approach to primary and continuing medical education. A number of imperatives for medical education are identified and some practical changes to a medical curriculum are described. MJA 1998; 168: 340-343 For editorial comment see Coiera Introduction - The information age - Management of healthcare - Information technology and medical institutions - Information technology in general practice - The changing patient-doctor relationship - Information technology and medical education - The direction of curriculum change - References - Authors' details - - ©MJA1998 Introduction More than two decades ago Alvin Toffler wrote prophetically about the need to recognise and manage the dramatic changes that he foresaw in our society.1 That change is certainly upon us and, as predicted by Toffler, is being driven by a multitude of technological and economic developments. In particular, the rapid development and popularisation of the Internet and the World Wide Web (WWW) have profoundly changed the accessibility of information for medical practitioners and their patients. Moreover, rapid developments in the basic and clinical sciences and in diagnostic and therapeutic technologies place their own particular pressures on medical practitioners. Now, more than ever before, we need to be equipped with the mental attitude and intellectual tools to deal with and to exploit such changes. Primary and continuing medical education needs to play a principal role in this process. Education needs a fundamental change of focus from simply delivering content to developing the ability to manage these changes. "Learning to learn" and "learning for life" should be a major guiding influence in curriculum development.2,3 In this article we examine the "information age" and explore its implications for medical education and future practice. The information age The fusion of computing and communications is considered the defining characteristic of the information age. For medicine, such changes need to be examined in the context of the explosion of relevant information from the basic and clinical sciences. The Internet and the World Wide Web The simplest manifestation of the information age is the popularisation of the Internet through the advent of the WWW. The digitisation of information and the globalisation of digital communications has been ongoing for more than three decades4 (see the Box). While the WWW is a relatively recent phenomenon, nearly every relevant economic, social and technological pointer indicates that, at least in Western society, what we are currently seeing is simply the bow wave of its impact.5,6 One principal effect of the WWW has been to shift the emphasis from institutions (public or private) to individuals as publishers of information. It has been argued that, as the users of this technology increase in number and degree of sophistication, this so-called "democratisation" of information will change many of our social institutions. For instance, the political process will undoubtedly be affected by the increased availability of government documents, court rulings, and an increased variety of political commentary (see the website at http://www2.eff.org/pub/Activism/). Similarly, the nature of education will change with the increased availability of on-line courses from a global range of institutions, together with appearance of just-in-time training (allowing selection of training programs when they are needed). This impact is likely to be greatest for institutions that rely on controlling particular types of information to maintain authority. In medicine, the doctor-patient relationship is likely to be affected by the increased availability to patients of medical information. Information technology and the information explosion in biomedical science Biomedical science, in which more than two million journal articles are currently published annually,7,8 is far too broad a discipline for individuals to be able to cover more than a small fraction of current content, let alone keep up with developments outside their own specialties. For medicine, the information explosion brings with it an increase in treatment options, accompanied by an increase in the possible treatment combinations and possible interactions. While dissemination and use of such information remains a problem, information technology (IT) is providing partial solutions. For example: Drug and prescription databases provide a means of checking for misprescriptions and alerting for interactions.9 The challenge here is to deploy such systems widely, and to educate practitioners about their advantages. Ongoing digitisation of patient information will greatly facilitate the assessment of treatment outcomes. The challenge in this area is to distribute this information efficiently and promptly. This has been met, to some extent, by the moves toward so-called evidence-based medicine.8,10 However, evidence-based medicine is itself critically dependent on the development of tools for, and training in, navigation, collation and timely assessment of the relevant literature10-12 (see particularly the website at http://hiru.mcmaster.ca/cochrane/default.htm). The development of such tools begins to address the problem of evaluating the ever-increasing volume of data. However, simply deploying technology for accessing this information is an inadequate response. Doctors need to become independent in their capacities to review and select the most valid and relevant information quickly and efficiently, and medical educators must address this need. Management of healthcare A recent Commonwealth Scientific and Industrial Research Organisation report indicates that the cost of healthcare has risen steadily from 5% of gross domestic product in 1960 to almost 9% today.13 This report is based on Australian and United Kingdom foresight studies which indicate that appropriate deployment of IT will play a role in containing health costs, principally through improving the mechanisms of collection, analysis and sharing of relevant data. As a result, investment in IT by health authorities is almost certain to increase in an effort to gain efficiencies and cost savings in the healthcare sector. Information technologies are already having a major impact on areas such as medical imaging and pathology. Image manipulation, remote consultation and patient records are increasingly managed by means of various forms of IT.11,14 While the interfaces to these systems are generally relatively straightforward, the current lack of standards is unhelpful, requiring an unnecessarily high level of sophistication for users to be able to generalise across systems. The development of an electronic patient record, which has been the focus of considerable effort both in Australia and internationally,15 will provide the basis for considerable improvements in standards for data access and manipulation.16 The development of standards for both electronic patient records and the interfaces that allow manipulation of these data should be driven by the data-handling needs of clinical users so that appropriate strategies are used. Data-access methods that are unnecessarily complex and user-unfriendly lead to a loss of user confidence and resistance to their use. Further, training -- informed by and designed for the healthcare workers using these systems -- is necessary. Such an approach will be an essential ingredient in the acceptance and success of such systems. Information technology and medical institutions In the medium term it is likely that hospitals will be equipped with bedside workstations, which would use a consistent user interface and provide the following kinds of data: all current vital signs and a history since admission; biochemical, haematological and pathology laboratory results; radiological and other diagnostic imaging data; prescription entry coupled with dosage and interaction checking; and report generation. Such technology is already in place today in the neonatal intensive care unit at the New Children's Hospital at Westmead (Sydney, New South Wales).17 This is seen by many as a pilot project for applying these kinds of technologies throughout that hospital. Accordingly, the New Children's Hospital also has a state-of-the-art IT infrastructure, a computer on every desk with universal e-mail access, and a film-less radiology department. Electronic mail and messaging are used heavily by most hospital staff. Without even looking over the technological horizon, a number of straightforward estimates can be made regarding the kinds of technologies very likely to be deployed within the next five years. The clinical environment of the near future, based on extant technology, will include: hand-held wireless terminals with colour screens, voice recognition and very powerful processors; integrated digital patient record systems that cover all points of clinical encounter; intelligent software agents (that are responsive to the patterns of a user's needs) for data retrieval and data management; and generalised diagnostic decision and prescription support systems. These are all systems that are currently in development or beginning to be trialled in different work environments. Information technology in general practice Among studies of the current and projected use of IT by general practitioners,18 many have been aimed at identifying areas where significant value or functionality could be added to the activities of a general practice using desktop systems and the Internet. Services identified included: prescription support and tracking; online access to pharmaceutical information (such as MIMS) and adverse reactions databases; links to international medical digital libraries (eg, MEDLINE, Cochrane library); patient advisory services and websites; information reviews, international journal watches; local and wider area medical news groups and forums; and continuing medical education programs. Many of these kinds of services are already available from providers such as the MIMS medical network or Internet service providers such as Mediserve (NSW, Australia), Health Communication Network Ltd (Australia) or Health Net (Australia). These systems exploit rapidly evolving technologies centred on the WWW as the principal means of delivery. The only certainty about these technologies is that their character and role will change dramatically over the short to medium term. However, as they are currently being exposed to the most stringent form of market testing -- that by relatively unsophisticated users -- their evolution will result in increasingly intuitive and transparent interfaces. The changing patient-doctor relationship The WWW is shaping up to be the world's greatest repository of rapidly accessible information, although this is uncatalogued in any conventional way. To date, the major search engines have indexed every word on more than 30 million Web pages. However, as yet there are no agreed protocols for renewal and evaluation of the information on the WWW, although there are a number of guidelines available (eg, http://www.science.widener.edu/~withers/inform.html), and the WWW consortium which sets internationally agreed standards has a number of working parties exam ining these issues (see http://www.w3.org/TandS/ and http://www.w3.org/PICS/). The number and type of websites is increasing exponentially (see the Box), and, although many sites contain information of little educational worth,19-21 there are also many very useful sites. The implications for medicine are that this is an information resource that is accessible by an increasing number of patients, and in many cases is being contributed to by patients. A keyword search on "HIV" using the AltaVista search engine provides pointers to about 300 000 pages of information on the WWW. Self-help and support groups for an increasingly large range of diseases and disorders provide complex indexes and WWW navigation trails to these information sources. In addition, local medical groups are increasingly looking to provide their patients with relevant information and pointers to the best information available internationally, and clinicians and hospitals are publishing on the WWW to provide local information and advice. It is important to recognise that patients will increasingly turn to such sites for medical and other information over the next few years. Patients are likely to become more medically literate and, as a consequence, there will need to be a shift in the doctor-patient relationship that focuses on sharing resources and negotiating treatments.22 Practitioners will need not only to review and evaluate relevant sites regularly, but also to offer advice on locating accurate and up-to-date information. Patient access to information on best practice will also have important implications for the centralised management of healthcare. For example, treatments that are favoured for their cost effectiveness may not always correspond with what a patient sees as his or her own most effective treatment.23 Information technology and medical education The combined pressures of the information explosion, administrative and fiscal pressures towards digital management and advances in diagnostic and therapeutic technologies all require a reasonable level of IT sophistication from medical practitioners and other healthcare workers. Information technologies are slowly being integrated into secondary and tertiary education.24,25 However, the way in which these technologies are generally being deployed in medical education needs to be radically overhauled. More often than not computers, computer-based education and informatics are offered as ancillary courses or additional learning resources. To be effective, it is essential that this training be integrated deeply into the medical curricula.26 Effective training must exploit the information and procedural models that are currently used and most likely to be used in future medical practice. Further, as a generation in computing terms has shrunk to around 18 months for both hardware and major systems developments, there is a need to emphasise generic computing skills rather than specific packages and interfaces. A recent survey of the directors of clinical training in teaching hospitals in Sydney indicates that the level of IT competency among interns and residents is generally low.27 Exacerbated by a lack of interface standards, such doctors are reported to have difficulty with generalising across different hospital systems to access the information they need in their clinical practice.27 In the area of fellowship training and in continuing medical education, IT competency is also important, as it provides access to a range of flexible teaching and learning options such as self-pacing, customisation and self-evaluation that are, in general, not being exploited at this level. These are very important messages for those who educate our doctors. The pedagogy needs to change significantly to enable tomorrow's doctors to manage and exploit the technological change necessary to cope with the information management demands that will come from their profession and their patients. There is no simple technological solution. The necessary change involves alterations in the way educators and practitioners incorporate information into their practice. Educators need to focus on the processes of learning and on reinforcing the natural curiosity that underpins an attitude of "learning for life".3,28 Doctors need to be able continually to evaluate new information that informs clinical practice in the context of evidence-based medicine.8,29 This capacity requires a range of intellectual and technical tools together with a flexibility of approach that has not been apparent in many mainstream medical curricula. For instance, there is generally a stark contrast between the didactic educational model in the preclinical years and the problem-solving required in the course of normal medical practice. This is being addressed by curricula developed at the Newcastle Medical School and now at the three graduate medical schools (Flinders, Queensland and Sydney).2,3,30 The direction of curriculum change It is clear that IT needs to be an integral part of the medical curriculum, and that the way it is taught needs to reflect the ways students will use these same technologies when they graduate. Such an approach is currently being implemented at the University of Sydney,31 where students are taught to make clinical decisions on the basis of a critical appraisal of the best evidence readily available. Students use computers to access information and learning resources (text, images, websites etc), communicate by electronic mail and electronic forums, consult databases, use word processors and presentation tools for preparing written work, and analyse data using spreadsheets. Translated to clinical practice, ready access to relevant and current data enables informed decision-making, which ensures quality care and can contribute to minimising the costs of that care. Medical education also needs to prepare students for changes in the doctor-patient relationship. Placing appropriate emphasis on personal and professional development helps students develop skills in evaluating the quality of information and in communicating their conclusions to increasingly literate patients. References Toffler A. Future shock. New York: Random House, 1970. Henry RL. Curricula and courses -- implementation of a philosophy at Newcastle, Australia. Ann Community-Oriented Education 1994; 7: 79-92. Sefton AJ. Australian medical education in a time of change: a view from the University of Sydney. Med Education 1995; 29: 181-186. Hafner K, Lyon M. Where wizards stay up late. New York: Simon and Schuster, 1996. Negroponte N. Being digital. Boston: Media Technologies, 1995. Stoll C. Silicon snake oil: second thoughts on the information highway. New York: Doubleday, 1995. Hancock L. Physicians guide to the internet. Philadelphia: Lippincott-Raven, 1996. Sackett D, Rosenberg W, Gray J, et al. Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-72. Sittig D, Stead W. Computer-based physician order entry: the state of the art. J Am Med Informatics Assoc 1994; 1: 108-123. Sackett DL. Evidence based medicine: how to practice and teach EBM. New York: Churchill Livingstone, 1997. Coiera E. Guide to medical informatics, the internet and telemedicine. London: Chapman & Hall, 1997. Cochrane AL. Effectiveness and efficiency. Random reflections on health services. London: Nuffield Provincial Hospitals Trust, 1972. Commonwealth Scientific and Industrial Research Organisation. A submission to the House of Representatives Standing Committee on Family and Community Affairs: Inquiry into health information management and telemedicine. Canberra: Australian Federal Parliament, 1996. Hovenga E, Kidd M, Cesnik B, editors. Health informatics: an overview. Melbourne: Churchill Livingstone, 1996. Hannan TJ. Electronic medical records. In: Hovenga E, Kidd M, Cesnik B, editors. Health informatics: an overview. Melbourne: Churchill Livingston, 1996: 133-148. Hovenga EJS. Standards in health informatics. In: Hovenga E, Kidd M, Cesnik B, editors. Health informatics: an overview. Melbourne: Churchill Livingston, 1996: 41-46. Pigott N, Gillis J. Clinical information systems in critical care. In: Gilles J, editor. Paediatrics intensive care. London: Bailliere-Tindall. In press. Hall LM. Health informatics in general practice. In: Hovenga E, Kidd M, Cesnik B, editors. Health informatics: an overview. Melbourne: Churchill Livingston, 1996: 303-312. Bower H. Internet sees growth of unverified health claims. BMJ 1996; 313: 381. Wyatt JC. Commentary: measuring quality and impact of the world wide web. BMJ 1997; 314: 1879-1881. Impicciatore P, Pandolfini C, Casella N, Bonati M. Information in practice. BMJ 1997; 314: 1875-1879. Lowe HJ, Lomax EC, Polonkey SE. The world wide web: a review of an emerging internet-based technology for the distribution of biomedical information. J Am Med Informatics Assoc 1996; 3: 1-14. Coiera E. The Internet's challenge to health care provision. BMJ 1996; 312: 3-4. On-line learning materials for the science classroom: design methodology and implementation. Chicago, IL: American Educational Research Association; 1997. Laurillard D. Rethinking university teaching : a framework for the effective use of educational technology. New York: Routledge, 1993. Barnett GO, Piggins JL, Raila WA, et al. Information technology. In: Tosteson DC, Adelstei SJ, Carver ST, editors. New pathways in medical education. Cambridge, Mass.: Harvard University Press, 1994. Carlile S. Issues relating to information technology literacy and access for junior medical officers. Sydney: Postgraduate Medical Council (NSW), 1996. Boud G, Feletti G, editors. The challenge of problem based learning. London: Kogan Page, 1991. Davidoff F, Haynes B, Sackett D, Smith R. Evidence based medicine. BMJ 1995; 310: 1085-1086. Henry R, Byrne K, Engel C. Imperatives in medical education . Newcastle: Faculty of medicine & health sciences, University of Newcastle, 1997. Carlile S, Sefton A, Barnet S, Uther J. Medical problem based learning suported by Intranet technology: a natural student centred approach. In: Swinkles W, Knaup P, Haux R, editors. Proceedings of the 6th International Conference on Health and Medical Informatics Education. Newcastle: University of Newcastle, 1997: 37-38. Authors' details Faculty of Medicine, Department of Educational Development and Evaluation, and Department of Physiology, University of Sydney, NSW. Simon Carlile, BSc(Hons), PhD, Sub-Dean (Information Technology); Ann Jervie Sefton, MB BS, DSc, Professor, and Associate Dean (Curriculum Development). Reprints: Dr S Carlile, Department of Physiology, F13, University of Sydney, NSW 2006. E-mail: simonc AT physiol.usyd.edu.au Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Simon Carlile