Medicine's balance needs readjusting

NINETEEN ninety-seven is an important year for medical education. Medical schools have recently come through the research assessment exercise with considerable misgivings and some trauma. Sir Rex Richards is due to report in July on the disincentives to a career in academic medicine, which have resulted in a steady flow of doctors out of academic medicine and very poor recruitment to replace them.

The last issue of Health Trends, the Department of Health magazine, reported that of 2,621 newly qualified doctors sampled in 1993, only nine opted for a career in academic or research work. So what is wrong with medical education that so few doctors wish to train their future counterparts?

Part of the difficulties of a university-based doctor lies with balancing a clinical workload with teaching and the ever-increasing demands to carry out research. Doctors need to be taught clinical skills and acumen by practising doctors, but those practising doctors are increasingly torn by the conflicting demands of the NHS and academic life. Medical schools cannot seem to agree on education as their major priority, as increasingly universities are dependent on research income, which is related to their research ratings.

As a result of recent changes particularly driven by the research assessment exercise, there is increasing emphasis by medical schools on recruiting non-medical personnel and non-practising doctors to medical academic positions. Medical schools are becoming schools of medical science - which although extremely beneficial for basic research - will not fulfil the need of tomorrow's doctors. It is difficult to see, when one reads the General Medical Council's "duties of the doctors", which lays down the standards for clinical practice, how those can be achieved if medical schools are forced down the pathway of becoming exclusively research oriented. For these reasons there are strong indications that medical education may be handed to the NHS as a postgraduate, vocationally based form of study. This too has its dangers, as there will be a potential loss of the priceless commodity of academic freedom and the ability for doctors to develop the learning skills that an undergraduate degree confers.

Is there another way? I believe there is an opportunity to be grasped that combines the best that an undergraduate university education and a postgraduate NHS vocational training can offer. This can be achieved by making medicine a postgraduate degree, but one which is still university based. The present medical degree should be divided into two parts: an undergraduate degree in medical science, which should be taught in our current medical schools, and a postgraduate clinically based degree "doctor of medicine" that should be taught in postgraduate medical schools - some of which already exist.

These schools, which concentrate on medical speciality-based postgraduate education, should be expanded by the formation of new schools to take on the clinical training that occurs in the latter part of the current medical degree. These new schools should be jointly funded by the funding councils and the NHS to balance the academic and vocational elements. They should be staffed by clinical academics who will then be able to exercise their currently suppressed enthusiasms for teaching and research into clinical medicine.

The undergraduate medical school should complete its ongoing transformation into a school of medical science and teach the undergraduate component of medical education, leading to a medical science degree. Training would thus be slightly prolonged to six years - three in medical science and three in clinical medicine - slightly increasing the cost, but allowing for a shortening of post-qualification training, which often includes a period of research.

This type of model is similar to the system of medical education in many other countries, particularly Canada and the United States, and seems to fit better with a system of continuing medical education after graduation. There are other advantages: a degree in medical science would be a useful undergraduate degree for a variety of future careers, leading to the possibility of other health-based professions developing a postgraduate structure - a type of core curriculum. It might also lead to other compatible degrees being taken prior to the medical postgraduate degree, which could result in an increase in the number of more mature students in medicine.

We have a system which is becoming increasingly compromised by its lack of balance between clinical, research and educational forces. Everyone involved in medical education needs to feel that they are working to produce the well-educated and caring doctor of tomorrow, and among them some of our brightest future stars in medical research.

Michael Rees is professor of clinical radiology at the University of Bristol.