The need for more efficacy and relevance in medical education

Traditional medical education has tended to emphasize rote memorization, thus maintaining students in a passive situation. According to the literature, a learning process is most efficient if it calls on pre-existing abilities, if it is achieved in conditions similar to those of the professional activity, and if it gives the learner the opportunity to elaborate on newly acquired knowledge. However, efficacy must always serve the cause of relevance to the health problems of the population. This gives importance to a careful evaluation and analysis of the health problems of the community. The concept of relevance further implies that the planning and the evaluation of medical education programmes ought to take into account the future professional role of the doctor to be. These concepts may be quite familiar to readers of Medical Education. The fact is they are yet to be implemented in 90% of the medical schools in the world. Bis repetita placent. Abusus non tollit usum. The community expects the doctor to embody all at once the qualities of a scientist, of a carer and healer, of a priest and of a prophet (Ryle 1948). Many people consider that the practice of such a profession is an art and that as such it is best taught by means of an apprenticeship (Godfrey 1991), allying a student and an experienced master. However, traditional medical studies continue to be centred on the disciplines and research interests of the teaching staff. They have required above all else, prodigious feats of memorization (Des Marchais & Dumais 1990) with no aim at developing the skills in critical thinking so necessary to the scientist, in clinical reasoning so useful to the caretaker, in communication and empathy associated with the priest and in vision attributed to the prophet. Given these realities, innovations have been advocated (McManus 1991). A possible path, realistic and proven to be feasible, is the replacement of a large part of traditional teaching with the problem-solving approach to training (Des Marchais 1991). Taking into account the contextual dimension of medical education (Rougemont & Allaz 1994), two qualities related to teaching are proven to be fundamental: the educational efficacy and the relevance of the programme (Guilbert 1992). Practitioners, be they generalists or specialists, focus their efforts on solving health problems. This obviously entails something other than simply repeating the knowledge acquired during basic studies. In fact, efficacy in adult training programmes is based on several principles (Knowles 1990). Adult learners are aware of their needs in training and know the interests they want to fulfil by learning. This is internal motivation. Adult learners' training objectives consist in finding solutions to real problems with which they are confronted in their professional or personal lives. This amounts to an awareness of personal responsibility. Learning is based on personal and professional experience, which becomes the platform of the whole process; this awareness is the framework onto which all new know-how and knowledge can be attached. This is the integration of learning into a given context. Adult learners feel responsible for their own education, and ask to be involved in the definition of the training objectives, learning methods and evaluation mechanisms. Learners become the architects of their own education. The most efficient learning methods will vary according to the experience of each learner. This is training adapted to the individual. The conclusion to the above resides in a single phrase: The learners can only be guided in their learning process (Guilbert 1992). In this context teachers become facilitators of learning and their tasks may be summarized as follows: help the participants to define their training needs and assist in formulating their educational objectives accordingly identify and construct training methods that help learners to reach the objective oversee the learning process while encouraging the active participation of the learners involve the participants in the planning and evaluation of the programme (content, method, organization) create a favourable atmosphere for learning (physical environment, quality of organization, interpersonal relationships) evaluate and refine the training programme. These principles underlie programmes devoted to problem- and learner-centred learning (Barrows & Tamblyn 1980). Students who are provided with the opportunity to practice, applying their knowledge to the resolution of problems, have greater confidence in their professional abilities. A summary of experience gathered to date (Schmidt et al. 1989; Nooman et al. 1990) shows that these types of programmes: maintain the cognitive performance of the students develop the aptitude to solve medical problems are perceived by students as being motivating and stimulating help lead students to careers in primary-care, general, ambulatory medicine do not appear to require supplemental resources (apart from an initial investment) although they do require a reallocation of resources. Yet, efficacy must be subservient to relevance. The notion of relevance implies that medical studies aim to train doctors to be capable of solving problems that arise and to respond to the community's health needs. The concept that medical training ought to be oriented to the health needs of the community has also been extensively discussed in the literature (Benor et al. 1989; Fülop 1990; White 1991; Marston & Jones 1992). In Table 1 key elements of a community-oriented programme are summarized. To help maintain coherence between medical studies and professional activity, it seems useful to define just what a doctor ought to be able to do with the aim to organize training around a predefined professional profile. Broadly speaking, a doctor ought to be able to (Fülop 1990): solve the health problems of individuals and respond to the health needs of the community work with the community in order to promote healthy lifestyles and implement and develop adequate health services collaborate with other health professionals and if necessary provide leadership to various groups and provide training undertake research activities suitable to his or her professional circumstances maintain a life-long commitment to continuing education. The definition of the professional profile of future doctors allows the institution in charge of their training to set educational objectives facilitating the coherence between studies and professional activity (Fülop 1990; Knowles 1990; Guilbert 1992). The educational approaches recommended in the context of a particular training programme centred on the community's health needs (Benor et al. 1989) are set out in Table 2. The evolution of modern societies and the prodigious proliferation of biomedical knowledge have led to increased societal expectations concerning the health services provided both to individuals and to the community (Rougemont & Allaz 1994). These trends argue in favour of both relevance and efficacy (White 1991; General Medical Council 1993; Seabrook et al. 1994; Field & Kinmonth 1995; Wharton 1995; Wilton 1995) in a type of medical education which would go beyond the standard biomedical paradigm (Engel 1977) through increased integration of the biologic with the social, preventive, economic and ethical aspects of medicine. Readers of Medical Education have heard for years that this is what is needed for healing the schism, as White (1991) puts it, between medicine and the public's health. This editorial from conservative Switzerland may sound an optimistic note. More than 90% of the medical schools in the world have yet to put these concepts in full operation.